Wellness Rounds

I’m addicted to watching the Tour de France.  It’s an amazing athletic event, and the images (at least on HD) are simple astonishing.

There was a really great “side story” on tonight’s Tour broadcast about Dr. Allen Lim, a PhD sports physiologist.  The segment was specifically about his rice cakes – a real food equivalent of a commercial energy bar used by the Radio Shack riders.   http://dailyburn.com/recipes/dr_allen_lim_rice_cakes.

I haven’t made these yet, but I’m pretty certain they are going to be really good and – more importantly – a great call/energy food for busy students and residents.  He has some other recipes that would probably be good on call energy food, too

Here’s a video on how to make these rice cakes.   http://www.cycle-ops.com/videos.html?id=50

Photo from http://bikefleet.blogspot.com/2009/03/allen-lims-rice-cakes.html

I was really inspired by a recent post by veggielady4life (a medical student, photographer and foodie!) on taking salads for lunch.  For medical students in basic sciences, this is a great “energy” lunch that lets you stay alert in class.  For students on rotations and residents, a fresh salad is a great lunch and an even better middle of the night meal when you are on call.

The concept couldn’t be easier – put lettuce, spinach, or the greens of your choice in a big container.  Top with protein, cheese, veggies, nuts and/or fruit.  If you don’t care what it looks like, it’s also really easy to dump it all in a big zip-lock bag.  When it’s time to eat, pour the salad dressing in the bag with the salad, shake, and then serve yourself from the bag.

Protein:  Beans from a can, beans you make yourself with a crockpot or pressure cooker (which saves money and avoid excess salt and additives), canned tuna, cooked chicken from the deli, prepackaged meats (look at the labels to make sure you aren’t getting a lot of additives you don’t want), shrimp, etc.

Cheese:  Shredded cheddar, Monterey jack or Mexican cheese (reduced fat or regular), feta, goat cheese, thin slices of parmesan

Veggies:  Any leftover in your refrigerator!  Another good idea for this is to buy what you need for a mirepoix when you do your once a week shopping.  A mirepoix is the basis of  French cooking and is one part onions, one part carrots, and one part celery.  The Cajun trinity is similar but substitutes green bell pepper for the carrots.  If you buy the ingredients for a mirepox (or trinity) and chop it up on the weekend, you can use handfuls in salads, omelets, soups, etc all week.  (You can add other things, too, like mushrooms, red bell pepper, etc – anything that can be eaten raw).  If its a really busy week and you don’t have time to chop up vegetables, you can used canned green beans, corn, beets… whatever vegetables you like.

Nuts and/or fruits: Adding some dried fruits and nuts, sunflower seeds, etc, will add some extra nutrition.  Fresh fruits like blueberries, strawberries, sliced peaches are delicious in salads.  Canned fruits, especially mandarin oranges, are good, too.

Salad dressing. Don’t put the dressing on the salad until you are ready to eat.  (The French say it “cooks” the salad… but the result in any language is soggy salad.) My favorite dressing is a homemade vinaigrette.  Start with vinegar (red wine, white wine, sherry or balsalmic), a clove of diced (not crushed) garlic, a healthy teaspoon of good Dijon style mustard, salt and pepper.  Stir these all together until the salt is dissolved and the mustard is blended with the vinegar.  Add olive oil while you are stirring (or shake it up at the end.)  The classic ratio is 1 part vinegar to 2 parts oil, but you can add less oil to taste.  I usually squeeze a little lemon juice in, too.  There are many different French vinaigrettes, so experiment!

The easiest thing by far is bottled salad dressings.  Be careful about calories (if you are watching your weight).  If you take salads to work regularly, you may want to leave the bottle there (unless the food snatchers raid your refrigerator on a regular basis).

http://allrecipes.com/Recipes/Salad/Green-Salads/Top.aspx

http://hubpages.com/hub/Favorite-Salad-Toppings-Lessons-From-Restaurant-Salad-Bars

http://www.fitsugar.com/Nutritional-Information-Salad-Toppings-7598444

Making a healthy sandwich for lunch is a great way to insure that you don’t eat the leftover pizza from last night’s call team.  A really good sandwich which balances protein and carbs is also a great way to get through a long call night.  Keeping your energy up when you are up all night on call is difficult but there are tricks to maintain energy for call. The most important way to have good energy on call is to eat good quality food every 3-4 hours. Sandwiches are great for call because they are so easy to make, easy to store and easy to put in a pocket to eat on the go.

Pick good ingredients whenever you can.  It’s worth paying a little more to have food that is just food (and not a lot of fillers, corn syrup, transfats, etc).  Make sure you get high quality bread – 100% whole wheat is best, but if you really don’t like whole wheat, at least try to get as much whole grain in the bread as you can. Whenever possible, add veggies to add nutritional value.

Peanut butter sandwiches have the advantage of not needing refrigeration.  You can keep them in your white coat pocket if you want to (an advantage on a busy day).  You can stay traditional (i.e. peanut butter and jelly), or up the nutritional content by adding banana (or other fruit) or with unusual combinations http://www.epicurean.com/articles/beyond-jelly-reinventing-the-peanut-butter-sandwich.html

Egg salad sandwiches are great in the middle of the night when you are on call.  101cookbooks.com egg salad recipe is a pretty classic recipe which is really wonderful.  If you want to up the protein and decrease the fat try the  Eat Clean Diet egg salad recipe. There are other sites that give you other options for traditional egg salad recipes or  healthy egg salad recipes

Tuna or chicken salad sandwiches can be made with classic recipes, or less traditional ingredients that up the nutritional content such as spicy tuna salad, or other unique tuna salad recipes.

Lean meat (chicken, ham, pork, beef) makes a great, high protein sandwich.  Add cheese, tomatoes, spinach, shredded carrots or other veggies to increase the nutritional value.  If you are watching your weight use low-fat cheese and avoid mayonnaise.  If you use hummus or avocado instead of mayonnaise or other spreads you’ll also make the sandwich more nutritious.

Here are a few other sites to help you be creative with your sandwich ideas:

Beyond Peanut Butter and Jelly: Healthy Sandwich Choices for Everyone

Healthy Sandwich Recipes & Tips

Love Your Lunch: 10 Healthy Sandwich Recipes

Healthy Sandwich Ideas

Good Nutrition is in the Bag: Healthy Sandwich Alternatives

I made a great dinner last night that took about 5 minutes to cook – absolutely within the “pizza rule” for medical students and residents (i.e. a recipe should take less time to cook than it takes to order a pizza).  It’s the kind of recipe I wish I’d had when I was a student/resident, so I thought I’d share it.  I know that many of you are not from Texas (or another state with a tradition that includes salsas), so here’s the basic concept.

1.  Buy tortillas (I like corn the best, but flour or whole wheat flour tortillas are fine).

2.  Choose a protein.  I prefer fish or shrimp (because they are so fast) but any meat will work.  An even easier alternative  is to buy a roasted chicken (or cooked beef or pork).   You can also use beans or tofu if you are vegetarian.

3.  Make a fresh salsa (see below)

When it’s time to eat:  Cook or heat up the meat (or alternate protein), heat up the tortillas (1 minute in the microwave).  Put the meat (or alternate protein) into the tortillas and top with the salsa. These soft tacos can make a compete meal, but serve a side of vegetables if you want … it’s a great dinner (and lunch the next day at work).

Salsas are best when you make them yourself.  You can buy good salsa in a jar but it’s never as good (or as healthy) as the ones you make.  Leftover fresh salsa can be used as a dip for tortilla chips – as is (diced) or blended.

The salsa I made last night was easy:  1 mango, 1 green tomato, red onion, cilantro, a jalapeno pepper – all diced fine and then mixed with lime juice and seasoned with salt and pepper.   All traditional fresh salsas are a variation on this same theme – tomato with or without fruit, cilantro, onion and peppers to taste.  On of the best examples is “Pico de gallo” (shown below), which is one of the most classic salsas – red tomato, onion, cilantro and jalepeno with lime juice and salt.  http://en.wikipedia.org/wiki/Pico_de_gallo

You can be creative!  Mix and match from this list or check out some of the recipe links  below

• Vegetables:  tomato, tomatillo,bell peppers, corn, cucumber
• Fruit:  melon, watermelon, peach, pear, mango, nectarine, avocado
• Onion:  white onion, yellow onion, green onions, garlic
• Chiles:  jalepeno, serrano, chipotle
• Spices:  oregano, parsley, cilantro

Links to salsa recipes:

http://allrecipes.com/Recipes/Appetizers-and-Snacks/Dips-and-Spreads/Salsa/Top.aspx

http://www.salsa-recipes.com/index.html

http://www.fresh-salsa-recipe.com/

I just got back from my weekly (when I’m not on call) trip to the farmer’s market.    I’m going to try to convince you why buying food at a farmer’s market should be a regular habit for any medical student or resident (although I think it applies to everyone else, too).

What the heck is a farmer’s market?

In general, farmer’s markets are open air markets where local farmers bring their food to sell. They usually take place once a week (often on Saturdays).

Just to give you an example – this is the market I go to most often in Houston:

http://www.urbanharvest.org/programs/market/index.html

How do I find out where they are?

The best way is to search the internet for your city.  Local harvest is a web site that covers most farmer’s markets, but there may be smaller (and possibly more convenient) markets in your city that aren’t listed here:   http://www.localharvest.org/farmers-markets/

If it doesn’t look like there is a farmer’s market near you, another option is to buy a share in a CSA (Community Supported Agriculture).  If you buy into a CSA you will pick up a fairly large quantity (usually a good sized box) of whatever is being grown at the time – usually once a week.   If you can find a group of friends to split this with, its a great option.  http://www.localharvest.org/csa/

What should I do to look cool if I’ve never been to a farmer’s market before?

Bring your own bags. This isn’t an absolute requirement, but it’s much cooler than relying on the vendors.  They often have small paper or plastic bags, but it will be easier if you bring your own.  In the big picture, you should do this no matter where you shop (good environmental karma!).  Fortunately, the “give away” bags at medical meetings are perfect for this!   A lot of grocery stores sell reusable shopping bags or you can find them on the internet.  I’m not endorsing this particular site, but here’s an example: http://cheaptotes.com/canvas_tote_bag_8.html

Bring cash. I’ve seen some people writing checks, but don’t count on it.  I’ve never seen a way to pay with a credit card at any farmer’s market.

Does it cost more?

Yes (but not a lot more).  But don’t let that stop you!  Value isn’t always measured by money – even if you are poor student or resident.  It’s not going to be a lot more and it’s completely worth it. (see below)

If it costs more and it takes more time, why should I bother?

The food absolutely and unequivocally tastes better.  The first time I bought potatoes at a farmer’s market was a revelation for me.  I knew that tomatoes and peaches would be better, but I had no idea that a potato would be in the same category.  The produce you buy at a farmer’s market was in the ground (usually) less than 24 hours ago.  It is incredible how much better it tastes!

The food is probably better for you.  Most farmer’s markets sell organic or near organic food.  There’s good data that organic plants are higher in many nutrients and it’s intuitively obvious that avoiding pesticide residues on your food should be beneficial. http://www.healthy-eating-made-easy.com/advantages-of-organic-foods.html

You’ll eat with the seasons. There are no data that this is better for you, but it really makes sense.  If nothing else, it will taste better and you’ll be helping the environment by not eating things that travelled thousands of miles to get to you.

You’ll get to know the people growing your food. This sounds trivial, but it’s really cool.  You can ask them about how they grow the food, and you’ll hear stories about what’s happening on their farms.  One of my favorite vendors has great pictures and stories about her farm which she also shares on Facebook and her website: http://blueherontexas.com/.  There is also something intangible (but cool) in knowing that someone (not just a big corporation) cares enough to grow your food.

The farmer’s market is a once a week “sanity break”. You are outside, surrounded by beautiful food and happy people.  At the market I usually go to, there is always some live music, too.  It’s a great experience and, combined with the fact that you are doing something healthy for yourself, it’s a once a week mood changer!

You may have read the title and thought this might be about work and stress… but, no, it’s not about the pressure cooker at work, it’s about cooking!

If you are trying to save time cooking (which is an essential part of cooking as a student or resident) you should really think about buying a pressure cooker.  This is a foreign cooking appliance to most people, but it is an incredible time saver.  Do not listen to your mother/grandmother/aunt who says they blow up… they don’t!  I use mine more or less weekly to make garbanzo beans.  Buy dry garbanzo beans (which are really cheap), soak them for 4-8 hours  and cook them with a little spice (or not) for 12 minutes on the second ring. (You can skip the soaking and cook for about 15 minutes instead)  They make a great snack (instead of peanuts) right out of the refrigerator.  Another really good use for pressure cookers is to make stock.  When you peel carrots, cut the ends off onions, etc just throw the pieces into a bag in the freezer.  Ditto for leftover bones and bits from fish, chicken, beef (if you want a meat stock).  When the bag is full, put the frozen bits in the pressure cooker with water and cook for 20-25 minutes.  This saves a lot of money and tastes tons better than store bought stock/broth.

Here’s a list of other things you can cook in a pressure cooker

• A whole chicken in 15 minutes
• Beans (from dried) in 5-10 minutes
• Artichokes in 10 minutes
• Potatoes in 5-10 minutes

http://busycooks.about.com/cs/appliances/a/pressurecooker.htm

http://fastcooking.ca/pressure_cookers/recipes_pressure_cooker_index.php

It’s Saturday and I’m on call – and it’s going to be a busy day!  We have about 75 patients on the service, we already have 4 cases done and another 4 posted, and it’s still early (~4pm)   I have a fantastic resident with me today.  We just were chatting about what we are going to do for meals today.  He didn’t have breakfast and has only had a Coke and a “borrowed” bowel of Kix cereal from the recovery room so far.  I had whole wheat toast with some goat cheese before I left my house this morning, and I here’s what I have to eat today:

• Strawberries
• A handful of frozen cooked shrimp with cocktail sauce (they’ll thaw by the time I want to eat them)
• Frozen peas (I put them in the microwave for a minute but, like the shrimp, frozen would be fine because they’ll thaw) + goat cheese, olive oil, vinegar, salt and pepper
• Leftover whole wheat orzo, artichoke hearts, tuna and lemon pasta from last night
• An apple
• Lemon wedges for water

My resident’s Coke is probably more than I used to have as an intern… which is STUPID.   Eating well is important to feel well, perform well and do the right thing for your patients. There is one word that explains the difference between my resident (and what I used to do) and what I do now… planning.   “I’ll just get something from the restaurant across the street later…”, “There will probably be food leftover from the GI conference…” .. “I can always eat a bagel from the lounge..” … NOT.   When you finally have a minute to grab something to eat, you won’t usually have time to go look for the food.  It’s a lot easier if its’ there and ready to eat.

Here’s how to do this right:

1. Buy a good “lunch box” .

I like the hard plastic ones that fit in an outside, insulated carrying case.  It’s a lot easier to clean up if something spills than the usual “lunch box”.

You can use plastic (disposable) containers to carry your meals with you.  I’ve switched to glass containers because some of the data about heating the plastic containers in the microwave started sounding convincing.  It does mean you have to keep track of them and bring them home, but I suspect in the long run (if I don’t lose them) it will be cheaper than the plastic containers.   I particularly like the ones I bought because the seal is so tight that they don’t ever leak  (even for things like soup).

2. PLAN.

The night before call, figure out what you are going to take. Make it good stuff, too!  Call nights are not the “what I know I should eat” nights.  You need to have real food (i.e. not processed) but don’t skimp.  When you get to the “I really deserve those french fries” time of your call (which we all do) you will have really delicious and balanced food  in the refrigerator.

3. Pack your meals for the next day the night before (no matter how late it is or how tired you are).

It’s the only way you’ll actually do this.   None of us when we work this hard have the energy to put together meals for the day at 5am.  This takes a little effort but the payoff is real.  You will absolutely eat better, have more energy, maintain your weight and do a better job.  Don’t forget to throw some fruit in – and to make sure it’s washed so you can just pull it out of the refrigerator for a snack.

Most medical students and residents eat poorly.  It’s not really a surprise – the days are packed with work from sun-up to sun-down.  There are no planned meals because there can’t be.  Food is a quick bite when it is available.  It’s feast or famine.  On the far end of the scale, the stereotypical diet of a resident is no breakfast (but usually coffee), a doughnut and coffee grabbed on the run once you get to work, some mid-day meal of fast food, and pizza on call.  Food, particularly fast food, becomes solace.  In the stressful world of residency, this kind of “comfort food” becomes a “reward” for the hard work and tribulations. It’s not rocket science.  This kind of diet doesn’t give you the energy you need to function at your peak.  It is also a diet that is very likely to lead to weight gain.  In your 20s, your body can cope with this suboptimal fuel, but it’s not ideal.  However, what “works” in your 20s won’t work as you get older and could even be responsible for a heart attack, diabetes, or other medical problems in your 40s and 50s.  On a more philosophical level, you would never advise this kind of diet to one of your patients.  None of us want to be hypocrites.

The answer is to cook for yourself.  Not everyone likes to cook, and not every one knows how.   I’m going to make a case that you should learn.  Trust me – if you can learn to take out an appendix, or diagnose a pneumonia, you can learn to cook.   I’m going to assume that you are single for the sake of this description.  But, if you have a significant other, it’s even more important to cook at home.  He or she can participate in helping with the meal preparation, and, by doing this together and for each other, there is added benefit for your relationship.  Having dinner at home with a significant other will become an “anchor” to your day that will become very important to you.  As hard as it is to work around a busy schedule, if you can eat together, and have a real conversation, you will both benefit greatly.

Cooking is a wonderful therapy for the stress of medical school and residency.  If you’ve never learned how to cook, this is a hard time to learn complicated techniques, but it’s not hard to learn simple techniques.  There are several advantages of cooking for yourself that outweigh (on most days) the hassle of spending the time.  The act of cooking for yourself can be a time of “decompressing” from work.  Arranging vegetables, cutting them, smelling the odor of the food appeals to all your senses and is a moment in the day that you can intentionally slow down.  It’s very important that the recipes you choose are simple and quickly prepared.  No one wants to come home to a 2 hour task in the kitchen after a hard day.  Cooking for yourself has other benefits as well.  First, it is tangible evidence that you are taking care of yourself.  This is not a trivial point.  There are days during your training when it seems no one is taking care of you.  Having concrete evidence that you are caring for yourself is an antidote to that feeling.  Secondly, you will eat better.  By cooking from fresh ingredients, you will decrease the amount of pre-packaged and fast food.  Even without medical school, you know that this will result in better nutrition.  Thirdly, you will eat cheaper.  Other than the “free” pizza (ethically debatable, but financially clear), processed food is usually more expensive.  And lastly, you can share.  It isn’t any more work to make 4 or 6 portions of a dish than it is to make 2, and it usually isn’t that much more expensive, either.  If you can convince one of your colleagues that this is a good idea, you can cook for each other on alternate days.   Likewise, you can cook larger amounts and, using freezer ready containers, freeze portions for yourself for the future.  Doesn’t homemade pasta with a side of fresh vegetables really sound better than the greasy middle of the night food that is available in most hospitals?   It’s true that you can’t cook just anything with the kind of schedule you will have in medical school and your residency.  But, there are few key rules that will make it possible for you to do this, enjoy it, and eat well.

Rule 1:  Don’t cook anything that takes more than 30 minutes to prepare.

Let’s be realistic – you are not going to walk into your home at 8 o’clock at night, hungry, and spend an hour preparing something.  But – there are very nutritious dinners that take less than 10 minutes, so getting home late is no excuse.

Rule 2:  Plan ahead.

The first step in preparing dinner for most busy people is to open the refrigerator door and ask “What can I eat tonight?:  If you are anything like I was in residency, the refrigerator had some cheese, some vegetables (often way past their prime), and maybe some leftovers.  Not very appetizing.  There is an easy way to prevent this from happening.  On whatever day you have off and have time to shop, spend 30 minutes making a menu.  Start by making a table for the week with what is happening.

	Breakfast	Lunch	Snack	Dinner	Comments
Sun
Mon					On call – take Tues meals, too
Tues
Wed				Out	Out with friends after rounds
Thur
Fri					On call
Sat

Once you have an outline of your week, fill in the blanks with the meals.  Now, most of us can handle “hamburgers” or “Raisin Bran” as a menu item… but it’s more fun, and healthier to branch out a bit.  So, if you are not used to looking for new things to cook, how do you find recipes?  Cookbooks can be fun, particularly if you are looking for a particular ethnic food or a style (e.g. low-fat) of cooking.  If you like cookbooks, and bookstores, find the used book store nearest you and go to town!  There are also web sites for recipes.  Many of them also have “cooking lessons” on line.  Most cooking shows have a web based recipe site as well.   So, say you start by searching the web and find this recipe. (for this particular recipe, I’m assuming you have no concerns about calories)  It looks easy, and like it would taste good.   So you print it out.

NEW ORLEANS PASTA

ESSENCE OF EMERIL (FOODTV)   SHOW #EE123 – http://www.recipesource.com/main-dishes/pasta/11/rec1100.html

1 tablespoon olive oil

16 ounces chicken breast half, cut into strips (about 1/2 cup)

1/4 cup chopped chorizo sausage

2 tablespoons chopped green onions, plus extra for garnish

1/2 tablespoon chopped garlic

Tabasco and Worcestershire sauce

3/4 cup heavy cream

1/4 cup grated Parmesan cheese

1/4 pound shrimp, peeled and deveined

1/2 pound penne pasta, cooked al dente and tossed in oil to coat

Creole spice, salt and pepper

In a large saute pan heat oil, add chicken and sausage and cook 5 minutes, stirring often. Add green onions, garlic, 2 dashes each Tabasco and Worcestershire sauce or to taste, and cook for 1 minute. Add cream, cheese, shrimp and pasta. Cook, tossing, to heat through. Adjust seasoning to taste with Creole spice, salt and pepper. Serve garnished with green onions.

Yield: 2 servings

Now what?  First, cut and paste the ingredient list to a shopping list.  If you are compulsive, you can organize it into meat, dairy, produce, etc (it makes shopping easier, but it’s not essential).  You’ll need to add a vegetable or salad to balance this out nutritionally. (I picked broccoli as an example) If you can afford the calories, add a desert. (Ice cream in this case)  Then decide what night in your schedule this will work best.  This recipe will take about 12 minutes total so it would be great for a night you are getting home late.  You can either share the other portion with your significant other or you can take it with you the next day as lunch.  You can double the recipe and have it more than one night.   For example:

	Breakfast	Lunch	Snack	Dinner	Comments
Sun
Mon					On call – take Tues meals, too
Tues
Wed				Out	Out with friends after roundsThaw shrimp for tomorrow
Thur				NEW ORLEANS PASTA (CHICKEN, CHORIZO)Steamed broccoliIce Cream	Freeze one portion for later
Fri				NEW ORLEANS PASTA (CHICKEN, CHORIZO)Steamed broccoli	On call
Sat		NEW NEW ORLEANS PASTA (CHICKEN, CHORIZO)Steamed broccoli

Shopping list:

2 lbs chicken breast (16 oz x 2)

1/2 cup chopped chorizo sausage

1/2 pound shrimp, peeled and deveined

heavy cream   (need 1 1/5  cup)

Parmesan cheese  (need 1/2 cup grated)

Olive oil

Creole spice

green onions

garlic

broccoli (4 portions to steam)

One pound penne pasta

Ice cream

Rule 3:  Cook (or prep) today today to eat tomorrow

As soon as you get home from the grocery store:

• Freeze any meat that is for later in the week (and make a note to yourself to put in into the refrigerator to thaw a day or two before you are going to use it.)
• Wash the vegetables, dry them and put them away
• Wash lettuce for salads and dry completely (a spin dryer is the best).  Store in a zip lock plastic bag with a paper towel in the bag (which absorbs any residual water).  Make sure you squeeze out all the air you can before closing the bag.

Take advantage of days off to cook things that may take a little more time or effort.  While  you are watch the football game on Sunday, you can cook chili in a crock pot for Wednesday.  If you know that your vegetable stir fry on Tuesday is going to be after a long day, go ahead and chop all the vegetables and meat a day or two before when you have the time and have them stored in the refrigerator.   When Tuesday rolls around (and you are exhausted from work), you’ll have all the ingredients chopped and ready to throw in the pan.