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Singapore investigates typhoid fever cases – Food Safety News

Posted: February 13, 2021 at 10:49 am

Officials in Singapore are investigating if two typhoid fever cases are linked to eating at a food outlet.

The Ministry of Health (MOH) and Singapore Food Agency (SFA) said two people fell ill after having food prepared by Hooi Kee Eating House on Clemenceau Avenue in Singapore Shopping Centre.

Both people ate at this site several times between Jan. 2 and 18. They were later admitted to hospital. One has since been discharged and the other is in stable condition in hospital.

SFA has suspended food operations at Hooi Kee Eating House until further notice.

Salmonella typhiThe agency advised people who have consumed food from Hooi Kee Eating House and then developed prolonged fever to consult their general practitioner and tell the doctor their food history.

Typhoid fever is a bacterial infection caused by Salmonella typhi. Items which could be contaminated include raw or ready-to-eat foods, such as raw milk or their products, seafood, and fresh produce including fruits and vegetables.

An infected person usually has a prolonged fever which may be accompanied by other symptoms such as headache, body aches, vomiting, diarrhea or constipation. People infected can spread it to others. Ways to prevent typhoid fever include good hand hygiene, safe handling, cooking and consumption of food.

All food handlers working in the implicated premises must re-attend and pass a food safety course and test negative for foodborne pathogens, before they can go back to work. The appointed food hygiene officer(s) are also required to re-attend and pass a food and beverage hygiene audit course before they can resume this work. The outlet has been told to clean and sanitize the premises, including equipment and utensils.

Supporting WHO in the Western PacificMeanwhile, the Singapore Food Agencys food safety monitoring and forensics department has been designated as a World Health Organization (WHO) Collaborating Centre for Food Contamination Monitoring from 2020 to 2024.

The department, under the National Centre for Food Science (NCFS), will use its expertise in foodborne pathogens and toxins to support WHO food safety initiatives in the Western Pacific region.

This includes providing technical assistance and testing services to investigate food safety incidents, with a focus on chemical contaminants and natural toxins and contributing monitoring data on levels of emerging chemical contaminants and natural toxins in food. The data will be used as a reference for setting food standards regionally and internationally.

Tan Lee Kim, deputy chief executive officer of SFA, said he recognized the importance of collaboration with international bodies and other food safety agencies.

This designation is a testament to NCFS food testing and research capabilities, which are critical in supporting our mission to ensure and secure a supply of safe food for Singapore, he said.

It is one of two such sites with the other being the China National Center for Food Safety Risk Assessment (CFSA).

Takeshi Kasai, WHO regional director for the Western Pacific, said the SFA is a valuable member in the network of collaborating centers.

We are pleased to have partnered with Singapores food safety authorities since 1992 to improve food safety in the Western Pacific, and look forward to more years of collaboration.

(To sign up for a free subscription to Food Safety News,click here.)

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COVID-19 and its impact on the food system – New Food

Posted: February 13, 2021 at 10:49 am

Two food technologists offer insights on nutrition, food safety and security in relation to the ongoing pandemic.

Food is an essential part of life, providing us with the nutrition we need for survival; but the pandemic has plunged the entire food system into eccentric circumstances. The lack of adequate food, combined with labour shortages, fragmented supply chains and panic over associated health hazards, could lead to paucity of proper nutrition and food scarcity.

Thus, various preventative actions should be taken by the concerned authorities to mitigate these negative impacts on the food system. This article will outline the most pressing issues related to nutrition, food safety and security during the current pandemic crisis, as well as strategies to mitigate them and novel approaches to reinforce the food system for the post-pandemic era.

COVID-19 mainly affects the lower respiratory tract and poses a significant risk for the older population, immune-compromised individuals (cancer, organ transplant and HIV-AIDS patients), and those with comorbid conditions (diabetes, obesity and blood pressure issues).

The food we consume has a significant impact on our health and wellbeing. Foods rich in micronutrients (vitamins and minerals), functional foods containing bioactive molecules (antioxidants, anti-inflammatory substances and immune boosters), herbs, spices, dietary fibres and probiotics all offer an immune system boost and help to combat viral infections.

The World Health Organization (WHO) has issued guidelines regarding nutrition for adults, which includes consuming eight to 10 glasses of water per day, fruits (two cups), vegetables (2.5 cups), whole grains, legumes, nuts, meat, milk, eggs and fish. In addition, WHO recommends consuming moderate amounts of fats and oils, and limiting the intake of salt, sugar and highly processed foods rich in saturated fats and refined carbohydrates.1

During this crisis, various bioactive compounds can help to improve our immunity.2 For example, vitamin C- (ascorbic acid) rich foods, such as citrus fruits, amla, kiwi and broccoli, can help enhance our immunity against respiratory tract infections. Likewise, vitamin A- (retinol, retinoic acid and -carotene) rich fruits and vegetables, including papaya, carrots, spinach and sweet potato, can also help to lower susceptibility to infections. Moreover, supplements of vitamin D, vitamin E and minerals such as copper, iron, zinc and magnesium have been highly acclaimed to enhance our resistance to coronavirus infections.

Apart from the above-mentioned immunity boosters, various herbs, spices, herbal concoctions, Chinese herbal formulations and other traditional medicinal systems (Ayurveda, siddha and Homeopathy) have also shown promising outcomes in battling COVID-19.

There have been no reports to date that suggest COVID-19 is foodborne. However, it has been stated that the transmission of SARS-CoV-2 through food is possible if the person handling the food is infected and then sneezes or coughs directly on the said food. The other routes of transmission might be through the consumption of raw meat from an infected animal or handling of contaminated food packages.

To minimise the risk of food contamination in food processing facilities, it is important to ensure that good hygiene practices are effectively implemented. In addition, it is crucial that all personnel involved in food handling (raw materials handling, processing, storage and distribution of the final food product to the consumer) follow stringent social distancing and sanitisation practices.

Furthermore, door, window and machine handles, taps and other high-touch areas should be frequently disinfected. The use of face masks, gloves, face shields and personal protective equipment (PPE) can also be beneficial in containing the spread of infection from human-to-human as well as from human-to-food.

Various research studies have proved that coronaviruses such as SARS-CoV and MERS are heat labile, becoming inactive at temperatures higher than 65C.3,4 Due to similarity between SARS-CoV and SARS-CoV-2, a study conducted by Chin, et al. (2020) found that SARS-CoV-2 gets inactivated at 70C after incubating for five minutes.5 Therefore, it is stressed that no viruses survive this thermal treatment, hence it is crucial for consumers to refrain from eating any kind of raw meat and consume only well-cooked foods.

Nevertheless, we cannot deny the fact that animal-based foods are of higher risk as there are opportunities for the re-emergence of novel viruses from animal sources (slaughterhouses and seafood markets) to humans. For this reason, it is essential to reconsider our food system, which is highly reliant on animal-based protein sources. We need to make paradigm shifts towards sustainable food sources such as plant-based foods, lab-grown meats, alternative proteins from insects and microalgae, and recover bioactive compounds from food byproducts and waste.

It has been reported that SARS-CoV-2 can survive up to two and three days on stainless steel and plastic, respectively.6 This suggests that it may be possible for the virus to transmit from packaging material to hand, and subsequently to the mouth, eyes or nose. Hence, hand washing and sanitising should follow every time a package is handled.

There is an emerging need and research potential to design and develop active and intelligent packaging materials with antiviral and antimicrobial properties. Sportelli, et al. (2020) has reported that the packaging films coated with nanomaterials and nanoparticles (Cu, Ag and Zn) has significant potential to inhibit microbial contamination of food packaging surfaces and thus lessen the transmission of infections.7

Disinfecting high-touch surfaces is crucial to keep food safe

The smooth functioning of all the operations involved in food production systems (farm to fork) is necessary to prevent global food shortages. However, the food industry is currently facing an unprecedented threat in terms of food security and food safety. It is evident from various epidemiological studies that COVID-19 spreads mainly through direct contact between individuals and with contaminated surfaces; consequently, those involved in the food chain have been at particular risk.

In order to ensure that food is available to all, it is imperative for all food processing businesses to strengthen existing food hygiene and sanitation practices, and introduce additional measures to protect food workers from contracting COVID-19. Strategies that balance the need for continuous production and protection of workers should be carefully designed.

Due to movement restrictions and lockdowns, transportation and shipping operations have become complicated, with food companies that import raw ingredients being badly impacted. An effective strategy to alleviate the crisis has been to strengthen and provide technical solutions to local producers and small food supply chains, as they are less restricted by lockdown regulations.

Overstocking of food by consumers, either due to panic buying or false information, may also result in food shortages. Some of the measures taken by China and Italy during the first few months of COVID-19 were to ban illicit trading, profiteering and hoarding of food products.

COVID-19 has created many unforeseen challenges for agriculturists, food manufacturers, scientists and consumers. Food industries need to strategically plan and ensure adequate supply of safe and nutritious food for everyone.

The possibility of COVID-19 being foodborne is negligible; however, there is still a need for advanced research studies to fully understand the possible transmission route of COVID-19 through food. Thus, there is a necessity to develop rapid and affordable methods for detection of SARS-CoV-2 throughout the food supply chain.

Until the world is fully vaccinated, there are opportunities for food technologists to design and formulate functional foods for different vulnerable groups in order to boost their immunity.

References

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On doctors orders: 10 rules to keep healthy on the bike during winter – Cycling Weekly

Posted: February 13, 2021 at 10:49 am

As I sat in the waiting room of my doctors surgery, dreading having my worries dismissed because I was there with a cycling injury, the sight of my GPs bike helmet hanging on the back of the door instantly dissolved my fears. I hoped that, as a cycling medic, she would get why cycling mattered and sympathise with my frustration at being sidelined from the sport I love, while doing her best to help me back on the bike. And she did.

Doctors seem to love cycling. The Whitfield Surgery in Dundee, Scotland, has just bought its own fleet of electric bikes for home visits. Bike racks outside hospitals are rammed, and when time-trial start sheets used to include titles, a surprising number of names were prefixed Dr. So why not make the most of our sport being full of health experts?

We thought we should quiz a selection of them to get their unique insight into how to be smartly and safely health-conscious as a cyclist. What would a cycling doctor do? What would he or she advise a fellow rider?

Seven bike-loving medics spanning A&E, orthopedics, endocrinology, psychiatry, sport and general practice agreed to get involved. This is their advice on how to stay healthy and injury-free over the coming Covid winter.

(Photo by Stuart Franklin/Getty Images)

We can all reel off our own personal list of the ways cycling benefits us, and doctors are no different. GP Dr David Spitzer is clear on its value to him. Cycling helps me switch off from work and lifes other stresses it clears my mind, as I find it impossible to think of anything other than the road.

Doctors have more than anecdotal evidence. A study of 263,450 UK commuters published in the British Medical Journal in 2017 looked at how they travelled to work and their health status years later. A significantly higher percentage of those who rode to work were alive five years later compared to those who drove, and there were fewer cases of cancer and cardiovascular disease among the regular cyclists.

Professor Chris Oliver recently retired as an orthopedic surgeon, but remains an endurance cyclist who loves long adventures on his bike: Cycling reduces the risk factors for a number of diseases, including cardiovascular and respiratory diseases, some cancers, as well as Type-2 diabetes.

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But is isnt only physical factors that interest Oliver. I dont think people really appreciate that cycling also has positive effects on mental health and general wellbeing, says Oliver, listing a reduced risk of dementia, improved sleep quality, greater sense of wellbeing and lower pollution from reduced car use.

The overall evidence is that the health benefits of cycling outweigh any potential health risks and harms.

2. Riding indoors can be a tonic

Naomi de Pennington (Daniel Gould)

Though we benefit from the time outside, there are times when the weather makes it less safe and less appealing. At such times, indoor riding provides a great alternative. Stephen Eastaugh-Waring, an orthopedic and trauma surgeon, suffered a heart attack in 2013. The Rapha Cycle club member now rides to a restricted heart rate, and so has become a huge fan of smart-trainers.

They have revolutionised training. I can do a worthwhile session in 30 minutes on Zwift, enthuses Eastaugh-Waring. It has kept me sane and allowed me to do 7,000km in the last three years. Apps like Zwift and Sufferfest make training interesting, structured, accessible, and safe.

3. Get savvy about stress

Whether we ride outside or in, have a high workload or more laidback lifestyle, we all get tired sometimes and experience the negative impact on our cycling performance. What is important to remember is that our bodies dont distinguish between different types of fatigue and it all adds up.

Professor Oliver says the biggest mistake he sees riders make is overtraining and being too competitive while chronically fatigued. If youre in a high-pressure job requiring lots of concentration, youre even more liable to hit upon problems. Trying to be a high-level cyclist while doing a busy job its just not possible.

One way to keep an eye on these mounting levels of fatigue and stress is through biomarker tracking, allowing us to keep an eye on how our hormones are behaving. Hormones are impacted by athlete behaviours, so testing biomarkers is a valuable training metric to see if you have the balance right, says Dr Nicky Keay, a sports endocrinologist.

4. Obey infection control basics

We may all roll our eyes when we see yet another newspaper headline telling us about yet another magical food to boost our immunity, but our doctors are clear that fending off infections comes down to common sense: A good healthy diet and appropriate sleep, advises Professor Oliver adding that, in our Covid world, social distancing and mask wearing are the added essentials.

James Chan, an emergency medicine doctor who uses his bike for commuting to work, told us that it also makes sense to avoid crowded indoor spaces. Meanwhile, Dr Keay urges vitamin D supplementation she ran a study a few years ago with 50 competitive male road cyclists, which found that many had low levels. Vitamin D is essential for bone and muscle strength, and also supports the immune system.

It isnt just about boosting the immune system to fend off bugs, but also to protect against our own behaviours. Dr Keay explains: The stress of heavy training increases cortisol, which can suppress your immune system. So it is important to factor in recovery and ensure you have good sleep patterns.

5. You can cycle too much

There is an upper limit on what is a healthy amount of exercise, says Dr Keay. Overtraining doesnt just impact our immune system, but increases our chances of bone injury and hormonal imbalances. This form of harm can show up as stress fractures or diminished sex drive; the first sign for a female rider may be a missed period.

Training too much has mental health effects too. Cyclists who persistently overreach and get depleted are at increased risk of developing mental health symptoms, warns Alan Currie, a consultant psychiatrist in a specialist centre for mood disorders based in Newcastle. In his work with the English Institute of Sport (EIS), Currie studies the impact of high-performance efforts. Cycling can be harmful to mental health at the high-performance end, where risk factors can congregate frequent injuries and concussions; contracts that are suddenly terminated; performance concerns. So, if your cycling has got closer to the elite end and you are riding at high intensity for prolonged periods several times a week, be aware of the risk.

6. Stay alert and ride defensively

A big fear for many riders is crashing. And it is a realistic fear. While we can make sure our bike is well maintained and roadworthy, when we are on the roads we have no control over the quality of the tarmac or the behaviour of drivers around us. It is the A&E and orthopedic doctors who patch up our road rash and broken bones after something has gone wrong.

Our doctors first piece of advice is not to drift off or daydream. Live in the moment, says Professor Oliver. Use mindfulness as a coping strategy for endurance rides, to stay focused on what is going on around you.

The medics we spoke to also advise riding defensively, expecting the worst to happen. Dr Chan attests to the dangers of not riding defensively from personal experience his arm is currently in a sling after an accident. I do find myself cringing when I see cyclists on very busy roads hugging the kerb with very fast cars passing too close. I wish more cyclists would take quieter routes, or if those busy roads are unavoidable, learning to ride defensively and owning the road and riding a metre away from the kerb.

If you feel it is too dangerous for a car to overtake, position yourself towards the middle of the lane, urges Chan. This helps keep other road users safe, and dissuades dangerous manoeuvres that could put you as a cyclist in harms way.

7. Keep calm and quell the rage

All of this riding defensively means the threat part of our brain is constantly alert, looking out for anything that might take us down deep potholes, careless drivers or pedestrians stepping out. This keeps us physically safe, but means we are in a constant fight, flight or freeze mode, which is not only tiring but also demanding on our mental health.

Psychiatrist Alan Currie warns against getting angry on the road. It doesnt help. It wont assist your cycling. It wont change the behaviour of the thoughtless majority, and arguing roadside with the belligerent and combative minority is both futile and potentially dangerous. Currie isnt calling for total serenity; he acknowledges that it isnt always easy to quell your frustration.

8. Dont expect cycling to be a panacea

Though cycling has numerous benefits, it doesnt fix everything. Sometimes we need to look further afield. All our doctors agree that what is most important is not specifically the type of exercise you do, but whether you enjoy it.

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If you dont enjoy an activity, you wont stick to it, says Dr Chan, while GP Spitzer tells his patients: The best, and probably only, way to lose weight with exercise is to find a form of exercise you enjoy.

And, of course, regular exercise doesnt excuse us from eating healthily. You cant out-pedal a lack of nutrients or glut of sugars. You cant eat with impunity no matter how much you cycle. Eating bad foods is still bad for you and you can still find yourself putting on too much weight, or putting yourself at risk of diabetes by consuming too much simple carbohydrate or sugar, warns Dr Chan.

9. Pedal back to health post-op

Stephen Eastaugh-Waring reminds us that cycling can be part of surgical rehabilitation, for example as joint replacement recovery.

Its low-impact, works the gluteus muscles and allows a high cardiovascular benefit, he says. I have two such patients in the GB tri team, and many others cycling 100 miles plus it debunks the myth that joint replacement ends hopes of meaningful exercise or competitive sport.

10. Shave away

Finally, less for our health and more for our aesthetics, Professor Oliver debunks the myth that waxing is superior to shaving. Shaving does not make the hair grow back faster, darker or coarser.

This was even backed up by a British Medical Journal paper in 2007, he says.

So heres our bike-loving doctors advice in very quick summary: keep riding over winter; jump onto the turbo when the roads get icy; dont try to do it all; sleep well; eat better; dont go OTT on the training hours; ride defensively (and calmly); find a type of riding you love and put away the wax strips!

None of which is merely CWs advice its doctors orders!

This featureoriginally appeared in the print edition of Cycling Weekly,on sale in newsagents and supermarkets, priced 3.25.

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Gluten intolerance: Everything you need to know – The Indian Express

Posted: February 13, 2021 at 10:49 am

Much awareness is being spread about the need to stay fit and healthy. People are now more careful than ever about following strict workout regimes, eating right and taking care of themselves. But, such a behavioural change is not without reason, says Dr Pooja Bohoro, Senior Consultant Nutritionist and Dietician at MFine.

Our daily lives are not getting any less stressful and amid the strenuous schedules we keep, it is obvious we would want to stay healthy and far from ailments, especially those that come with poor lifestyle choices, stress, and dietary habits, she tells indianexpress.com.

When it comes to our diet, most of us no longer throw caution to the wind. We watch what we eat, and our list of things to avoid is longer than it ever was. Also, a certain word called gluten has crept into our dictionary and a lot of us who are calorie conscious and mindful of our diet avoid it as much as we can, if not completely.

But, what is gluten? What are the adverse effects it could have on the body? Why do we need to avoid it? What is gluten intolerance? Lets address a few questions.

What is gluten?

A family of proteins commonly found in grains like wheat, barley, rye, and spelt is known as gluten. Of these, it is wheat that is most consumed and hence, one would typically avoid it in a gluten-free diet. We are talking about no roti or bread, here.

When you mix flour with water, it is the gluten proteins you thank for making the dough elastic. It also helps bread rise when baked. It is not without reason that gluten is called so, it gets its name from the glue-like texture it offers with wet dough, she explains.

The two primary proteins in gluten are gliadin and glutenin, of which the former causes the most harm to the body if a person is sensitive to it. Otherwise, it remains relatively safe and healthy for consumption.

It is primarily found in the following items:

Bread Pasta Breaded meat and seafood Cakes and cookies Beer

What is gluten intolerance?

While some can tolerate gluten, many with certain health conditions cannot. Among the most severe forms of this condition is celiac disease an autoimmune disorder where the body rejects this protein. The immune system attacks gluten and resultantly, the gut lining.

A damaged gut lining leads to several other complications that include obvious digestive problems, diarrhoea, headache, constipation, lethargy, depression, and skin rashes, among other health issues. Notably, certain symptoms of celiac disease that are not related to digestive issues are difficult to diagnose and hence, a lot of people with the condition arent even aware of it.

There are also those who might not be affected by celiac disease and still be gluten intolerant. Such a condition is known as non-celiac gluten sensitivity.

Symptoms

While digestive issues are the most common symptoms associated with gluten intolerance, there are several others ranging from skin rashes to mood disturbances. Heres a look at some of them:

Digestive problems like abdominal pain, diarrhoea, constipation, heartburn. These could further lead to malnutritional effects like weight loss, lethargy, etc. Skin issues like redness, rashes, bumps, itching, etc. Depression, migraines, and lack of concentration Frequent mood swings Attention-Deficit Hyperactivity Disorder (ADHD) Treatment

Often, it is a gluten-free diet that is the most effective solution. However, other symptomatic effects like skin rashes, and migraines, among others, need to be treated accordingly by a doctor, she says.

Here is a list of foods you can include in your diet:

Gluten-free pasta Fresh fruits and vegetables Meat and seafood (not breaded) Unflavoured dairy products

If you have any of the above symptoms with any obvious cause, make sure to consult your doctor and try removing gluten-containing products from your diet.

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How to celebrate and avoid the virus during this double holiday – WHYY

Posted: February 13, 2021 at 10:49 am

One perennial Valentines Day favorite is going to restaurants, and some in Philadelphia were allowed to expand to 50% indoor capacity on Friday if they passed an air ventilation test.

Still, Usama Bilal, an assistant professor in the Urban Health Collaborative and the Department of Epidemiology & Biostatistics at Drexel Universitys Dornsife School of Public Health, cautions people against indoor dining at all costs for their own safety and the safety of the restaurant workers.

Its a holiday where people usually go to restaurants, and we are increasing the capacity of indoor dining. The combination of those things can be very dangerous for the city, Bilal said.

Bilal worries about indoor dining because people would have to remove masks to eat and drink. And if you plan on eating outdoors in a tent or enclosed space as an alternative to eating indoors, Bilal would recommend against that too.

Those places [outdoor tents], ventilation may even be worse than indoors, Bilal said. At least some indoor spaces have ventilators, but those outdoor spaces really are in some cases worse because of the false sense of security. If you want to do outdoor dining, truly do outdoor dining, If you see walls around you, thats not outdoor.

With wintry temperatures forecast for the weekend, its unlikely people will want to eat outdoors in the way Bilal recommends, however.

If you absolutely have to meet people indoors, Bilal suggests indoor activities that do not involve taking your masks off. The CDC takes it one step further and advises that if you are hosting an indoor event, make sure to clean and disinfect frequently touched items between use, limit the number of guests, and bring in fresh air by opening windows and doors.

Since most people have not yet been vaccinated and are still susceptible to the coronavirus, celebrating indoors is still very risky.

With the vaccine or vaccination rates going up, there will be a time where well be able to do this again, Bilal said. But until then, people can avoid meeting indoors without a mask with people they dont live with. That should be a priority at this moment.

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Hooi Kee Eating House’s operations suspended after 2 diners hospitalised with typhoid fever – CNA

Posted: February 13, 2021 at 10:49 am

SINGAPORE: An F&B outletat Singapore Shopping Centre was directed to suspend operationsfromThursday (Feb 11)after two diners were hospitalisedwith typhoid fever, said the Ministry of Health (MOH) and the Singapore Food Agency (SFA).

The authorities said they are investigating the cluster of two typhoid fevercases who were reported to have symptoms including fever, headache, diarrhoea and cough after consumingfood prepared by Hooi Kee Eating House on several occasions from Jan 2 to Jan 18.

In view of the "suspected ongoing transmission", SFA has directed the business, which is located at 190 Clemenceau Avenue, #01-19/20, to suspend operations until further notice.

Both cases were hospitalised. One hasbeen discharged and the other is in a stable condition in hospital, said SFA and MOH.

"Members of the public who have consumed food from Hooi Kee Eating House and subsequently develop prolonged fevershould consult their general practitioner immediately and inform the doctor of their food history," the authorities added.

All food handlers working in the premises are required to re-attend and pass the Food Safety Course Level 1 and test negative for foodborne pathogens before they can resume work as food handlers.

The appointed food hygiene officers working at the premises are also required to re-attend and pass the Workforce Skills Qualifications' Conduct Food and Beverage Hygiene Audit course before they can resume work asfood hygiene officers. The licensee is also required to clean and sanitise the premises, including equipment and utensils.

SFA reminded food operators to observe good food and personal hygiene practices at all times, saying it "will not hesitate to take firm action against anyone found to be in violation of the Environmental Public Health Act".

"In the interest of maintaining a high standard of food hygiene at all eating establishments, we would also like to advise members of the public who come acrosspoor hygiene practices in food establishments not to patronise such outlets but to report to SFA," said the authorities.

TYPHOID FEVER

A person with typhoid fever usually has prolonged fever, which may be accompanied by other symptoms common to many diseases, such as headache, body aches, vomiting, diarrhoea or constipation, according to the authorities. Typhoid fever is treatable with antibiotics.

It is a bacterial infection caused by Salmonella typhi. Food items that can be contaminated by the bacteria includeraw or ready-to-eat foods, such as raw (unpasteurised) milk or their products, seafood, and fresh produce including fruits and vegetables.

"The key to prevention of typhoid fever lies in hand hygiene, safe handling, cooking and consumption of food," said MOH and SFA.

This can be done by washing and peeling raw fruits or vegetables that can be peeled before consumption; cooking food thoroughly; avoiding raw (unpasteurised) milk or food made from raw milk; washing hands and kitchen utensils such as knives and cutting boards thoroughly before handling food; and using separate sets of knives and cutting board for raw and cooked food.

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[Full text] A Bidirectional View of Migraine and Diet Relationship | NDT – Dove Medical Press

Posted: February 10, 2021 at 8:54 pm

Introduction

Interest in headache1 is potentially as old as recorded human history. With all the advancements in understanding and management of headaches over the years, headache in general has remained a major complaint for which patients feel an urge for a medical consult. Costs related to headaches are high and are classified as direct (medical care) and indirect costs (loss of productivity). Therefore, if headaches can be diagnosed correctly and earlier, and if they can be managed properly, the burden to patients and societies will be dramatically reduced.

Based on the latest version of the headache classification, migraine is a form of primary headaches,2 ranked among the most disabling medical conditions.3 Number four of the Trndelag Health Survey (HUNT4 study) revealed that 18.1% of the studied population had active migraine.4 Migraine is characterized by headache attacks and associated symptoms presented in a multiphasic nature,5 where both peripheral nervous system and central nervous systems are considered involved.5,6 The recurrent nature of migraine and the fact that it can be triggered,7 have provided a key feature to explore internal and external triggers and through those, to study the mechanisms underlying the disorder. This phenomenon has also presented a unique opportunity to modify triggering factorsthose that can be modifiedto reduce intensity of migraine and how often it occurs. This concept is attractive, as it has been found that lifestyle factors,8 such as diet,9 can trigger migraine, and lifestyle modifications,10 for example diet modifications, and nutraceutical interventions11 have collectively shown beneficial effects in patients with migraine. Considering these options is important, because despite remarkable advancement in understanding of the pathogenesis of migraine and targeting migraine by the novel therapeutic options,6 challenges remain related to sufficient efficacy, and desirable safety, and the fact that nonresponders are present.12 In addition, a number of individuals with migraine are continuously searching for natural and device- or drug-free interventions outside of the typical therapeutic options. In this line, functional medicine approach to manage migraine has been proposed as a potential tool. This approach considers individual's genetic, biochemical, and lifestyle factors to construct plans for personalized treatment. Functional medicine consists of timeline, matrix, and the therapeutic lifestyle factors (for example, sleep, exercise, diet, and stress). Within this framework, functional food can also be defined for migraine. Generally, a food is defined functional if it is satisfactorily demonstrated to affect beneficially one or more target functions in the body, beyond adequate nutritional effects in a way that is relevant either to an improved state of health and well-being and/or reduction of risk of disease.13 Functional food has been tested to identify if it can exert beneficial effects for several diseases, for example for metabolic syndrome.14 This syndrome consists of several metabolic disorders (eg, high levels of fasting glucose and obesity) and enhances the risks of other diseases, for example stroke, diabetes, and cardiovascular diseases.14 Interestingly, migraine has also been recognized as a disorder related to metabolic imbalance, and that highlights a potential for functional food for migraine.15 William Amery in 1982, provided the first evidence that the metabolism is linked to the pathogenesis of migraine.16 Recent studies investigating metabolic alterations in migraine have proposed that a mismatch seems to exist between brain energy sources and the consumption of the sources,17 and have linked this energy deficit to mitochondrial dysfunction in migraine.18 It is hypothesized that energy-reserve deficit alone or combined with an overload of sensory input could activate the trigeminovascular system in the cascade of pathophysiological events in migraine.18 Based on this, a metabolic treatment of migraine has been proposed.17,19

While identification of dietary triggers and dietary interventions for migraine prevention are profound in the literature, the concept of dietary choices, and pattern of diet in migraine patients have been investigated less.20,21 The idea that mechanisms underlying migraine pathogenesis might influence dietary choices is valuable, but has sporadically been discussed.20,21 Epidemiological findings have demonstrated that choice of diet by individuals with migraine is different compared with individuals without migraine. Potential reasons for such difference have been explained by several factors, for example, contribution of neurotransmitters such as serotonin and orexin, hormones, and state of aura.21 A potential bidirectional relationship (Figure 1), where migraine influences food intake, and consumed food affects the manifestations of migraine, needs further investigation. Within this framework, investigation of the gutbrain axis contribution seems highly valuable.21

Figure 1 A potential bidirectional relationship between migraine and diet.

In the following sections, some examples from the current literature are presented to highlight what we already know about the effects of diet on migraine and the effects of migraine on dietary choices, and what remains unknown to stimulate further research. Therefore, the purpose of this targeted review is not to provide a comprehensive systematic review of the current literature on the role of diet in migraine; since several excellent reviews are already available (eg,9,2226). PubMed, Cochrane Library, EMBASE, and Web of Science databases were searched for studies using keywords of diet, migraine, food, and lifestyle with the aim of providing the current overview, and a viewpoint to the potential future directions. The ultimate goal is to form testable scientific hypotheses for future investigation of the bidirectional relationship of migraine and diet.

Studies that have investigated whether and how the consumption of dietary components can influence the manifestations of migraine are abundant. The potential role of dietary triggers, contribution of the immune system, metabolic systems, and the gutbrain axis contribution are among the examples focused on the effect of diet on migraine. The other direction, where migraine might also influence the food intake, has been less investigated. Presence of aura,2729 some neurotransmitters involved in pathogenesis of migraine (eg, serotonin,30,31 and orexin32), hormones (eg insulin33), and level of adiocytokines34 have been proposed to influence the choice of diet by affected individuals in terms of content, pattern, and amount of food intake.21 Several familiar and unknown factors can potentially influence this bidirectional relationship. These include, but are not limited to, gender, age, and geographical locations.9,24,3537

A large number and diverse range of factors (eg, dietary factors) with a high degree of heterogeneity have been reported capable of triggering migraine.38 For example, stress has been shown to exacerbate migraine, and having or expecting a migraine can negatively affect stress level of affected individuals. Menstrual migraine is a typical example of the link between hormones and migraine. Sleep and migraine have also been found interrelated where sleep disturbances aggravate migraine. Other environmental factors such as intense light, strong odors and high altitude have also been reported to influence migraine.39 Consequently, long lists of recommendations exist for avoiding potential triggers or coping strategies in order to prevent migraine or subsiding its frequency and severity; hence, enhancing the quality of life in affected patients.40

A meta-analysis of available studies for headache triggers has summarized data from 27,122 participants from 85 articles published between 1958 and 2015, and has provided 420 triggers.41 86% of the included participants in this meta-analysis had the minimum of one trigger for their headaches. Findings from this study highlighted that stress was the most prevalent trigger.41 Heterogeneity, however, was high and intra- and interindividual variations among trigger frequency and potency were also profound.41 Knowledge of migraine triggers can help in improving the management, coping, and care for migraine; but studying migraine triggers is not challenge-free. Using smartphone-based dairy studies that use ecological momentary assessment systems, has presented fatigue, sensory sensitivity, negative affect, specific foods, menstruation, and yawning as the most frequent triggers of migraine.4244 Correct understanding of trigger perception has been discussed by Turner et al45 to highlight how important are the behavioral changes in response to a headache trigger that is perceived by patients as a precipitating factor. An example is the avoidance of bright light if the individual with migraine perceives it as a migraine trigger. This controlling avoidance behavior may influence the scope of individual activities, and can negatively influence the quality of life.40,46,47 Perhaps that is why coping strategies are prioritized to avoidance strategies, in general.47

Collectively, the current ultimate recommendation for individuals with migraine has pointed to the value of maintaining an appropriate and healthy lifestyle.48 Lifestyle can be defined as the controlled behavior and activities of a person and many activities, habits, and practices involve risk factors. The contribution of dietary factors within the lifestyle modification has been recognized; however, proposed beneficial changes in lifestyle, consider a broader spectrum to not only include dietary aspects, but also monitoring of exercise, sleep, and stress.49

It has been proposed that modification of lifestyle might prevent migraine, which in turn would decrease the burden to individual patients, and health-related costs.50 However, due to the complexity of migraine, as a multidimensional disorder, and also the complexity of designing studies to test how dietary factors can influence migraine,49 inconsistency exists in the literature, ranging from a limited importance of dietary modification for migraine to some promising effects. Cross-sectional studies have been important in providing an overview of potential triggers;51 however, if the goal is to prove (or falsify) that a causal or a bidirectional relationship exists in the dietmigraine interaction, prospective studies with proper control groups must be designed that are also longitudinal in nature. For example, age of onset is extremely important.51 A migraine patient passes through different phases in an age span, from pediatric to geriatric migraines, for example. Puberty has been shown linked with migraine and migraine that occurs before puberty differs from post-puberty migraine. Several factors such as alteration in lifestyle, habits, and hormonal levels have been proposed to shape this evolution from pre- to post-puberty. A recent study52 has investigated this evolution in a selected pre-pubertal patients who were diagnosed with migraine. Researchers in this study collected medical records, migraine manifestations, and lifestyle-related factors, at baseline and at the two-year follow-up. Nineteen patients (migraine with aura: 27.5%) were recruited. The results of this study demonstrated that migraine accompanying symptoms changed with a significantly higher prevalence of dizziness, vertigo, mood changes, confusion, and allodynia.52 Prodromal symptoms became more prevalent, where sleep disturbances and schedule changes showed a significant increase as migraine triggers. Interestingly, at baseline, food was triggered at 11% of cases, but after two years, it went down to zero. Another study on the participants aged above 16, has also identified the appearance of new triggers over time. For example, new factors, including pain in neck, consumption of alcohol, hormonal changes, and smoking were notified.53 These studies provide valuable information that migraine triggers show changes during puberty, and new triggers can appear together with changes in habits along with physical and lifestyle changes, which collectively highlight attention to a potential dynamic pathological process that deserves further investigation. These studies also present a valuable point that besides studying dietary factors other daily lifestyle features, for example how a patient sleeps, makes a workrest balance, and deals with stressful situations are important to observe and note, because these factors are often interrelated and can influence each other directly or through indirect interactions. Comorbid conditions, such as other neurological, psychological, or cardiovascular disorders are also important and influential, because patients, influenced by those conditions, might follow a special lifestyle, including certain diets.1 For example, those who are diabetic or have a heart disease may follow a vegan diet for its beneficial effects,54,55 and some migraine patients might be on a vegan diet for comorbidy or other reasons.

A systematic review from 202022 has summarized the findings from 43 studies that have investigated and reported dietary patterns (11 studies), triggers (20 studies), and dietary interventions (12 studies) in patients with migraine.22 Level of evidence was determined as low level, because the authors identified that >50% of the studies were cross-sectional or patient surveys. Caffeine and alcohol were found as major triggers that could increase migraine frequency.22 Several dietary interventions were also reviewed, for example, elimination diets, low-fat diet, and ketogenic diet that presented promising results in managing migraine.22 However, this review did not present a choice or a favorable, so-called migraine diet, due to lack of qualified and sufficient information.

Elimination diets can be based on a diary for identification of triggers, or based on tests for the IgG-positive food, both strategies to limit those triggers. When participants were tested for antibodies against 266 foods and individually eliminated those foods that they had positive tests for, a reduction of 29% in migraine days was found.56 This study was, however, a small cross-sectional study, with some limitations. Another study, which was designed as a randomized controlled trial, eliminated those foods from diets of migraine patients who participated and were positive for certain food-related antibodies. When headache days were determined after four weeks on the elimination diet, a 19% reduction was found.57

Dietary interventions have mostly been investigated in a small population with no proper control group, hence results are heterogeneous and a sharp conclusion cannot be made. For example, a diet high in carbohydrate and low in tryptophan was tested in a group of seven patients and showed beneficial to subside headaches. The authors proposed that the positive effect has been apparently due to a mixture of lower intake of food that could trigger headache and also elevated levels of serotonin following the tested diet.58

Dietary lipids were investigated afterwards, because it was proposed that a diet high in lipids could cause headache following a potential lowering of serotonin levels in plasma that might be a result of higher platelet aggregation.59 A diet with a very low level of lipids (~20 g per day), therefore, was proposed to prevent headaches.60 A randomized, crossover trial reported in 201561 that low lipid compared with moderate lipid dietary intake could subside occurrence of migraine and headache intensity. It has also been reported that the dietary approaches to stop hypertension (DASH) diet could diminish the intensity of headache and duration in migraine.62 This particularly points to the importance of migraine comorbidities, and how dietary factors can influence an overall well-being of the affected patient.

Supplementation by a diverse range of vitamins and minerals has been reported beneficial for migraine. For example, based on a review from 2018, vitamin D, vitamin B2, vitamin B12, magnesium, carnitine, and niacin have reduced frequency of magnesium, carnitine, and niacin have reduced frequency of migraines.63

Even though beneficial effects of these dietary interventions have been reported in the literature,22 one must consider that individual patients may require special needs that importantly points towards the concept of precision medicine in migraine.64 Including larger cohorts of patients and considering follow-ups of longer duration could help in properly examining the effect of dietary interventions, a point to be considered in the future investigations. In this line, patient adherence and age influence on diet choices and dietary patterns emphasize the value of long-term assessments. However, plan, design, and conduct of long-term studies are difficult and several intractable factors need to be considered and integrated into the assessments. At present, comparisons between studies remain difficult because age, gender, cultural, and religious variations among different studied populations have largely been ignored. Gender of affected individuals is an important factor to consider,51 because changes in hormonal concentrations, for example plasma estrogen concentrations, have shown an association with migraine.65 Alternatively, dietary intakes that can alter estrogen activity to a lower level have been shown beneficial for premenstrual symptoms.66 Therefore, low fat, high fiber, or vegan diets, might help some patients, for example those who have menstrual migraines. In fact, a study67 has tested this hypothesis, by investigating the effects of a four-week low-fat vegan diet in migraine. Overall, headache severity, headache days and frequency subsided, but this study has some limitations in design preventing drawing a sharp conclusion.67 Besides linking beneficial effects of a vegan diet to a low fat content, and lowering estrogen activity, several other mechanisms have been proposed, for example antioxidant and anti-inflammatory properties of plant-based food. Since an involvement of neurogenic inflammation in migraine68 has been suggested, this might be an explanation. In addition, dairy products (eg, cheese) and meat49 are not present in a vegan diet and these components have often been reported as migraine triggers in the literature.69,70 Therefore, absence of these components in a vegan diet might exert an anti-inflammatory effect against migraine.

Weight loss has been reported beneficial in migraine,71,72 although open questions remain in the field due to design and studied populations in the current literate. A proof of concept study in 2015 presented that weight loss could result in symptom improvement.73 Based on a pilot study published in 2019,11 enhancing the quality of diet and maintaining a healthy weight, could improve some clinical features of migraine. In this open, and nonrandomized study, women with migraine received an individualized diet plan, which was based on a professional nutritional diagnosis. This study was first to provide evidence that diet quality and maintaining a healthy weight are important,11 not the weight loss per se. This means that for underweight patients a weight gain might be the successful strategy, while for overweight patients, a weight reduction strategy would provide beneficial effects on migraine.11

Bond et al74 designed a study to test if two different strategies for weight loss would be comparable or different. Migraine patients who were overweight or obese women (a population considered to be most affected by obesityrelated migraine risks)35,75,76 were included and divided into two groups. One group received a behavioral weight loss (BWL) that included both exercise and diet, and the other group received educational instructions on migraine. Findings from this study showed that both groups benefited from a reduction in headaches following the two strategies and there was no significant difference between the groups. This study presented that independent of the type of strategy; strategies for weight loss might be beneficial for this special population.

According to a systematic review and meta-analysis77 that has summarized and compared two strategies for weight loss, it was revealed that independent of technique, weight loss could reduce headache severity, frequency, duration, and associated disabilities. Therefore, weight loss was highlighted as the critical factor, not the amount of weight reduction, or the strategies that were used to achieve the loss.77 In fact, the obesity and migraine link has been a matter of investigation for a while. The fundamental questions are, do people with migraine gain weight because of migraine related disability? Or does obesity lead to greater migraine frequency? In other words, which comes first, obesity or migraine. Results are mixed in the literature. Winter et al in 201278 found that among 19,162 middle-aged women, those with migraine had a significantly higher risk to shift towards being overweight or obese. The risk was not different for women with or without aura.78 Age plays a role in obesitymigraine interactions,79 because age affects the body mass index (BMI), distribution of body fat, hormones, and prevalence of migraine. Reported in 2020, the HUNT3 (the third population-based Nord-Trndelag Health Study)80 showed that a greater association exists between migraine and obesity in younger adults, ie, those >50 years old, still within the reproductive age. Therefore, one must consider that in the study by Winter et al,78 where middle-aged women were included, other risk factors might have played a role.

A meta-analysis81 of 12 studies, including data from 288,981, demonstrated that body composition is a critical factor. When pooled data were adjusted for age and sex in this analysis, an increase risk of migraine (27%) was identified in obese vs normal weight and was not lost even after multivariate adjustments. The risk was shown slightly elevated (13%) in underweight vs normal weight and again it was not changed even after application of multiple adjustments. Therefore, it seems based on these results, that obesity and being underweight could enhance risk of migraine.81 An increased risk of migraines in underweight and obese women vs normal weight was presented in 2015 by Ornello et al.82 However, pre-obese subjects did not show any increasing risk.82

Multiple underlying mechanisms for the impact of obesity on migraine have been proposed, one of which is a neurometabolic impact.18 This has been based on reports in the literature that metabolic factors can trigger migraine, for example, fasting/hypoglycemia, dehydration, stress, alcohol, and lack of sleep. These factors have been found linked to reduced brain energy levels in migraine patients. It has been proposed that these triggers could reduce mitochondrial function, ATP generation, cellular glucose transport, and lipid oxidation, promote neuroinflammation (neuronal and glial signaling modulation), and astrocytic signaling.18,19 These mechanisms are also linked to increased cortical excitability that has been proposed in migraine pathophysiology.83 The review by Gross et al18 in 2019, summarized the available literature on the metabolic changes in migraine and how those changes can contribute in pathophysiology and being potential targets for treatments. One important feature in this context is that nutritional intervention to improve nutrient metabolism, neuroinflammation, and oxidative stress, can eventually improve migraine.18 This has shed light on the concept of obesity and migraine. Observations have provided evidence that the hypothalamus which is the first station for detecting of changes in peripheral energy status, is involved in migraine pathogenesis.84 Interestingly, it has been found that hypothalamic astrocytes have distinct responses to nutrients, ie fatty acid and glucose metabolism coupling.85 In addition, it has been found that different brain cells utilize, store, and modify their response to lipids. L-carnitine, which transports fatty acids into the mitochondria, where those are oxidized to produce ATP, has shown efficacy in blunting migraine.86 In contrast, saturated high-fat diets leading to obesity, promote metabolic dysfunction, depressive like behavior, and neuroinflammation.87 This has led to applying a strategy in which targeting obesity could suppress neuroinflammation and consequently block the depressive symptoms. Interestingly, increased mood disorders have been seen in migraine patients, so these basic research findings are clarifying some underlying mechanisms that might share commonalities in obesity, migraine, and mental health.88

The concept that migraine might be a response to low brain energy level or uncompensated oxidative stress,89 has brought the ketogenic diet back into attention.90 This diet acts in a similar way to fasting, where ketone bodies are elevated and can be used as an alternative source of energy to correct abnormalities in glucose metabolism reported in migraine. Some reports, including a proof of concept study,73 have demonstrated beneficial effects of a ketogenic diet to reduce migraine frequency. Recently, an alternative method has been considered to apply exogenous ketogenic substances.91 This means to provoke nutritional ketosis with ketogenic substances, for example, beta-hydroxybutyrate (HB) salts.91 A recent review90 summarized the potential mechanisms underlying the effect of ketone bodies and presented those as signaling molecules that can interfere with pathways involved in migraine pathophysiology.90 For example, ketogenic substances can reverse mitochondrial dysfunction, subside oxidative stress, reduce cerebral excitability, or lower the inflammation.90 Even though an extensive amount of work has been done in animals, clinical research is lacking to validate the findings as if these protective effects of ketone bodies (KBs) would also be present in patients with migraine. Supplementation with HB without a strict dietary change is under investigation91 and could help provide evidence and address those open questions.

Diet-induced obesity has been shown to reduce brain fatty acid uptake.92,93 This has opened up a concept that obesity could enhance deficits in brain energy reserves and metabolism that characterize migraine. Within this concept, omega-3 fatty acid supplementation has shown antidepressive action and reduced migraine frequency.94 Fish oil supplementation in obese mice95 has shown reduction in metabolic and anxiodepressive effects of diet-induced obesity and related alterations in the composition of brain lipid. Further investigation is required in humans, as mood, food, and obesity have been found interrelated in a complex interaction.96 In addition, it is still not known whether a migraineobesity association is different in females and males, in different ages, and in different subtypes of migraine, considering mood disorders and emotional behaviors in humans.

As the evidence continues to accumulate, it is suggested that physicians recommend weight loss to their patients who have comorbid obesity. This is because weight loss has proven to improve sleep, mood, and other factors that increase susceptibility for having more frequent or severe migraine attacks. Lifestyle changes overlap with migraine and can be beneficial in migraine management, in particular when migraine is comorbid with other conditions, such as depression. There are lifestyle modification approaches for obesity. For example, according to Wadden et al,97 diet, exercise, and behavioral therapy were major determinants of lifestyle modification, where a reduced-calorie diet and a high level physical activity could yield a long-term weight loss.97 Based on a recent review,26 diets that promote weight loss, such as the ketogenic diet, and low-calorie diets, could be considered beneficial for those headache patients who are obese. In addition, lowering intake of omega-6 and intake of higher amount of omega-3 in this group can be advantageous. However, another review9 has emphasized that the net outcome depends on several factors, for example, age, gender, genetic predisposition, and environmental factors. Therefore, in order to provide evidence-based dietary recommendations for migraine, we need to consider these influential factors in study designs. In addition, the more we know about the mechanisms leading to migraine, the better we can investigate different factors, including dietary factors, which can interfere with those mechanisms. Future research is needed to provide evidence of whether diet can be a disease-modifying agent for migraine, and how. Considering the big picture, this would also enable personalized recommendations that - are in line with biopsychosocial considerations in targeting migraine.

In addition, one must consider that if comorbidities exist with migraine, dietary modification might be beneficial in controlling the condition. For example, several studies have highlighted a solid link between migraine and gastrointestinal diseases, in particular, irritable bowel syndrome (IBS). For review see Camara-Lemarroy et al.98

The gutbrain axis is a term to describe a potential two-way relationship between the gut and the brain. The gutbrain axis might potentially explain the existing link between IBS and migraine.98 Evidence is accumulating on the role of gutbrain axis in several neurological disorders, and migraine is not an exemption, where this has been reviewed in a recent review.99 However, we still do not know how the gut and the brain may interact in migraine.99 Several mechanisms have been proposed,100 for example, composition of gut microbiota, proinflammatory substances such as interleukins, neuropeptides (eg, calcitonin gene-related peptide; CGRP), hormones, and dietary components.101

In a recent metagenome-wide association study (MWAS),102 fecal samples of elderly women with migraine have been compared with matched controls to determine if gut microbiota is associated with migraine. Results showed that patients and controls are different in terms of diversity of species in the gut. Clostridium species (an unhealthy composition) were significantly higher in the migraine group. However, a healthy composition (eg, Faecalibacterium prausnitzii, Bifidobacterium adolescentis, and Methanobrevibacter smithii) were profound in controls. Patients also presented a diminished metabolic function of the gut compared with the controls.102 These findings may pave the way toward diagnosis, prognosis, and response to treatment strategies, or point to a novel therapeutic target. Based on the results,102 and to maintain healthy composition of the gut microbiota, proper probiotics have been suggested to correct dysbiosis in migraine patients. The concept of using probiotics for maintaining well-being is not new,103 however, identification of the role of probiotics in minimizing neuroinflammation, a mechanism proposed for migraine,104 has attracted attention toward the use of probiotics for alleviating migraine attacks.105,106 In patients with episodic and chronic migraine, a multispecies probiotic supplement has been investigated to identify a potential beneficial effect and profile of inflammatory markers.106 Findings revealed that probiotic supplementation could reduce the frequency and severity of migraine attacks. In addition, patients had a lower number of migraine days in the month and consumed a lower number of drugs to stop migraine headaches.106 According to the findings by Sensenig et al, mineral and vitamins added into a probiotic regimen for 12 weeks could result in a remarkable improvement in headache in 60% of migraine patients. Improvement in quality of life was reported by 80% of patients.107

Probiotic interventions as a prophylactic way to treat migraine have been summarized in a recent systematic review.108 Out of 68 screened studies, only two studies were analyzed, one with negative 109 and one with positive outcome106 in diminishing migraine frequency and intensity. The authors of this review108 have recommended points for inclusion and exclusion for the enrolment of patients, considerations for study design that can recruit standard and comparable methods, and proper control groups, within sufficient time.108 Microbiome analysis, pre- and postintervention, has also been encouraged.108

Another potential explanation for the existing link between gastrointestinal disorders and migraine is the gut permeability,110 where the leaking of lipopolysaccharides from the lumen into the blood can trigger a proinflammatory response,111 which is known to play a role in migraine pathogenesis.112 In a group of migraine patients diagnosed with comorbid IBS, probiotics combined with an elimination diet were tested.113 Sixty patients were randomized into three groups to receive the elimination diet, probiotics, or diet plus probiotics.113 The study results demonstrated that the combination method was superior for improving migraine comorbid with IBS.113

In addition to gut composition, which was found different in migraine patients, collected samples from the oral cavity of patients with migraine have demonstrated different composition from controls.114,115 Significantly higher nitrate, nitrite, and nitric oxide reductase genes were found in oral cavity samples of migraine patients. Interestingly, nitrates and food additives are reported among headache triggers, and nitric oxide pathway has been linked to migraine.116,117 Therefore, bacterial composition can be investigated in oral cavity and fecal samples in migraine and composition might reveal differences from controls.114

Identification of the CGRP role in migraine, has led to the development of new targets118 such as monoclonal antibodies that target CGRP itself, or its receptor, and also new oral gepants, antagonists of CGRP receptor.119 Evidence is limited as if dietary components could interfere with CGRP in migraine. Cady and Durham treated rats with cocoa-enriched diets for 14 days and investigated the expression of CGRP in the trigeminal ganglion cells, where they reported a significant decrease in the expression.120 In cell models, CGRP secretion has also been diminished after treating cells with petasin, which is the active component of butterbur, grape seed, and ginger extract.121,122

In relation to CGRP, a new study123 has demonstrated that when migraine patients with episodic migraine were supplemented with vitamin D, they had lower headache days and disability assessed on the migraine-related disability score (MIDAS) showed a significant improvement after 12weeks.123 Researchers in this study analyzed the serum levels of CGRP and presented that in the group on vitamin D supplementation, CGRP level was significantly lower.123 Based on the findings and correlational analysis, the authors have proposed that vitamin D might exert some of its effect through lowering of the CGRP levels.123 A larger study with a longer duration together with supportive basic research studies to look into underlying mechanisms of vitamin D in lowering CGRP and exertion of antinociceptive effect through this path, have been suggested.123

Considering beneficial effects of targeting CGRP with recent compounds,118,119 this line of investigation remains open to identify how dietary components or patterns might interact with expression and function of CGRP to interact with migraine manifestations.

Neurologists often encourage their patients with migraine to follow a consistent lifestyle. This is based on the observation that sudden changes in any lifestyle component may provoke migraine attacks. This includes several components, such as exercise, sleep, workrest cycles, diet, etc. However, evidence is still limited. In addition, the pattern of diet or habits of dietary choices might be equally as important as content of the diets. A cross-sectional study in 2015124 that used logistic regression, found that migraine is associated with low intake of food, regardless of the type of food.

A review125 on dietary consistency has presented the topic from three different views to migraine. The authors have proposed migraine as an illness, a disease, and a state of inflammation.125 Within this proposed framework, the authors looked at the relationship between diet and migraine as a function of changes in these three.125 Other researchers have considered migraine a brain disorder of maladaptive response and have described a feedforward allostatic cascade model that can lead to migraine.126 In this model specific stressors such anxiety, noise, food, odors, and bright light can be tested. Each of these factors can contribute to the allostatic load with a different magnitude, and factors can be summed over time. Therefore, the authors have proposed that modification of these effectors or stressors can help to intervene with the skewed allostatic load in migraine.126 Independent of the viewpoint to migraine, maintaining consistency in daily living is not easy and most likely requires education, monitoring, and support, and scientifically driven patterns.125

Studies are vast in the literature to examine dietary triggers for migraine and to lesser to examine dietary intervention. However, the question remains open as to whether certain dietary intake patterns are specific to migraine and whether migraine pathogenesis would influence dietary choices and patterns. In this line, it is important to identify if the subtypes of migraine can have an influence on the choices. For example, if the state of aura would lead patients with migraine to select a specific dietary component or patterns, while those choices might be different from those patients who do not have aura, and in comparison with migraine-free individuals. To address this side of the diet-migraine relationship, studies with proper control groups, such as nonheadache and nonmigraine control groups, and including subtypes of migraine (episodic, chronic, with and without aura) would allow for a proper evaluation. However, the evidence is very limited. Pattern of food intake has been investigated in one study,124 where a large population of middle-aged women was included. This study124 was designed based on a hypothesis that migraine patients and healthy individuals are different when it comes to food intake and food avoidance behavior, and that subtypes of migraine (eg, with and without aura) may influence these behaviors even further. This study124 demonstrated that a migraine-specific pattern of food intake existed that was different from healthy individuals. The only exception was alcohol consumption. In addition, and based on the presence or absence of aura in migraine subtypes, the choice of certain food items was influenced. Those items were, for example, chocolate, processed meats, dairy products, and wine.124 Interestingly, lower intake of dietary compounds known as migraine triggers was not evident. This led to an assumption that those food items might have been avoided by patients within a particular subtype of migraine.124 Further studies, however, are required to investigate this arm of migrainediet relationship. Epidemiological findings have demonstrated that choice of diet by individuals with migraine is different from individuals without migraine and the difference reflects on several nutritional metrics,21 for instance, diet quality,127 diet composition,128 dietary schedule,50 and amount of consumption in a wide range of different foods.23,124,129 We still do not know if mechanisms underlying migraine pathogenesis might influence dietary intake.20,21 Future studies are warranted to identify the patterns and potential underlying mechanisms and to examine if migraine type, migraine frequency, and food intake are interrelated. Besides, longitudinal studies are preferred to cross-sectional studies.

Migraine pain and related disturbances may influence individuals with migraine to select a convenient, simple, or easy choice in diet, which might differ from those without migraine that have a tendency for a more complex dietary pattern. The choice can reflect on the amount, quality, timing, and patterns of dietary intake. This might be due to the fact that the hypothalamus has been found activated in the premonitory phase of migraine, the time that food cravings often occur.28,130 Food cravings, for instance for chocolate, have been reported to present and have accounted for triggering migraine attacks while this might be a part of the onset.1 Interestingly, chocolate has been a matter of investigation as one of the migraine triggers.131 A recent systematic review132 has looked into 25 studies that evaluated if chocolate acts as a trigger in migraine, where 23 studies reported that chocolate could trigger migraine. There were also three provocative studies133135 that tested the triggering effect of chocolate compared with placebo, and neither of those could identify a significant outcome. Therefore, based on these findings, the authors of the systematic review concluded that evidence is still lacking to draw any recommendation for migraine patients about eating or avoiding chocolate.132

Neurotransmitter, hormone, and adipocytokine levels in migraine patients are different compared with controls that might also influence the desire for food, or food intake or even the metabolic control of the hypothalamus18,136 in affected patients. For example, orexin A, was elevated in headache phase,32 while serotonin levels were lower during the interictal phase.30,31 Higher insulin resistance and elevated adipocytokines such as leptin are also reported in migraine patients compared with controls.33,34

The choice of mealtime by migraine patients might also affect the meal intake and its properties. There is a gap here for understanding how migraine history would influence a preferred mealtime in an attempt to manage migraines proactively. Mealtime can influence the content of meal depending on the time, and hence plays a role in the bidirectional loop of migraine-diet. In fact, a study from 2016137 has looked into the pattern of regular lifestyle behavior for three elements of sleep, mealtime, and daily exercise in patients with episodic and chronic migraine. This is the first study of the combined three variables compared with previous studies138140 that considered each domain separately. Findings from this study137 demonstrated that all three elements (ie, regular mealtime, regular sleep, and daily exercise) were lower in frequency among migraine patients with chronic migraine compared with episodic migraine. Interestingly, regular mealtime was found as the element that was adopted the best by both groups of migraine patients.137 The authors, therefore, proposed that self-regulated behaviors, such as regular mealtimes, would be beneficial for the affected patients to control their migraine.137 It is interesting to investigate whether genetic or epigenetic factors64 can influence the choice of mealtime by patients with migraine and if this differs between episodic and chronic migraine.

A small number of patients have been seen anecdotally to respond to the paleo diet or variations of this diet. The rationale follows a theory that modern era diseases, for example, diabetes, heart disease, and obesity were absent in the Paleolithic era. Therefore, a clear diet could also help prevent migraine. This diet is known for weight loss, and it is free from refined and processed food, additives and preservatives.

The gutbrain axis that is a bidirectional path, might also affect dietary choices here. Interestingly, the gutbrain axis has been discussed in terms of psychological aspects,141 named as gutbrain psychology, which brings mind to the equation of the brain and gut relationship. Based on this synchronism of gut, brain, and mind, it has been proposed that the gut microbiota could affect normal mental processes and under pathological mental and neurological disorders.141 Whether this can influence choice of diet in migraine, or when migraine is co-existent with other psychological conditions, eg, stress and anxiety, needs further investigation. This also remains to be tested as if other factors, eg, gender of migraine patients can affect this (by, eg, hormones or psychology-related factors). Figure 2 is an overview of the gutbrain axis and potential players in the bidirectional relationship of migraine and diet.

Figure 2 A bidirectional relationship of the gut and brain, and different factors that can potentially influence migrainediet bidirectional relationship within this system. Green arrows are toward improvement of migraine headache, while red arrows reflect on negative impact. For a comprehensive review on the gutbrain axis and migraine headache, please see Arzani et al.99

Taken together, a potential bidirectional relationship, where migraine influences food intake, and consumed food affects the manifestations of migraine, needs further investigation. The question, therefore, remains open as to whether migraine can affect dietary choices and to what extent, and how dietary choices can influence migraine. In a broader spectrum, the allostatic model in migraine126 could potentially help studying the influence of migraine on food intake and the influence of dietary intake on migraine. Table 1 provides an overview of the main points mentioned earlier for the dietmigraine relationship and considerations for future studies.

Table 1 A Summary of Main Elements in Bidirectional Aspects of DietMigraine and MigraineDiet Relationship

Diet as a potential trigger for migraine has been discussed for some time. Identification of potential dietary triggers for migraine125 has mainly emerged via keeping dairies, avoidance behavior, or elimination diets to help managing migraine.142,143 Some triggers appear common among the migraine population, while others appear to be unique to individuals. Therefore, identification of personal food triggers in each individual seems valuable to assist with a better way of coping with migraine. No particular migraine diet exists yet to lean on a strong evidence, and hence the investigation of dietary patterns is needed to confirm efficacy before recommending for migraine prevention. Types of evidence, including level of effect are, therefore, expected from these interventions. For each, one must consider the burden of various diets for patients and if any potential side effects or safety issues may occur.20

Comorbidities are also important to consider, such as IBS and in this regard, studying the role of the gutbrain axis is encouraged. Migraine has been also associated with cardiovascular and psychological disorders. Therefore, studying dietary interventions that can be beneficial for comorbid conditions are valuable. Dietary recommendations for migraine may aid in immediate control, slow progression, or prevention of diet-related comorbidities (eg, obesity, diabetes, and cardiovascular diseases). These recommendations are often included in a broader lifestyle modification, including sleep hygiene, stress management, regular exercise, or smoking cessation. A focus on maintenance of a consistent healthy lifestyle, in addition to nonpharmacological and pharmacological management of migraines seems to be the key for most of migraine patients.20 Implementation of any lifestyle changes, including dietary factors, needs a careful evaluation and a clear communication to help both clinicians and patients to achieve expected and reasonable goals. Education, monitoring, and support are essential elements in particular in long-term interventions and follow-ups.20 Effect of migraine or its evolution over age and among the genders for dietary choices, and dietary pattern is not known.51 Pattern, quality, and amount of food can also be influenced by geographical locations, cultural, and religious factors. These factors must be considered and reported in future studies of any potential bidirectional relationship between migraine and diet.

The author reports no conflicts of interest in this work.

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Walter Willett looks at what’s healthy for you and the planet – Harvard Gazette

Posted: February 10, 2021 at 8:54 pm

GAZETTE:We dont have to give up meat?

WILLETT: I co-chaired the Eat Lancet-Commission, and we did conclude that theres room for about two servings of animal-source foods per day, one being dairy and one being some combination of fish or poultry a couple of times a week, or some eggs, with red meat just once a week. People could become vegans, of course, if theyre careful about getting enough vitamin B12, but this does provide a lot of flexibility. Were quite off target at this point in time though, especially in the United States.

GAZETTE:How aligned are the goals of human health and sustainability as a planet?

WILLETT: There are no serious conflicts in that, very broadly, the healthiest diet for humans will be a diet that is healthy for the planet. But there is this divergence in that you can have a diet that is relatively healthy for the planet, but very bad for humans. And thats the diet that is low in animal source foods but high in starch, especially if its refined starch, and sugar. We often call that a poverty diet in that the cheapest sources of calories are starch and sugar. That has a light footprint on the planet, but its not healthy.

GAZETTE:Would you tell us about your current research?

WILLETT: Were working on a lot of fronts so I will just briefly talk about our long-term cohort studies. This is the Nurses Health Study and the follow-up study. Weve been following over 250,000 people starting in 1980. Were able to look at the long-term consequences of diet, and we are really starting to see some things that we didnt see in the first couple of decades. We now see that the development of diseases like cancer occurs over many decades. What girls consumed during childhood turns out to be more important for their [risk of] breast cancer at age 60 than what they were eating at age 50. It really does highlight the importance of paying attention to what we feed our kids in schools as well as at home.

GAZETTE:What should we be eating?

WILLETT: Variety, but there are some parts of that are important to include in that variety. We do see, for example, that the dark orange and green leafy vegetables like carrots and greens are important for helping reduce breast cancer risk, and the cruciferous vegetables like broccoli and cabbage are related to lower risk of breast cancer later in life. For cognitive function, it looks like including tomato products, like tomato sauce, is important. Its not that theres one magic bullet there, but making sure we include these kinds of vegetables is important.

GAZETTE:And is such a diet sustainable?

WILLETT: In general vegetables have a light- to moderate-impact environmental footprint, but it varies tremendously. If we produce them in California and ship them across the country, there is an appreciable-impact carbon footprint, not from producing the vegetables per se but from the process of keeping the cold chain. Some colleagues at Michigan have shown that by very simple low technology, like greenhouses where they dont use fossil fuels for heat, they can produce greens pretty much year-round in Michigan with about 1/10 of the environmental footprint compared to those that are produced and shipped from California. So its not just what we eat, but how its produced.

GAZETTE:Does that mean we should be eating local?

WILLETT: All else being equal. But if you have a greenhouse in New England thats burning a lot of fossil fuel to produce tomatoes in January, that isnt necessarily going to be good. We do have pretty much every day whats called a fruit train come up the East Coast from Florida to the Boston markets. Were taking advantage of the warmth and sunlight in Florida, and train transportation is pretty inexpensive, so thats probably better than putting a couple of bushels of fruit in your pickup in Western Massachusetts and driving to Boston. We want to simplify things, but not oversimplify things.

Interview was edited for clarity and length.

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Regular walnut diet may cut symptoms of H pylori infection, animal study suggests – The Tribune India

Posted: February 10, 2021 at 8:54 pm

New Delhi, February 10

Eating a diet rich in walnuts may help protect against negative outcomes associated with Helicobacter pylori infection, a widespread bacterial infection that affects more than half of the world's population, a study conducted in mice suggests.

H. pylori infection is a major cause of ulcers in the stomach and small intestine as well as stomach cancer and peptic ulcer disease.

The research, published in the Journal of Clinical Biochemistry and Nutrition, found that extracts from whole walnuts may help create protective proteins and anti-inflammatory actions in the gut that may safeguard against H. pylori infection and resulting cancer in mice.

The researchers from the CHA Cancer Prevention Research Center in South Korea noted that prevalence of H. pylori is most common in developing countries.

It is generally related to socioeconomic status and hygienic conditions and is thought to be spread through person to person contact or even through food and water, they said.

While treatments are currently available, there are concerns about the bacteria's growing resistance to antibiotics, according to the resaerchers.

Due to increasing challenges associated with antibiotic resistance, researchers have been investigating dietary and other non-bacterial approaches to improve impact from H. pylori infection.

The researchers said this is not the first time walnuts have been linked to a lower risk of gastrointestinal cancer development in mice.

Previously, a study published in the journal Cancer Prevention Research found that walnuts in the diet may suppress colon tumour development by modifying gut bacteria.

Another study in the journal Nutrients found that walnuts in diet may also supress the progression of colorectal cancer by suppressing angiogenesis, the development of new blood vessels which facilitates the growth of cancer cells.

Animal studies are valuable for providing background information and can be used as a basis for future research in humans, the researchers noted.

Based on the existing body of evidence, dietary approaches to reduce symptoms of H. pylori infection, such as inflammation, seem worthwhile to pursue in a well-designed clinical trial to confirm the findings, they added. PTI

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Childhood Diet Has Lifelong Impact You Are What You Eat AND What You Ate as a Child – SciTechDaily

Posted: February 10, 2021 at 8:54 pm

Study in mice finds high-fat, high-sugar diet has long-lasting effects on the microbiome. Credit: UCR

Eating too much fat and sugar as a child can alter your microbiome for life, even if you later learn to eat healthier, a new study in mice suggests.

The study by UC Riverside researchers is one of the first to show a significant decrease in the total number and diversity of gut bacteria in mature mice fed an unhealthy diet as juveniles.

We studied mice, but the effect we observed is equivalent to kids having a Western diet, high in fat and sugar and their gut microbiome still being affected up to six years after puberty, explained UCR evolutionary physiologist Theodore Garland.

A paper describing the study has recently been published in the Journal of Experimental Biology.

The microbiome refers to all the bacteria as well as fungi, parasites, and viruses that live on and inside a human or animal. Most of these microorganisms are found in the intestines, and most of them are helpful, stimulating the immune system, breaking down food and helping synthesize key vitamins.

In a healthy body, there is a balance of pathogenic and beneficial organisms. However, if the balance is disturbed, either through the use of antibiotics, illness, or unhealthy diet, the body could become susceptible to disease.

In this study, Garlands team looked for impacts on the microbiome after dividing their mice into four groups: half fed the standard, healthy diet, half fed the less healthy Western diet, half with access to a running wheel for exercise, and half without.

After three weeks spent on these diets, all mice were returned to a standard diet and no exercise, which is normally how mice are kept in a laboratory. At the 14-week mark, the team examined the diversity and abundance of bacteria in the animals.

They found that the quantity of bacteria such as Muribaculum intestinale was significantly reduced in the Western diet group. This type of bacteria is involved in carbohydrate metabolism.

Analysis also showed that the gut bacteria are sensitive to the amount of exercise the mice got. Muribaculum bacteria increased in mice fed a standard diet who had access to a running wheel and decreased in mice on a high-fat diet whether they had exercise or not.

Researchers believe this species of bacteria, and the family of bacteria that it belongs to, might influence the amount of energy available to its host. Research continues into other functions that this type of bacteria may have.

One other effect of note was the increase in a highly similar bacteria species that were enriched after five weeks of treadmill training in a study by other researchers, suggesting that exercise alone may increase its presence.

Overall, the UCR researchers found that early-life Western diet had more long-lasting effects on the microbiome than did early-life exercise.

Garlands team would like to repeat this experiment and take samples at additional points in time, to better understand when the changes in mouse microbiomes first appear, and whether they extend into even later phases of life.

Regardless of when the effects first appear, however, the researchers say its significant that they were observed so long after changing the diet, and then changing it back.

The takeaway, Garland said, is essentially, You are not only what you eat, but what you ate as a child!

Reference: Early-life effects of juvenile Western diet and exercise on adult gut microbiome composition in mice by Monica P. McNamara, Jennifer M. Singleton, Marcell D. Cadney, Paul M. Ruegger, James Borneman and Theodore Garland, Jr., 11 January 2021, Journal of Experimental Biology.DOI: 10.1242/jeb.239699

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