May-June 2023

Nutrition Health Review The Consumer’s Medical Journal

PREVENTATIVE NUTRITION

• Superfood Spotlight— Mushrooms

• Know Your Nutrients—Calcium

• Nut and Seed Butters—A Comprehensive Guide

• Summer Vegetables—What’s in Season Now?

HEALTH CONDITIONS

• Asthma—A Primer

• Other Chronic Respiratory Diseases

EXERCISE TIPS & TECHNIQUES

• Yoga—How to Do Navasana (Boat Pose)

• Exercising with Chronic Respiratory Disease

BODY BASICS

• Unraveling Age-related Hearing Loss

RECIPES

• Mushroom Quinoa Burger with Special Sauce

• Carrot Ginger Soup with Raisin Relish

• Peanut Butter-Fruit-Oat Energy Squares

• Grilled Salmon with Blueberry Sauce

• DIY Nut Butter

EDITORIAL MESSAGE

Dear Readers:

May–June 2023 | Volume 146

Welcome to the May–June 2023 (Volume 146) issue of Nutrition Health Review (NHR). In this edition, the Superfood Spotlight is on mushrooms, a very diverse group of edible fungi, and this edition’s Know Your Nutrients star is calcium, an essential mineral not only for making strong bones and teeth, but for maintaining healthy heart functioning.

Love nut butters? Then you’ll love the comprehensive guide to nut and seed butters we’ve included in this issue. You’ll also want to check out our summer vegetable highlights article to see what’s currently in season at the farmer’s market.

As in past editions of NHR, we continue to explore different health conditions of the human body, and in this issue we focus on respiratory diseases, including causes, risk factors, and treatments for asthma and other chronic conditions of the lungs. With this theme in mind, we’ve provided some exercise and nutrition tips for individuals with chronic respiratory disease. And, because inflammation is such a common factor in respiratory diseases, we’ve also included lots of tasty healthy recipes using ingredients with evidence-based anti-inflammatory properties.

And as always, you’ll find various summaries of the latest research in health and nutrition sprinkled throughout our pages that we hope you find informative and beneficial, as we hope you find the issue as a whole. Happy Memorial Day!

With warm regards,

Elizabeth A. Klumpp Executive Editor NHR

NHR EDITORIAL STAFF

Elizabeth Klumpp

Executive Editor

Julia Eckert

Associate Editor

Austin Vitelli

Associate Editor

Amanda Tolvaisa

Assistant Editor

Gannon Vitelli

Assistant Editor

Aliza Becker

Contributing Writer

BUSINESS STAFF

Robert Dougherty

President/Group Publisher

Giselle Geddes, MD

Chief Medical Officer

Joseph Morris

Senior Vice President

Elizabeth Klumpp

Vice President/Editorial Director

Ali Kinnie

Publisher, Director of Media Relations

E. Patrick Scullin

Director of Finance

Emily Scullin

Associate Director of Business Development

Shannon Gillespie

Associate Director of Business Development

Kimberly Hooven

Project Manager

Nutrition Health Review: The Consumer’s Medical Journal© ISSN 0164-7202 is published 6 times a year by Matrix Medical Communications © 2023 all rights reserved. Opinions expressed by authors, contributors, and advertisers are their own and not necessarily those of Matrix Medical Communications, the Vegetus Foundation, the editorial staff, or any member of the editorial advisory board. Matrix Medical Communications and the Vegetus Foundation are not responsible for accuracy of dosages given in the articles printed herein. The appearance of advertisements in this journal is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality, or safety. Matrix Medical Communications and the Vegetus Foundation disclaim responsibility for any injury to persons or property resulting from any ideas or products referred to in the articles or advertisements.

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egutus Foundation

VETERANS CORNER

VA Innovation Collaboration continues through Greenhouse Initiative. One of VHA Innovators Network’s (iNET) signature programs is the Greenhouse Initiative, an opportunity for the healthcare innovation community to collaborate with iNET sites across the nation at the earliest stages of innovation. This allows them to receive input from Veterans and employees to impact solutions aimed to improve Veteran care. Visit https://news.va.gov/119569/collaboration-continuesgreenhouse-initiative/6 for more info.

Studies show VA health care is better than or equal to non-VA health care. The Journal of General Internal Medicine and the Journal of the American College of Surgeons published articles based on a systematic review of studies about VA healthcare, concluding VA healthcare is consistently as good as or better than non-VA healthcare. The findings come from a national review of peer-reviewed studies that evaluated the VA on quality, safety, access, patient experience, and comparative cost/efficiency. Of the 26 studies that looked at nonsurgical care, 15 reported VA care was better than non-VA care and seven reported equal or mixed clinical quality outcomes. Of the 13 studies that looked at quality and safety in surgical care, 11 reported VA surgical care is comparable or better than non-VA care. Visit tinyurl.com/29nb2urk for more info.

Veterans and survivors have filed more than 500,000 toxic exposure-related benefits claims under the PACT Act. The VA announced that Veterans and their survivors have filed more than 500,000 claims for toxic exposure-related benefits under the PACT Act since President Biden signed it into law Aug. 10, 2022. To date, VA has awarded more than $1 billion in earned benefits to Veterans and survivors who filed PACT Act-related claims. VA also announced that more than 3 million Veterans have received VA’s new toxic exposure screenings since President Biden signed the PACT Act into law, with approximately 42% reporting a concern of exposure. More than 215,000 Veterans have enrolled in VA health care during that time frame, a 15% increase from the same time frame the year before. Visit https://www.va.gov/opa/pressrel/ pressrelease.cfm?id=5877 for more info. NHR

MUSHROOMS

Amushroom is a spore-bearing fruiting body of a fungus—a simple definition for a rather complex group of living organisms. Indeed, mushrooms and other fungi are considered neither plant nor animal—they comprise their very own self-named kingdom within the Eurkarya domain of the taxonomy of living things.1 In fact, recent studies indicate that fungi are actually more closely related to animals than to plants and play an essential role across the various ecosystems of the world.2 Unfortunately, describing what makes the over six million species of fungi worldwide different from plants and similar to animals, as well as how they impact nature as a whole, is well-beyond the scope of this article. So, you’ll just have to settle for this review article in which we focus on edible species of mushrooms and the roles they play in human diet and health.

HISTORY OF MUSHROOM CULTIVATION

Cultivation of mushrooms likely began with the Chinese—Tao Hongjing (456–536 CE) included a commentary on cultivating the

mushroom Wolfiporia cocos in Bencao Jing Jinzhu, an extension of an extension of the Shennong Bencao Jing, the oldest surviving Chinese materia medica, which categorized medicinal uses of 365 herbs.3 In contrast, early cultivation of mushrooms in Europe was documented much later, during the mid-1600s, beginning in abandoned quarries and caves near Paris.4 Both Asian and European mushroom cultivation practices were subsequently introduced in the United States in the 1870s.5 Today, of about 2,000 species of mushrooms considered safe for consumption, 25 to 35 are widely eaten, and fewer than that are commercially cultivated.6,7

MUSHROOM NUTRIENT COMPOSITION

While the primary mass of most mushroom fruitbodies is water, depending on the species—and even within the same genus— mushrooms contain varying percentages of carbohydrates (3–42% dry matter [DM]), protein (4–44%; maximum, 57.3% DM), and lipids (2–6% DM).8 Mushrooms

are low in calories yet contain a variety of vitamins, polyphenols, carotenoids, macroelements, and other bioactive components.8,9 In an analysis, the addition of an 84g serving of commonly consumed raw mushrooms (e.g., the white, brown/ cremini, and portabella states of Agaricus bisporus) to United States (US) Department of Agriculture Food Patterns resulted in a 2- to 3-percent increase in fiber, an 8- to 12-percent increase in potassium, a 12- to 18-percent increase in riboflavin, an 11- to 26-percent increase in niacin, an 11- to 23-percent increase in selenium, and a 16- to 26-percent increase in copper depending upon the pattern type and calorie level but only one-percent or less increase in sodium, a one-percent increase in calories, and no effect on saturated fat or cholesterol.10 Adding a serving of raw specialty mushrooms (Pleurotus ostreatus) also increased dietary vitamin D by 8 to 11 percent and dietary choline by 10 to 16 percent.10

The nutrient profiles of mushrooms can also vary depending on the environment in which they grow; for example, a comparison of wild and

commercial species of mushrooms revealed that the latter generally contained more fat, less protein, and more sugar. When considering types of vitamin E, higher levels of α-tocopherol but undetectable levels of γ-tocopherol were found in the wild species, and the wild species also contained lower concentrations of monounsaturated fatty acids but higher concentrations of polyunsaturated fatty acids as well as higher concentrations of phenols but a lower concentration of ascorbic acid compared to commercial mushrooms.11 A separate study confirmed the greater phenol content and antioxidant capacity of wild mushrooms compared to commercial mushrooms.12

MUSHROOMS AS MEDICINE

Views on the consumption of mushrooms varied across the ancient world; while leading Roman medical practitioners were wary of mushroom consumption due to numerous cases of accidental poisoning and excessive consumption of edible mushrooms leading to indigestion by the populace,13 Eastern populations, such as the Chinese, Japanese, and Indians, have long viewed mushrooms as medicinal aids.14,15 Today, the health benefits of various mushrooms are known to include antioxidant, prebiotic, antihypertensive, antiinflammatory, antiviral/antimicrobial, neuroprotective, hepatoprotective, and antitumor/anticancer effects, among others.16–18

Cardiovascular and metabolic health. Research suggests that edible mushroom consumption may favorably alter metabolic markers (e.g. cholesterol, triglycerides) and

reduce blood pressure,19–21 although the effects can differ depending on the mushroom. For example, among spontaneously hypertensive rats (a common animal model of hypertension and cardiovascular disease) in one study, those fed maitake mushrooms (Grifola frondose) experienced a decrease in their total cholesterol level compared to the control group, while those fed shiitake mushrooms (Lentinus edodes) experienced a reduction in their free cholesterol level.20 There was no difference in the plasma triglyceride or phospholipid levels between the experimental groups; however, shiitake consumption resulted in a decrease in both very-low-density lipoprotein (“bad”) cholesterol and high-density lipoprotein (“good”) cholesterol compared to the control group, while maitake consumption elicited a decrease in very-low-density lipoprotein (“bad”) cholesterol only.20 Some of the same investigators reported in another study that the blood pressure of spontaneously hypertensive rats was significantly reduced following eight weeks of maitake mushroom consumption, but this effect was not true with shitake consumption. Moreover, although the investigators affirmed the reduction in plasma-free cholesterol levels and reported reductions in triglyceride and phospholipid levels with shiitake intake, they did not observe reductions in either total or free cholesterol levels or triglyceride and phospholipid levels with the consumption of maitake mushrooms.21 Keeping in mind all these findings and that free cholesterol has cytotoxic effects (which may be mitigated by high-

density lipoprotein cholesterol),22 the intake of both mushrooms (ensuring variety) rather than either alone, in combination with other healthy foods (i.e., those that increase highdensity lipoprotein cholesterol and phospholipid concentrations on their own), may lead to the best outcome.

Collectively, edible mushrooms appear to support glucose control by a variety of mechanisms, including inhibiting glucose absorption, protecting β-cells (which produce and release insulin in the pancreas) from damage, increasing insulin release, and regulating different relevant pathways in the body.23 In Type 2 diabetic C57BL/6 mice (which carry a genetic predisposition to develop Type 2 diabetes), oral administration of 250 or 500mg/kg of chaga mushroom (Inonotus obliquus) extract significantly alleviated insulin resistance, with a dose–effect relationship noted within a certain range; indeed, the authors reported that the 500mg/kg dose of extract achieved an effect similar to that of the diabetes drug metformin.24 Along these lines, oral administration of 900mg/kg of chaga mushroom in another study led to reductions in fasting blood glucose levels, an improved glucose-tolerance ability, an increased hepatic glycogen level (to better prevent high blood glucose levels), and ameliorated insulin resistance in a Type 2 diabetic mouse model induced by a high-fat diet and streptozotocin (a compound with preferential toxicity toward pancreatic β-cells) compared to diabetic control mice.25

Immune function. Research has attributed the beneficial effects of edible mushrooms on the immune system to their ability to modulate

different cytokine responses. In cancer, maitake, Ganoderma lucidum (reishi), Cordyceps sinensis, and Trametes versicolor (turkey tail) may increase the production of T helper (Th)1 cytokines, such as interferon-γ, which activate death receptors on the surfaces of tumor cells to help Th1 cells locate and kill them.26 Edible Agaricus, maitake, reishi, Cordyceps, and turkey tail mushrooms may also downregulate Th2 cytokines, which reduce Th1 cytokine concentrations, thus showing an additional benefit in treating cancer by maintaining higher concentrations of tumor-destroying Th1 cells.26

Edible mushrooms may also increase the therapeutic efficacy

of mainstay treatments for cancer.26 During chemotherapy, chemotherapeutic agents penetrate and accumulate in tumor cells to induce cell cycle arrest and apoptosis; as such, some edible mushrooms, such as Agaricus spp., may help drugs such as doxorubicin to accumulate intracellularly at greater doses, increasing their therapeutic efficacy.27 Other edible mushrooms, when combined with such drugs, may help to inhibit tumor growth; one study concluded that administering an extract of Cordyceps sinensis in combination with cisplatin could inhibit tumor growth,28 and another determined that the combination

Mushrooms and Beta-Glucans

Beta-glucans, a type of polysaccharide found in bacteria, yeasts, fungi, and plants, help to regulate inflammation (e.g., by decreasing levels of pro-inflammatory cytokines1) and activate or enhance the functional activity of various innate and adaptive immune cell populations, including macrophages, dendritic cells, and lymphocytes.2 In cancer, β-glucans may increase counts of M1-phenotype tumor-associated (antitumor) macrophages and decrease counts of M2-phenotype tumor-associated (protumor) macrophages.3 Lentinan, a fungal β-glucan constituent, has shown the ability to prolong cancer patient survival when combined with chemotherapy, compared to chemotherapy alone,4,5 and it has also been linked to reductions of systemic inflammatory markers, such as serum C-reactive protein and macrophage inflammatory protein-1α/chemokine C-C ligand 3, and increases in the anti-inflammatory response markers interleukin-4 and interleukin-10.6 Lentinan may also be useful for reversing hyperglycemia in the early and late stages of Type 1 diabetes.7

Pleuran, the β-glucan isolated from Pleurotus ostreatus, was found to reduce peripheral blood eosinophilia and stabilized serum levels of total immunoglobulin E in children with recurrent respiratory tract infections, which the study investigators suggest is due to its potential antiallergic effect.8 According to other research, supplementation with a β-glucan derived from Aureobasidium pullulans was effective for the prevention of influenza in mice,9 and β-glucan supplementation also led to reduced mortality in a mouse model of influenza.10 Finally, a comparative study of β-glucans from different sources determined that treating keratinocytes with a β-glucan derived from Schizophyllum commune promoted in-vivo wound closure.11

of polysaccharide K (a derivative of turkey tail mushrooms) and trastuzumab reduced cell growth in colorectal tumors by 96 percent.29 Mushrooms may also minimize associated undesirable side effects of chemotherapy and radiation therapy, such as nausea, bone marrow suppression, anemia, and insomnia.30

Other research has examined mushroom intake for managing inflammatory conditions. According to a literature search, the various bioactive molecules found in mushrooms, including peptides, polysaccharides, terpenes, sterols, fatty acids, and phenols, may inhibit major proinflammatory biomarkers

SOURCES

1. Um MY, Park JH, Gwon SY, Ahn J, Jung CH, Ha TY. Agaricus bisporus attenuates dextran sulfate sodium-induced colitis. J Med Food. 2014;17(12):1383–1385.

2. Chi-Fung Chan GC-F , Chan WK, Sze DM-Y. The effects of beta-glucan on human immune and cancer cells. J Hematol Oncol. 2009;2:25.

3. Wang W-J, Wu Y-S, Chen S, Liu C-F, Chen S-N. Mushroom β-glucan may immunomodulate the tumor-associated macrophages in the Lewis lung carcinoma. Biomed Res Int. 2015;2015:604385.

4. Ina K, Furuta R, Kataoka T, et al. Lentinan prolonged survival in patients with gastric cancer receiving S-1-based chemotherapy. World J Clin Oncol. 2011;2:339–343.

5. Oba K, Kobayashi M, Matsui T, Kodera Y, Sakamoto J. Individual patient based meta-analysis of lentinan for unresectable/recurrent gastric cancer. Anticancer Res. 2009;29:2739–2745.

6. Dai X, Stanilka JM, Rowe CA, et al. Consuming Lentinula edodes (Shiitake) mushrooms daily improves human immunity: a randomized dietary intervention in healthy young adults. J Am Coll Nutr. 2015;34(6):478–487.

7. Wu T, Cai Z, Niu F, et al. Lentinan confers protection against type 1 diabetes by inducing regulatory T cell in spontaneous non-obese diabetic mice. Nutr Diabetes . 2023 Apr 8;13(1):4.

8. Jesenak M, Hrubisko M, Majtan J, Rennerova Z, Banovcin P. Antiallergic effect of pleuran (β-glucan from Pleurotus ostreatus) in children with recurrent respiratory tract infections. Phytother Res. 2014;28:471–474.

9. Muramatsu D, Iwai A, Aoki S, et al. β-Glucan derived from Aureobasidium pullulans is effective for the prevention of influenza in mice. PLoS One. 2012;7(7):e41399.

10. Vetvicka V, Vetvickova J. Glucan supplementation enhances the immune response against an influenza challenge in mice. Ann Transl Med. 2015;3(2):22.

11. Seo G, Hyun C, Choi S, Kim YM, Cho M. The wound healing effect of four types of beta-glucan. Appl Biol Chem. 2019;62(20). NHR

and associated pathways, thus exerting anti-inflammatory effects.31

Mushrooms such as chaga,34 maitake,35 and reishi36 also seem to have antiallergic effects by inhibiting the process of mast cell degranulation (during which mast cells release mediators, such as histamine).

Certain edible mushrooms may also combat viral infection by preventing viral entry or replication and stimulating immune cell responses. Polysaccharides from Agaricus blazei Murrill, for example, were found to reduce the cytopathic effects of Western equine encephalitis virus, herpes simplex virus (HSV), and poliovirus in Vero cells (a lineage of cells derived from kidney epithelial cells extracted from an African green monkey).37 A sulfated derivative of a polysaccharide from Agaricus brasiliensis Fr. suppressed HSV-1 and HSV-2 cell attachment, cell penetration, and intracellular spread in vitro 38 Interestingly, the sulfated derivative in question also displayed a synergistic antiviral effect against HSV when combined with the antiviral drug acyclovir, suggesting the potential of combining edible mushrooms with antiviral medications to improve treatment effects.38

Neuroprotection and neuroregeneration. According to investigators, edible mushrooms could play a role in the prevention39 and treatment40,41 of dementia, with various mushroom species displaying the potential to reduce or inhibit the production of beta-amyloid and phosphorylated tau.42 However, mushroom consumption may also help to limit or prevent more general

Mushrooms and the Central Nervous System

Different edible mushrooms may play a role in the prevention1 and treatment2,3 of dementia by reducing or inhibiting the production of β-amyloid and phosphorylated tau.4 One study in which patients with mild Alzheimer’s disease were administered either erinacine A–enriched lion’s mane capsules or placebo demonstrated a significant reduction in the Cognitive Abilities Screening Instrument scores in the placebo group, a significant improvement in the Mini-mental State Examination scores in the lion’s mane group, and a significant difference in Instrumental Activities of Daily Living scores between the two group after 49 weeks of treatment.2 In mice, tests performed to evaluate memory and learning function suggested that lion’s mane supplementation prevented the impairments of spatial short-term and visual recognition memory induced by amyloid β25–35 peptide.5

Lion’s mane consumption may also benefit patients with depression and anxiety: in a study of 30 women, those who consumed lion’s mane cookies for four weeks had reduced scores on the Center for Epidemiologic Studies Depression Scale and Indefinite Complaints Index, compared to those who consumed placebo cookies.6 Separately, treatment with psilocybin, a naturally occurring psychedelic substance present in Psilocybe mushrooms, combined with psychedelic psychotherapy, relieved major depressive disorder symptoms in adult patients for up to one year,7 and a systematic review and meta-analysis determined that psilocybin was more effective than placebo in treating state (threat-specific) anxiety for up to two weeks and trait (general) anxiety up to six months after treatment.8

SOURCES

1. Li I-C, Chang H-H, Lin C-H, et al. Prevention of early Alzheimer’s disease by erinacine A–enriched Hericium erinaceus mycelia pilot double-blind placebo-controlled study. Front Aging Neurosci. 2020;12:155.

2. Yanshree, Yu WS, Fung ML, Lee CW, Lim LW, Wong KH. The monkey head mushroom and memory enhancement in Alzheimer’s disease. Cells. 2022;11(15):2284.

3. Phan CW, David P, Naidu M, Wong K-H, Sabaratnam V. Therapeutic potential of culinarymedicinal mushrooms for the management of neurodegenerative diseases: diversity, metabolite, and mechanism. Crit Rev Biotechnol. 2015;35(3):355¬368.

4. Feng L, Cheah IK-M, Ng MM-X, et al. The association between mushroom consumption and mild cognitive impairment: a community-based cross-sectional study in Singapore. J Alzheimer’s Dis. 2019;68(1):197–203.

5. Mori K, Obara Y, Moriya T, Inatomi S, Nakahata N. Effects of Hericium erinaceus on amyloid β(25-35) peptide-induced learning and memory deficits in mice. Biomed Res. 2011;32(1):67–72.

6. Nagano M, Shimizu K, Kondo R, et al. Reduction of depression and anxiety by 4 weeks Hericium erinaceus intake. Biomed Res. 2010;31(4):231–237.

7. Gukasyan N, Davis AK, Barrett FS. Efficacy and safety of psilocybin-assisted treatment for major depressive disorder: prospective 12-month follow-up. J Psychopharmacol. 2022;36(2).

8. Yu C-L, Yang F-C, Yang S-N, et al. Psilocybin for end-of-life anxiety symptoms: a systematic review and meta-analysis. Psychiatry Investig. 2021;18(10):958–967. NHR

cognitive decline: among 663 participants 60 years of age or older in the Diet and Healthy Aging study in Singapore, those who consumed greater than two portions (>300g) of mushrooms per week had reduced odds of having mild cognitive impairment independent of age, sex, education, cigarette smoking, alcohol consumption, hypertension,

diabetes, heart disease, stroke, physical activities, and social activities.43 Similarly, greater mushroom intake was associated with better scores on certain cognitive performance tests among adults 60 years of age or older from the 2011–2014 U.S. National Health and Nutrition Examination Survey.44 Along these lines, a

Poisonous Mushrooms and Medicine

Research has shown that edible mushrooms from a range of genera exert various anticancer treatment effects.1 In addition, further investigation of α-amanitin, a toxin found in the poisonous Amanita phalloides mushroom, as a possible anticancer treatment has progressed with the development of antibody–drug conjugates, allowing for its safe delivery into the body,2 and mouse studies have suggested its efficacy in treating colorectal cancer3 and pancreatic cancer,4 among others. In vitro, the administration of α-amanitin was also shown to inhibit subpopulations of cancer cells that survive in the presence of drugs (i.e., “drug-tolerant colonies”), suggesting its potential to prevent post-treatment cancer relapse.5 Separately, illudins, which are terpene compounds derived from the poisonous mushroom Omphalotus illudens and related basidiomycetes, are rapidly (<2 hours) cytotoxic to different hematopoietic leukemia and solid tumor cells at pico- to nanomolar concentrations, while normal bone marrow progenitors and fibroblasts require longer exposure times at micro- or millimolar concentrations to experience similar effects,6 which may support their development as cancer therapeutics. Importantly, mushrooms should not be used to replace prescribed medications or therapies without prior discussion with a physician.

SOURCES

1. Patel S, Goyal A. Recent developments in mushrooms as anti-cancer therapeutics: a review. Biotech. 2012;2(1):1–15.

2. Heidelberg Pharma. A targeted cancer chemotherapy with a new mode of action. Available at: https://www.nature.com/articles/d43747-020-01103-2. Accessed April 30, 2023.

3. Liu Y, Zhang X, Han C, et al. TP53 loss creates therapeutic vulnerability in colorectal cancer. Nature. 2015;520(7549):697–701.

4. Moldenhauer G, Salnikov AV, Luttgau S, Herr I, Anderl J, Faulstich H. Therapeutic potential of amanitin-conjugated anti-epithelial cell adhesion molecule monoclonal antibody against pancreatic carcinoma. J Natl Cancer Inst. 2012;104(8):622–634.

5. Kume K, Ikeda M, Miura S, et al. α-amanitin restrains cancer relapse from drug-tolerant cell subpopulations via TAF15. Sci Rep. 2016;6:25895.

6. Kelner MJ, McMorris TC, Montoya MA, et al. Characterization of cellular accumulation and toxicity of illudin S in sensitive and nonsensitive tumor cells. Cancer Chemother Pharmacol. 1997;40:65–71. NHR

study from western Norway that recruited elderly participants (70–74 years) from the general population confirmed a linear increase in the dose–response association between mushroom consumption and cognitive test performance.45

The neuroprotective effects of edible mushrooms may be attributable to the amino acid ergothioneine, which the human body cannot synthesize itself but can source from certain foods, including mushrooms. Notably, however, whole-blood concentrations of ergothioneine were found to decline

significantly after 60 years of age,46 and ergothioneine levels were lower in individuals with mild cognitive impairment (plasma)46 or Parkinson’s disease (serum)47 compared to age-matched healthy individuals. Some edible mushrooms, such as Hericium erinaceus (lion’s mane), contain compounds that may also boost hippocampal memory by encouraging nerve growth.48 The antioxidants in mushrooms may also help to control oxidative stress levels and maintain antioxidant defenses to prevent age-related neurodegeneration.53

Antioxidation. Mushrooms contain both primary and secondary antioxidants as well as compounds with antioxidant properties that act as cell signals and/or inducers, leading to alterations in gene expression that activate enzymes to eliminate reactive oxygen species.50 Certain mushrooms also inhibit lipid peroxidation, a process in which reactive oxygen species trigger the oxidative deterioration of lipids.55 One study determined that mushrooms contain unusually high amounts of ergothioneine and another antioxidant, glutathione, although the levels vary between species: among 13 species tested, maitake (2.41mg/g of dry weight) and Agrocybe aegerita (1.92mg/g of dry weight) mushrooms contained the most glutathione, and Boletus edulis (7.27mg/g of dry weight) and Pleurotus citrinopileatus (3.94mg/g of dry weight) mushrooms contained the most ergothioneine.52

Mushrooms also contain different amounts of other antioxidants, including phenolics, flavonoids, glycosides, polysaccharides, tocopherols, carotenoids, vitamins, minerals, and ascorbic acid.50 In a study from Ethiopia, testing of two cultivated (Pleurotus ostreatus and shitake) and five wild (Laetiporus sulphureus, Agaricus campestris, Termitomyces clypeatus, Termitomyces microcarpus, and Tapura letestui) mushroom species indicated that, among them, Agaricus campestris exhibited significant antioxidant potential due to having the highest levels of multiple phenolic compounds, including ferulic acid, gallic acid, and p-hydroxybenzoic acid.53 In another study investigating hot

water extracts of Agaricus, Antrodia, Auricularia, Coprinus, Cordyceps, Hericium, Grifola, Ganoderma, Lentinus, Phellinus, and Trametes mushrooms, researchers reported concentrations of polyphenolic compounds and polysaccharides to be responsible for their high antioxidant potential, with Ganoderma mushrooms exhibiting the greatest antioxidant potential.54 In another study, among 16 of the most popular edible species of wild-growing mushrooms, Boletus chrysenteron and Boletus edulis had high polyphenol contents and antioxidant activity.55

SUPPLEMENTING WITH MUSHROOMS

As an alternative to consuming mushrooms during meals, mushroom supplements are available and often combine multiple mushrooms that are heat-treated and milled to disrupt the chitinous cell wall matrix and increase the surface area for digestion and absorption.56 When choosing a mushroom supplement, however, one may need to consider whether the mushroom mycelium (a web of fibers found underground) or the fruiting body (the cap and stalk) provides better nutrition, as different supplement companies opt to include one, the other, or both.56 Ultimately, to secure one’s preferred nutrient profile, the choice between a mycelium or fruiting body supplement may depend on the mushroom: one study comparing the antioxidant properties of commonly cultivated mushrooms between in-vivo (fruiting body) and in-vitro (mycelium) samples determined that the mushroom species with the greatest antioxidant potential

was the brown Agaricus bispous, while, among the mycelium samples, shiitake mushrooms showed the highest antioxidant activity.57 Similarly, other studies reported that the mycelium of Pleurotus ostreatus had greater concentrations of ergosterol and phenolic compounds than the corresponding fruiting body,58 while fruiting bodies of Agaricus bisporus, when compared to both farm (old mycelium) and in-vitro (young) mycelium, contained higher levels of different phenols and ergothioneine.59 In other cases, both parts of the same mushroom may contain unique nutrients: take, for example, lion’s mane, where hericenones were isolated from the fruiting body but erinacines were isolated from the mycelium.60

A NOTE OF CAUTION

Like other foods, edible mushrooms should be consumed after being properly prepared. Cutaneous reactions (e.g., shitake dermatitis61,62) have been documented following the ingestion of raw or undercooked mushrooms. Raw Agaricus mushrooms also contain agaritine,63,64 a hydrazine-derivative mycotoxin with carcinogenic properties in which concentrations may be reduced—although not removed entirely—by exposing the mushrooms to heat.63 Similarly, Agaricus bisporus and another edible mushroom, Gyromitra esculenta, contain hydrazine analogs, which were found in an animal study following administration in drinking water continuously for life to directly or indirectly (by way of their derivatives) to cause tumors in various tissues in Swiss mice and Syrian (golden) hamsters.65 Of course, serious

anaphylactic reactions can occur in susceptible individuals following the consumption of even the most commonly eaten edible mushrooms.66 Finally, mushroom supplementation should be monitored in individuals with more complex health conditions; for example, authors of a case series report of three Japanese patients with cancer suggested a causal relationship between the patients’ severe hepatic damage and their use of Agaricus blazei extract as alternative medicine.67

Editor’s note. Please discuss the consumption of mushrooms or mushroom supplements with your primary care practitioner.

SOURCES

1. Canadian Forest Service website. Forest mushrooms. What is a mushroom? https:// www.for.gov.bc.ca/hfp/publications/00029/ mushwhat.htm. Accessed 16 May 2023.

2. Lovett B. Three reasons fungi are not plants. 6 Jan 2021. American Society for Microbiology website. https://asm.org/ Articles/2021/January/Three-ReasonsFungi-Are-Not-Plants#:~:text=This%20is%20 our%20final%20reason,related%20to%20 animals%20than%20plants.Accessed 16 May 2023.

3. Lu D. Ancient Chinese people’s knowledge of macrofungi as medicinal material during the period from 581 to 979 AD. Int J Med Mushrooms. 2014;16(2):189–204.

4. Bertelsen, C.D. Mushroom: A Global History; Reaktion Books: London, UK, 2013

5. Bunyard, B. A History of Mushroom Cultivation in America Timeline; FUNGI: Basel, Switzerland, 2021; pp. 24–25

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38. de Sousa Cardozo FTG, Camelini CM, Mascarello A, et al. Antiherpetic activity of a sulfated polysaccharide from Agaricus brasiliensis mycelia. Antiviral Res. 2011;92(1):108–114.

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Y, Tsuji I. Mushroom consumption and incident dementia in elderly Japanese: the Ohsaki Cohort 2006 study. J Am Geriatr Soc. 2017;65(7):1462–1469.

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44. Ba DM, Gao X, Al-Shaar L, et al. Mushroom intake and cognitive performance among US older adults: the National Health and Nutrition Examination Survey, 2011-2014. Br J Nutr. 2022;128(11):2241–2248.

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GR. Antioxidant property of edible mushrooms collected from Ethiopia. Food Chem. 2014;157:30–36.

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Mushroom Quinoa Burger with Special Sauce

Serves 4

Ingredients

1 large portobello mushroom, gills removed, roughly chopped

1 cup canned black beans, rinsed

2 tbsp almond butter

3 tbsp mayonnaise, divided

1 tsp ground pepper

¾ tsp garlic powder, divided

½ tsp salt

½ cup cooked quinoa

¼ cup rolled oats

1 tbsp ketchup

1 tsp Dijon mustard

1 tbsp olive oil

4 whole-wheat hamburger buns

Directions

1. Place chopped mushroom, black beans, almond butter, 1 tablespoon mayonnaise, pepper, 1/2 teaspoon garlic powder, and salt in a food processor. Pulse, stopping once or twice to scrape down the sides, until a coarse mixture forms that holds together when pressed. Transfer to a bowl and add quinoa and oats; stir well to combine. Refrigerate for 1 hour.

2. While mushroom mixture chills, whisk ketchup, mustard, and the remaining 2 tbsp mayonnaise and 1/4 teaspoon garlic powder in a small bowl until smooth. Set aside.

3. Shape the chilled mushroom mixture into four patties.

4. Heat oil in a large grill pan or nonstick skillet over medium-high heat. Add the patties and cook until golden and beginning to crisp, 4 to 5 minutes. Carefully flip and cook until golden brown, 2 to 4 minutes more.

5. Serve the burgers on buns with the special sauce and add your favorite toppings, such as lettuce, spinach, pickles, tomatoes, jalapeños, and/or red or sweet onions.

Estimated Nutrition Information (one sandwich)

Calories: 494; Total Fat: 15.8g; Saturated Fat: 2.1g; Cholesterol: 3mg;

Sodium: 559mg; Total Carbohydrate: 72.6g; Dietary Fiber: 13.3g; Total Sugars: 6.6g; Protein: 19.8g; Calcium: 121mg; Iron: 6mg; Potassium: 1117mg NHR

Calcium is the most abundant mineral in the human body. It plays a vital role in body structure, but it has other critical functions in human physiology. Ninety-nine percent of whole-body calcium is incorporated into the structure of bones and teeth. The remaining one percent is distributed throughout the body. Many cells contain calcium channels in their membranes. Calcium ions moving through these channels trigger nerve impulses, muscle contraction (including in the heart), blood vessel contraction and relaxation, and secretion of endocrine hormones. Calcium is also part of the clotting cascade, interacting with vitamin K in the activation of clotting factors.

Calcium from foods and some types of dietary supplements must become ionized in an acid medium in order to be absorbed in the small intestine. It is believed that calcium must be in an acid medium for approximately one hour for this to occur. Some forms of calcium bound to highly soluble ligands can be absorbed in non-ionized forms.

Calcium

Calcium is absorbed by more than one mechanism throughout the small intestine. Active transport occurs in the duodenum and proximal jejunum and is dependent on both dietary intake and the needs of the body at the time of intake. This process is highly vitamin D-dependent.1 Transport in the duodenum is thought to be most efficient. Passive diffusion of calcium can occur anywhere in the small intestine, but the ileum is the most abundant area. It is completely dependent on the amount of ionized calcium present in the gut and is not dependent on vitamin D status. Some passive diffusion can also occur in the colon, and, under the right circumstances, this can account for up to four percent of calcium absorption.2 There is some indication that individuals with less absorption of calcium in the proximal intestine will be able to absorb more calcium from the colon.

Dietary factors can have a great influence over calcium bioavailability. Dietary oxalate can significantly bind to calcium, making it unavailable for absorption. Oxalate is found in

many vegetables, such as spinach, sweet potatoes, and beans, as well as berries and chocolate. Phytate, mostly found in grains, can impair absorption to a much lesser degree. Magnesium and calcium will compete for absorption if both are present in substantial amounts. Phosphorus at a level greater than calcium may impair calcium balance, though this is a complex relationship. Large amounts of sodium and protein both increase calcium loss. Caffeine can significantly increase calcium loss in the urine and gut. Steatorrhea (fatty stool) will cause decreased calcium absorption when undigested fats bind with calcium in the gut, creating soaps that cannot be absorbed.

It is important to know that calcium within the body is tightly regulated. Parathyroid hormone (PTH), calcitonin, and vitamin D are the primary regulatory agents, but sex hormones, adrenal hormones, insulin-like growth factor 1 (IGF1), and leptin have influence over bone mineralization or loss as well.

Because of the vital functions that calcium regulates, any changes in

blood calcium levels above or below the desired range signal the calcium regulatory system to remove calcium from bone, absorb more or less calcium from the gut, and excrete more or less calcium in the urine. Thus, when dietary calcium levels are low or absorption is poor (or both), the body will simply remove calcium from bone to keep blood levels in the desired range. In many cases, this is painless and causes few dramatic symptoms until bone loss is severe.

DEFICIENCY

In discussing calcium deficiency, it is important to consider both hypocalcemia and metabolic bone disease. Isolated hypocalcemia (too little calcium in the blood) tends to occur when disorders of calcium metabolism are present, the most common of which is hypoparathyroidism. Other causes of hypocalcemia include low calcium intake, low protein, malabsorption, hypo- or achlorhydria, hypomagnesemia, and vitamin D deficiency. Metabolic bone disease includes the conditions of osteoporosis, osteomalacia, and hyperparathyroidism.

Mild or even moderate hypocalcemia can be completely asymptomatic. Neuromuscular irritability can manifest with spontaneous muscle cramping, paresthesia (pins-and-needles) in the fingers and sometimes toes, numbness of the fingers and hands, and loss of sensation around the mouth. Individuals might also experience muscles that are stiff, painful, and cramp easily with minimal work, as well as gastrointestinal cramps. Another symptom is bronchospasm, which

can lead to difficulty breathing, and those with asthma may report more frequent, hard to control attacks. Hypotension can result in faintness, increased spontaneous sweating, and difficulty swallowing. In people with a history of epilepsy, there may be an increased frequency of seizure activity.

Since bone is the storage pool for almost all calcium in the body, chronic deficiency leads to bone loss and can result in skeletal problems, including fractures. Fractures are often associated with a major trauma, such as falls, but the incident may also be minor and unmemorable. Years-long bone loss can lead to loss of height, thoracic kyphosis (“dowager’s hump”), and lumbar flattening. Other chronic manifestations of low calcium include dry skin, brittle hair and nails, poor dental health, psoriatic skin lesions, itching, anxiety, agitation, depression, hypertension, and increased risk for colon cancer. Chronic or mild hypocalcemia should be treated with oral calcium, and, when necessary, underlying causes of deficiency, such as low protein, must be addressed. Treatment of acute or severe hypocalcemia may require intravenous (IV) repletion in an inpatient setting.

RECOMMENDED INTAKE AND SOURCES

The recommended daily allowance (RDA) for calcium is 1,000mg for adults 19 to 50 years of age; for women aged 51 to 70 years, this increases to 1,200mg daily. Adolescents aged 9 to 18 years should have 1,300mg per day. Dairy products (e.g., milk, yogurt, cheese), tofu, and fortified drinks

(e.g., fruit and vegetable juices, soy milk, rice milk, almond milk) are the best sources of calcium. Beans and dark green vegetables, such as kale and broccoli, also have substantial calcium, but it is much less bioavailable due to phytates and oxalates. Fish in which the bones are edible (e.g., sardines, anchovies, canned salmon) are excellent sources of calcium, with high bioavailability.3

TOXICITY

There is very little toxicity caused by oral calcium. The Institute of Medicine set the tolerable upper limit (UL) at 2,500mg. The most common problems associated with excess calcium are gastrointestinal in nature and include constipation, nausea, vomiting, dry mouth, and loss of appetite. There is also increased risk of kidney stone formation in individuals who are prone to such condition. Those with a history of kidney stones should be instructed to take calcium with food rather than between meals.

INTERACTIONS

Calcium has many known interactions with nutrients and drugs. Iron absorption can be significantly impaired by large doses of calcium or by consumption of calcium-rich foods. Co-consumption of iron with a high calcium load can decrease iron absorption by up to 62 percent.4 Phosphorus can both cause increased calcium excretion in the gut and reduce calcium loss in the urine. A chronic highphosphorus, low calcium diet can result in elevated PTH and overall net bone loss. Excessive intakes of sodium and caffeine also increase calcium loss from the body. Zinc

and calcium also have reported interactions. High calcium levels taken concurrently with zinc can decrease zinc absorption by as much as 50 percent,5 yet in individuals with low dietary intake of calcium, zinc supplementation has been shown to decrease calcium uptake.6 Ultimately, when using supplemental calcium for long-term risk reduction, it is important to ensure that other minerals are adequately represented.

Some medications are not adequately absorbed in the presence of calcium. These include many antibiotics (e.g., tetracycline, doxycycline, minocycline, quinolones) and thyroid hormones. Some cardiac medications, such as propranolol and its derivatives and calcium channel blockers, may be less effective in those taking calcium supplements. There are also many drugs that contribute to calcium loss. Individuals who need to be on calcium supplements and are also taking prescription

medication should consult with their pharmacists.

Editor’s note. Consult with your physician or a certified dietitian/ nutritionist to determine a diet best suited to your individual needs.

This article was adapted with permission from Jacques J. Calcium. Micronutrition For The Weight Loss Surgery Patient. Edgemont, PA: Matrix Medical Communications; 2005: 85–92.

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3. National Institutes of Health. Calcium: fact sheet for consumers. Updated 6 Oct 2022. https://ods.od.nih.gov/factsheets/ Calcium-Consumer/. Accessed 26 Apr 2023.

4. Wood RJ, Zheng JJ. High dietary calcium intakes reduce zinc absorption and balance in humans. Am J Clin Nutr 1997;65(6):1803–1809.

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6. van Meurs JB, Dhonukshe-Rutten RA, Pluijm SM, et al. Homocysteine levels and the risk of osteoporotic fracture. N Engl J Med. 2004;350(20):2033–2041. NHR

MENTAL WELLNESS IS IMPORTANT FOR A HEALTHY HEART AND BRAIN

Anxiety, depression, and stress could potentially increase the risk of heart disease and stroke, according to research from the American Heart Association (AHA). The body can react to negative psychological health through irregular heart rate, increased blood pressure, and increased inflammation, explains Michelle A. Albert, MD, MPH, FAHA. Furthermore, negative psychological health is associated with smoking, lower physical activity levels, unhealthy diet, and other factors that can increase the risk of heart disease and stroke. Tips to improve mental wellbeing include meditation, adequate sleep, regular exercise, and staying connected to family and friends.

Source: American Heart Association. Mental wellness is important for a healthy heart and brain. 5 May 2023. https://newsroom.heart.org/news/mental-wellness-is-important-for-a-healthy-heartand-brain. Accessed 9 May 2023. NHR

STUDY EXPLORES THE ROLE OF DIET IN SUPPORTING A HEALTHY GASTROINTESTINAL MICROBIOTA

Recent research suggests that following the Dietary Guidelines for Americans (DGA) promotes a gut microbiota that positively impacts overall health. Having a diverse gut microbiota helps protect against disease. Among 432 individuals who participated in the study, those with the best adherence to the DGA had the most diverse gut microbiota and a larger abundance of bacteria known to play a role in beneficial bodily functions, such as fiber fermentation.

Source: Medical News. Study explores the role of diet in supporting a healthy gastrointestinal microbiota. 5 May 2023. https://www.newsmedical.net/news/20230505/Study-exploresthe-role-of-diet-in-supporting-a-healthygastrointestinal-microbiota.aspx. Accessed 9 May 2023. NHR

ASTHMA A Primer

According to the World Health Organization (WHO), asthma is one of the most common chronic conditions in the world.1 The Global Initiative for Asthma (GINA) defines asthma as “a heterogeneous disease, usually characterized by chronic airway inflammation…[with] a history of respiratory symptoms, such as wheeze, shortness of breath, chest tightness, and cough, that vary over time and intensity, together with variable expiratory airflow limitation.”2 Asthma is more prevalent in developed countries than in low-to-middle income countries,3 which is thought to be related to the greater incidence of urbanization/ westernized lifestyle, higher rates of obesity, and/or pollution in firstworld regions.4

WHAT CAUSES ASTHMA?

Asthma has several root causes involving endogenous (e.g., immune system functioning, age, sex) and/or exogenous (e.g., lifestyle, environmental exposures) factors.3 Most cases of asthma develop during childhood in association

with immunoglobulin E (IgE) sensitization—which is when the body develops IgE antibodies, due to an abnormal lymphocyte T-helper type 2 (Th2) immune response, against common environmental allergens.3,5 However, asthma can develop later in life, and late-onset asthma may be more closely linked to environmental exposures. Clusters of observable characteristics (e.g., demographics, symptomatology, pathophysiology) have been identified and categorized into asthma “phenotypes,” which include allergic asthma, nonallergic asthma, adult onset (late onset) asthma, asthma with persistent airflow limitations, and asthma with obesity.2

WHAT HAPPENS DURING AN ASTHMA ATTACK?

When a pollutant or other environmental trigger (e.g., house dust mites, animal allergens, mold) is inhaled, sensitized IgE antibodies are released by plasma cells. IgE antibodies then attach to highaffinity mast cells and basophils, which release cytokines that in turn

trigger the release of histamine, prostaglandins, and leukotrienes. These cells then signal the smooth muscle surrounding the bronchi and bronchioles in the lungs to contract, causing the airway to constrict. During this process and over the next several hours, Th2 cells produce and send several immune-response cells to the lungs, which causes and sustains inflammation in which the inner lining of the airways swells and produces mucus.6 This combination of constriction, inflammation, and mucous make it difficult for a person to breathe normally.

WHAT ARE THE RISK FACTORS FOR ASTHMA?

According to the American Lung Association, risk factors for asthma include the following:7

• Family history—Having a parent with asthma increases a child’s risk of developing the disease 3- to 6-fold.

• Allergies—Certain allergic conditions, such as eczema and hay fever, are associated with the development of asthma.

NUTRITION AND LUNG HEALTH

Research has been showing that the development and management of chronic respiratory diseases, such as chronic obstructive pulmonary disease (COPD) and asthma, are influenced by dietary intake.1–5 COPD and asthma are both characterized by inflammation and obstruction of the airways, systemic inflammation, and decreased lung function. A high intake of fresh fruits and vegetables, whole grains, nuts and seeds, and fatty fish provides the body with many anti-inflammatory and antioxidant nutrients and micronutrients to prevent or manage respiratory disease. The following food types can help reduce inflammation in the body:

OMEGA-3 FATTY ACIDS. Omega-3 fatty acids are essential to our overall health, helping to form cell membranes and cell receptors throughout the body. They play a critical role in making hormones that regulate blood clotting, contraction and relaxation of arterial walls, and

SOURCES

1. Berthon BS, Wood LG. Nutrition and respiratory health-feature review. Nutrients. 2015;7(3):1618-43.

2. Nurmatov U, Devereux G, Sheikh A. Nutrients and foods for the primary prevention of asthma and allergy: systematic review and meta-analysis. J Allergy Clin Immunol. 2011;127(3):724-33.e1-30.

3. Varraso R, Fung TT, Barr RG, et al. Prospective study of dietary patterns and chronic obstructive pulmonary disease among US women. Am J Clin Nutr. 2007;86(2):488-95.

4. Shaheen SO, Jameson KA, Syddall HE, et al; Hertfordshire Cohort Study Group. The relationship of

• Viral respiratory infections

Children who experience viral respiratory infections are at greater risk of developing chronic asthma.

• Occupational exposures

Exposure to certain industrial or wood dusts, chemical fumes and vapors, and molds can increase the risk of developing late-onset asthma (i.e., developing asthma as an adult with no previous history of the disease).

inflammation. Sources of omega-3 fatty acids include fatty fish (e.g., salmon); vegetable oils (e.g., olive oil), nuts (especially walnuts), flax seeds, flaxseed oil, and leafy vegetables.6

VITAMIN C. With its powerful antioxidant and anti-inflammatory properties, vitamin C plays an important role in the immune system, helping the body fight infection, heal wounds, and neutralize free radicals. Vitamin C is also needed to make collagen, several hormones, and chemical messengers, as well as help the body absorb non-heme iron. Fruits and vegetables are the biggest source of dietary vitamin C, such as citrus, bell peppers, tomatoes, strawberries, and cruciferous vegetables (e.g., broccoli, Brussels sprouts).7

POLYPHENOLS. Polyphenols (e.g., phenolic acid, flavonoids) are reducing agents with antioxidant properties that help protect the body’s tissues against oxidative stress and inflammation and associated diseases, such as cancers, coronary

dietary patterns with adult lung function and COPD. Eur Respir J. 2010;36(2):277-84.

5. Scott HA, Jensen ME, Wood LG. Dietary interventions in asthma. Curr Pharm Des. 2014;20(6):1003-10.

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7. Harvard TH Chan School of Medicine website. The

• Smoking—Smoking not only increases risk of developing asthma, but causes more severe symptoms and makes the disease more difficult to treat. Those whose mothers smoked during pregnancy or who have been exposed to secondhand smoke are also more likely to develop asthma.

• Air pollution exposure—Exposure to ground-level ozone, the main component of smog, increases the risk for asthma.

heart disease, and respiratory disease. Most plant-based foods contain polyphenols, but good sources include berries, dried herbs and spices, cocoa powder, nuts, flaxseeds, artichoke, red onion, spinach, olives, and coffee and tea.8

FOODS THAT PROMOTE GUT HEALTH. Higher intake of animal foods, processed foods, alcohol, and sugar is associated with a gut microbial environment characteristic of inflammation, whereas higher intake of fruits and vegetables have the opposite effect.9 A healthy gut microbiome can benefit the body in many ways, one of which is helping to regulate inflammation.10 All fruits and contain soluble and insoluble dietary fiber; however, soluble fiber is more easily metabolized by gut bacteria.10 Black beans, Lima beans, kidney beans, asparagus, Jerusalem artichoke, sweet potato, pears, figs, apricots, and flax seeds are examples of plant-based foods high in soluble fiber.

nutrition source: vitamin C. Mar 2023. https://www. hsph.harvard.edu/nutritionsource/vitamin-c/. Accessed 9 May 2023.

8. Nourish by WebMDwebsite. Health foods high in polyphenols. 23 Nov 2022. https://www.webmd.com/ diet/foods-high-in-polyphenols. Accessed 9 May 2023.

9. Bolte LA, Vich Vila A, Imhann F, et al. Long-term dietary patterns are associated with pro- inflammatory and anti- inflammatory features of the gut microbiome. Gut 2021;70:1287–1298.

10. Guan ZW, Yu EZ, Feng Q. Soluble dietary fiber, one of the most important nutrients for the gut microbiota. Molecules. 2021;26(22):6802. NHR

• Obesity—Being overweight or obese increases the risk of developing asthma, though the reasons for this are unclear. Lowgrade inflammation in the body that occurs with extra weight is thought to be a factor. People with asthma who are obese typically have worse symptoms and more difficulty controlling their disease, compared to those with normal weight.7

HOW IS ASTHMA TREATED?

While there is no cure for asthma, there are several treatment options and techniques to help manage or prevent exacerbations.

Medications. Inhaled corticosteroids (ICSs)—ICSs are considered a first-line treatment option for asthma and are used as a maintenance therapy.2,8 ICSs work by regulating capillary permeability and lyosomal activity at the cellular level to reduce inflammation. ICSs can be delivered to the lungs by way of nebulizer (a device that turns the liquid medicine into a mist, which is then inhaled through a mouthpiece or mask), metered dose inhaler (a device that delivers a measured amount of medication as a mist, which is inhaled through a mouthpiece), or dry powder inhaler (a portable device that is breath-activated, delivering the medication when the individual takes a deep, fast breath through the inhaler). With consistent use, it can take hours to days for an ICS to reach its full therapeutic benefit.8

Short-acting beta-2 agonists (SABAs)—SABAs, also considered a first-line treatment option in asthma, are typically used as “rescue” medication because they provide quick relief (in under 5 minutes) from exacerbated asthma symptoms, as well as prevent exercise-induced asthma attacks. SABAs work by modulating the bronchial smooth muscle, causing the airway to dilate and relax, which makes breathing easier. SABAs can be administered in the form of an inhaler, nebulizer solution, or tablet, and can be used as a monotherapy or in combination with other agents.2,9

Long-acting beta-2 agonists (LABA)—LABA inhalers, such as

formoterol, dilate and relax the airway via modulation of the bronchial smooth muscle. Though quick to work compared to an ICS, formoterol usually takes at least five minutes provide relief and so does not work as quickly as a SABA. But formoterol has long-term therapeutic effects, and thus can be used for symptom relief and/or, when combined with an ICS, as a long-term maintenance therapy. Formoteral is available as a monotherapy or in combination with an ICS and/or SABA.2,10

Long-acting muscarinic agonists (LAMAs)—LAMAs have long been used in the treatment of chronic obstructive pulmonary disease (COPD). Recently, however, tiotropium became the first (and only, so far) LAMA inhaler to be FDA-approved for the treatment of asthma. Tiotropium works by inhibiting muscarinic-3 (M3) receptors, which results in reduced inflammation and increased bronchodilation. Tiotropium is recommended for use in adolescents and adults with poorly controlled asthma who are not adequately responding to first-line treatments. Treatment recommendations. Current guidelines. Current guidelines recommend using a step up/step down approach when treating asthma. In adults and adolescents with mild asthma, the preferred initial treatment is a lowdose ICS-formoteral combination therapy taken as needed for symptom relief. For moderate asthma, a low-dose ICS-formoteral combination therapy taken on a daily basis is recommended. For more severe asthma, medium-dose ICS-formoteral combination therapy is recommended. For severe asthma

that fails to respond adequately to previous treatments, the dosage of ICS-formoteral therapy may be increased and tiotropium therapy may be initiated.

Though not the GINA Science Committee’s preferred initial treatment method, for individuals with asthma for whom the preferred method is not possible or for those with stable asthma (i.e., haven’t had an exacerbating event within the last year) who are adherent to their current treatment regimen, SABA monotherapy or ICS-SABA combination therapy on an as needed or daily basis may be recommended.2

Lifestyle modifications. GINA guidelines2 recommend the following lifestyle modifications to mitigate symptoms/exacerbations of asthma:

1. Quit smoking and/or avoid second-hand smoke exposure.

2. Get regular exercise. Exercise can improve cardiopulmonary functioning and improve quality of life. Individuals with exerciseinduced asthma should consult with their physician on ways to prevent breakthrough symptoms while exercising.

3. Avoid occupational exposure to irritants (e.g., industrial dusts, gases).

4. Consume a diet high in fruits and vegetables. Several studies have found a positive association between regular consumption of fruits and vegetables and improvement in asthma symptoms.11 A reduction in proinflammatory cytokines and increase in antiinflammatory markers have been linked to increased fruit and vegetable intake in children and adults with asthma.11

5. Lose weight. For individuals with overweight or obesity, a physician-monitored weight loss program that includes both diet modification and regular strength and aerobic exercise is more effective in improving asthma symptoms than diet modification alone.

6. Avoid outdoor allergens and air pollution. If sensitive to outdoor allergens, such as pollen and mold, and/or air pollution, keeping inside a climate-controlled environment as much as possible, with windows and doors shut, when environmental conditions are unfavorable may help mitigate exposure.

7. Address emotional stress. In some individuals, emotional stress can

CARROT GINGER SOUP WITH RAISIN RELISH

Servings: 2 INGREDIENTS

Raisin Relish

3/4 cup raisins

1 tbsp minced fresh ginger

1 1/2 tsp honey

1/4 tsp mustard seeds

1/4 tsp ground cinnamon

1/4 tsp cayenne pepper

1/4 tsp salt

worsen the symptoms of asthma. Seeking help from a qualified mental health professional is recommended in individuals with asthma who are experiencing symptoms of anxiety or depression.

BOTTOM LINE

Asthma is a chronic condition of the respiratory system that involves abnormal immune-system functioning and environmental exposures. Genetics are thought to play a role in its development; however, exposure to occupational or environmental contaminants, having overweight or obesity, and/or lifestyle factors such as smoking have all been linked to developing asthma in adulthood. There is no cure for asthma,

DIRECTIONS

Raisin Relish

but there are medications that can help control and prevent exacerbations of the disease, including inhaled corticosteroids, short- and long-acting beta-2 agonists, and long-acting muscarinic agonists. Environmental and lifestyle modifications, such as avoiding triggering occupational/ environmental contaminants, eating plenty of fresh fruits and vegetables, getting regular exercise, stopping smoking, and losing weight, can also help improve symptoms.

Editor’s note: Consult with your physician if you think you have asthma or if your existing asthma is not improving with treatment.

SOURCES

1. World Health Organization (WHO). Chronic respiratory diseases: asthma. 3 May

1. Rinse raisins with fresh water.

2. Place all relish ingredients in a food processor or blender and pulse until just well combined. Store in the refrigerator.

Carrot Ginger Soup

1. Place all soup ingredients except salt in a blender and blend on the highest setting until completely smooth. Season with salt to taste after blended.

2. Serve at room temperature straight from the blender OR heat gently over medium heat and serve warm.

1/4 cup vinegar (preferably apple cider vinegar)

Carrot Ginger Soup

3 cups carrot juice

1/2 cup orange juice

1 avocado, peeled and deseeded

1/4 cup lemon juice

1 tbsp honey

1 tbsp minced fresh ginger

1/8 tsp ground nutmeg

Salt to taste

3. Pour soup into large soup bowls and top with a few spoonfuls raisin relish. Best if consumed within 24 hours.

Estimated nutrition information per serving (approx 2 cups/serving):

Calories: 423; Total Fat: 20.6g; Saturated Fat: 4.6g; Cholesterol: 0mg; Sodium: 713mg; Total Carbohydrate: 59.6g; Dietary Fiber: 12.7g; Total Sugars: 34.2g; Protein: 5.2g; Calcium: 93mg; Iron: 3mg; Potassium: 1,422mg NHR

2021. https://www.who.int/news-room/ questions-and-answers/item/chronicrespiratory-diseases-asthma. Accessed 3 May 2023.

2. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention—2023. Updated May 2023. https://ginasthma.org/2023-gina-mainreport/. Accessed 3 May 2023.

3. Holgate ST, Wenzel S, Postma DS, et al. Asthma. Nat Rev Dis Primers. 2015 Sep 10;1(1):15025.

4. Enilari O, Sinha S. The global impact of asthma in adult populations. Ann Glob Health. 2019;85(1):2.

5. Skaaby T, Husemoen LL, Thuesen BH, et al. IgE sensitization to inhalant allergens and the risk of airway infection and disease: a population-based study. PLoS One. 2017;12(2):e0171525.

6. Sinyor B, Perez LC. Pathophysiology of asthma. StatPearls [internet]. 8 May 2022. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. https://www.ncbi.nlm.nih.gov/ books/NBK551579/. Accessed 3 May 2023.

7. American Lung Association. Asthma causes & risk factors. 19 Apr 2023. https:// www.lung.org/lung-health-diseases/ lung-disease-lookup/asthma/learn-aboutasthma/what-causes-asthma. 3 May 2023.

8. Liang TZ, Chao JH. Inhaled corticosteroids. [Updated 2022 May 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/

NBK470556/

9. Hsu E, Bajaj T. Beta 2 agonists. [Updated 2022 Jun 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www. ncbi.nlm.nih.gov/books/NBK542249/

10. Drug Bank Online website. Formoteral. https://go.drugbank.com/drugs/DB00983. Accessed 8 May 2023.

11. Alwarith J, Kahleova H, Crosby L, et al. The role of nutrition in asthma prevention and treatment. Nutr Rev. 2020;78(11):928-938.

NHR

IT’S NOT THEM, IT’S YOU: POTATOES DON’T DESERVE THEIR BAD REPUTATION

Researchhas shown that health issues associated with potatoes may actually be due to how people are preparing them and what they’re eating them with.

Read more here: https:// www.sciencedaily.com/ releases/2022/12/221205104240. htm. NHR

Health Conditions

Other Chronic Respiratory Diseases

Chronic respiratory disease (CRD) is an umbrella term for diseases that prevent the lungs from working correctly, often affecting the airways, lung tissue, or lung circulation.1 Environmental and/or genetic factors can increase the risk of developing a CRD.2 Since most CRDs are incurable, the goal of treatment is to alleviate symptoms, prevent further lung damage, and improve quality of life. This article reviews several types of CRDs.

BRONCHIECTASIS

Bronchiectasis is a condition in which the walls of the airways widen, often due to scarring or inflammation, and thus cannot clear out mucus. This mucus buildup can lead to bacterial growth and infection. Symptoms include persistent cough, coughing up large amounts of mucus, wheezing, fatigue, and thickening of the skin under the nails (clubbing).3,4 Bronchiectasis can be caused by lung infections, disorders of the cilia, constantly inhaling food or liquids into the lungs, airway blockage, and other CRDs.3,4 About half of all cases of bronchiectasis in the US are due to cystic fibrosis. Treatment methods include medications (e.g., antibiotics, inhaled steroids, bronchodilators, mucus thinners), chest physical

therapy, and drinking enough water, which can prevent mucus from thickening.3

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

COPD is a group of progressive diseases characterized by inhibited airflow and breathing-related problems. COPD affects about 6.4 percent of individuals in the US and was the fourth leading cause of death in 2018.5 Most cases of COPD involve emphysema, in which air sacs and the walls between them are damaged and become less elastic, and chronic bronchitis, in which constant irritation and inflammation of the airways leads to swelling and overproduction of mucus.6 Symptoms include shortness of breath, persistent cough, coughing up large amounts of mucus, difficulty taking deep breaths, and making a whistling sound when breathing.5,6 Comorbidities, such as cardiovascular disease and arthritis, are prevalent in those with COPD.5,7 Smoking is one of the leading causes of COPD,6 and other risk factors include pollution, occupational exposures, respiratory infections, history of asthma, and alpha-1 antitrypsin deficiency. Quitting smoking and avoiding secondhand smoke are important for COPD

prevention, as well as treatment. Other treatments include medication (e.g., bronchodilators, antiinflammatory agents), pulmonary rehabilitation, pneumococcal pneumonia and influenza vaccination, oxygen therapy, and, in severe cases, surgery.5–7

CYSTIC FIBROSIS

Cystic fibrosis is an inherited disorder that alters mucus production. Normal mucus is slippery and thin, but in cystic fibrosis, mucus is thick and sticky. Therefore, instead of acting as a lubricant, mucus blocks ducts and passageways in the body, particularly the lungs and pancreas.8 Respiratory symptoms include coughing up mucus, persistent cough, wheezing, recurring lung infections or chest colds, excess salt in sweat, and frequent sinus infections. Treatment aims to slow disease progression and improve quality of life.9,10 Medications targeting gene mutations, other medications (e.g., antibiotics, anti-inflammatory agents, bronchodilators, mucus thinners), chest physical therapy, pulmonary rehabilitation, oxygen therapy, and nasal and sinus surgery can be used to treat cystic fibrosis.10

INTERSTITIAL LUNG DISEASE (ILD)

Over 200 types of lung disorders fall under ILD.9 ILD causes scarring, or fibrosis, in the interstitium, the tissue surrounding air sacs. Fibrosis stiffens the interstitium, making it difficult to breathe and reducing the amount of oxygen that can get into the body. Causes of ILD include autoimmune diseases (e.g., sarcoidosis, rheumatoid arthritis, lupus), hypersensitivity

pneumonitis (i.e., lung inflammation due to exposure to harmful foreign substances, including mold, dust, and fungus), breathing in other hazardous materials (e.g., asbestos [asbestosis], silica dust, coal dust, or cotton dust), certain medications, chest radiation therapy, and infection or partial recovery from certain diseases, including COVID-19. However, in many cases, such as with idiopathic pulmonary fibrosis, the cause of ILD is unknown. Shortness of breath that worsens over time is the most common symptom, and others include dry cough, fatigue, chest discomfort, and weight loss; advanced cases can result in clubbing, low blood oxygen, and high blood pressure.11,15 Treatment options depend on the underlying cause and disease severity; for example, those with an autoimmune disorder can take certain medications to suppress the immune system and alleviate swelling in the lungs.15 Other treatment options include corticosteroid use, pulmonary rehabilitation, and oxygen therapy.11,15

OBSTRUCTIVE SLEEP APNEA

(OSA)

OSA involves episodes of complete or partial collapse of the upper airway, accompanied by decrease in oxygen saturation or arousal from sleep. The prevalence of OSA in the US has increased over the years, and risk factors include male sex, older age, obesity, and craniofacial and upper airway abnormalities (e.g., undeveloped jaw, swollen tonsils).13,14 OSA has been associated with other medical conditions, such as congestive heart failure, atrial fibrillation, obesity hypoventilation

syndrome, asthma, COPD, ILD, and pulmonary hypertension.13–15 Sleep fragmentation results in fatigue and, in individuals with another CRD, can exacerbate existing symptoms and further decrease quality of life.15 Additional symptoms include snoring, excessive daytime sleepiness, choking or gasping during sleep, interrupted breathing while sleeping, and morning headaches.13,14 Treatment options include avoiding alcohol and drugs that might worsen OSA (e.g., opiates, sedatives, some antidepressants), treatment of comorbid disorders, positional therapy, continuous positive airway pressure (CPAP) therapy, use of custom-fitted oral appliances, and surgery.13

PULMONARY HYPERTENSION

Distinct from systemic hypertension, which affects the whole body, pulmonary hypertension occurs when there is high blood pressure in the arteries of the lungs. The arteries narrow, and the right side of the heart must work harder to pump blood.9,16,17 CRDs, autoimmune diseases that damage the lungs (e.g., scleroderma, rheumatoid arthritis), heart disease, heart failure, chronic low blood oxygen levels, birth defects of the heart, pulmonary embolism, and some medications (e.g., appetite suppressants) can cause pulmonary hypertension.9,16

Shortness of breath is the most prevalent symptom, and others include fatigue, lightheadedness, chest pain, swelling of the ankles and legs, and heart palpitations.16,17 Underlying medical conditions should be addressed when treating pulmonary hypertension. Various types of oral, intravenous, and

inhaled medications, as well as oxygen therapy, blood thinners, diuretics, and digoxin, can be utilized to treat pulmonary hypertension.16,18 Individuals taking blood thinners should consult with a physician before taking nonsteroidal antiinflammatory drugs (NSAIDs). People with pulmonary hypertension should avoid over-the-counter decongestants and medications that contain stimulants and consult with a physician before taking any herbal therapies, as they can lead to complications when taken with certain medications.18

EDITOR’S NOTE

Consult with a healthcare professional if you experience symptoms related to a CRD.

SOURCES

1. Medline Plus. Lung disease. Reviewed 13 Jul 2022. https://medlineplus.gov/ency/ article/000066.htm. Accessed 2 May 2023.

2. John Muir Health. Chronic lung disease. https://www.johnmuirhealth.com/healtheducation/conditions-treatments/lungsheart-blood/chronic-lung-disease.html. Accessed 2 May 2023.

3. Cedars-Sinai. Bronchiectasis. https:// www.cedars-sinai.org/health-

PEANUT BUTTER— FRUIT—OAT ENERGY SQUARES

Servings: 16

INGREDIENTS

1 cup creamy peanut butter

½ cup maple syrup

2 cups rolled oats, toasted

½ cup of your favorite dried fruit

library/diseases-and-conditions/b/ bronchiectasis.html. Accessed 2 May 2023.

4. World Health Organization. Chronic respiratory diseases: bronchiectasis. 18 Sep 2019. https://www.who.int/ news-room/questions-and-answers/ item/chronic-respiratory-diseasesbronchiectasis. Accessed 2 May 2023.

5. Centers for Disease Control and Prevention. Basics about COPD. Reviewed 9 Jun 2021. https://www.cdc. gov/copd/basics-about.html. Accessed 2 May 2023.

6. MedlinePlus. COPD. Updated 5 Oct 2021. https://medlineplus.gov/copd.html. Accessed 2 May 2023.

7. Institute of Medicine (US) Committee on a National Surveillance System for Cardiovascular and Select Chronic Diseases. Chronic lung disease. In: A Nationwide Framework for Surveillance of Cardiovascular and Chronic Lung Diseases. National Academies Press (US); 2011:3.

8. Mayo Clinic Staff. Cystic fibrosis –symptoms and causes. Mayo Clinic. 23 Nov 2021. https://www.mayoclinic.org/ diseases-conditions/cystic-fibrosis/ symptoms-causes/syc-20353700.

Accessed 2 May 2023.

9. Story CM. Chronic lung diseases: causes and risk factors. Healthline. Updated 11 Mar 2022. https://www. healthline.com/health/understandingidiopathic-pulmonary-fibrosis/chroniclung-diseases-causes-and-risk-factors. Accessed 2 May 2023.

10. Mayo Clinic Staff. Cystic fibrosis –diagnosis and treatment. Mayo Clinic. 23 Nov 2021. https://www.mayoclinic. org/diseases-conditions/cystic-fibrosis/

diagnosis-treatment/drc-20353706.

Accessed 2 May 2023.

11. American Lung Association. Interstitial lung disease (ILD). https://www.lung. org/lung-health-diseases/lung-diseaselookup/interstitial-lung-disease.

Accessed 2 May 2023.

12. Hadjiliadis D. Interstitial lung disease. Penn Medicine. Reviewed 6 Dec 2021. https://www.pennmedicine.org/ for-patients-and-visitors/patientinformation/conditions-treated-a-to-z/ interstitial-lung-disease. Accessed 2 May 2023.

13. Slowik JM, Sankari A, Collen JF. Obstructive sleep apnea. Updated 11 Dec 2022. In: StatPearls [Internet]. StatPearls Publishing.

14. Kline LR. Clinical presentation and diagnosis of obstructive sleep apnea in adults. UpToDate. Updated 13 Jan 2023. https://www.uptodate.com/contents/ clinical-presentation-and-diagnosisof-obstructive-sleep-apnea-in-adults. Accessed 2 May 2023.

15. Locke BW, Lee JJ, Sundar KM. OSA and chronic respiratory disease: mechanisms and epidemiology. Int J Environ Res Public Health. 2022;19(9):5473.

16. MedlinePlus. Pulmonary hypertension. Reviewed 20 Jan 2022. https:// medlineplus.gov/ency/article/000112. htm. Accessed 2 May 2023.

17. Pulmonary Hypertension Association. About pulmonary hypertension. https:// phassociation.org/patients/aboutph/. Accessed 2 May 2023.

18. Pulmonary Hypertension Association. Treatments. https://phassociation.org/ patients/treatments/. Accessed 2 May 2023. NHR

coat the parchment with cooking spray.

2. Mix peanut butter and maple syrup in a large bowl. Stir in oats, dried fruit, nuts, and salt. Spread the mixture firmly and evenly into the prepared pan. Refrigerate until cold, about 1 hour. Cut into 16 squares.

3. Store in an airtight container at room temperature for up to 3 days or refrigerate for up to 1 week.

Estimated nutrition information (per square):

½ cup chopped pistachios or your favorite nut

½ teaspoon salt

DIRECTIONS

1. Line an 8-inch-square baking pan with parchment paper, leaving extra hanging over two sides. Lightly

Calories: 206; Total Carbohydrate: 22g; Dietary Fiber: 3g; Total Sugars: 11g; Protein: 6g; Total Fat: 11g; Saturated Fat; 2g; Vitamin A: 17IU; Vitamin C: 1mg; Folate: 7mcg; Sodium: 127mg; Calcium: 20mg; Iron: 1mg; Magnesium: 17mg; Potassium: 108mg NHR

Exercising with Chronic Respiratory Disease

Chronic respiratory diseases (CRDs), such as asthma, chronic obstructive pulmonary disease (COPD), and interstitial lung disease (ILD), affect lung function, making it harder to breathe. Though individuals with CRDs might become more sedentary due to their symptoms, low levels of physical activity can decondition skeletal muscles, leading to increased breathlessness, and leg muscle deconditioning can cause leg fatigue and discomfort.1 In those with asthma, avoiding exercise can result in chronic deconditioning and lower cardiorespiratory fitness than those without asthma.2 In contrast, people with CRDs who perform regular physical activity exhibit improved exercise tolerance, lessened disease symptoms (e.g., labored breathing), increased ability to perform tasks of daily living, and enhanced quality of life.2–4 Furthermore, exercise promotes blood flow to the lungs

and heart, which improves oxygen delivery to the muscles.4,5

For individuals with COPD, exercise, particularly strength training, is one of the best tools to improve muscle function and quality of life.2,6 Many patients with COPD have comorbidities, such as hypertension, Type 2 diabetes, and/or cardiovascular disease, but research has shown that exercise training is beneficial, regardless of presence of comorbidities.6 Exercise also improves all-cause mortality in those with COPD.2 For individuals with ILD, research suggests that participating in pulmonary rehabilitation programs, which provide patients with exercise training along with education and support,7 can improve exercise tolerance, strength, and health-related quality of life.8

People with CRDs should practice a combination of aerobic and strength training. Experts recommend aerobic exercise 2 to 5

days per week for about 20 to 30 minutes per session and strength training 2 to 3 days per week with 2 to 3 sets of 8 to 15 repetitions.1,9 For those who cannot tolerate continuous aerobic training or who experience extreme exercise-induce oxygen depletion, interval aerobic training is an option.9 Examples of aerobic exercise include walking, cycling, and swimming. Examples of strength training include weight training machines, free weights, and bodyweight exercises targeting both arms and legs. Individuals should aim to perform exercises at a load that they can maintain for 8 to 15 repetitions while still experiencing muscular exhaustion by the end of the repetitions.1,9

Individuals with CRD should take certain precautions before exercising. They should avoid exercising outdoors when the air quality is poor. Some individuals might need to use an inhaler prior

to exercising to prevent breathing difficulties.5,7 Those with asthma can reduce their risk of exercise-related adverse events through disease control.2,3

When exercising, individuals with CRD (and supervising professionals when applicable) should continually monitor their condition.2 Exercise should be stopped if any adverse symptoms, such as shortness of breath, chest pain or discomfort, tightening or pressure in the chest, unusual aching or joint pain, nausea, or lightheadedness occur, and a healthcare professional should be immediately consulted.4

TIPS

• Always perform warm ups and cool downs before and after exercising.

• Find a workout buddy who will join you in physical activities.

• Stay hydrated, especially while exercising.

• Don’t forget to stretch after each workout.

SOURCES

1. Fierro-Carrion GA, Mahler DA. Exercise prescription for patients with chronic lung disease. Clin Pulm Med 2002;9(1):1–5.

2. Physiopedia. Physical activity and respiratory conditions. https://www. physio-pedia.com/Physical_Activity_ and_Respiratory_Conditions. Accessed 4 May 2023.

3. Burr JF, Davidson W, Shephard RJ, Eves N. Physical activity in chronic respiratory conditions: assessing risks for physical activity clearance and prescription. Can Fam Physician. 2012;58(7):761–764.

4. My HealtheVet. Exercise to build healthy lungs. Updated 27 Oct 2022. https:// www.myhealth.va.gov/mhv-portalweb/ss20181019-build-healthy-lungs. Accessed 4 May 2023.

GRILLED SALMON WITH BLUEBERRY SAUCE

Makes 4 servings

INGREDIENTS

4 skinless salmon filets

1 ½ cups blueberries, fresh or frozen

½ yellow onion, chopped

1 cloves of garlic, minced

1 tbsp olive oil

2 tbsp balsamic vinegar

2 tbsp lemon juice

½ tsp lemon zest

1 tbsp packed light brown sugar

½ tbsp fresh basil, chopped

½ tsp salt

¼ tsp pepper

DIRECTIONS

1. Cook onion and garlic in a medium saucepan over medium-high heat, until softened, 3–4 minutes. Add blueberries (thawed, if frozen), balsamic vinegar, lemon juice, lemon zest, and brown sugar.

2. Bring the ingredients to a boil, then reduce heat. Let simmer for 15 minutes.

5. American Lung Association. Being active with asthma. Updated 28 Nov 2022. https://www.lung.org/lung-healthdiseases/lung-disease-lookup/asthma/ managing-asthma/asthma-andexercise. Accessed 4 May 2023.

6. Spruit MA, Burtin C, De Boever P, et al. COPD and exercise: does it make a difference? Breathe (Sheff) 2016;12(2):e38–e49.

7. Sockrider M, Corn J. Exercise with lung disease. Am J Respir Crit Care Med Vol 2019;200(12):P22–P23.

8. Mendes RG, Castello-Simões V, Trimer R, et al. Exercise-based pulmonary rehabilitation for interstitial lung diseases: a review of components, prescription, efficacy, and safety. Front Rehabil Sci. 2021;2:744102.

9. Gloeckl R, Zwick RH, Fürlinger U, et al. Prescribing and adjusting exercise training in chronic respiratory diseases - expert-based practical recommendations. Pulmonology 2022:S2531-0437(22)00215-X. NHR

3. Meanwhile, pat the salmon dry. Drizzle with olive oil. Season with basil, salt, and pepper.

4. Preheat grill to medium-high heat. Grill salmon for 4 to 6 minutes on each side.

5. Drizzle blueberry sauce on top of salmon and serve. Estimated nutrition information: Calories: 238; total fat: 15.8g; saturated fat: 3.1g; cholesterol: 65mg; sodium: 360mg; total carbohydrate: 12.5g; dietary fiber: 1.9g; total sugars: 8.4g; protein: 22.9g; calcium: 37mg; iron: 2mg

Tips: Can’t grill outside? Use a stove-top grill pan or bake salmon in the oven at 450 degrees for 10 to 12 minutes. NHR

How to do Navasana (Boat Pose)

Navasana, or the boat pose, strengthens and tones the abdominal and lower back muscles. It also builds mental focus because this is a challenging pose and requires you to push through the discomfort to open and stretch your body. There are two stages— Stage 1 takes physical effort and mental focus, but it is not as challenging as Stage 2. If you find you cannot achieve the Stage 2 pose yet, repeat Stage 1. You will reap the same benefits, and with consistency and dedication, you will eventually achieve full navasana as you build your core muscles and sharpen your mind. Namaste.

Source: Brown C. Boat pose (navasana). In: The Yoga Bible: The Definitive Guide to Yoga Postures. Cincinnati, OH: Walking Stick Press, 2003;178–179. NHR

STAGE 1

1. Start from a sitting position on the floor, with legs straight out in front of you and hands resting flat on the floor beside the hips.

2. While exhaling, lean your body back slightly as you bend the knees and lift your legs off the floor. The shins should be parallel with the floor. Hold the back of your thighs with your hands.

3. Keep your back somewhat concave. Stretch arms forward so the palms are lightly touching the outside of the calves. Pull the shoulders back and lift the chest forward toward the knees.

4. Hold this position for several breaths, then release on exhale, rest, and repeat or move on to Stage 2.

STAGE 2

1. From the bent knee pose in Stage 1, slowly straighten legs upward until fully extended. Your feet should be higher than your head. Using your core muscles, focus on keeping legs extended and upper body lifting upwards so that the back doesn’t round out.

2. For more advanced practitioners, interlace fingers behind head, keeping elbows wide. Do not sag into your lower back or collapse your chest toward your tummy. Hold for several breaths, then release on an exhale.

Nut and Seed Butters A Comprehensive Guide

The world of nut and seed butters has expanded greatly over the past few years, and it’s easy to see why. They’re flavorful, great in a meal or snack, and, best of all, most varieties have much of the same health benefits as their respective unprocessed nuts and seeds because they do not contain any added sweeteners, oils, or preservatives.1 From classic peanut butter to allergy-friendly sunflower seed butter, there’s enough variety to please anyone.

MAKING NUT AND SEED BUTTERS

The manufacturing process is similar for nut and seed butters. The nuts or seeds are roasted, then rapidly cooled to prevent oil loss. Blanching then removes the skin, and unacceptable nuts or seeds are removed via sorting. Following that, the nuts or seeds are ground, often via a two-step process. Coarse grinding first processes the nuts or seeds to a medium fineness, after which other flavor-enhancing ingredients can be added. Then, the

ingredients are more finely ground. For chunky nut butter, the grinding process can be stopped before all the chunks are processed into a smooth creamy texture or chopped nuts can be mixed into the butter after fine grinding.1

SPREAD VS. BUTTER

A nut butter is defined as containing at least 90-percent nuts,1,2 while a nut spread is defined as containing at least 40-percent nuts, which can be added in various forms, such as a paste or slurry.2 According to United States (US) Food and Drug Administration (FDA) requirements, commercial peanut butter must be made of at least 90-percent peanuts, with up to 10 percent added seasoning and stabilizing ingredients being allowed; these additional ingredients may include hydrogenated vegetable oil, salt, and sweeteners, though the fat content may not exceed 55 percent. Furthermore, commercial peanut butter may not contain artificial

flavorings, artificial sweeteners, chemical preservatives, or color additives.3,4 Commercial natural peanut butter may not contain stabilizers.1

VARIETIES OF NUT AND SEED BUTTERS

Peanut butter. Compared to the other nut and seed butters in this article, peanut butter tends to be the most affordable5 and has the highest protein content, at 7g per two tablespoons.4,6 Peanut butter is an excellent source of nutrients, with two tablespoons providing 20 percent or more of the daily value (DV) of manganese and niacin and 10 to 19 percent of the DV of magnesium, phosphorus, selenium, and vitamin E.6 High niacin intake has been associated with lowered risk of glaucoma,7 and niacin and vitamin E have shown protective effects against Alzheimer’s disease.8 Most of the 16g of fat in a serving of peanut butter are unsaturated fats, which have been shown to reduce the risk of heart disease.

When selecting a peanut butter, avoid reduced-fat alternatives, since not only is peanut butter mostly composed of healthy fats, but to make up for the lower fat content, reduced-fat spreads have a higher carbohydrate content due to added sugars.8

Almond butter. Another popular option is almond butter. Two tablespoons have 6.7g of protein and 18g of fat. It provides 20 percent or more of the DV for vitamin E, magnesium, and manganese, and is a good source of dietary fiber, phosphorous, calcium, copper, and riboflavin.6

Compared to peanut butter, almond butter is an even better source of monounsaturated fat, which helps fight inflammation, improve brain function, reduce low-density lipoprotein (LDL) levels, raise highdensity lipoprotein (HDL) levels, and prevent heart disease;6,7,9 almond butter also has significantly less saturated fat than peanut butter.6 Eating almond butter has been associated with improved bone health and reduced cell damage due to its calcium and antioxidant content, respectively.7,9

Cashew butter. If you’re looking a nut butter with a very creamy texture, choose cashew; this variety is so creamy, you can substitute it for milk and cream in some recipes!5

Cashew butter has less protein than other nut butter options, ranging from 4 to 6g in a two tablespoon serving, and more carbohydrates at about 10g per serving. Cashew butter contains about 10 percent of the DV for magnesium, iron, and phosphorus, as well as small amounts of vitamin E, vitamin K, and potassium.10,11 Cashew butter

provides over 20 percent of the DV for copper,10 a mineral involved in energy and muscle tissue production and iron metabolism.7

Like other nut butters, the 16g of fat per serving is largely composed of unsaturated fat, which helps lower LDL and total cholesterol and improves heart health.7,11

Walnut butter. The main draw of walnut butter is its high content of omega-3 fatty acids, which fight inflammation and improve cholesterol. The trade-off is a lower protein content, around 5g in two tablespoons, as well as less fiber than some other options.5,12

Sunflower seed butter. Sunflower seed butter was developed as an option for those with peanut and tree nut allergies through the collaboration of the US Department of Agriculture Agricultural Research Service (USDA-ARS) and the sunflower seed producer Red River Commodities.13 Sunflower seed butter has less protein than nut butters, with 5.5g in a twotablespoon serving. However, compared to almond and peanut butters, sunflower seed butter has significantly more phosphorus, zinc, copper, magnesium, and selenium, and is a good source of manganese and vitamin E. It provides 11 percent of the DV of niacin as well. Sunflower seed butter contains about 18g of fat, with more monounsaturated fatty acids than both almond and peanut butters and less saturated fat than peanut butter.6 As with nut butters, the healthy fats in sunflower seed butter have cardioprotective effects, and the antioxidants it contains can reduce cell damage.14,15 Additionally, sunflower seed butter has anti-inflammatory properties.15

Pumpkin seed butter. Pumpkin seed butter has a unique, earthy flavor.14 The protein content in pumpkin seed butter can range from 5 to 9g per two tablespoons.12,16,17 It is a good source of manganese, magnesium, iron, and vitamin E.12,18 Pumpkin seed butter also provides high amounts of vitamin K, which plays an important role in blood clotting, metabolism, and bone health.14

BUYING TIPS

Aim for one-ingredient nut and seed butters to avoid added sugars, sodium, or oils. Try to avoid “no stir” products as well, as these often contain palm or rapeseed oil, both of which increase the saturated fat content.5

SOURCES

1. McHugh T. How nut and seed butters are processed. Food Technology Magazine 1 Nov 2016. https://www.ift.org/newsand-publications/food-technologymagazine/issues/2016/november/columns/ processing-how-nut-and-seed-butters-areprocessed. Accessed 26 Apr 2023.

2. Shakerardekani A, Karim R, Ghazali HM, Chin NL. Textural, rheological and sensory properties and oxidative stability of nut spreads—a review. Int J Mol Sci 2013;14(2):4223–4241.

3. United States Food and Drug Administration. CFR - Code of Federal Regulations Title 21. Updated 28 Mar 2023. https://www.accessdata.fda.gov/ scripts/cdrh/cfdocs/cfcfr/CFRSearch. cfm?fr=164.150&SearchTerm= peanut%20butter. Accessed 26 Apr 2023.

4. National Peanut Board. Mythbusters: natural peanut butter vs. regular peanut butter. https://www.nationalpeanutboard. org/news/mythbusters-natural-peanutbutter-vs-regular-peanut-butter.htm. Accessed 26 Apr 2023.

5. Cedars-Sinai Staff. Nut butters: which one is healthiest? Cedars-Sinai. 17 Jan 2020. https://www.cedars-sinai.org/blog/nutbutters.html. Accessed 26 Apr 2023.

6. Thomas R, Gebhardt S. Sunflower seed butter and almond butter as nutrient-rich alternatives to peanut butter. https://www. ars.usda.gov/ARSUserFiles/80400525/ Articles/ADA10_SunflowerAlmondButter.

pdf. Accessed 26 Apr 2023.

7. Kadey M. Healthy nut butters to add to your postrun meals. Runner’s World. 18 Oct 2022. https://www.runnersworld.com/ nutrition-weight-loss/a41646858/healthynut-butters/. Accessed 26 Apr 2023.

8. Campbell A. Is peanut butter good for diabetics? Diabetes SelfManagement. 23 Sep 2020. https://www. diabetesselfmanagement.com/healthyliving/nutrition-exercise/is-peanut-buttergood-for-diabetics/. Accessed 26 Apr 2023.

9. Lehman S. Almond butter nutrition facts and health benefits. Verywell Fit. Updated 15 Oct 2022. https://www.verywellfit.com/ almond-butter-nutrition-facts-calories-andhealth-benefits-4115426. Accessed 26 Apr 2023.

10. FoodData Central. Cashew butter. United States Department of Agriculture. https:// fdc.nal.usda.gov/fdc-app.html#/fooddetails/2343013/nutrients. Accessed 26 Apr 2023.

11. Garone S. Cashew butter nutrition facts and health benefits. Verywell Fit. Updated 11 Sep 2020. https://www.verywellfit.com/ cashew-butter-nutrition-facts-and-healthbenefits-4800934. Accessed 26 Apr 2023.

12. Penner E. Your guide to nut and seed butters. Foodsmart. https://www.foodsmart. com/blog/guide-nut-seed-butters.

Accessed 26 Apr 2023.

13. United States Department of Agriculture. Sunflower butter. Nov 2010. https://www. ars.usda.gov/is/br/sunbutter/sunbutter.pdf.

Accessed 26 Apr 2023.

14. Kadey M. Here are the nutritional facts on sunflower and other seed butters. Runner’s World. 1 Feb 2021. https://www. runnersworld.com/nutrition-weight-loss/ a35362933/seed-butter-vs-nut-butter/.

Accessed 26 Apr 2023.

15. Frey M. Sunflower seed butter nutrition facts and health benefits. Verywell Fit. Updated 28 Sep 2022. https://www.verywellfit.com/ sunflower-seed-butter-nutrition-facts-andhealth-benefits-5093491. Accessed 26 Apr 2023.

16. FoodData Central. Organic pumpkin seed butter. United States Department of Agriculture. https://fdc.nal.usda.gov/fdcapp.html#/food-details/1859379/nutrients. Accessed 26 Apr 2023.

17. FoodData Central. Roasted pumpkin seed butter, roasted pumpkin. United States Department of Agriculture. https:// fdc.nal.usda.gov/fdc-app.html#/fooddetails/1979362/nutrients. Accessed 26 Apr 2023.

18. Amidor T. What are seed butters and are they healthy? 15 Feb 2019. Food Network. https://www.foodnetwork.com/healthyeats/ news/2019/02/what-is-seed-butter-and-isit-healthy. Accessed 26 Apr 2023. NHR

DIY NUT BUTTER

Makes approximately 11/2 cups of nut butter

INGREDIENTS

3 cups of your favorite nuts, raw Optional add-ins salt (~1/2 tsp per 3 cups nuts) flax, chia, and/or hemp seeds chocolate vanilla extract (to taste)

DIRECTIONS

1. Preheat oven to 350 degrees F.

2. Spread raw nuts out on a baking sheet and roast them in the oven for until golden brown (about 8–12 mins). For nuts with skins, remove skins after roasting.

3. Add roasted nuts to a food processor or blender and blend until very smooth and creamy.

4. Once creamy, add in any optional ingredients.

5. Place nut butter in a clean glass jar with lid and store in the refrigerator for up to 3 weeks.

Estimated nutrition information (per tablespoon, no salt added): Calories: 104; Carbohydrates: 3.8g; Protein: 3.8g; Fat: 9g; Saturated Fat: 0.7g; Trans Fat: 0g; Cholesterol: 0mg; Fiber: 2.2g; Sugar: 0.8g NHR

POST-WORKOUT PROTEIN: SEPARATING FACT FROM FICTION

You may have read or heard that muscles are more receptive to protein uptake immediately after a workout; however, research has not supported that theory. Rather, various studies are showing that muscles are more receptive to protein intake at one, two, and three hours following a workout, and benefits might extend up to 24 hours after exercising. Eating an adequate amount of protein is important for building and repairing muscle fibers, especially after a tough workout. But more isn’t necessarily better—the muscles can only absorb about 15 to 30g at a time, so no need to overdo it on protein consumption after a workout.

Source: Fetters KX, Howley EK. Post-workout protein: separating fact from fiction. US News. 5 May 2023. https://health.usnews.com/wellness/fitness/articles/do-you-really-need-protein-rightafter-your-workout. Accessed 8 May 2023. NHR

Unraveling Age-related HEARING LOSS

Age-related hearing loss (ARHL), also known as presbycusis, is a common condition affecting older adults in the United States (US). About onethird of adults between the ages of 65 and 74 years have hearing loss, and prevalence increases to about half of adults over the age of 75 years.1 In general, ARHL occurs in both ears and develops gradually, so some adults might not notice their hearing loss until later stages;1,2 in some cases, family members or friends might notice hearing loss in a loved one before the individual notices it themselves.3

Multiple factors can contribute to the development of ARHL. Agerelated factors include changes to the inner and middle ears and along the neural pathways to the brain.1,3 Use of certain medications (e.g., salicylates, loop diuretics, aminoglycoside) or exposure to toxins, such as lead, carbon monoxide, styrene, mercury, and toluene, can contribute to ARHL as

well. Genetics, long-term exposure to noise, and hormonal factors are also associated with ARHL.3 Diseases associated with hearing loss include Type 2 diabetes, stroke, cardiovascular disease, and hyperlipidemia. Smoking has been associated with ARHL as well.3,4 Other risk factors include male sex, being of non-Hispanic White descent, and lower education level.4,5

Adults with hearing loss experience difficulty understanding speech, which, along with other changes associated with ARHL, is thought to be due to age-related alterations in the peripheral and central auditory pathways and cognitive functions.4,6 Research has shown that older age is correlated with poorer recognition of time-compressed (rapid) speech, compared to younger adults,6 as well as difficulty understanding speech in the presence of other noise or reverberation.4,6

Multiple studies have shown an association between ARHL and

cognitive decline and dementia, but the exact mechanisms behind this link is unknown.3–7 Cognitive processes involved in speech comprehension that can become impaired with age include working memory, processing speed, selective attention, and divided attention.4,6 Several hypotheses have been posited to explain the association between ARHL and cognitive decline. The common cause hypothesis proposes that there is a common neurodegenerative mechanism responsible for both ARHL and cognitive decline.4,7 The information degradation hypothesis suggests that impaired hearing causes an increased demand for resources required for cognitive processing, which therefore results in taking resources that were to be used for other cognitive functions, such as memory, and reallocating them toward auditory perception.3,4,7 The sensory deprivation hypothesis postulates that long-term reallocation of cognitive resources

toward auditory perception due to the sensory deprivation caused by ARHL is responsible for cognitive decline, emphasizing the role of cortical reorganization.4,7 Furthermore, the decreased social interaction and increased depression associated with ARHL could contribute to cognitive decline.4,6,7

If you suspect you might have hearing loss, consult with a primary care physician, otolaryngologist, or audiologist. Work to prevent hearing loss by limiting your time around loud noises, wearing earplugs or protective earmuffs when exposed to high levels of environmental noise, and monitoring your risk factors.1,3 While ARHL cannot be cured, it can be managed. Hearing aids can be utilized to amplify sounds and have been associated with improved communication and

quality of life3 and decreased risk of cognitive decline.2 Hearing aids can be prescribed, and over-thecounter hearing aids have recently become available for those with mild-to-moderate hearing loss.1,2 It is important to note that adjusting to a hearing aid can take time and effort, and some may find them uncomfortable to wear.3 Cochlear implants are a surgical option to treat severe hearing loss.1,2 Numerous assistive devices, such as those that amplify sounds or send visual signals or vibrations, can help as well.2

SOURCES

1. National Institute on Deafness and Other Communication Disorders. Age-related hearing loss (presbycusis).Updated 17 Mar 2023. https://www.nidcd.nih.gov/ health/age-related-hearing-loss. Accessed 3 May 2023.

2. National Institute on Aging. Hearing loss: a common problem in

older adults. Reviewed 19 Jan 2023. https://www.nia.nih.gov/health/ hearing-loss-common-problemolder-adults. Accessed 3 May 2023.

3. Cheslock M, De Jesus O. Presbycusis. Updated 12 Feb 2023. In: StatPearls [Internet]. StatPearls Publishing.

4. Jayakody DMP, Friedland PL, Martins RN, Sohrabi HR. Impact of aging on the auditory system and related cognitive functions: a narrative review. Front Neurosci 2018;12:125.

5. Sheffield AM, Smith RJH. The epidemiology of deafness. Cold Spring Harb Perspect Med 2019;9(9):a033258.

6. Li-Korotky HS. Age-related hearing loss: quality of care for quality of life. Gerontologist. 2012;52(2):265–271.

7. Slade K, Plack CJ, Nuttall HE. The effects of age-related hearing loss on the brain and cognitive function. Trends Neurosci 2020;43(10):810–821. NHR

Summer Vegetables

What’s in Season Now?

It’s farmer’s market time! Spring and early summer crops being harvested, so grab your reusable shopping bags and head on over to your local farmer’s market to check out the goods. Here’s what’s in season now:

BEET

Benefits: low in calories, potent anti-inflammatory properties, high in fiber, high in nitrates, good source of potassium

Preparations: roasted, pickled, raw, juiced

BLUEBERRY

Benefits; potent anti-inflammatory properties; rich in antioxidants; good source of vitamins C and K, manganese, and soluble fiber

Preparations: raw, juiced, baked, simmered, made into jams and jellies

GARLIC

Benefits: antiinflammatory, antibacterial, immune-boosting, and antifungal properties

Preparations: raw, roasted, sautéed

LETTUCE

Benefits: low in calories, high in fiber, hydrating, good source of vitamins A and K

Preparations: raw

PARSNIP

Benefits: nutritionally dense (low calorie/ high nutritional content), excellent source of vitamin C and potassium, good source of fiber

Preparations: baked, boiled, roasted, mashed, sautéed, raw

SPINACH

Benefits: nutritionally dense (low calorie/high nutritional content); high in vitamin C, lutein, vitamin K, vitamin A, and iron; good antioxidant properties

Preparations: raw, juiced, steamed, baked, sautéed

Source: Nourish by WebMD website. Diet and weight management. Food reference. https://www.webmd.com/diet/ medical-reference/default.htm Accessed 15v May 2023. NHR

NEW POTATO

Benefits: good source of fiber, resistant starches (soluble and insoluble fiber), magnesium, potassium, vitamin C, and vitamin B6; antioxidant properties

Preparations: boiled, mashed, baked, roasted, sautéed

RADISH

Benefits: antioxidant properties; high in phenolic compounds; good source of vitamin C, calcium, potassium, and nitrates

Preparations: raw, pickled, roasted

STRAWBERRIES

Benefits: rich in vitamin C and polyphenols;l anti-inflammatory; good source of magnesium, phosphorous, calcium, potassium, folate, and vitamin K

Preparations: raw, juiced, baked, simmered, made into jams and jellies