• Hope everyone is coping well with July in an academic hospital. The ER has been very busy, but our residents are rising to the challenge. We have been impressed with all of the new faces of consultants in the ER. Everyone has been sticking to Mama’s Rules. Check out the article, it is from a commencement speech. Quote sums it up well:
“No,” Ric replied. “I want to talk to your mother. It’s 9 PM. I know she’s awake. If you can convince her that you’re doing the right thing, I’ll accept her decision and make other arrangements for the patient. Do you think she’ll agree with you?”
• Hang in there everyone, remember our job is about providing the best care for patients. Not the most care, not about gaining money or recognition. Just treating each patient the best we can.

Ok here are your monthly wellness ideas. 

Physical Fitness:

• We covered this article in a resilience themed EM journal club last month. Authors argue that physical fitness enhances life and work in more ways than simply prolonging life. Improved physical fitness increases stress tolerance and decreases depression and anxiety. People who are more physically fit show less cortisol response to stress and less illness over time. This “stress buffering” effect is relevant especially to people undergoing major life stressors – residency and medical school count. People who are fit have higher self esteem and self efficacy. A difficult call day or an encounter with a rude colleague seems a little less serious when you run until you almost throw up. 
• Try 10 burpees right now. 

Sunlight:

• Posted in January a cool article on why sunscreen might be depriving us of health benefits. This article is shorter while still having several great links to real literature on the topic. They cover many of the same points: some sunlight is better than no sunlight. Do not overdo it, avoid sunburn. 15 minutes a day with no sunscreen is good. Avoidance of sunlight might be like smoking a pack of cigarettes! Follow some of the links. 

Kefir:

• You have seen advice to eat probiotic “live foods” on Practice of Wellness, hereand here. Well its about time I hit you with a dense scholarly article on benefits of Kefir (IMO (and Dr. Barve’s) the most efficient way to take in the good bugs).
• This article goes beyond Kefir’s role in the favorable alteration of microbiota to its other impressive effects. 
“Recent studies show that mechanisms of actions of kefir in cardiometabolic diseases include recruitment of endothelial progenitor cells, improvement of the balance vagal/sympathetic nervous system, diminution of excessive generation of reactive oxygen species, angiotensin converting enzyme inhibition, anti-inflammatory cytokines profile.”
• On an empty stomach, drink a serving of Kefir mixed with cold water. This tastes like buttermilk and is very easy to get down the hatch. Thanks Dr Barve for this recommendation. You can also leave out the water, throw a handful of blueberries and some nuts in the cup, and eat with a spoon.  

Pasta:

• Here is a low carb pasta option from the Great Low Carb Bread Company with a very real texture and great taste. Similar to Carbanada, but less net carbs. More expensive but certainly worth it for keto dieters and diabetics. I have not tried their bread. 

Hungry Brain:

• This book is a couple years old now. Written by a PhD who is a biochemist and neuroscientist. Guyenet has some notoriety from conflicts with Gary Taubes. Taubes thinks carbs and insulin are the problem, Guyenet thinks it is carbs + fat + salt + refined foods + plus some other stuff. Check out their not completely civil debate on Joe Rogan. Guyenet’s notes are located here. Spoiler alert, both of them are probably right. Each focusing on a different part of the elephant. Check out the podcast, but here I will focus on take home points from the book.
• I would summarize the chief concept as overeating being a problem originating in the brain. Much of the genetics of obesity, the biochemistry, the decisions driving weight gain, relate to the brain. 
• Everyone has a different relative reinforcing value of food, and we all have different set points, like an adipose thermostat (‘lipostat’). You can use nurture to modify all of that nature, but it is very difficult in this modern environment. Guyenet is no paleo hater as he indicts the over-processed, hyper-palatable foods as major contributors to the obesity problem. 
• The book highlights the features of a food item that allow us to eat large quantities without feeling full, ie the satiety index. The foods that have low satiety, ie you will overeat them, are: high caloric density, high palatability, high fat content (*less satiety per calorie), low fiber, and low protein. So if you want to feel full, do the opposite. 
• The”buffet effect” occurs when you can keep eating different foods at a buffet because of the variety.  Nonindustrial (hunter gatherer data) diets have themes: limited variety, limited concentration of food properties, few cooking methods. So to eat less, give yourself less choices at one time (but you still want to eat a lot of different foods, especially plants).
• Junk food can actually damage the brain (satiety center in hypothalamus) by inflammation. 
• Appetite can now be controlled in mice with extreme precision using brain stimulation. This is felt to be unethical for humans.
• We overeat when stressed, but if junk food is not available when were stressed, we are not likely to overeat healthy food.  
• Sleep loss makes us crave junk food specifically and impairs our lipostat. Eating out of sync with circadian rhythm makes rats (and almost definitely humans) actually gain more fat from the same amount of calories. 
• Much of this book is congruent with Ted Naiman’s emphasis on high protein, low “energy” (fat and carb) foods. Many gurus out there now are agreeing on 2 very important rules: don’t combine carbs and fat, don’t eat ultra-processed foods. 
• Final recommendations from the author are: fix environmental cues, manage appetite, beware of strong rewards, sleep, move, and limit stress. 

Processing:

• What does it even mean to say a food is healthy? The problem with nutrition research and the nutrition industry is that there are too many conflicting recommendations. One feature of a food (or diet) that is clearly unhealthy is the level of processing. This is why I love the advice to “Eat Real Food.” Some have argued that this doesn’t mean anything, “what is Real Food?” Well there is a book called Real Food you can start with. Additionally, publications are increasing that describe processed food, ultra-processed food, and what it all means.
• This article looks at healthfulness of the US food and beverage supply. They define healthy with a Health Star Rating depending on energy, sat fat, sugar, sodium, fruits/veg/legume/nut, protein and fiber. Then they give a NOVA classification for 4 levels of processing, with the 4th level being “ultra processed.” The NOVA classification gives a decent objectivity to what is real vs processed food. “The four groups include ‘unprocessed or minimally processed foods’ (e.g., fresh fruits and vegetables), ‘processed culinary ingredients’ (e.g., salt, sugar, and honey), ‘processed foods’ (e.g., canned vegetables, cheese, and salted nuts) and ‘ultra-processed food and drink products’ (e.g., carbonated drinks, breakfast cereals, cakes, and pastries).”
• Conclusion: “The US packaged food and beverage supply is large, heterogeneous, highly processed, and generally unhealthy.” Of course this is looking specifically at packagedfood. So do your best to not buy food in a package. And think about how sophisticated you would have to be to create that food item. Cooking is technically processing, but probably not as bad as using hexane. 

Cereal:

• We all know cereal is highly processed and in most cases unhealthy. But 2019 is a big year for cereal. Two high protein, very low carb, short-ingredient-list cereals have been released. Magic Spoon and Cereal School. 
Magic Spoon: superior taste, comes in regular box, 4 flavors, less expensive
Cereal School: very bland, individual bags, 2 flavors, more expensive, no guarantee (they won’t take our order back!)
• The Huecker adults and kidshighly recommend Magic Spoon. If you subscribe to a monthly order and use coupon codes, you can get 4 boxes for $30 and free shipping (as cheap as I could get it). 

Quote:
“Humans are the only animal species smart enough to manufacture their own food and dumb enough to eat it.”
One of my favorite quotes but I cannot find the name of the guy who said it; a now deceased British nutrition researcher