American College of Physicians: Internal Medicine — Doctors for Adults ®

Friday, September 21, 2012

The myth of exploding cookies

If you reduce the sodium content of cookies you bake (or talk someone into baking for you), they won't explode. I have data! We'll get back to this.

There seems to be debate these days about almost everything we thought we knew about nutrition and health. There is the argument that sugar, and more specifically fructose, is toxic and the one thing fundamentally wrong with the modern diet, and there are opposing views, mine among them.

There is the argument that excess sodium may be the single most important liability of modern eating, accounting for some 150,000 deaths a year, and opposing arguments. There are the time-honored arguments for the importance of the calorie, and arguments that calories don't really count.

I maintain, however, through all the sound and fury, much of which signifies nothing more than a theory du jour, that we are NOT clueless about the basic care and feeding of Homo sapiens. The basic pattern of healthful eating is very well-established, and convincingly evidence-based. And the health benefits attached to such a pattern are profound.

That pattern, foods close to nature, minimally processed, mostly plants, is inextricably associated with less sugar intake, less sodium intake, and lower calorie intake. So however important each of these trees is or isn't, they are an important part of the forest.

Getting there from here would be a good thing, but it's clearly something most Americans can't figure out how to do. The fact that it's so hard is not by accident, the food industry has done all it can to keep you lost in the dark woods of a profitable status quo.

Part of what the industry has done is to propagate an arms race, with your taste buds. Human taste buds are predisposed to like sweet, so putting sugar in food is apt to make people like it. Now imagine, though, that your competitor's product is outselling yours because it has just a bit more sugar, what are you to do? Increase your own sugar content.

See where this can lead? More sugar means sweeter; sweeter means tastier; tastier means more sales. As manufacturers compete in this area, taste buds start acclimating to more, and more, and more sugar. The more they get, they more they want. And so we wind up with ever more sugar in our food partly because we're asking for it! We're asking for it because our taste buds are desensitized to sugar the more they get, and need ever more to register satisfaction.

This same scenario applies to salt, and other properties of foods, too, such as creaminess. The more we get, the more we tend to want. The more we want, the more we get.

Personally, I remain convinced that excess sugar, sodium, and calories are harmful for most if not all of us. But whatever your point of view about sucrose, fructose, or salt, we should be able to agree on this: Whatever blocks our path to a basic, healthful dietary pattern is bad.

Well, sugar and salt do exactly that. Because if your taste buds have acclimated to high levels of both, you will simply prefer more highly processed foods, and reject the simple, unadulterated flavors of simple foods close to nature. You will NOT eat "food, not too much, mostly plants," because you won't like doing that! And you, and perhaps your family, will miss out on the enormous health benefits associated with doing so, which is a terrible shame, because healthy people have more fun.

But this is all fixable. Taste buds can be rehabilitated. They are, in fact, very malleable little fellas: When they can't be with a food they love, they can quite readily learn to love the food they're with. Particularly if the food they're now with is familiar overall, but just a bit better for you. I maintain: We can love foods that loves us back.

The food industry arms race, the race to make and sell products we can't resist, has resulted in some very odd formulations. Breakfast cereals routinely are more concentrated sources of added salt than items in the salty snack aisle. Pasta sauces and salad dressings are frequently more concentrated sources of added sugar than desserts. And we're supposed to be ok with this?

Apparently we are. Every recipe for home-baked cookies, for instance, includes added salt. Have you ever thought to ask, why do cookies need salt? Do I LIKE salty cookies?

My wife and I did ask, some years ago while working on one of our books. We made the obvious inference: If you don't put salt in home-baked cookies, they presumably explode. But we are both scientists, my wife has a Ph.D. in neuroscience, so we decided to test our hypothesis.

Well, my wife did, really, I mostly watched. We are both scientists, but only my wife knows how to bake! She grew up in Southern France, and learning at her mother's and aunt's knee, is a whiz in the kitchen. But I think my "ra, ra, go Catherine!" was crucial.

In any event, we took the salt in cookie recipes down, and out, and the cookies did not explode. The shelf life didn't seem to change much either, although admittedly, cookies don't tend to sit around too long! But no obvious liabilities with texture, survival time, or tendency to detonate were discerned.

We really noticed only one thing: Suddenly, the cookies were too sweet. We had not altered the sugar content at all, but now they were too sweet. The reason is that salt can mask the taste of sugar, and vice versa. Less salt competing for taste buds' attention meant the sugar was more discernible.

So we did the obvious thing: We took down the sugar content, too. And with the sodium reduced, we found the cookies tasted plenty sweet enough with half the sugar they had at the start. We've been eating variations on the theme of these cookies ever since. Much less sodium, much less sugar, and still delicious. Go figure!

The real message of the non-exploding cookie epiphany is, of course, how it can be generalized. There are commercial products that aren't supposed to be salty, like breakfast cereals, with a lot of added salt. But there are others without that salt. Choose those lower-salt versions, and you are not just reducing salt in your diet, you are helping your taste buds be more sensitive to salt. Doing so helps them help you to prefer, and get to, a more wholesome diet overall.

Ditto for the sugar in places like pasta sauce. I call this "stealth sugar" because it may make you eat more, but you don't even realize it's there. Cut down on stealth sugar, and you can make your taste buds more sensitive to sugar, getting to satisfaction with less, before ever touching dessert. Before long, you will prefer your desserts less sweet, too.

Personally, I think we eat too much sugar, salt, the wrong kinds of fat, and calories, and I think all of this counts. But regardless of your position on the competing dietary theories du jour, the benefits of a wholesome diet overall are a forest we should all be able to see through these trees. Getting rid of stealth additions of sugar and salt to innumerable foods, and rehabilitating your taste buds, is an important strategy for getting out of these dark woods, to the luminous health benefits beyond.

Our homegrown data suggest it can readily be done, we can love food that loves us back, and there will be very few injuries related to exploding cookies along the way.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

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Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

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Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

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Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

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Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

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Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

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Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

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The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

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Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

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Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
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