Hospital Food: Tray Unappealing

Hospital food. What comes to mind? Is it a mouthwatering, colorful plate of fresh, whole foods? More likely it’s a hospital tray with items shaded in a monotonous palette of white and yellow, punctuated by brightly colored sugary beverages and desserts. 

How did hospital food get to be that way-and what are the consequences?

Hospital food service, like all other hospital departments, are typically regarded as separate business units or “cost centers.” Like other cost centers, not only are they expected to turn a profit, but they are routinely assessed for patient satisfaction. A subpar patient rating of can incur a number of adverse consequences for the management of hospital food services.

That helps explain why hospital meals are often designed to provide “comfort food”, including hot dogs, soda, and sugary desserts. The rationale behind the rating oriented hospital meal offering is to give patients the food they want-whatever it is. Underlying this plan is the well-meaning, but misdirected, idea that hospitalized patients are already suffering enough, so they might as well take comfort in their food.

But is hospital comfort food really a good idea?

Most people are aware that long term eating habits have a major impact on health, but few realize that even a single poor quality meal can trigger an immediate undesirable impact. Normally, our arteries are quite elastic and distensible – a critical property that allows all of our arteries, including the delicate vessels that supply the heart, to quickly expand and allow more blood to flow in times of need. But a clever study of arterial function showed that the normally generous capacity of the arteries to enlarge can be abruptly stunned after eating even a single fast-food meal (see reference). Not a good plan for anyone, least of all a patient hospitalized with a coronary condition.

The fallout from poor hospital food can extend far beyond the hospital stay. It is logical for patients to believe that the inpatient meals they receive are good for them, or at least tacitly approved by the hospital staff. If they’re served hot dogs in the hospital-why shouldn’t they feel good about eating them at home? How are they to know, for example, that the World Health Organization has concluded that processed meat is carcinogenic (see reference).

On the flip side, admission to the hospital could be a remarkable opportunity as a “teachable moment”- for patients to learn and experience craveable foods that promote health rather than cause disease. Imagine if hospital meals consisted of delicious preparations of vegetables, fruit, beans and whole grains, to which could be added, if patients request, healthy preparations of fish or condiment sized portions of other protein.

Even better if such meals could be paired with consistent messages from the hospital dietary, nursing, and physician teams that healthy eating is a critical component of recovery-and continued good health. Doing so would make it easier for patients to understand why they weren’t being served foods they might be more accustomed to eating-and ones that perhaps contributed to their reason for being hospitalized in the first place.

What’s needed is more than simply a change in patient food offerings-but a transformation of culture throughout the hospital.

Patients could then better understand that new medicine might be introduced during the hospital stay that will be necessary for future health-but so might new food choices be essential as well.


Arterial Function Impaired After Poor Quality Meal

World Health Organization Statement on Processed Meat

More Gaples Institute Posts

Prediabetes: Are You Just a Little Too Sweet?

Prediabetes is all the rage. Nearly 40% of adults in the US  have “it”- sugar levels higher than normal, yet not high enough to be considered diabetic. But if so many people are affected, is it really a disease? 

First, some definitions: diabetes is diagnosed when fasting blood sugar (glucose) is repeatedly over 125 mg/dL, with normal under 100 mg/dL. That leaves the middle zone, repeated fasting blood sugars of 100-125 mg/dL, as the territory of prediabetes.

Does prediabetes truly live up to it’s name? That is, do people with borderline blood sugar levels frequently move on to develop full diabetes? As you might expect, the answer is yes! Nearly 40% of people with prediabetes gradually increase their blood sugar until they are firmly in the diabetic camp (see references).

In addition to the risk of full on diabetes, prediabetics are 60% more prone to vascular disease and heart attacks compared to those with normal sugar levels (see references).

The best part of the story is that prediabetes is imminently reversible-and it doesn’t take all that much to turn it around. A landmark study, the Diabetes Prevention Program, studied more than 3,000 prediabetics assigned to one of three groups: mild weight reduction diet and exercise, the diabetic drug metformin, or a control group.

The results were strikingly in favor of lifestyle: nearly twice as many prediabetics in the lifestyle treatment group (58% vs 31%) avoided progressing to full diabetes compared to those taking the potent medication.

You might imagine that the diet and exercise regimen needed to achieve those results was extreme-but in fact they were not: exercise was of moderate intensity-including brisk walking-for 150 minutes (ie. 30 minutes 5 days a week), and modest weight loss averaging less than 10 pounds at the end of the 4 year study.

Another measure that can be helpful to lower blood sugar is to cut down on foods with high glycemic load. In addition to the obvious sweet foods, starchy foods-especially white rice, white bread products, and white potatoes, can make blood sugar soar.

A fact that many don’t realize is that foods don’t have to be sweet to raise your blood sugar: a bagel can sweeten your blood twice as much as a sugar donut!

In addition, protein-specifically protein from animal sources-can raise blood sugar. Plant protein, for reasons that are not entirely clear, does not boost glucose levels. Yet one more reason to shift toward healthy foods from plants.

What Not to Do 

Prediabetes is taken too lightly by some practitioners. A friend relayed a story about a recent doctor visit where he was told his sugar was a little high-and they would need to check back in 6 months to determine if the sugar level was high enough to require medication. No dietary or lifestyle measures were discussed. A very poor plan!

Preferred Proactive Approach

If your fasting glucose level is repeatedly over 100 mg/dL (a single measure is not always reliable), don’t be content to just mark time and wait until things get worse. Whether prediabetes qualities as a disease or not, it certainly is a yellow flag. Think about your diet and level of physical activity and talk to your doctor about making some positive changes.

It’s important to add that for some people with prediabetes, sugar levels rise despite intensive lifestyle changes, and medication is ultimately needed. But even in that case, more physical activity and a healthy diet will still position you for the best possible outcome.


Prevalence of Prediabetes

Prediabetes Increases Heart Attack Risk 

Plant vs Animal Foods and Diabetes


More Gaples Institute Posts

Whole Foods: More Than The Sum of Their Parts

Both 2×4 boards and sawdust are made of wood, but you wouldn’t want your contractor to use them interchangeably. The same principle applies to food. Even healthy foods can lose some of their beneficial properties when ground or pulverized into flour.

Whole Grains: Size Matters

The importance of eating whole grains over refined is well understood. A whole grain has all 3 parts of the natural grain: the bran (great source of fiber), germ (filled with antioxidants including natural Vitamin E), and endosperm (mostly starch). Refined grains are largely made from the starchy endosperm.

Adding whole grains in preference to refined is recommended because the healthy parts of whole grains are linked to lower rates of heart disease, cancer, high blood pressure, and more.

But even with whole grains, size matters.  For instance, when whole grains are pulverized into flour and baked into whole grain products, the finely ground grain flour is rapidly absorbed, boosting blood sugar in the process.

A study that of whole grains and blood sugar found that foods made from whole grain flour dumped more than twice as much sugar into the bloodstream as the same amount of whole grains that were not ground.

The study went on to examine how filled up the research subjects felt after eating various preparations of whole grains. Of special interest to those seeking to lose weight, the study found that whole grains eaten intact were significantly more satiating than when consumed as flour in a whole grain baked product.

There’s lots of ways to introduce more intact whole grains into your diet. Usually boiled, with some creative spicing, whole grains are great side dishes to consider in place of starchier potatoes. Think beyond plain wheat and look for recipes that include barley, bulgur, and farro.

Almonds: Butter vs Whole Nut

Did you ever wonder how the calorie counts for foods are established? A calorie is the energy needed to raise 1 gram of water by 1 degree Celsius (are you sorry you asked?). The real way to check the calorie count of a food is to set it on fire and measure the energy that is generated.

But our bodies are more complicated than a bunsen burner-and we don’t necessarily “burn” all the food that passes through-including whole nuts.

In a very scientific study involving an indelicate bathroom analysis, the calories actually absorbed from eating whole almonds was 30% less than the calorie count listed on the nutrition label. That’s because much of the chewed whole nuts pass right through and out of our bodies.

But nuts, when ground into almond butter, were much more readily metabolized, with  detailed calorie analysis showing 48% more calories absorbed from almond butter compared to chewed whole almonds.

Bottom Line

As Michael Pollard has written, the most important dietary priority is to focus on eating whole foods, mostly plants. But taking it one step further, whole foods can be eaten in many different ways-and form matters.

Best to eat the whole foods, as much as possible, in the form in which they were grown. Whole foods not shaken or stirred-but served straight up!


Grain Particle Size, Satiety


More Gaples Institute Posts


Ancient Wisdom of Food Pairings

Did you ever wonder how certain food combinations became popular? Nutrition science now affords us the insight to understand how certain food pairings produce synergies that yield surprising health benefits. 

Turmeric and Black Pepper

Turmeric, and it’s active ingredient curcumin, is a potent anti-inflammatory agent. Alzheimer’s disease has a strong inflammatory component, and  experimental evidence is mounting that curcumin might help slow it’s progression. Consumption of turmeric is especially high in India, and is suspected to be one of the reasons why the age-adjusted rate of Alzheimer’s disease in India is much lower than in the US, 1/8th by some estimates.

A problem is that curcumin is rapidly metabolized in the liver and it is difficult to achieve significant blood levels. Here is where the wisdom of food combinations come to play. In India, one of the common ways to consume turmeric is in curry that typically includes black pepper. Black pepper contains “piperine”,  a chemical that blocks the pathways that clears curcumin from the body.

The addition of piperine in black pepper to curcumin increases blood levels more than 20 fold. Lots of ancient wisdom in that combination!

Rice and Beans

A great many cultures have some tradition of eating rice and beans together. Although widely considered a tasty combination, there is actually a great deal of ancient wisdom at play here as well. Beans and grains, both excellent sources of protein, are each “incomplete” in that neither contains all of the protein building blocks, or amino acids, needed by the body.

Grains often lack the amino acid “lysine” found in high levels in beans. And beans are typically short on “methionine”,  in ample supply in most grains. So put them together, and voila-a complete (and delicious) protein combination!

Veggies and Healthy Fat

Why is olive oil often added to vegetables in traditional salads and veggie preparations? Many find that the addition of a small amount of olive oil enhances the taste, but the combination might be biologically adaptive as well. A small amount of fat added to veggies improves the absorption of some key nutrients, most prominently the fat soluble vitamins.

After eating a salad, blood levels of lycopene and carotene were shown to be minimal without fat, but rose up to 4-fold when healthy fat was added.

Turns out that a few drops of olive oil or a slice of avocado adds a lot more than taste to your salad.

Lemon Juice and Vegetables 

Lemon, as all forms of citrus, are rich sources of Vitamin C. And Vitamin C is important for a whole host of reasons. Vitamin C prevents scurvy, a historic scourge of sailors until the citrus solution was identified in the late 1700’s.

Vitamin C also plays a role in a health issue of current concern-iron deficiency. Iron deficiency is a global problem, and the US is no exception. Women of child bearing age are especially vulnerable.

Iron is plentiful in both animal products as well as in some plant foods, but the type of iron from these sources is different. Iron in meat (heme-iron) is readily absorbed by the body. In contrast, iron from plant foods (“non-heme iron) is not easily absorbed-only 1/3 to 1/2 as much as from animal sources. But given all of the reasons to cut down on meat, the answer isn’t to eat (more) meat!

Fortunately, there is a solution-and it involves more plants! Plant derived iron is much more readily absorbed when taken with Vitamin C, including lemon juice! Maybe that “splash” of lemon on your veggies may be just the boost you need.

  • Plant foods rich in iron include: lentils, spinach, swiss chard, and brown rice.
  • Foods rich in Vitamin C are: lemon juice, orange juice, and yellow peppers. Fun fact: yellow peppers have almost twice the Vitamin C as green

It’s intriguing to consider that many of our taste preferences might have evolved over time to confer survival advantages to those who ate certain food combinations. And it’s even better to enjoy the end-result: craveable food pairings that are ever so satisfying.

More Gaples Institute Posts

Vegetables Get A Marketing Boost

How do you decide what to eat? No doubt that appearance and smell are important. But you might not realize that the words used to describe food might be even more persuasive than other sensory cues. The implications for our health are considerable.

A clever study conducted at a university cafeteria told the story (see reference).  Vegetables were served on alternate days with identical preparations, differing only in how they were described, either: 1) plainly; 2) healthfully in a restrictive way; 3) healthfully in a positive way; or 4) indulgently.

For example, green beans were described on some days as just “green beans”, on other days as “light ‘n’ low-carb green beans”, or “healthy energy-boosting green beans” or, most indulgently, as “sweet sizzling’ green beans”.

What difference did the food descriptions make? As it turned out, quite a bit! The descriptions had a significant impact on not only how many diners chose to eat vegetables, but also on how much they consumed.

Vegetables described with indulgent language were chosen 25% more often then when described plainly and a whopping 41% more often when they were labeled with healthful and restrictive language. The conclusion was that messaging that emphasizes healthfulness of foods, especially using restrictive language, can be off-putting.

Conversely, the same items, described “indulgently”, were much more appealing: zesty ginger-turmeric sweet potatoes, twisted garlic-ginger butternut squash, and slow-roasted cartelized zucchini bites. Enticing, don’t you agree?

Similar findings were observed with young children in another study (see reference).  Children age 8 to 11 years from diverse backgrounds were offered vegetables alternatively labeled as “x-ray carrots” or “food of the day.” Interestingly, there was no difference in number of children who selected both of these choices, but children actually ate more than twice as many vegetables when described with words like “x-ray carrots” compared to being labeled as the “food of the day.”

The bottom line is that when it comes to promoting healthy eating, marketing matters. Purveyors of junk food have long known that-and are much better at it than health enthusiasts who have arrived much later to the marketing game.

The twist is that food marketing that appeals to healthfulness doesn’t often appear to be helpful-in fact, sometimes it can be counterproductive. Rather, the message from these studies of children and young adults is that the path to healthier eating is paved with more creative, indulgent descriptions.

But the need for creative messaging to promote healthy eating isn’t limited to children. For adults, maybe some visual messages would work better. Perhaps something like this…Carrots anyone?


Indulgent Descriptions and Vegetable Consumption

Attractive Names and Increased Vegetable Intake in Schools


More Gaples Institute Posts



Press Release: New Survey Finds Most Cardiologists Receive Minimal Nutrition Education

A new study notes serious deficiencies and substantial opportunities to improve cardiovascular care, save lives and reduce healthcare costs. The lead author is Dr. Stephen Devries, Executive Director of the nonprofit Gaples Institute.

Like most Americans, even cardiologists fail to eat to enough fruit and vegetables. And, while cardiologists overwhelmingly believe their role includes personally providing patients with at least basic nutrition information, less than a third describe their nutrition knowledge as “mostly up to date” or better. These are among the findings from the report A Deficiency of Nutrition Education and Practice in Cardiology, recently published by The American Journal of Medicine and authored by a dozen physicians and healthcare professionals in the United States and Spain.

“Although cardiovascular guidelines describe nutrition as a foundation of care neither education nor practice among cardiologists and cardiovascular team members reflect that priority,” said lead author Stephen Devries, M.D., Executive Director, Gaples Institute for Integrative Cardiology.

The nonprofit Gaples Institute provides advocacy and education that empowers healthcare professionals and the public to promote heart health through greater attention to nutrition and lifestyle. “While the report notes serious deficiencies, it highlights tremendous opportunities to improve cardiovascular care, save lives and reduce healthcare costs. We hope these findings serve as a call to action for much greater emphasis on nutrition in the training and practice of cardiovascular specialists.”

The report is based upon what is believed to be the largest survey of physicians and healthcare professionals – and the only such survey of cardiologists – on personal dietary habits, level of nutrition education, and attitudes and practices regarding nutrition in patient care. Cardiologists, fellows-in-training and cardiovascular team members completed 930 online surveys.

Even though poor diet is the leading cause of premature death and disability in the U.S. with heart disease as the condition most responsible, cardiologists reported inadequate training in nutrition. Ninety percent reported receiving no or minimal nutrition education during cardiovascular fellowship training, 59 percent reported no nutrition education during internal medicine training and 31 percent reported no nutrition education in medical school.  Further, nearly two-thirds of cardiologists reported spending just three minutes or less per visit discussing nutrition with patients.

“Using nutrition as medicine is probably one of the most cost effective ways to treat disease but is incredibly underutilized by healthcare providers,” explained Andrew Freeman, M.D., cardiologist, National Jewish Health, Denver, Colorado, and one of the study’s co-authors. “If we could empower healthcare providers with information on how to implement this in daily practice, we could transform healthcare rapidly, prevent healthcare cost explosions, and reduce morbidity and mortality.”

The report noted the total annual cost related to heart and vascular diseases in the U.S. is a staggering $315 billion. Given that dietary changes have reduced documented cardiovascular events between 30 and 70 percent, the potential cost savings to be realized through increased nutrition education is substantial.

Survey respondents agree. Nearly 90 percent believe that “dietary interventions are likely to provide substantial additional benefit to patients with cardiovascular disease who adhere to guideline-based pharmacologic therapy.”

Healthcare Pros Skimp on Fruits and Vegetables

The diets of the healthcare professionals surveyed were no better than the public at large with only 20 percent of cardiologists noting they ate the recommended five or more daily servings of fruits and vegetables. The implication of this finding extends far beyond the cardiologists’ own heart health as the report notes strong evidence that physicians with healthier personal behaviors are far more likely to counsel their patients about lifestyle changes than physicians with less favorable lifestyle habits.

“Cardiologists with the most vegetable and fruit consumption were also more likely to believe it was their responsibility to discuss detailed dietary information with their patients,” explained Dr. Devries. “Therefore one way to possibly improve patient counseling and health is for physicians to first optimize their own diet.”

The report cited a concerning development that heightens the sense of urgency to improve nutrition education in medicine and patient counseling. For more than a decade, the mortality rate from cardiovascular disease had been on the decline but, because of the high prevalence of diet-related obesity and diabetes, the mortality rate has now plateaued.

The report, available at, outlines recommendations to improve nutrition education across all stages of cardiovascular specialist training and continuing education programs.


More Gaples Institute Posts

Dying With Normal Lab Values

Good lab results can be dangerous. Now don’t get me wrong: “normal” is the preferred result for your blood work, x-ray, or stress test. The problem with “normal” is not the finding itself, but more the false sense of security that it can impart.

On the subject of stress tests, many people get one as a rite of passage, kind of a medical “coming of middle-age” birthday present. It’s certainly true that too many people, without any bodily warning shot whatsoever, suddenly drop dead.

You might ask: why not do some digging to look for a hidden heart problem and take care of it before disaster strikes?  Makes perfect sense. Too bad it doesn’t work.

A heart attack often arises from a type of fault line in one of the arteries that supplies the heart. The diseased area typically has plaque build up from cholesterol and inflammation. The surprising finding, contrary to popular belief, is that the artery that gives rise to a heart attack is often just mildly narrowed right before the disaster happens.

What often occurs is that the fault line in the artery suddenly shifts, and causes damage that quickly triggers a blood clot lot to form that leads to a heart attack.

The arterial fault line is a lot like the geologic sort: everything is very quiet until its not. The eruption can be triggered by a variety of stressors, but as often as not, the timing is without apparent rhyme or reason.

An artery with a very serious fault line but only narrowed by 40% could easily slip by to yield a “normal” stress test result because results are typically normal unless the artery is narrowed by 50-70% or more.

Blood tests are another area ripe for encouraging overconfidence in “normal” results for two reasons: 1) drugs can normalize some tests while leaving other risks unattended; 2) medical science isn’t advanced enough to measure everything that matters.

Consider the person who is seriously overweight and doesn’t exercise. Very likely has  high cholesterol, and at least borderline diabetes. Given the right drugs, it is fairly easy to drive the lab results down an acceptable, and possibly an exemplary level. All without losing a pound or moving a muscle. Too often, I’ve seen how “normal” lab results in this situation can drain the motivation right out of people.

It’s understandable-the lab “numbers” all look great so people wonder why they should do more?


For example, statins used to treat high cholesterol, at best, reduce the risk of a heart attack by about 30-35% in high risk individuals-especially those with a history of heart disease. Of course that’s very significant and statins should be encouraged for high risk patients.

But at the same time, even with statins on board, the treatment leaves 65-70% of the risk still on the table…quite literally! And there are mountains of data that  excess weight and inactivity are major risks-regardless of “normal” blood tests.

Lab tests can be misleading for another reason-we don’t know enough to measure everything that matters. Having normal lab results for the “usual suspects” is a good thing, but those tests will miss other, possibly equally important risks, ones that we don’t know enough to account for. Like  genetic factors that require higher tech to identify, or psychological states like anxiety or feelings of social connectedness that are more difficult to assess.

To put all of this into perspective, of course, if you need a lab test, I hope it turns out to be “normal.” And if not, you may be better off to take reasonable steps to make it normal. Just don’t stop there.

Eating healthfully, being physical activity, managing stress, and connecting with people in meaningful ways are all integral to your wellbeing-above and beyond whatever any lab test shows.

In a quote often attributed to Albert Einstein, “Not everything that can be counted counts and not everything that counts can be counted.”


More Gaples Institute Posts

Don’t Fear the Fruit

Sugar is the new fat. The latest wave of books and documentaries paints sugar as the root of all dietary evil. And for sure there’s good reason to be concerned. Sugar laden drinks and snacks are prime contributors to our obesity epidemic. But in the zeal to rid themselves of sugar, some people are going too far by shunning fruit.

It’s a fact that fruit contains sugar, mostly fructose. And fructose, often in the adulterated form of “high fructose corn syrup”, is the source of unwanted added sugar in everything from ketchup to peanut butter.

The argument goes that if we need to avoid the sugar in a cookie, shouldn’t we be just as concerned about sugar in an apple? The answer is NO!

Although the apple and cookie are both vehicles for fructose, there are some important differences. First, the sugar in fruit is mixed together with fiber, a buffer that limits the amount of sugar that is absorbed. Junk food, on the other hand, is generally devoid of fiber, allowing the sugar unfettered access to the bloodstream.

The second important difference between fruit and other sugar containing foods are the many health promoting nutrients in fruit that are mostly missing in sugar filled processed foods. For example, many fruits are rich in potassium that helps keep blood pressure in check-in addition to a host of other vitamins and antioxidants.

Despite the concern that eating fruit increases the likelihood of diabetes-the data shows exactly the opposite. A deliciously counterintuitive finding is that some fruits, despite their sugar content, are actually helpful to prevent diabetes. For example, blueberries eaten 3 times a week have been shown to reduce risk of risk of diabetes by 26%. Grapes, prunes, apples, and bananas were also helpful.

How fruit drops the odds of developing diabetes is not well understood. Fiber content is certainly a factor, but there’s certainly more to the story. One key is a special antioxidant concentrated in blueberries called “anthocyanins.” Anthocyanins suppress the body’s internal production of sugar, in addit.

A new study not only confirmed that the most fruit eaters had a lower risk of diabetes – it went one step further. The latest report showed that among those who already have diabetes, eating more fruit was linked to a longer life, and one more likely to be free of the serious vascular complications of diabetes.

Of course, it’s possible to overdo any healthy habit-including eating fruit. And everyone reacts a bit differently-some may experience an unusually high bump in blood sugar with certain fruit and need to be a bit more careful.

But for the vast majority, eating at least two servings of fruit per day is a strongly positive health move. And remember, we’re talking about whole fruit-not fruit juice or fruit loops.

Instead of focusing on any one part of the food, think of the whole package. Please don’t throw the fruit out with the bath-or sugar-water.


Fruit and Risk of Diabetes

Fresh Fruit, Diabetes, and Complications

More Gaples Institute Posts

The Absurdity of Shared Medical Decision Making as a “New Concept”

Decisions regarding medical care are often not very straightforward due to  the uncertainties, risks, and limited options involved. But, beyond the actual choices to be considered, the process of how the choices are made has become a red-hot topic. And the value of the patient-as opposed to the doctor-as the driver of medical decision is, quite curiously, just beginning to be recognized in a model called shared decision making.

Shared decision making is the process between a healthcare professional and patient to help the patient decide between several medically reasonable choices based on the patient’s preference and values. It is startling to consider the idea that shared decision making is presented as a new model, since the basic tenet of the patient as being in charge appears to be self-evident. But sadly, there is indeed a need to spotlight this “new” idea –precisely because it has, heretofore, been too often missing in action.

An interesting question to ask relates to timing. Why is shared decision just now attracting so much attention? The reason is not so high minded. Spoiler alert: non-nutritive greenery is involved.

Studies show that more informed patients tend to cost less. A fascinating observation is that the more patients are informed about various treatment options, the more likely they are to opt for the conservative approach and avoid expensive procedures and surgeries. Giving people more information saves money. Cost savings is not the most noble reason to encourage shared decision making-but it’s likely the side-benefit that’s needed to give it the attention it deserves.

No area of medicine is more ripe for shared decision making than my specialty-cardiology. A cardiac procedure of particular interest for medical decision making is angioplasty. Angioplasty involves threading a catheter into the heart, where a balloon is inflated to open a narrowed coronary artery. Although intuition might suggest that angioplasty would improve the outlook for patients with chronically constricted arteries, surprisingly, this has not been proven to be true.

A landmark medical trial published 10 years ago studied patients with coronary blockages: all were treated with medication according to guidelines, but half were randomized to initial treatment with angioplasty. At follow-up that averaged about 5 years, angioplasty failed to show an improvement in survival or reduction of heart attacks. The study was named according to the clever acronym COURAGE (Clinical Outcomes Utilizing Revascularization and AGgressive Drug Evaluation).

But as it turned out, the only ones who needed courage were the physicians, as the patients apparently already had plenty. In a study that analyzed 59 recorded conversations of cardiologists discussing the decision to undergo an angiogram and possible angioplasty, better informed patients were more than 3 times as likely to avoid invasive treatment.

Backtracking for a bit, it might be reasonable to ask, what is the alternative to shared-decision making? Isn’t it obvious that patients need to be fully informed about all of the options, and that their own preferences and values should be integral to the final decision?  You might think so-but historically-you would be wrong.

For instance, in the cardiologist/patient procedure discussion just mentioned, only 3% of the conversations analyzed contained all of the key elements deemed essential for informed decision making, and merely 14% met even a less stringent set of criteria.

One might argue that it is entirely proper for physicians, advantaged by extensive training, knowledge, and experience, to direct their patients to make the “best” medical decision. In certain situations, especially emergent ones where risks and benefits are more clearly established and urgency is required, a strong case can be made for physicians to be more directive. But even in those situations, there needs to be an accommodation, if not a full welcoming, of patient values and preferences. This issue arose several times in my medical career, including several instances when patients who were Jehovah’s Witnesses refused blood transfusions in situation where that decision could possibly have resulted in a fatal outcome.

Moreover, the idea of a “best “medical decision assumes, often incorrectly, that there is one. In a 2009 analysis of clinical guidelines from the American College of Cardiology/American Heart Association approved clinical guidelines, only 11% of the recommendations were found to be supported by the highest level “A” evidence. Fully 48% of the recommendations had their origin in level “C” evidence, nothing more than “expert opinion, case studies, or standard of care.”

The fact that medical science often isn’t sufficiently developed to identify a clear “best” answer-even from a purely objective perspective – is not a fatal flaw, but it is humbling. And most importantly of all, it is the truth. Acknowledging this reality paves the way for a wide open, shared discussion that can be liberating both for the physician and patient. And give both breathing room to add hearty doses of personal values and individual preferences to the mix.

There’s little doubt that greater adoption of shared medical decision will be a major step forward to advance the best medical care of each patient, with the realization that “best” treatment is more an absolute than a relative term.  And although the sudden surge in interest in shared decision making is largely financially motivated-for once, all the interests are aligned in the right direction.


Prime Time for Shared Decision Making


Informed Decision Making for Angioplasty

Scientific Evidence Underlying Guidelines


More Gaples Institute Posts


How Much Health Can You Buy for $14,000?

Unparalleled reductions in cholesterol levels are now possible with a new class of cholesterol medicine, a PCSK9 antibody, as recently reported in one of the large national cardiology meetings. But this latest example of high tech cholesterol treatment comes with a staggering price-tag, $14,000 a year for the new genetically engineered injectable.  As a preventive cardiologist, I began to wonder if this is the best way to spend our money.

A few caveats first. This novel treatment for cholesterol promises to be a breakthrough for a small but significant group of people with a severe inherited form of high cholesterol for which effective treatments were previously lacking.  And certainly, there is another group of people in need of extreme cholesterol lowering who stand to benefit from this pricy new drug because they cannot tolerate the side-effects from conventional treatment with statins.

While acknowledging these important exceptions, my concern is that the accepted indications for this shiny new medicine will eventually creep, as so many do, into a wider range of situations that could be more effectively, and economically, addressed through lifestyle changes.

To illustrate the point, I used the $14,000 annual cost of the new cholesterol medicine as the basis to construct an alternative shopping list-one related to evidence-based healthy food and lifestyle choices.

To stack toward the high end, organic food prices were obtained from my visit to a large, organic grocery store known for selling Foods in Their Entirety.

This is what $14,000 can purchase (daily cost listed):

  • Spinach (2 cups/day): $4.00
  • Tomatoes (1 a day): $1.50
  • Avocados (1 a day): $1.66
  • Apples (1 a day): $1.50
  • Blueberries: (1 cup/day): $2.90
  • Red Beans (1 cup/day): $1.28
  • Quinoa (1 cup/day): $1.14
  • Oatmeal (1 cup/day): $0.20
  • Nuts: (1 handful/day) $0.90
  • Wild caught salmon (6 oz twice a week): $10.50/week
  • Tofu (1 serving/day): $0.40

Since men and women do not live on quinoa alone…

  • Red Wine (1 glass/day from a $12 bottle): $2.40

Annual Costs

  1. Food: $7,073.70
  2. Fitness Club Membership: $1,000
  3. Exercise Trainer ($80/week): $4,160
  4. Yoga Class ($20/week): $1,040
  5. Charitable Donation (good for the heart): $726.30




Potential Side-Effects of This Healthy Lifestyle Plan:

  • Increased energy
  • Greater sense of well-being
  • Blueberry stains

How do we get the most value for our $14,000 per year? For the select group, who by inheritance, or drug intolerance, have few options, there is no doubt that the expensive new cholesterol drugs offer significant promise.

But current indications for these expensive medicines also includes a great many more people with coronary disease who take conventional medication but can’t quite lower their cholesterol sufficiently. For those and others, who knows how the $14,000 high tech drug would hold up to the same investment in a healthy lifestyle? We’ll never know because no pharmaceutical company is likely to ever sponsor such a study.

It’s not an issue of high or low tech. We need both. But the high price tag of the newest cholesterol drug begs the question as to whether there might be an even more effective, and more economical, lifestyle-based solution for all but a select group.

Of course, a healthy lifestyle can’t just be bought. But $14,000 could provide a lot of the tools-both in terms of access for those in whom it is currently limited, and in effective education and coaching for individuals who have the means but have been overly directed to pharmaceutical solutions. As a preventive cardiologist for over 25 years, I speak from experience to say that an investment in healthy lifestyle is priceless.


More Gaples Institute Posts

What Did You Try to Do Slowly Today?

Chances are that you tried to do something faster today-probably several times. Walked faster. Drove faster. Ate faster. Less likely was a conscious effort to do anything slower. Ever wonder why not?

The thought came to me during my weekly Tai-Chi class. As I focused on the carefully choreographed routine, I reflected back to a time, not long ago, when the slow pace of this “meditation in motion” seemed strange to me. A common reaction to the thought of doing anything especially slowly.

But the converse-fast action-is not a bit unusual. In fact, its the norm. Consider your reaction to watching a pedestrian zipping along through a crowd. He must be late for an appointment. And that driver tearing up the fast lane-must be rushing to the delivery of a baby…or at least a pizza.

Of course, there are lots of good reasons we need to move quickly during the day. But our bodies aren’t built for being all on all the time.

The inner workings of the heart provide us valuable insight into the need for modulation.

Like a puppet, the heart rate is operated by strings of nerves with opposing functions – sympathethetic and parasympathetic. Switching on the “sympathetic” nerve signals the heart rate to speed-up. In contrast, the “parasympathetic” branch acts applies the brakes to slow the pace. The scientific measure of these speed swings is called  heart rate variability.

Only the sickest hearts have an unwavering cadence-an unflappable rate usually on the high side. A very constant heart rate is called dead regular for a reason-it foreshadows low survival.

In contrast, normal hearts have the highest heart rate variability. A true marvel of engineering, opposing nerves normally discharge a flurry of stimulating and suppressing forces that alternate as needed to speed and slow the heart. A finely tuned operation, the heart maintains the perfect tempo, appropriate to the situation.

The wide variation in heart rate is the signature of heart health – and perhaps can serve as a model for achieving the balance in pace of our daily lives needed for optimal health. Most people have no problem putting the fast action into practice: running out the door, gulping down lunch, and hightailing on the highway.

But returning to our original question, what do you intentionally do to move slower than usual? Eat slowly, walk slowly, meditate, or…even Tai Chi? It’s an interesting question to explore-and to consider as you go about your day.

Follow your heart and you’ll never go wrong.


More Gaples Institute Posts

Omega-3s on Land and Sea

Omega-3s sourced from the ocean are not the same as those  from land. The distinction between aquatic and terrestrial omega-3s has influenced human civilization over millennia, and continues to have significant implications for our health today.

First, a bit of chemistry to set the stage. Land based sources of omega-3s are made of 18 carbon atoms laid end to end in a chain. Examples of plant sources loaded with this smaller length of omega-3s are flax, chia, and walnuts.

In contrast, the size of aquatic omega-3s are larger than the land based versions, 20 carbons for EPA and 22 carbons for DHA.

Here’s why these distinctions matter: our brains are largely made from lipid, and a significant percentage of that is omega-3. But the form of omega-3 in the brain is the longer marine type, DHA, not the shorter version found on land. 

The easiest way to get the longer chain omega-3s needed by the brain-as well as many other essential functions-is to consume them ready made from ocean life.

Fish have highest concentration of these omega-3s, but they are mostly intermediaries, filtering and concentrating the true source of long chain omega-3s, the lowly algae.

Marine algae, both the tiny versions like chlorella, as well as the more visible “macro algae”, seaweed, are the primordial source of the larger omega-3s.  Although not a common food in most of  the US and Europe, seaweed is a staple in the diet of much of Asia. Seaweed is actually a rich source of a great many nutrients, but stands out as a rare non-animal source of the prized longer chain omega-3s.

And that’s where the the omega-3 story intersects with human evolution. A fascinating book entitled Nutrition and Evolution by Michael Crawford and David Marsh, describes how the growth and development of the human brain parallels the access of early man to marine sources of food, including both sea plants and fish. There is good evidence that the brain of early man expanded after exposure to the long chain omega-3’s found in coastal habitats.

However, there is another way for the body to get much needed longer omega-3s, more of a DIY plan. Our bodies are capable of converting the shorter 18 carbon omega-3 found on land into the longer DHA and EPA needed by the brain and other organs. The problem is that humans don’t make the conversion very efficiently so that only a small amount of DHA and EPA are internally produced. 

Nevertheless, the more “land based” omega-3s are eaten from foods like flax, chia, and walnuts, the greater the production of DHA and EPA.

What happens with vegetarians and vegans? Predictably, vegetarians have lower levels of DHA and EPA than omnivores. And vegans have even lower levels as they completely avoid fish. What you might not expect, however, is that vegetarians and vegans, on average, don’t consume any more of the land based omega-3s than omnivores. As such, they may not consume enough of the shorter chain omega-3 to fuel the reaction that makes DHA and EPA.

Does this mean that vegetarians and vegans are necessarily “shortchanging” themselves? Absolutely not! A carefully chosen vegetarian and vegan diet is linked to a much lower rate of chronic disease than other dietary plans. But even the healthfulness of a vegetarian or vegan diet could likely be further enhanced by attention to consuming more omega-3s.

Practical Tips For Vegans and Non-Fish Eating Vegetarians

  1. Load your diet with as many of the short chain, “land based”, omega-3s as you can-including flax, chia, and walnuts. These have their own health benefits, and will also fuel your body’s internal production of the long-chain, “marine” forms needed for optimal health.
  2. Consider taking an omega-3 vegan supplement. These are made from algae and are now available in forms that contain both DHA and EPA.
  3. Consider adding seaweed (nori in Japanese) to your diet.

Practical Tip for Fish Eaters

  1. Eat two or more servings per week of omega-3 rich, responsibly caught, fish with lower mercury and toxin levels.
  2. Wild caught salmon is one of the best choices. You can find others by checking the Environmental Working Group Consumer Guide to Seafood (see below).



Aquatic Food and Implications for Human Development

Environmental Working Group Consumer Guide to Seafood


More Gaples Institute Posts

Are Antinutrients Real?

Despite a name that invites skepticism, antinutrients really do exist. So what exactly are antinutrients and…do they matter?

Antinutrients are compounds in food that chemically tie up key nutrients. The result is that fewer of the helpful nutrients are available to the body.

The most important of the antinutrients are called phytates. Phytates, while a concern for humans, are essential for plant growth because they are the primary source for plants of much needed phosphorus. Grains are the #1 source of phytates, mostly concentrated in the outer shell, or bran layer. Other phytate containing foods include seeds, beans and nuts. Another important dietary source of phytates are soy based products, especially processed “soy isolates” found in some protein bars and meat substitutes.

Phytates have a strong negative charge, and since opposites attract, they readily bind to positively charged nutrients like iron, calcium, and and zinc. Once bound by phytates, these helpful nutrients can not be easily absorbed.  Depending on the amount of iron, calcium, and zinc in the diet-as well as how much of the antinutrient phytates are consumed-the clinical impact can range from minimal to very significant.

For example, iron deficiency anemia affects an estimated 30% of the world population. Low dietary intake of iron is mostly to blame, but phytate blockade of iron absorption is thought to be a very major contributor-especially in populations that are heavy consumers of grains.

Although not as commonly recognized as iron deficiency, zinc is also a nutrient of worldwide concern. Low levels of zinc, made worse with heavy reliance on grain intake, can lead to problems with skin and hair, let alone more serious issues with vision and immune function.

Do Antinutrients Matter to Your Health?

For people who eat a wide variety of healthy foods, the answer is probably no. Individuals who might be more vulnerable to ill effects from antinutrients are those whose diet is especially shifted toward grains-especially those with limited intake of foods rich in iron, calcium, and zinc. Another group that might be at risk are those with poor nutrient intake who rely heavily on soy isolates found in many protein bars and meat substitutes.

If you believe you are at risk for problems from antinutrients, you might consider some of the food selection/preparation steps as below:

Culinary Strategies to Reduce Antinutrients

Soaking grains and beans removes a significant amount of phytates, assuming that the soak water is not consumed.

Fermenting grains, as in bread making, also reduces phytate concentration, with sourdough fermentation lowering levels even more than yeast fermentation.

Sprouting grains and beans is perhaps the most effective way to lower phytates. You can buy sprouted grains (and sprouted bread), as well as sprouted beans-or sprout them yourself at home.

But, as with almost any dietary concern, eating as varied a nutrient rich diet as possible, without a particular focus on any one food group (including grains or processed soy), is your best protection.



Enhancement of Bioavailable Micronutrients in Food Grains

Phytates in Food


More Gaples Institute Posts

Mind Your Heart

Every once in a while, a new study reveals the science that underlies a great mystery. A new report on the connection between the stress, inflammation, and heart disease does exactly that.

A recent paper published in the international journal, The Lancet, examines how activity in the brain’s stress center relates to inflammation and, ultimately, to heart disease.

The study used a very high tech method of measuring the metabolic “traffic” in the body, a PET or Positron Emission Tomography scan. PET scans display images that “light up” depending on the the cellular activity throughout the body. Activity was tracked in the amygdala (the brain’s stress center), the bone marrow (where inflammatory cells are made) and in the arteries.

Participants were then followed to see how many developed heart attacks, strokes, and other vascular problems.

The results were striking: a strong link was uncovered between activity in the brain’s stress center, the amygdala, and serious cardiovascular complications. The association held firm even when adjusted for other known risk factors.

But the study went one step further to examine how activation of the brain’s stress center led to heart attacks. The missing link… inflammation.

When the amygdala is “stressed out”,  the bone marrow, where inflammatory cells are made, is mobilized to churn out white blood cells. These warrior cells head straight to the arteries, which literally light up  PET scans with inflammatory changes.

That completes the stress circuit: from activation of the amygdala in the brain, to mobilization of an army of white blood cells in the bone marrow, to an all out inflammatory assault on the arteries. And  inflammation spells trouble because it weakens blood vessels and sets them up for heart attacks and strokes.

Although many of us are familiar with the concept of certain foods being pro-inflammatory, the idea of our mind being the source of inflammation, or its relief, is not commonly recognized.

No wonder why a recent study of meditation, published in one of the most prestigious cardiology journals, showed a nearly 50% reduction in serious heart complications among patients with heart disease who added regular meditation to their conventional treatment program compared to those on medication alone.

Don’t let too much stress get under your skin, or in your arteries. You’re in control-use all of your power to, quite literally, mind your heart!



Stress Activation in the Brain and Cardiovascular Events

Meditation Cuts Risk of Heart Attacks


More Gaples Institute Posts

Statin Problems? Consider Low Vitamin D

The benefit of statins in high risk patients is unmistakable, but so is the potential for side-effects. In some studies, up to 20% of statin users report adverse reactions, most commonly muscle aches or weakness.

There are many reasons for statin related muscle problems, but one that is commonly missed-and easily fixed – is a low blood level of Vitamin D.

There is an interesting link between Vitamin D and muscle function. Muscles are rich in specialized receptors, or docking stations, for Vitamin D. When blood levels drop too low, the Vitamin D hook-up in those receptors doesn’t happen, and muscle function can suffer.

Muscle irritation is a possible adverse reaction from statins, a problem compounded by low Vitamin D. In several studies, people who develop muscle side-effects from statins had significantly lower Vitamin D levels than those without side-effects.

But problems related to low Vitamin D are easily remedied. In one study of people with low Vitamin D levels and statin related muscle pain, restoring normal levels of Vitamin D allowed 91% of patients to take a statin without side-effects.

Our bodies make Vitamin D in response to sunshine, so levels tend to plummet in the winter, particularly in northern areas. Foods highest in Vitamin D content include dairy products (usually fortified with Vitamin D). Significantly low Vitamin D levels, however, usually require a supplement or prescription.

If you take a statin and suspect a problem-talk to your health care provider. And armed with this information, ask about the possibility of low Vitamin D. There’s no way to know for sure if your level is low without a blood test.



Statin Intolerance Resolved by Vitamin D Supplementation

The Relationship of Vitamin D Deficiency to Statin Myopathy


More Gaples Institute Posts

You Don’t Have to Wear Your Genes

“If it’s gonna happen, it’s gonna happen.” I’ve heard that more times than I can recall from patients with a family history of heart disease. But, as Gershwin wrote, it ain’t necessarily so-not by a long shot!

A recent study of over 55,000 participants followed for close to 20 years explored the connection between genes, lifestyle, and serious heart disease. Scientists examined each of the participants for 50 genes linked to heart disease. The results: a few simple lifestyle changes are able to knock 50% off the risk of even the most hostile heart genes.

You might imagine that the lifestyle changes needed to make a difference would be fairly extreme-a complete diet makeover or a grueling exercise training program. But what was found was something quite different-very modest changes were all that were needed to trim much of the excess hereditary risk.

The investigators studied the impact of 4 healthy lifestyle factors-and the bar was set low. No current smoking, no obesity (BMI less than 30), physical activity (even once a week counted), and a “healthy diet” (liberally defined as following at least 50% of common recommendations to eat more vegetables, fruit, nuts, whole grains, nuts, fish and less red meat, refined grains, sugar sweetened beverages). Individuals who met 3-4 of these criteria were described as having a “favorable” lifestyle while those with 0-1 were regarded as “unfavorable.”

The study did confirm that a bad inheritance had a negative impact across all groups. But the most astonishing finding was that regardless of how the genetics were stacked, lifestyle changes improved health outcomes dramatically.

For those at low genetic risk, a favorable lifestyle was associated with a nearly 50% lower heart risk than those with the poor lifestyle. But surprisingly, even in individuals who inherited the worst heart genes, a favorable lifestyle improved their cardiac outlook by about the same 50%.

The very positive and empowering conclusion is that regardless of whether you have inherited friendly or hazardous genes-a healthy lifestyle goes a very long way to better health.

The discouraging news is that fewer than 50% of the people studied met even the watered down criteria for a healthy lifestyle. But, on the flip side, therein lies an opportunity-the possibility of extending colossal health benefits to so many at low cost, and with major side-effects, all positive.

Your genes are hand me downs you can’t refuse-but the science shows you don’t always need to wear them!



Genetic Risk, Adherence to a Healthy Lifestyle, and Coronary Disease


More Gaples Institute Posts

GMO Surprise

With questions remaining about the safety of GMO foods, many well known products are now non-GMO. And that’s a good thing. But there might be one small downside you should be aware of: the impact of non-GMO on vitamin content.

Interestingly, vitamins added to “fortified” foods are often made from food that is genetically modified. In other instances, GMO bacteria and yeast are used to produce the vitamins used to fortify food.

For example, added Vitamin E  in fortified food is often derived from GMO soy and Vitamin C from GMO corn. In contrast, “extra” Vitamin B12 added to food is commonly obtained from genetically modified bacteria.  Because these nutrients are difficult and expensive to produce conventionally, food companies often skimp on fortification, or eliminate it entirely, in non-GMO products.

You can check this out for yourself by pricing vitamin supplements-both conventional and non-GMO. The non-GMO versions are both harder to find and significantly more expensive.

Fortification has been credited with some important health outcomes: folic acid added to food has drastically reduced serious nervous system deformities in newborns, iron helps guard against anemia, and iodine prevents goiters (“non-GMO salt” may not contain iodine.)

What to do: If you avoid GMO foods (a reasonable plan until we know more) be aware that the non-GMO versions may not be extensively fortified. You can still assure adequate nutrient intake by eating a diet rich in vegetables and fruit, and consider taking a multivitamin as a nutrient insurance policy.


More Gaples Institute Posts

Gaples Institute Nutrition Conference Reignites the Joy of Medicine

The look of joy on their faces was irrepressible-a sight to behold. The Gaples Institute held a nutrition conference for doctors and nurses.

We delved deep into the science and reviewed the key literature. Lots of graphs and tables. But we went one step further, beyond the facts and figures and into the feelings of food. With cooking demonstrations, we explored how to make the science come alive-and how it tastes on a plate.

Then we put it all together was a hands-on experience where participants made their own lunch-using all the principles of healthy eating they had learned about. Doctors and nurses exchanged their usual white coat for one of a different style-but similar in its connection to health-a cooking apron. Then they chopped, sliced, mixed, and baked.

But something deeper was happening. In all my years in medicine, I have never seen physicians and nurses look so happy. Between the mounting paperwork, time demands, and complexity of modern medical practice, it’s sometimes easy for doctors to lose sight of why they went into medicine in the first place.

But this immersion into nutrition-complete with the feel, smell, and taste of preparing food-took them to another place. The same place I imagine they don’t visit often enough but one they likely wrote about in their application for medical school-a desire to help and connect with people on a deep level. I’d like to see it happen more often-and the Gaples Institute is working on doing just that.

Something wonderful happened during the conference. Take a look at the faces and see for yourself. It will make your heart smile.


More Gaples Institute Posts

Smile Therapy

Why do I feel so happy after Tai Chi class? It’s partly the Tai Chi. But I think it’s more about the smiles. Our instructor, Gordon, has an ear-to-ear, gold medal version. It’s an infusion of good energy. But more than that, smiling is good for the heart…

What Is a Smile?

Believe it or not-there’s a whole lot of science that’s gone into understanding a smile. There’s even a scientific definition of a smile that specifies which muscles are involved. A “standard” smile is one where the corners of the mouth are slightly upturned. A “genuine” smile, defined as one with both upturned corners of the mouth as well as scrunching of the eyes, is called a “Duchenne” smile after the French biologist who described it in the mid-1800s.

The Curious Biology of a Smile

Enjoyable experiences activate specific “pleasure” areas in the brain. But researchers have found that the mere physical act of smiling-even when done in the absence of the positive experiences-activates those same areas in the brain. Interestingly, not any smile will do. Only the full “Duchenne” smile, with  upturned corners of the mouth and squinted eyes, can fully trigger the pleasure centers – a “Mona Lisa” half smile won’t cut it.

The implications are intriguing: the act of smiling is not only a sign of being happy, it can actually help make you happy!

Smile Experiment You Can Do at Home

You might be interested to learn how scientists were able to differentiate the effects of smiling without the emotional content that usually accompanies it. They couldn’t just tell people to smile on command; simply using that would could elicit an emotional response and cloud the results.

So how did they get people to smile without them realizing it? In one study, participants were asked to bite down on a chopstick placed end-to-end across the mouth (in the direction of a mustache). Doing so automatically creates a full “Duchenne’ type smile.

Try it out at home for yourself-a chopstick (or toothbrush) and a mirror are all you need for this smile experiment!

Smile On Your Heart

The experimenters went one step further to study the effect of smiling on heart rate. All participants were given a fake story that they were part of a multi-tasking study, a cover used to mask the true goal of studying the effects of smiling on heart rate.

One group of individuals were asked to smile just prior to performing a stressful task. The other group was not told anything about smiling, but simply asked to briefly do the chopstick maneuver, artificially manipulating their facial muscles to resemble a natural smile. They were then asked to do a stressful task and heart rate was measured.

A third, “neutral” group, did not smile before performing the stressful task.

The results were striking: the group with artificial, chopstick induced smile (a smile that the participants were not even aware they were making), had a much lower heart rate after the stressful task then the non-smilers. The second group, those who had been asked to smile,  had a still lower heart rate, but one that was only a bit less than the group who made the “unaware” smiles.

It’s a wild idea, but one with a basis in science: even if you don’t feel happy, putting on a smile can help you manage stress, and may even make you feel as happy as you look. Or, more succinctly, fake it till you make it!

Healthcare Could Use More Smiles

When I talk to health care professionals about how to develop an integrative practice, I emphasize that the most essential part of integrative medicine is the attitude. A waterfall in the office is not required and no particular complementary approach needs to be advised-simply leading the patient conversation with a smile is a great way to begin. A smile can do wonders to elevate the mood and encourage a higher level of collaboration in the exam room.

Back To My Tai Chi Class

Our Tai Chi instructor, Gordon, refers to me as “doc”. Gordon, with his huge smile and amazing energy, may not be a physician, but is no less a healer.




More Gaples Institute Posts

Can of Confusion

Is a can of tuna on your shopping list? Although choosing a can of tuna appears to be a simple task, the assortment of labels and claims can be bewildering. What do you really need to know?

A deep dive into tuna involves 3 topics: mercury levels, omega-3 , and sustainability. A little bit of knowledge will help you to wade through the confusion  and make the best choice.


Fish accumulate mercury that leaches into the water from both airborne pollution and sewage sludge. Once mercury enters the water, it forms an organic compound called methylmercury that easily accumulates in tissues. A key point is that larger, older fish tend to have more more concentrated levels of mercury than smaller, younger fish.

Albacore, or white tuna, (comes in “chunk” and “solid” varieties) are the big fish in the tuna world, with an average weight of up to 45 pounds. Consequently, albacore has the  highest mercury level of all the canned tunas.

For that reason, the Environmental Protection Agency recommends that pregnant and breast feeding mothers limit their intake of albacore tuna in particular to no more than 6 ounces a week (see reference).

Skipjack, or light tuna, tend to be much smaller fish than albacore, with a typical weight of up to 12 pounds. The amount of mercury in a given weight of skipjack tuna is about 1/3 that of albacore tuna.


Skipjack, or light tuna, has a lower level of Omega-3s than albacore, but is still a rich source of the most efficiently used Omega-3s, EPA and DHA. Fish with even higher levels of Omega-3 than tuna are wild salmon, rainbow trout, and sardines.


Brand really matters here. Some brands are known to use fish caught in giant nets that use “fish aggravating devices” that, in addition to tuna,  trap a large number of other species, including dolphins. The most responsible fishing methods use “pole and troll”, two systems that minimize trapping of other fish. Brands that do a better job with responsible fishing methods tend to advertise “pole and troll” on their labels. 

Greenpeace assembles a list of tuna brands based on catch method (see reference). Some of the most well known brands are rated poorly by Greenpeace.

Practical Tips

For those who eat fish, canned tuna can be an excellent choice for both price and convenience. But many people, when faced with the dizzying variety of choices on the supermarket shelf, instinctively reach for the lowest price or most familiar brand. But there’s much more to consider.

Health attributes-both personal and global-vary widely. And sustainable fishing practices are important. My advice is to stick to skipjack (also known as “light” tuna) because of the much lower mercury content and to look for “pole and troll” on the label.




Greenpeace Evaluation of Tuna Brands

EPA Advisory on Mercury During Pregnancy/Lactation

Research Study of Mercury in Tuna 

Omega-3 Content in Various Fish