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CHAPTER ONE
The Principles of Eating Well

When I use the words eating well, I mean using food not only to influence health and well-being but to satisfy the senses, providing pleasure and comfort. In addition to supplying the basic needs of the body for calories and nutrients, an optimum diet should also reduce risks of disease and fortify the body's defenses and intrinsic mechanisms of healing. I believe that how we eat is an important determinant of how we feel and how we age. I also believe that food can function as medicine to influence a variety of common ailments.

The American Council on Science and Health, a New York-based nonprofit organization dedicated to "helping distinguish between real and hypothetical health risks," recently suggested ten resolutions for a healthy new year. The council included obvious ones, such as don't smoke, wear seat belts, and install smoke detectors, but addressed diet in only one paragraph:
Eat a balanced and varied diet. Avoid obesity and fad diets. There are no magical guidelines for good nutrition. Patients should resolve to plan their diet around the watchwords "variety, moderation, and balance." Remember: There are no "good" or "bad" foods. The primary danger from food is overindulgence.
I find this advice to be remarkably unhelpful. Eat a balanced diet What is that? I meet people who think that adding a salad with creamy dressing to a cheeseburger and French fries balances the meal. Avoid obesity? Sure, that sounds like a good idea, but how do you do it? There are no "good" or "bad" foods? What about soybeans? They contain healthy fiber, a fat that may help lower cholesterol, and unusual compounds called isoflavones that may offer significant protection against common forms of cancer. Soybeans seem like a good food to me. What about margarine? For years I've been telling my patients to avoid it because it contains trans-fatty acids (TFAs), unnatural fats that promote inflammation, heart disease, and cancer. Sounds like a bad food to me — I won't eat it, even in moderation or in the pursuit of variety.

The primary danger from food is overindulgence? I'm sure my distant ancestors had no problem in that area, but what am I supposed to do when everywhere I look I see tempting offerings of food in ever more novel preparations, when many restaurants score points for the size of portions they serve, when I get more for my money buying giant sizes of food and drink, and when people who love me or want my attention give me food and more food as expressions of their affection or interest?

The poor advice about diet and health that people get far too often when they ask physicians, nurses, registered dietitians, and other representatives of the health-care establishment for help reflects the dearth of good nutritional education in our professional schools. If you look to other sources — alternative practitioners, bookstores, health food stores, the Internet, for example — there is no shortage of information about nutritional influences on health. In fact, there is much too much of it out there, most of it contradictory, unscientific, and intended to promote particular foods, diets, or dietary supplements.

While scanning nutrition-related sites on the Internet, for example, I came across glowing recommendations for products made from "super blue-green algae," microorganisms from a lake in Oregon. I was told that:
Super Blue Green Algae gives us nutrients and energy at almost no cost to the body's reserves. This algae is 97% assimilable, and many of the nutrients are in forms that are directly usable. For example, the algae's 60% protein content is of a type called glycoproteins, as opposed to the lipoproteins found in vegetables and meat. As a result, the body doesn't have to spend its valuable resources converting lipoproteins into glycoproteins as it does with other foods. Super Blue Green Algae contains almost every vitamin and mineral needed by the body . . . [and] is one of the richest sources of chlorophyll — a cell regenerator and blood purifier.
Should I rush to order this costly "superfood"? Can it be that all my life my body has been wasting its valuable resources converting lipoproteins to glycoproteins when it could have been getting just what it wanted from pond scum? As for chlorophyll, while it performs a vital function in the life of green plants, it has no role that I know of in human nutrition.

At one extreme are authorities telling us that we are what we eat, that health, good and bad, is entirely or mostly a creation of what we put in our mouths. There is a kernel of attractive logic in that formulation that resonates with common sense. We have to eat to live, because food is fuel for the metabolic engine. The quality of fuel you burn must influence your body, just as the grade of fuel you put into an internal combustion engine influences its performance for better or worse, not only in the short run — a smooth purr versus a ragged knock, for example — but also in the long run, retarding or accelerating the accumulation of deposits that reduce the longevity of valves, rings, and ultimately the entire engine. But it is a long way from this simple observation to the conclusion that diet is everything.

At the other extreme are voices telling us it doesn't matter. "Eat healthy, exercise, die anyway." "Just eat a balanced diet." "My uncle Jake ate big helpings of bacon, eggs, steak, and butter every day of his life and lived to be ninety-nine." "There are no good and bad foods." "People who say you can affect your health and treat disease by changing your diet are food faddists." "It's all in your genes, anyway."

I know of no subject more confused, emotionally charged, and important in our lives than food and nutrition and their influence on our well-being. When I give public talks on health and medicine, the questions I get reveal both the interest and confusion. Here are some examples:

How can I lose weight? I've tried everything.
It seems as if I gain weight just by looking at food. Why?
I've had cancer. What foods should I avoid?
I have no energy. Could my diet be the problem?
I thought we were supposed to avoid dietary fat. Now I'm hearing that fat is okay and carbohydrates are bad. What are the answers?
Is it okay to eat soybeans if I had breast cancer?
If I change my diet, can I get off all the drugs I'm taking for my arthritis?
My five-year-old has asthma. Are there foods he shouldn't be eating? My doctor doesn't seem to know.
A holistic doctor told me I'm allergic to wheat. What does that mean? I love bread and pasta.
If I'm eating pretty well, do I need to take vitamins?
If I'm supposed to be eating more fruits and vegetables, do I have to worry about pesticides on them?
I don't have time to cook. How can I eat a healthy diet?
My children like only macaroni and cheese. How can I get them to develop better eating habits?
I love chocolate. Is it bad for me?
The cafeteria food at my school is wretched. How can I persuade the school to improve it?
Is it all right to eat eggs if heart disease runs in your family?
Is sugar bad for you?
Are microwave ovens safe?
Is it dangerous to cook in aluminum pots?
I read that dairy products could be causing my sinus problems. Isn't milk supposed to be the perfect food?
Are artificial sweeteners safe?
Is it okay to drink water with your meals?
What's the best way to eat if I want to live to be a hundred?

I could extend this list to fill dozens and dozens of pages. It shows the keen interest people have in this subject, their inability to get answers, and their concern about opinions that are contradictory and confusing. People sense the possibility of improving health by making informed choices regarding food, and they sense danger in making uninformed ones, but they do not know where to get information they can trust.

Physicians are at almost the same disadvantage as the rest of us. My medical partner, Dr. Brian Becker, tells me that he was completely turned off the subject of nutrition at the age of ten, when he was forced to listen to a dietitian talk to his fifth-grade class about healthy eating and the four basic food groups then in fashion. "She was overweight, slovenly, smoked at the break, and was in no way anyone I wanted to identify with," he recalls. "Furthermore, the information she gave us was later proved wrong. That one experience stayed with me for years and has made it impossible for me to read or hear anything about nutrition without feeling bored and resentful."

My purpose in writing this book is to explore the issues and controversies surrounding food and nutrition in order to bring clarity to the subject and establish for readers a sense of what eating well means. First I want to state seven basic propositions that underlie my philosophy of food and nutrition and how they both influence health.

We Have to Eat to Live.

The body requires energy for all of its functions, from the beating of the heart and the elimination of wastes to the transmission of electrical and chemical signals in the nervous system. It gets its energy from food, by taking it in, digesting it, and metabolizing its components. Food is fuel that contains energy from the sun, originally captured and stored by green plants, then passed along to fruits, seeds, and animals. Humans eat these foods, and burn the fuel they contain — that is, combine it with oxygen in a controlled fashion to release and capture the stored solar energy. As long as we live, we have to eat and eat often.

Or do we? Throughout history there have been unsubstantiated reports of persons who survive without eating. Their ability to do so is usually ascribed to sainthood or to mastery of esoteric mental powers. I can understand that some people are fascinated by the possibility of surviving without eating because of a philosophical quandary: the fact that we live at the expense of other life. Whether we destroy carrots or cows, it is a fact that we are unable to survive and grow without ending the existence of other life-forms; "nature red in tooth and claw" includes us. (Green plants, of course, are not burdened with this requirement: They eat light, binding the energy of photons from the sun into chemical bonds that forge carbon dioxide and water into glucose, the simple sugar that is the most basic foodstuff. They can later burn this glucose as fuel or convert it into starch or fat for storage.)

In my case and for most of us the reality is that we must eat to live, usually several times a day. Not having enough food is seen as an ultimate misfortune and a cause of human suffering, and having it in abundance is cause for rejoicing.

Eating is a Major Source of Pleasure.

In societies where food is scarce, it is seen primarily as a necessity of life and little thought is given to it beyond that. In societies where food is abundant, people use it for purposes far beyond mere survival. In our society, a great deal of time, energy, and money goes into the preparation and consumption of food that is intended to provide pleasure. Gastronomic pleasure is complex, however. We respond not only to the odors, tastes, and textures of food but to its associations. Think of the comfort foods you would turn to if you were sick, hurt, or sad. Would you choose a baked potato? buttered toast? a steak? ice cream? Do you associate comfort with foods that a caring parent brought you when you were sick in childhood: chicken soup or rice pudding, for example? The appearance and smell of such food combines with its taste and feel in the mouth to create a pleasurable experience that also includes satisfaction at being nourished.

I respond positively to food prepared with care and attention and negatively to food that is careless and artless. When I am traveling and go into a strange restaurant, I can often tell at once whether food will be good by the feel of the place. I have found wonderful food in simple, inexpensive establishments and disappointing food in many expensive ones. The simplest meals can be extraordinarily satisfying if they are prepared and served with care and with the intention to provide pleasure as well as sustenance. And I have observed that when truly wonderful food is served to a group of diners, conversation virtually stops, and people concentrate almost entirely on the pleasure of eating.

Psychologists describe food as a primary reinforcer — that is, something with intrinsic power to shape behavior. Give an animal food when it exhibits a certain behavior, and it will behave that way more frequently. Food is an especially powerful reinforcer, used by trainers to elicit performances of animals in circuses and movies in apparent contrast to their wild natures. In order for food to exert this effect, it must be presented to an animal that is hungry. In other words, a state of relative deprivation of the reinforcing stimulus must exist for it to exert its power over behavior. If an animal is sated it is in a refractory state, not responsive to the reinforcing stimulus of food.

Everyone knows the equivalent human state, when deprivation makes food so appealing that we would do almost anything to get it. A quirk of the human condition is that the imagined pleasure of consuming food that is not there often exceeds the actual pleasure of consuming food that is.

Pleasure we experience in our minds must also be in our brains. Neuroscientists have identified a number of systems in the brain that correlate with pleasurable experience, focusing especially on the neurotransmitters dopamine, serotonin, and noradrenalin. Disturbances in these systems may be associated with addiction, risk-seeking behavior, and the calamitous symptom of anhedonia, the inability to experience pleasure that often accompanies severe depression. The identification of imbalances in neurotransmitters and their receptors on neurons opened the way to inventions of new psychopharmaceutical drugs that are now widely prescribed to correct the imbalances with variable clinical success.

It may well be that all addictive behavior has common correlates in neuroreceptor physiology and that we will one day understand this physiology well enough to treat addiction effectively by means of drugs. What is certain, however, is that addictive behavior can form around all pleasurable experiences, eating among them. People who develop addictive patterns of eating are often trying to reduce anxiety, alleviate depression, anesthetize themselves, or otherwise manipulate their psychophysical states, because food and eating modify neurochemistry, including that of brain centers regulating pleasure, arousal, and mood. Looking at addictive eating in this way makes it appear more understandable yet more complex than simple craving or failure of willpower.

Most of us know people who eat immoderately, although many food addicts may conceal their behavior and indulge themselves in private. Here is a snapshot of one prodigious eater, the writer A. J. Liebling, provided by his fellow writer and friend Brendan Gill in his memoir Here at The New Yorker:
It is said to be a weakness in my character not to be much interested in food, and Liebling was a true trencherman, whose appetite astonished and appalled me. I saw that he was, in the old saying, digging his grave with his teeth, but there was nothing to be done about it; the pleasure he took in gourmandizing was obviously identical to the pleasure other people took in listening to a Chopin nocturne. One day at lunch at the Villa Nova, during a period when, on doctor's orders, Liebling was making a valiant effort to eat lightly, he ordered a succulent dish of veal, peppers, and eggplant, which, in the Villa Nova tradition, arrived at the table aswim and asizzle in a large pewter platter. Liebling quickly polished off the entire platter, then, breaking chunks of bread from a long loaf on the table, soaked up the remaining gravy, all but literally licking the platter clean. It was a meal the very thought of which was enough to keep me from feeling hungry for a week. Liebling beckoned to the waiter. I thought he would be asking for the check, but not at all. "I'll have one more of the same," he said.
Obviously, not all of us respond to food in the same way. Although it acts as a primary reinforcer for everyone who is hungry, individuals derive various degrees of pleasure from it. For some, eating is mostly a necessity of life; attention paid to the sensual aspect of food is minimal, and pleasure is sought elsewhere — in listening to music or in sex, for example. Nonetheless, I think it is fair to say that food is an important source of pleasure for most of us, and a primary source of it for some of us. For that reason, any recommendations for healthy eating that diminish or eliminate the pleasure of the experience of eating are certain to fail.

Food That Is Healthy and Food That Gives Pleasure Are Not Mutually Exclusive.

A common lament I hear from patients is, "Everything I like to eat is bad for me." This is often paired with a question: "If it's bad for you, why does it taste so good?" Actually, as I will soon explain, there are perfectly good reasons why our senses guide us to foods high in fat and sugar, to large portions of meat, to fast food, and to what even those who love it characterize as "junk food." The fault is not with our taste but in the way we have changed the environment to make once scarce foods readily available.

A more puzzling question is, "Why is healthy food so dull?" I have my own answer to that one, which is that many people who preach the virtues of healthy eating do not really like food, or, more precisely, are not the people who are neurochemically programmed to derive significant pleasure from the experience of eating. Many writers of diet books are in this category as are many nutritionists, dietitians, and health professionals who tell others how they should eat. They are not lovers of good food.

Consider this recipe for Sun Garden Burgers from a book of "simple recipes for living well":
Combine carrot pulp [leftover residue after juicing carrots], ground flax and sunflower seeds, finely minced celery, onion, parsley, and red pepper; season with soy sauce; shape into patties and leave them in the sun until warm or place in warm oven for 15 minutes. These are delicious served in a cabbage leaf "bun": fold a cabbage leaf over the burger with any condiments you like or cut two squares of cabbage from the large leaves and place the burger in between them.

I rest my case.

Years ago, when I was first experimenting with vegetarian cooking, I had an English couple as houseguests. I served them a meal of whole grains and, I thought, artfully prepared vegetables. They ate it with curiosity and mild enthusiasm, but when one of them came to breakfast the next morning, he said with a wry face and one hand on his stomach, "Health food really gives you gas, doesn't it?"

If your main experience of healthy food is that it gives you gas, you are not likely to come back for more. Or, if you do, you must be one of those who find virtue in suffering, convinced that health and pleasure do not come together at the table.

My job is to convince you otherwise. I like food. I experience pleasure from eating, and I am unwilling to sacrifice that experience in a quest for better health. I have spent years studying the medical literature on nutrition, working with patients who need to improve their diets, exploring the cuisines of other cultures, and testing and devising recipes that conform to healthy guidelines. My conviction is that healthy food and delicious food are not mutually exclusive; the concept of "eating well" must embrace both the health-promoting and pleasure-giving aspects of food. This is the most important assumption underlying the philosophy of this book. If you have had dreadful encounters with health food, if it has given you gas or worse, I can assure you that I will show you how to change your diet in ways that will move you toward optimum health and longevity without your having to give up everything you like to eat.

Eating Is an Important Focus of Social Interaction.

Coming together to share food is a behavioral pattern we have in common with many other creatures. The word companion derives from the Latin word for bread, panis. Breaking bread together both establishes and symbolizes a fundamental social bond. A Japanese phrase for an intimate companion is "one who eats rice from the same bowl."

Think of the elaborate rituals of communal eating that have evolved from the simple act of sharing the most basic foodstuffs. Think of the service industries that have developed to provide us with power breakfasts, business lunches, and romantic dinners. Consider the communal feasts that punctuate the calendars of the world's religions. In fact, the words festive, festival, and feast have a common Latin root, suggesting that occasions merry, joyous, and significant are all distinguished by eating in company.

The social importance of food and eating, like their association with pleasure, must be honored by anyone advocating eating well. Too often people who follow rigid diets in the name of health isolate themselves from the social interaction that is itself an important factor in optimum health. I can think of no better illustration of this observation than this excerpt from an article entitled, "Camaraderie Is the Best Diet," by Ronald Koetzsch that appeared in Natural Health magazine:
I spent a month in Russia, teaching at Moscow State University. One weekend, Martha (my teaching partner) and I went with several Russian students to visit St. Petersburg. . . . We arrived around 11:00 p.m. Our hosts were a baby-faced medical student and his wife, and they had prepared a Russian banquet for us. There was borscht, thick slabs of dark bread, mounds of butter, salted fish, apples, pastry, cheese, and vodka. By the time we sat down to eat, it was well past midnight. . . .

I was tired and not particularly hungry. And I remembered that eating late usually makes me feel lethargic and dull in the morning. Like Buddhist monks who do not eat after midday, I prefer to go to bed on an empty stomach.

So when the eating began, I politely explained that I wasn't feeling well and that I would just have some water and apple juice. My hostess said, "If you don't feel well, the answer is to eat. Yes. Yes. Eat for health." . . .

I held to abstinence, though, with a slight sense of self-righteousness. While everyone else, including Martha, ate, drank, and was merry, I sipped juice and water and waited for the moment when I could politely excuse myself and go to bed. After an hour or so, I did, but the eating, drinking, conversation, and laughter continued long thereafter. One of my last thoughts before sleep was: "Well I, anyway, will be clear and energetic tomorrow when we tour the city."

Alas, such was not the case. I was groggy and out of sorts, and I felt alienated from the others. And they, despite going to bed full of food and vodka, were cheerful and brimming with energy.

I was a bit dismayed by the apparent injustice. . . .

Soon after my Russian sojourn, I was in Germany . . . visiting a friend in a village near Kassel, and we attended a breakfast marking the end of a local holiday. The meal was served in a huge hall. In the middle was a 30-piece German brass band playing "oom-pah-pah" music at a mind-numbing volume. Hundreds of men dressed in dark suits and frilled white shirts were sitting at long tables, drinking beer, talking, laughing, and occasionally breaking into song.

As soon as I sat down, a large mug of frothy beer was placed before me, and my immediate neighbors — red-faced and smiling — raised their mugs in salute . . . it did not seem a time to ask for peppermint tea. . . . [I] took a sip of my beer. It was thick and delicious. I took another sip and started talking to my neighbor, a policeman from the town. When I finished my mug, another appeared in front of me. . . .

Eventually, breakfast was served. It featured a deep-fried pork cutlet about the size of a Frisbee. To one who has eaten little meat and no pork for over two decades, it seemed "The Mother of All Pork Cutlets" . . . what was I to do? — ask our Walkyrie of a waitress to bring my hummus and alfalfa sprout sandwich instead? I dug in, eating the cutlet, potato salad, and everything else on the plate with relish. It was delicious.

When we left, I was relaxed, happy, and so alert that I noticed the floor and other parts of the seemingly solid German building were actually moving. I had a sense of foreboding, though. When will the ax of judgment fall upon my dietary sins? I wondered. But it never did. I felt unusually energetic and ebullient that whole day and for days afterward. . . . I look forward to my next breakfast of beer, pork cutlet, and song.
Koetzsch's conclusion is that when "food is blessed by being shared, by being eaten in fellowship amidst conversation and laughter . . . all food is 'health' food." I agree.

Mediterranean Tuna Steaks
2 ahi tuna steaks, 4-6 ounces each, about 1 inch thick
2 teaspoons extra-virgin olive oil salt and pepper to taste
1 medium ripe tomato, diced fine
6 green olives, pitted and chopped
1 tablespoon scallions, chopped
2 teaspoons capers
1 clove garlic, mashed a pinch of dried whole oregano
1. Rinse the tuna steaks under cold running water and pat dry. Brush them with 1 teaspoon of the olive oil and season them with salt and pepper.

2. Preheat grill or broiler. Meanwhile, mix all the remaining ingredients, season with salt and pepper, and set aside.

3. Grill the steaks on high heat or broil, about 2-3 minutes per side or until desired doneness.
4. Cover the steaks with topping mixture, and serve. Good hot or cold.

Servings: 2. Calories 161, fat 7 g (40% of calories from fat), saturated fat 1 g, protein 20.5 g, carbohydrate 3 g, cholesterol 38 mg, fiber 1 g
Nutritional benefits: Protein from fish

Pasta Puttanesca
5-6 cups fresh tomatoes, peeled, seeded, and crushed (or use canned Italian tomatoes, drained and crushed)
1 tablespoon extra-virgin olive oil
1 teaspoon dried hot red pepper flakes
1 ½ tablespoons capers, drained and rinsed
3 tablespoons black olives (Kalamata or oil-cured), pitted and chopped
1 tablespoon garlic, minced
2 tablespoons fresh basil leaves, minced
1 pound dried penne pasta
¾ cup Parmesan cheese, grated
1. In a large bowl, combine the tomatoes, olive oil, red pepper flakes, capers, olives, garlic, and basil. Let stand at room temperature for 1 hour.

2. Cook the pasta until it is al dente. Drain well.

3. Toss the hot pasta with the tomato mixture. Add the grated Parmesan cheese and serve immediately.

Servings: 6. Calories 391, fat 7.5 g (17% of calories from fat), saturated fat 2.5 g, protein 15.5 g, carbohydrate 66 g, cholesterol 8 mg, sodium 247 mg, fiber 4 g
Nutritional benefits: Good carbohydrate; micronutrients from tomatoes and garlic

Apple Crisp
12 large green apples, peeled, cored, and sliced juice of 1 fresh lemon
¼ cup raisins
1/3 cup brandy
¼ cup light brown sugar, packed
1 teaspoon cinnamon
2 tablespoons whole-wheat pastry flour
1 ½ cups old-fashioned rolled oats
½ cup toasted wheat germ
¾ teaspoon salt
1 ½ teaspoons cinnamon
½ cup brown sugar, packed
1/3 cup light olive oil
1/3 cup maple syrup nonstick cooking spray

1. Preheat oven to 375 degrees F.

2. In a mixing bowl, toss the apples with the lemon juice, raisins, brandy, brown sugar, 1 teaspoon cinnamon, and the flour.

3. Pile the apples in a glass or ceramic baking dish sprayed with nonstick cooking spray.

4. Mix together the remaining ingredients and cover the apples with the mixture.

5. Cover the baking dish with aluminum foil and bake 20 minutes. Uncover and bake 30-40 minutes more until the apples are soft. Serve warm.

Servings: 12. Calories 244, fat 7.5 g (27.5% of calories from fat), saturated fat 1 g, protein 4 g, carbohydrate 40 g, cholesterol 0 mg, sodium 140 mg, fiber 5 g
Nutritional benefits: Fiber and carbohydrate from whole grains; monounsaturated fat; micronutrients