Enjoy a warm and comforting Winter Berry Tart made easy with frozen berries and puff pastry. This simple recipe is perfect for a quick dessert and offers a burst of fresh flavor. Creative Cooking for the Health-Conscious Gourmet FibonacciRECIPES  | Culinary Medicine   Recipe This deliciously simple recipe provides the fresh flavor of berries made with frozen mixed berries folded into a puff pastry crust. Ingredients: 2.5 Cup frozen mixed berries, unsweetened 2 Tbsp granulated sugar 1 tsp lemon juice 1 Tbsp corn starch 1 sheet frozen puff pastry 1 tsp flour 2 Tbsp turbinado sugar 2 Tbsp milk  Cooking spray Ice cream or whipped cream, if desired  Instructions Thaw berries. Drain excess liquid and mix in corn starch, granulated sugar and lemon juice. Set aside Thaw the puff pastry until it can be unfolded without breaking, about 20 minutes Pre heat oven to 375 degrees Coat a cookie sheet with cooking spray On lightly floured surface, roll the puff pastry to a form a 9” circle, about ¼” thick Carefully lift puff pastry onto prepared cookie sheet Spoon berry mixture into the center of the pastry Fold up sides of pastry circle overlapping to form an edge surrounding the berries, as shown in the photo  Brush the edge with a light coating of milk  and sprinkle edge and berries with turbinado sugar Bake in preheated oven for 30-35 minutes until crust is brown and berries are bubbly Cool on cookie sheet for at least 10 minutes before cutting. Serve as is, or top with ice cream, or whipped cream. Nutritional Information Makes 6 Servings Nutrients in a serving:  Calories  210, Total Fat 9.5g, Saturated Fat 1g, Cholesterol 0 mg, Total Carbohydrate 27g, Dietary fiber 3g, Protein 3g, Potassium 60mg, Sodium 145mg Chef and Author : Mary B Grosvenor, MS, RD   Medically Reviewed by FibonacciMD editors. Editor’s comments- appropriate for low calorie, low cholesterol, lactovegetarian dietary regimen.

Like the taste of chili con carne but don’t want to eat the meat? Try this plant-based, stove-top Chili Non Carne recipe and enjoy the tasty benefits of chili peppers and a powerful protein and fiber punch. Creative Cooking for the Health-Conscious Gourmet FibonacciRECIPES  | Culinary Medicine   Low-Fat | NO-Cholesterol | High Fiber | High-Protein Chili non Carne Recipe Enjoy a bowl of this warming chili that skips the carne (meat) and uses a plant-based meat substitute to replicate the texture and substance of beef. This chili provides plenty of protein, fiber, vitamins and minerals without the saturated fat and cholesterol of red meat. Ingredients: ½ onion, chopped 1 clove garlic, diced 2 tb olive oil 1 tsp cumin 2 Tb Chili powder 1 tsp oregano 1 tsp basil ½ tsp cinnamon ½ tsp cayenne pepper ½ tsp salt 1 4-oz can diced roasted green chilis ½ red bell pepper, chopped 1.5 cups Gardein™ Plant-Based Ground Be'f  (or 2 servings of other plant-based meat substitute) 1 15-oz can diced tomatoes 2 15-oz cans beans, drained and rinsed – use any combination of dark or light red kidney beans and pinto beans,  1 cup  low sodium vegetable broth  2 tb masa harina  ½ tsp lime juice Garnishes such as with sliced jalapeno, shredded cheese, scallions, parsley, and cilantro Directions: Sauté diced onion in olive oil until translucent, 3-5 minutes Add chopped garlic and cook for 1 minute Stir in dry spices: cumin, Chili powder, oregano, basil, cinnamon, and cayenne  Add canned green chilis, red bell pepper and 2 tb of water. Stir, cover, and turn off heat. Allow flavors to meld for 5-10 minutes Add plant-based meat and cook on low heat covered for 5 minutes Add canned tomatoes with liquid, drained beans, vegetable broth and salt.  Bring to a boil, reduce heat and simmer for 30 minutes.   Stir in Masa harina to thicken Simmer for an additional 15-30 minutes, stir occasionally. Taste and add more chili powder as needed Add lime juice just prior to serving NOTES:  Appropriate for low fat, no cholesterol, high protein, and high fiber diet regimens. Nutritional Information: Serves 5 Calories 246, Total Fat 7g, Saturated Fat 0.9 g, Cholesterol 0mg, Total Carbohydrate 32g, Dietary fiber 11g, Protein 16g, Potassium 744mg, Sodium 675mg Chef and Author : Mary B Grosvenor, MS, Registered Dietitian Medically Reviewed by FibonacciMD editors. More about chili Check out the article " Chilly Outside? Reach for a Bowl of Chili " and find out why chili is the ultimate cold-weather comfort food. Explore its health benefits, and uncover the nutritional value not only of a bowl of chili but also of its star ingredient—the mighty chili pepper.  initially posted 2/2024

Loaded with fresh vegetables, this easy minestrone soup is low in calories, fat, and cholesterol—yet rich in fiber and flavor. Creative Cooking for the Health-Conscious Gourmet FibonacciRECIPES  | Culinary Medicine   Recipe There’s nothing like a warm bowl of soup on a cold winter day. This hearty soup is chocked full of vegetables. It uses canned and frozen vegetables along with fresh ones that are typically available all winter. (Explore the nutritional benefits of fresh, frozen, and canned vegetables in our article “ Eat Your Vegetables: Fresh, Frozen, or Canned? ”) Ingredients: 1 medium onion, diced  ½ cup diced carrots ½ cup diced celery 2 cloves garlic, sliced  1 Tbsp dried parsley flakes 1 tsp dried basil ½ tsp salt ¼ tsp black pepper 1 (15.5 oz) can kidney beans 1 (28 oz) can diced tomatoes with juice 1 cup shredded cabbage 1 cup frozen peas 1 (10-12 oz) bag frozen Italian vegetables  2 oz (1/2cup) dry spaghetti, broken into pieces 5 cups low-sodium chicken broth Instructions Spray large pot or Dutch Oven with cooking spray. Sauté diced onion for 3-5 minutes until translucent. Add carrots and celery, cook for another 3 minutes. Stir in garlic, parsley, basil, salt, and pepper and cook for another 2 minutes. Add kidney beans and tomatoes with juice. Cook on medium heat for 10 minutes. Stir in shredded cabbage, peas, and Italian vegetables and cook for 2 more minutes. Add dry pasta and chicken broth and bring to boil, reduce heat to a simmer and cook for 30 minutes, stirring occasionally. Nutritional Information Makes 6 1.5 cup Servings Nutrients in a serving:  Calories  155, Total Fat 0.7g, Saturated Fat 0g, Cholesterol 0mg, Total Carbohydrate 30g, Dietary fiber 7g, Protein 9g, Potassium 660mg, Sodium 430mg Chef and Author : Mary B Grosvenor, MS, RD   and Lori A Smolin, PhD Medically Reviewed by FibonacciMD editors. Editor’s comment- Ideal for low-calorie, low fat, low cholesterol, high fiber dietary regimen. Replace the chicken broth with vegetable broth and then suitable for vegetarians too.

Vegetarian Lasagna: A Flavorful, Low-Calorie Feast Packed with Veggies and Cheese! Creative Cooking for the Health-Conscious Gourmet FibonacciRECIPES  | Culinary Medicine   Recipe This hearty vegetarian lasagna is a perfect blend of wholesome ingredients like spinach, zucchini, mushrooms, and ricotta cheese, layered with savory spaghetti sauce and gooey mozzarella. Easy to make and packed with flavor, it’s a crowd-pleaser that fits into a low-calorie, high-fiber diet. Serve it up for family dinners or special occasions—it’s sure to impress!.  Ingredients: 6 cups spaghetti sauce 0.5 cup carrot, grated 0.5 tsp oregano 6 lasagna noodles, cooked 16 oz ricotta cheese 1 package frozen, chopped spinach, thawed and well drained 2 eggs 1.5 cups zucchini, thinly sliced 1 cup mushrooms, sliced 3 cups mozzarella cheese, shredded 0.5 cup parmesan cheese, grated Salt and pepper to taste Instructions Preheat oven to 350oF. Mix carrots, oregano, and spaghetti sauce together; season to taste. In a separate bowl, mix ricotta, spinach, and eggs and season. Spread 0.5 cup spaghetti sauce in bottom of 9 x 13 inch baking dish. Layer three lasagna noodles and half of the remaining sauce, the ricotta mixture, the sliced zucchini, the sliced mushrooms, the mozzarella, and the parmesan cheese. Repeat layers with remaining ingredients. Bake for about 45 minutes. Nutritional Information Makes 8 Servings Nutrients in a serving:   Calories: 343, Total fat: 11.4: g, Saturated fat: 6.3 g, Trans fat: 0 g, Cholesterol: 89 mg, Sodium: 630 mg, Potassium: 691 mg, Total carbohydrates: 38.4 g, Dietary fiber: 3.6 g, Sugars: 5.7 g, Protein: 23.7 g Chef and Author : Justin Gillette, certified executive chef and chef author Medically Reviewed by FibonacciMD editors. Editor’s note: Appropriate for a low-calorie, high-fiber, ovo-lacto vegetarian regimen.

Muffaletta Makeover: A Leaner, Flavor-Packed Delight Creative Cooking for the Health-Conscious Gourmet FibonacciRECIPES  | Culinary Medicine   Recipe Muffaletta is a New Orleans favorite. The typical recipe includes several processed cured meats; this healthier version replaces them with leaner, lower sodium options.  This recipe requires preplanning as the filling must be refrigerated overnight before assembling the sandwich but the deliciousness is worth it.  Ingredients: 1 cup green pimento olives ½ cup black olives ½ cup olive oil ½ cup diced pimentos 1/3 cup Giardiniera (Italian relish) 2 Tbsp capers ½ cup chopped parsley 1 Tbsp fresh or 1 tsp dried oregano  1 tsp dried basil ½ cup Red bell pepper 7 ounces  chicken breasts, thinly sliced  7 ounces uncured ham 7 ounces provolone cheese, sliced 1 Italian bread round (~1 pound) Instructions Drain and dice green pimento and black olives Drain and dice Giardiniera Combine olives, pimentos, Giardiniera, and olive oil Add capers, chopped parsley, oregano, and basil  Stir well, cover and refrigerate overnight Thinly slice the red bell pepper Cut bread in half horizontally and remove most of the soft crumb from the top and the bottom leaving about 1” of bread and crust on each, so it resembles 2 bread boats Drain the refrigerated mixture, reserving the liquid Spread about 1 tsp of the liquid on each bread half  Add the olive mixture to each bread half  Layer each half with chicken, red peppers, provolone, ham Put the bread halves back together  Wrap in plastic and refrigerate for at least 1 hour placing a weight on the loaf to compress Remove from refrigerator about 20 minutes before serving Slice and enjoy Nutritional Information Makes 10 Servings Nutrients in a serving:  Calories  355, Total Fat 15g, Saturated Fat 4g, Cholesterol 35mg,  Total Carbohydrate 34g, Dietary fiber 2.2g, Protein 19g, Potassium 180mg, Sodium 800mg Chef and Author : Mary B Grosvenor, MS, RD chef author Medically Reviewed by FibonacciMD editors. Editor’s note: Editor’s note: appropriate for low-calorie, low carb, low saturated fat, high protein meal.

Craving a vibrant and satisfying salad? This Cauliflower Chickpea Salad delivers! Creative Cooking for the Health-Conscious Gourmet FibonacciRECIPES  | Culinary Medicine   Recipe Roasted crispy chickpeas meet tender cauliflower, sweet apple, and creamy avocado, all tossed in a tangy honey-mustard-lime dressing. Packed with flavor, fiber, and plant-based protein, it's a healthy and delicious meal or side perfect for any occasion. Ingredients: Cauliflower salad: 1 14-oz can chickpeas, drained and rinsed Chili powder Salt Ground black pepper 1 head cauliflower, cut into small florets 1 apple, sliced thin 1 shallot, sliced thin Handful of fresh parsley and mint 2 firm avocados, cut into chunks Dressing: 2 tbsp grainy mustard 2 tbsp honey 0.25 cup olive oil 0.25 cup water Juice and zest of one lime Instructions: Preheat oven to 400°F. Place chickpeas on a baking sheet lined with parchment. Drizzle with olive oil, and sprinkle with salt, pepper, and chili powder to taste (chickpeas may be poured into a bowl, tossed with olive oil and spices,and then spread onto a baking sheet). Roast for 20-30 min until crispy and browned. Add all dressing ingredients to a jar and shake well. Toss with cauliflower, chickpeas, apple, shallot, and avocado. Nutritional Information Makes 8 Servings Nutrients in a serving:  Calories: 383, Total fat: 19.4 g, Saturated fat: 3.3 g, Cholesterol: 0 mg, Sodium: 68 mg, Total carbohydrate: 45.5 g, Dietary fiber: 13.9 g, Total sugars: 13.6 g, Protein: 11.6 g Nutrition Chef Authors : Medically Reviewed by FibonacciMD editors. Editor's Note:  Appropriate for a low-calorie, low-cholesterol, high-protein, high-fiber, vegan diet regimen. Appropriate for low-carbohydrate regimen when half the honey is used.

Looking for a healthy and satisfying alternative to your favorite fried rice? This cauliflower fried rice is bursting with flavor, fiber, and fresh ingredients — all while keeping the calories low. Creative Cooking for the Health-Conscious Gourmet FibonacciRECIPES  | Culinary Medicine   Recipe This Cauliflower Fried Rice is a game-changer. It's light, flavorful, and loaded with good-for-you ingredients. Ingredients: 1 medium cauliflower head, cut into florets 0.5 tbsp sesame oil 1 small onion, diced 2 cloves garlic, minced 1 tsp freshly grated ginger 1 cup frozen peas and carrots, thawed 2 large eggs, whisked 2-3 tbsp low-sodium soy sauce Sea salt and ground pepper, to taste Instructions: Rinse the cauliflower, chop into florets, and place in a food processor. Pulse until the cauliflower resembles rice.  Heat the sesame oil in a large skillet over medium-high heat.  Sautee the garlic, ginger, and onion until soft (about 2-3 min).  Add the peas and carrots, and cook until heated through (about 3 min).  Slide the vegetables to the side, and pour the beaten eggs onto the other side. Using a spatula, scramble the eggs. Mix the cooked eggs with the vegetables.  Add the cauliflower rice, soy sauce, salt, and pepper.  Stir and cook for 4-5 min until tender and a bit crispy. Remove from heat and serve Nutritional Information Makes 4 Servings Nutrients in a serving:  C alories: 152, Total fat: 8 g, Saturated fat: 1.6 g, Cholesterol: 93 mg, Sodium: 523 mg, Total carbohydrate: 15.1 g, Dietary fiber: 5.4 g, Total sugars: 6.3 g, Protein: 8 g Nutrition Chef Authors : Justin Gillette, Certified Executive Chef, Chef Author Medically Reviewed by FibonacciMD editors. Editor's Note:  Appropriate for low-calorie, low-cholesterol, low-fat, high-fiber, ovo-vegetarian diet regimen.

Craving that classic mac and cheese but looking for a healthier spin? This cauliflower recipe delivers all the cheesy, comforting flavors you love, with the added goodness of tender cauliflower mixed right in! Creative Cooking for the Health-Conscious Gourmet FibonacciRECIPES  | Culinary Medicine   Recipe Mac and cheese is a classic comfort food. This version has all the rich tastes and textures of the original along with the nutritional benefits of added cauliflower. Ingredients: Cooking spray 2 cups cauliflower florets 1 cup elbow macaroni, dry 1 1/2 Tbsp unsalted butter 1 Tbsp flour 1 tsp yellow mustard 1 cup whole milk 4 oz block cheddar cheese ½ tsp salt ¼ tsp pepper ½ tsp onion powder 1 tsp Worcestershire sauce 3 Tbsp panko breadcrumbs 1 tsp paprika 1 Tbsp parmesan cheese Instructions: Preheat oven to 350°F. Coat a 2 quart baking dish with cooking spray. Steam or microwave cauliflower for 3-5 minutes (it should still be crisp), drain. Boil macaroni until al dente, drain. Shred cheese (packaged shredded cheese does not melt well). Melt butter in a medium saucepan. Add flour and mustard, stir constantly until smooth – about 1 minute. Add milk to butter mixture and cook on low for about 10 minutes, stirring frequently, until thickened. Stir in onion powder, salt, pepper, and Worcestershire sauce. Mix macaroni and cauliflower into the sauce, coating well Transfer to the baking dish and sprinkle with panko and parmesan. Bake for 20-25 minutes until top is slightly browned. Remove from oven and let set for 5-10 minutes before serving. Nutritional Information Makes 6 one-cup Servings Nutrients in a serving:  215 Calories, 11g fat, 6g sat fat, 31mg cholesterol, 20g carbohydrate, 2g fiber, 10g protein, 390mg sodium, 264 mg potassium Nutrition Chef Authors : Lori A Smolin, PhD  and Mary B Grosvenor, MS, RD Medically Reviewed by FibonacciMD editors. Editor's Note: This is a low-calorie, low-carb meal and would be appropriate for a lacto-vegetarian dietary regimen if you use an alternative to rennet containing parmesan. There are vegetarian hard cheeses made with plant-based rennet, like some brands of Grana Padano or Parmesan-style hard cheeses.

Nonalcoholic fatty liver disease (NAFLD) vs Nonalcoholic steatohepatitis (NASH) PART 2 of two CME articles that look at liver transaminase levels, signs, symptoms, causes, diagnosis, and management. (eligible for CME credit. Read both and follow the link for the online FibonacciCME test) Part I. Transaminitis Part II. Nonalcoholic Fatty Liver Disease Gastroenterology b y Madeleine Beckman and David Kauvar, MD Nonalcoholic steatohepatitis (NASH), a form of liver disease, is associated with obesity, high blood pressure, type-2 diabetes, high cholesterol and triglyceride levels, use of certain medications, and genetics. In addition, it commonly is seen among patients with metabolic syndrome and insulin resistance. NASH is most prevalent during middle age, but it has been seen in pediatric populations. Primary complications of the disease include fibrosis, cirrhosis, and liver cancer. Nonalcoholic fatty liver disease (NAFLD), a condition caused by fat accumulation in the liver, may progress to NASH, which includes further fat accumulation and progressive inflammation. Increased inflammation can lead to scarring of the liver and/or cirrhosis. Approximately 20% of people with NAFLD develop NASH, and some 12% of NASH patients develop cirrhosis. Signs and symptoms associated with NAFLD include enlarged liver, obesity, elevated serum liver transaminase levels, and insulin resistance. Evidence of liver fibrosis can be identified by utilizing the NASH Fibrosure blood test, magnetic resonance elastography or vibration-controlled transient elastography. Consider one of these assessments if the patient is at higher risk for developing steatohepatitis (e.g., those with poorly controlled diabetes). Fatty Liver Biopsy Pathologic evaluation by biopsy is the most accurate way to truly distinguish NAFLD from NASH; however, the need for a biopsy should be decided by either a hepatologist or an experienced gastroenterologist. The primary physician should try to exclude other causes of elevated liver transaminases, such as alcohol consumption, viral hepatitis , autoimmune disease, or hemochromatosis. Fatty Liver The association between genetic variations and NAFLD and NASH is being widely studied. Results of one study by Speliotes et al. at the Massachusetts General Hospital showed that certain inherited variations in lipid metabolism precede and possibly lead to the development of liver disease. Variation of the PNPLA3 gene correlates with an increased risk of severe histologic features of NAFLD without having a strong effect on metabolic syndrome component traits. The PNPLA3 gene produces adiponutrin, a protein that seems to help regulate the production of adipocytes, lipogenesis, and lipolysis in hepatocytes and adipocytes. PNPLA3 appears to be part of a family of enzymes that affect lipid metabolism. Altered lipid metabolism, particularly within the liver, can affect fat accumulation, subsequent development of NAFLD, and possibly NASH. Genetic analyses may allow researchers to chart the causal pathways that lead to disease complications of NAFLD and other metabolic risk factors to potentially target them for therapeutic intervention. Results from a recent Temple University study by Gerhard et al. showed that increased expression of the AEBP1 gene correlates with the severity of liver fibrosis in patients with NASH. Having the AEBP1 gene appears to correlate with the onset and severity of fibrosis in NASH patients, suggesting that AEBP1 may represent a specific therapeutic target to prevent development of NASH fibrosis. DIAGNOSIS NAFLD is usually asymptomatic. However, some patients report feeling tired or experience discomfort in the right upper quadrant of the abdomen if they have progressed to NASH or cirrhosis. NASH can be diagnosed using bloodwork (NASH Fibrosure) or imaging (Elastography) ; however, needle biopsy is considered to be the diagnostic “gold” standard. MANAGEMENT A serious concern with respect to diagnosis and treatment of NASH is the growing obesity rate. In 10 years, there may be more than a 50% annual increase in NASH patients needing a liver transplant. The basic and most effective strategy for treating NASH is for patients to improve their overall health by changing their lifestyles. Steps include: Lowering high blood pressure Eating a low-fat diet Restricting alcohol Lowering triglyceride and cholesterol levels Losing weight Getting more exercise In patients with type II Diabetes Mellitus, pioglitazone (Actos), should be considered as it has been shown to reduce fibrosis, steatosis, and inflammation. Vitamin-E supplementation may also be useful in noncirrhotic patients with biopsy confirmed steatohepatitis. Recently, use of obeticholic acid (Ocaliva), an agonist of the farnesoid X receptor that was approved by the US Food and Drug Administration to treat primary biliary cholangitis, was shown to significantly improve regression of fibrosis in NASH patients. The Randomized Global Phase 3 Study to Evaluate the Impact on NASH with Fibrosis of Obeticholic Acid Treatment (REGENERATE) was conducted by the National Institutes of Health and is now in phase-III testing with 931 patients. Results have shown a 28% rate of fibrosis regression, and a significant number of study patients showed normalization of liver enzyme levels. Conclusion NASH, whether driven by genetics, body composition, dietary indiscretion, use of toxic medications, or possible viral infections, still remains a mostly elusive condition in cause, prognosis, and management. More complete information on its etiology, diagnosis, and treatment ultimately will lead to a healthier population and a lesser demand for liver transplantation. This article is PART 2 of a CME topic on transaminitis and fatty liver disease. Read PART 1: Transaminitis - What Does it Mean and What Should be Done When it Occurs? A Common Conundrum in Primary Care REFERENCES Adinolfi LE, Gambardella M, Andreana A, Tripodi MF, Utili R, Ruggiero G. Steatosis accelerates the progression of liver damage of chronic hepatitis C patients and correlates with specific HCV genotype and visceral obesity. Hepatology. 2001;33:1358–1364. Benichou C, Danan G, Flahault A. Causality assessment of adverse reactions to drugs–II. An original model for validation of drug causality assessment methods: case reports with positive rechallenge . J Clin Epidemiol. 1993;46:1331–1336. Boettcher E, Csako G, Pucino F, et al. Meta-analysis: pioglitazone improves liver histology and fibrosis in patients with non-alcoholic steatohepatitis. Aliment Pharmacol Ther. 2012; 35:66-75. Bril F, Kalavalapalli S, Clark VC, et al. Response to pioglitazone in patients with nonalcoholic steatohepatitis with vs without type 2 diabetes. Clin Gastroenterol Hepatol. 2018;16:558-566.e2. Chopra S, Lai M. Management of nonalcoholic fatty liver disease in adults. UpToDate Web site . Updated June 24, 2019. Accessed August 15, 2019. Danan G, Benichou C. Causality assessment of adverse reactions to drugs–I. A novel method based on the conclusions of international consensus meetings: application to drug-induced liver injuries. J Clin Epidemiol. 1993;46:1323–1330. Gerhard GS, Hanson A, Wilhelmsen D, et al. AEBP1 expression increases with severity of fibrosis in NASH and is regulated by glucose, palmitate, and miR-372-3p. PLoS One . 2019;14:e0219764. Harrison SA. Correlation between insulin resistance and hepatitis C viral load. Hepatology. 2006;43:1168. Houglum K, Venkataramani A, Lyche K, Chojkier M. A pilot study of the effects of D-alpha-tocopherol on hepatic stellate cell activation in chronic hepatitis C. Gastroenterology. 1997;113:1069–1073. Kirkendoll SM. NASH may overtake hepatitis C as top liver transplant cause. M Health Lab Web site . October 31, 2017. Accessed August 15, 2019. Kotronen A, Juurinen L, Hakkarainen A, et al. Liver fat is increased in type 2 diabetic patients and underestimated by serum alanine aminotransferase compared with equally obese nondiabetic subjects. Diabetes Care. 2008;31:165–169. Molloy JW, Calcagno CJ, Williams CD, Jones FJ, Torres DM, Harrison SA. Association of coffee and caffeine consumption with fatty liver disease, nonalcoholic steatohepatitis, and degree of hepatic fibrosis. Hepatology. 2012;55:429-436. Moucari R, Asselah T, Cazals-Hatem D, et al. Insulin resistance in chronic hepatitis C: association with genotypes 1 and 4, serum HCV RNA level, and liver fibrosis. Gastroenterology. 2008;134:412–423. Nonalcoholic fatty liver disease. Barnes-Jewish St. Peters Hospital Web site . Accessed August 15, 2019. Patel A, Harrison SA. Hepatitis C virus infection and nonalcoholic steatohepatitis. Gastroenterol Hepatol (N.Y.) 2012;8:305-312. Patal B, Sanyal AJ. Drug-induced steatohepatitis. Clin Liver Dis. 2013;17:533-vii. Pessayre D, Fromenty B, Berson A, et al. Central role of mitochondria in drug-induced liver injury. Drug Metab Rev. 2012;44:34–87 Rivera C. Risk factors and mechanisms of non-alcoholic steatohepatitis. Pathophysiology. 2008;15:109-114. Sanyal AJ, Chalasani N, Kowdley KV, et al. Pioglitazone, vitamin E, or placebo for nonalcoholic steatohepatitis. N Engl J Med. 2010; 362:1675-1685. Shteyer E, Villenchik R, Mahamid M, Mator N, Safadi R. Low serum lysosomal acid lipase activity correlates with advanced liver disease. Int J Mol Sci . 2016;17:312. Sookoian S, Pirola CJ. Genetic predisposition in nonalcoholic fatty liver disease. Clin Mol Hepatol. 2017;23:1-12. Speliotes EK , Butler JL , Palmer CD , et al. PNPLA3 variants specifically confer increased risk for histologic nonalcoholic fatty liver disease but not metabolic disease. Hepatology. 2010;52:904-912. Younossi Z, Lavine JE, Charlton M, et al. The diagnosis and management of nonalcoholic fatty liver disease: Practice guidance from the American Association for the Study of Liver Diseases . Hepatology. 2018;67:328–357. Zoler ML. Obeticholic acid reversed NASH liver fibrosis in phase 3 trial. MDEdge Web site. April 12, 2019. Accessed August 15, 2019. .

Culinary Medicine A study published in January 2025 looked at 8,766 Japanese subjects 65 years of age or older, who did not have dementia, for the effects of coffee and green tea drinking on MRI measured cerebral white matter lesions and hippocampal and total brain volumes. White matter lesions are from demyelination of nerve fibers in the brain and while there are a number of causes, they most commonly represent small blood vessel disease which can lead to dementia. They reported that the total volume of white matter lesions was significantly reduced in green tea drinkers with the reduction increasing with the more green tea they drank per day. Four levels of daily green tea drinking were compared, 0 to 200 mls (milliliters), 201-400 mls, 401 to 600 mls, and over 601 mls per day. (a cup is equal to  240 mls) They did not find any significant differences in the total volume of white matter lesions in coffee drinkers with increasing amounts of coffee ingestion.  When controlling for multiple confounding factors such as hypertension, exercise, and cholesterol levels no differences were found in either tea or coffee drinkers for total brain volumes and hippocampus size.  They performed some subgroup analyses and found that the positive effect of green tea on the reduction of white matter lesions was only found in people without a history of depression and was not present in people with a history of depression. The researchers  also reported that subjects with the ApoE ε4 gene ( a gene that if present increases risk for Alzheimer’s disease) did not demonstrate reduced white matter lesions from green tea ingestion while those without it did. The authors did suggest that the sample sizes for these two analyses might have been too small for adequate statistical evaluation.  The authors concluded that increased green tea consumption was associated with reduced cerebral white matter lesions and that as those lesions are predictive of vascular dementia and Alzheimer’s disease, drinking green tea, especially three or more glasses per day, may help prevent dementia. A weakness of the study was that it only had Japanese participants so the results may not be applicable to other ethnic groups. As with any study of this type, there may be unknown confounding variables and a correlation of two factors does not mean that one was definitively the cause of the other.  Comments: Green tea in other research has been found to have antioxidant, anti-inflammatory, neuroprotective, antihypertensive and have anti-platelet aggregation effects. In this study, drinking more daily green tea correlated to fewer white matter lesions. When controlling for multiple variables, drinking green tea did not have any effect on total brain or hippocampal volumes.   Coffee drinking was not found to have any beneficial effect on the measured variables.  The fact that people with a history of depression or having the ApoE ε4 gene did not show the same reduction in white matter lesions as other subjects may be due to competing metabolic processes in people with those conditions or as the authors suggest the sample size may have been too small to truly evaluate the issue.  Possible issues with drinking green tea in large amounts include caffeinated green tea does contain a significant amount of caffeine, tannins in tea can reduce iron absorption and very high amounts of green tea ingestion may possibly damage the liver. If you found this article interesting, click here to read about Olive Oil Consumption and Reduction of Dementia-Related Death. To learn more about the ApoE ε4 gene, click here to read APOE4 Genetic Variants and Alzheimer’s Disease. References Shibata, S., Noguchi-Shinohara, M., Shima, A. et al. Green tea consumption and cerebral white matter lesions in community-dwelling older adults without dementia. npj Sci Food 9, 2 (2025). Retrieved from: https://www.nature.com/articles/s41538-024-00364-w#citeas

Is raw milk a healthier, more natural choice, or does it pose unnecessary health risks? We explore the science behind pasteurization and the claims surrounding raw milk's benefits and dangers. Culinary Medicine by Lori A Smolin, PhD   and Mary B Grosvenor, MS, RD Raw milk is milk straight from the cow. The “regular” milk we buy at the grocery store has been treated by a process, called pasteurization, which heats the milk to kill disease-causing microbes. Before pasteurization became the norm, about a quarter of foodborne illnesses in the United States were related to consumption of dairy products.[1]  Now that most of the milk sold in the U.S. is pasteurized, less than 1% of foodborne illness outbreaks are traced to dairy consumption and 70% of these cases are linked to unpasteurized milk.[1] Despite this, raw milk sales are on the rise.[2] Proponents suggest that pasteurization alters the flavor, nutrient content, and health benefits of raw milk. History of Pasteurization Pasteurization was developed in the 1860s by Louis Pasteur to preserve wine and was later adapted for other liquids, including milk. [3] In the U.S. today the most common method of pasteurization heats milk from cows, sheep, and goats to 161° F for 15 seconds.[4] This combination of heating time and temperature is designed to kill pathogens while minimizing alterations in taste or nutritional composition. Milk was first pasteurized in the United States in the 1890s but pasteurization did not become widespread until passage of the 1924 Standard Milk Ordinance.[5]   Regulation of the production, processing, and sale of milk has expanded since the 1920s; in 1987 the FDA mandated pasteurization of all milk sold or distributed across state lines.[6]  Milk sales within states however are regulated at the state level.[7] Some states allow the sale of raw milk from retail outlets, others only allow sales at farms or farmer’s markets. And some only allow sales through a cow or herd share, which is an agreement that requires customers to buy a share of a cow or herd to purchase the milk. Only a few states completely restrict the sale of raw milk. Health Claims and Scientific Evidence Some people choose raw milk because they prefer natural, unprocessed foods or are looking for the latest superfood to improve their health. Others just do not want to be told what to do and consider mandatory pasteurization government overreach. Proponents of raw milk argue that pasteurization affects milk’s flavor, reduces its nutrient content, and compromises its health benefits. Milk that comes right from the cow does have a creamier texture and sometimes a sweeter taste than milk from the grocery store. But these differences are not related to pasteurization. Milk straight from the cow is creamier because it has about 4% fat while the standard for whole milk sold in stores in the US is 3.25% fat. [9] Some raw milk has a sweet taste depending on the breed of cow and what she ate. Milk from grocery stores is often pooled from multiple sources; this blunts differences in flavor due to breed and feed. Pasteurization as well as processing and packaging may cause slight changes in flavor. Despite claims that pasteurization destroys nutrients, pasteurized milk does not significantly affect levels of the key nutrients that milk provides in the American diet. Milk is a reliable source of protein and neither the amount nor quality of the protein are altered by pasteurization. Likewise, milk provides calcium, phosphorus, and other minerals; heat heat does not change the content and bioavailability of the minerals. Pasteurization also does not affect the fat-soluble vitamins A, D, E, and K. In fact, pasteurized milk is much higher in vitamin D because it is fortified; raw milk only contains trace amounts. The water-soluble vitamins that are plentiful in milk, riboflavin, and vitamins B6 and B12, are only minimally affected by pasteurization. The only vitamin that is significantly degraded by heat is vitamin C, but milk is not a significant source for this vitamin.[10] There is no evidence that pasteurization destroys health-promoting compounds in raw milk that help digestion and immunity. Although raw milk does contain enzymes that facilitate milk digestion by breaking down protein and fat, so does pasteurized milk. These enzymes are not affected by the heat treatment of pasteurization, but they are destroyed in the acidic environment of the stomach before the milk can move to the intestine for digestion.[10] Raw milk devotees claim that pasteurization destroys the natural antimicrobial properties of milk as well as factors that promote immunity. There are enzymes in raw milk that have antimicrobial properties, but levels are too low to kill pathogens. There are also antibodies in raw milk, but the concentration of these is too low to have an impact on human health and the predominant fraction is heat stable so it is not affected by pasteurization. [10] Raw-milk enthusiasts also claim that unpasteurized milk is healthier because it does not cause milk allergies and reduces the symptoms of lactose intolerance. There is no evidence to suggest that raw milk is less allergenic than pasteurized milk; those allergic to milk should avoid all milk. [10] The idea that raw milk reduces symptoms of lactose intolerance is also not substantiated. Lactose intolerance causes gas, bloating, and diarrhea due to the inability to completely digest the milk sugar lactose, which is found in both raw and pasteurized milk. Advocates claim that raw milk contains probiotic bacteria that secrete the enzyme lactase, which breaks down lactose before it can cause symptoms. However, there is no evidence that raw milk contains either probiotic bacteria or lactase. [10] Raw Milk and the Risk of Foodborne Illness Consuming raw milk increases the risk of foodborne illness from pathogens such as Salmonella, E coli, Listeria, and Campylobacter. The risks of getting sick are greatest in pregnant women, babies, older adults, and anyone with a weakened immune system. Milk can be contaminated from infected cows as well as from contact with machinery, feces, insects, other animals, or humans. [6] Because raw milk typically comes from cows on a single farm advocates argue that the milk is safe if the cows are healthy and the farm is clean.[11] In contrast, milk sold in grocery stores is usually pooled from multiple farms so one infected cow can contaminate hundreds of gallons of milk, making pasteurization, which kills the pathogens, essential. Raw milk proponents contend, however, that even pasteurized milk is a risk because it can be contaminated after pasteurization. Although it is true that some foodborne illness is caused by mishandled pasteurized milk, the frequency of illness is far less than with raw milk.[12] Unpasteurized dairy products cause over 800 times more illnesses and 45 times more hospitalizations than pasteurized products. [13,14] And new risks are emerging. In March of 2024, the H5 N1 Avian flu virus was detected in dairy cattle. High titers of infectious virus have been found in milk from infected cows. The impact of ingesting the virus is still unknown, but it has been shown that pasteurization inactivates the virus.[15] Bottom line Social media influences, antiestablishment sentiments, and a desire to return to simpler times, contribute to the appeal of raw milk: a whole, unprocessed food that promises to taste better and be healthier than pasteurized milk. However, pasteurization does not cause significant changes in the taste, nutrient content, or health benefits of milk and both the CDC and FDA advise against consuming raw milk. Despite the allure of an all-natural alternative, consumers should consider the risk of serious illness posed by unpasteurized milk. Editor’s note- Having worked on my friend’s two hundred cow dairy farm for two years I still cherish the taste of their fresh but pasteurized, non-homogenized milk. They now sell directly to consumers and to grocery stores. References [1] Virginia Department of Health. Pasteurization – Environmental Health. Virginia.gov. Published 2021. https://www.vdh.virginia.gov/environmental-health/food-safety-in-virginia/milk-safety/pasteurization/ [2] News P. Raw milk sales spike despite CDC’s warnings of risk associated with bird flu. PBS News. Published May 14, 2024. https://www.pbs.org/newshour/health/raw-milk-sales-spike-despite-cdcs-warnings-of-risk-associated-with-bird-flu [3] Weigel G. Heroes of Food Safety: Louis Pasteur and the Invention of Pasteurization. blog.smartsense.co. Published September 3, 2019. https://blog.smartsense.co/louis-pasteur-pasteurization [4] International Dairy Foods Association. Pasteurization. IDFA. Published January 25, 2020. https://www.idfa.org/pasteurization [5] Nutrition Center for Food Safety and Applied Nutrition. Pasteurized Milk Ordinance Centennial. FDA. Published online January 16, 2024. https://www.fda.gov/food/milk-guidance-documents-regulatory-information/pasteurized-milk-ordinance-centennial [6] CDC. Research Anthology: Raw Milk. Public Health Law. Published May 13, 2024. https://www.cdc.gov/phlp/php/publications/research-anthology-raw-milk.html [7] CDC. Map of State Laws on the Sale of Unpasteurized Cow’s Milk, 2012–2019. Public Health Law. Published May 13, 2024. https://www.cdc.gov/phlp/php/publications/unpasteurized-cow-milk.html [8] Velasquez-Manoff M. Some Raw Truths About Raw Milk. New York Times Magazine. Jan 13, 2025. https://www.nytimes.com/2025/01/13/magazine/raw-milk-danger-benefits.html [9]Arnarson A. Milk 101. Healthline. Published October 20, 2021. https://www.healthline.com/nutrition/milk#nutrition ‌[10] Center for Food Safety and Applied Nutrition. Raw Milk Misconceptions and the Danger of Raw Milk Consumption. U.S. Food and Drug Administration. Published November 1, 2011. https://www.fda.gov/food/buy-store-serve-safe-food/raw-milk-misconceptions-and-danger-raw-milk-consumption ‌[11] Raw Milk Institute. Common Standards. Published 2020. https://www.rawmilkinstitute.org/common-standards ‌[12] Sebastianski M, Bridger NA, Featherstone RM, Robinson JL. Disease outbreaks linked to pasteurized and unpasteurized dairy products in Canada and the United States: a systematic review. Canadian Journal of Public Health. 2022;113(4). doi:https://doi.org/10.17269/s41997-022-00614-y ‌[13] Costard S, Espejo L, Groenendaal H, Zagmutt FJ. Outbreak-Related Disease Burden Associated with Consumption of Unpasteurized Cow's Milk and Cheese, United States, 2009-2014. Emerg Infect Dis. 2017;23(6):957-964. doi:https://doi.org/10.3201/eid2306.151603 [14] Center for Food Safety and Applied Nutrition. Unpasteurized Milk Can Pose a Serious Health Risk. U.S. Food and Drug Administration. Published August 11, 2018. https://www.fda.gov/food/buy-store-serve-safe-food/dangers-raw-milk-unpasteurized-milk-can-pose-serious-health-risk [15]Kaiser F, Morris DH, Wickenhagen A, et al. Inactivation of Avian Influenza A(H5N1) Virus in Raw Milk at 63°C and 72°C. New England journal of medicine/˜The œNew England journal of medicine. Published online June 14, 2024. doi: https://doi.org/10.1056/nejmc2405488

Did you know . . . Abducens nerve palsy, or cranial nerve VI palsy, affects the lateral rectus muscle, leading to esotropia and diplopia. Understanding its causes, from trauma to systemic diseases, is crucial for proper diagnosis and treatment. InBrief by:  Evan Mostafa, MD and George Florakis, MD Cranial nerve VI, the abducens nerve, is solely responsible for motor innervation of the lateral rectus muscle. Abducens nerve palsy refers to dysfunction of the nerve at various points as it traverses from the pons to the lateral rectus muscle. Its location at different aspects of the cranium makes it susceptible to injury from trauma, ischemia, inflammation, infection, and increased intracranial pressure. Patients with abducens nerve palsy experience esotropia of the affected eye, such that the orbit will be turned medially towards the nose. Signs and Symptoms Signs and symptoms of abducens nerve palsy include esotropia/strabismus, head turned toward affected eye, diplopia (binocular horizontal), headache, ocular pain, nausea, and vomiting. Strabismus is the general term meaning when the eyes do not align when focusing on an object. Causes and Risk Factors In children, abducens nerve palsy may be congenital or acquired, although the latter is more common and typically due to orbital or head trauma. Pediatric patients with Lyme disease, venous sinus thrombosis, or even shunt failure are susceptible to increased intracranial pressure, which can damage the abducens nerve. Meningitis and tumors may also result in damage. In adults, there are similar etiologies (eg, trauma, infection, inflammation, tumors). Multiple sclerosis, microvascular conditions, and diabetes may be risk factors.   Causes and Risk Factors Injury, especially a skull fracture Stroke or other vascular conditions (Giant Cell Arteritis) Infection, such as Lyme disease or a virus Brain tumor Inflammation of the nerve, such as from a disease like multiple sclerosis Increased pressure in the brain, from meningitis or other causes Hypertension and arteriosclerosis Diabetes mellitus Diseases that are present at birth (congenital diseases) Diagnostic Evaluation and Differential Diagnosis Patients with abducens nerve palsy should be given a full ophthalmologic examination. Strabismus measurement should be taken. Timing of symptoms may help to determine etiology. Sudden onset refers to microvascular problems, whereas progressive onset can be related to compression. Clinically, the patient will not be able to properly abduct the affected eye. The patient will be have an eye turned medially towards the nose and may compensate by turning their head toward the affected eye. Patients with suspected abducens nerve palsy may be offered magnetic resonance imagining (MRI); however, MRI is not the gold standard and may not be needed. Laboratory testing includes complete blood count, erythrocyte sedimentation rate, C-reactive protein, hemoglobin A1c blood test, Lyme titer, rheumatoid factor test, and antinuclear antibody test. Differential diagnosis includes congenital esotropia, blowout fracture of the orbit, and myasthenia gravis.   Imitators of Cranial Nerve VI Palsy Thyroid eye disease Myasthenia gravis Duane syndrome (congenital strabismus) Spasm of the near reflex (pseudomyopia, convergent strabismus and miosis) Old orbital blowout fracture Congenital esotropia. Treatment and Recommended Follow-Up Treatment of abducens nerve palsy differs based on age and etiology. Most adults with microvascular etiology do not require treatment and can see symptoms resolve within months. Patients with increased intracranial pressure can have lumbar punctures or surgeries performed to lessen intracranial pressure, which may resolve the subsequent palsy. (Lumbar puncture in the setting of increased intracranial pressure may be extremely dangerous and must be performed under the direction of an experienced neurosurgeon.) Children with diplopia should be given prism therapy or alternative patching therapy. Use of botulinum toxin and strabismus surgery may be indicated in more severe cases. Systemic diseases such as diabetes should be treated if identified. Pearl to Know The abducens nerve is the most frequently injured ocular motor nerve in adults and the second most commonly injured in children. If Lyme disease is suspected and the initial titer is negative, repeat the titer in 1 month. The erythema migrans rash, even without a positive Lyme titer, is pathognomonic for active Lyme disease. Sources: Bendszus M, Beck A, Koltzenburg M, et al. MRI in isolated sixth nerve palsies.  Neuroradiology.  2001;43:742-745. Graham C, Mohseni M. Abducens nerve (CN VI), palsy. StatPearls Web site. https://knowledge.statpearls.com/chapter/nurse-anatomy/17031/ . April 4, 2019. Accessed October 7, 2019. Murchison AP, Gilbert ME, Savino PJ. Neuroimaging and acute ocular motor mononeuropathies.  Arch Ophthalmol.  2011;129:301-305. Wysiadecki G, Orkisz S, Gałązkiewicz-Stolarczyk M, Brzeziński P, Polguj M, Topol M. The abducens nerve: its topography and anatomical variations in intracranial course with clinical commentary.  Folia Morphol (Warsz).  2015;74:236-244.