Sunday, May 15, 2016

Gastroparesis in Diabetics

Gastroparesis, also called delayed gastric emptying, is a disorder in which the stomach takes too long to empty its contents. It often occurs in people with type 1 diabetes or type 2 diabetes.

Gastroparesis happens when nerves to the stomach are damaged or stop working. The vagus nerve controls the movement of food through the digestive tract. If the vagus nerve is damaged, the muscles of the stomach and intestines do not work normally, and the movement of food is slowed or stopped.
Diabetes can damage the vagus nerve if blood glucose levels remain high over a long period of time. High blood glucose causes chemical changes in nerves and damages the blood vessels that carry oxygen and nutrients to the nerves.

Signs and Symptoms of Gastroparesis

  • heartburn
  • nausea
  • vomiting of undigested food
  • an early feeling of fullness when eating
  • weight loss
  • abdominal bloating
  • erratic blood glucose levels
  • lack of appetite
  • gastroesophageal reflux
  • spasms of the stomach wall
These symptoms may be mild or severe, depending on the person.

Complications of Gastroparesis

If food lingers too long in the stomach, it can cause problems like bacterial overgrowth from the fermentation of food. Also, the food can harden into solid masses called bezoars that may cause nausea, vomiting, and obstruction in the stomach. Bezoars can be dangerous if they block the passage of food into the small intestine.
Gastroparesis can make diabetes worse by adding to the difficulty of controlling blood glucose. When food that has been delayed in the stomach finally enters the small intestine and is absorbed, blood glucose levels rise. Since gastroparesis makes stomach emptying unpredictable, a person's blood glucose levels can be erratic and difficult to control.

Major Causes of Gastroparesis

Gastroparesis is most often caused by
  • diabetes
  • postviral syndromes
  • anorexia nervosa
  • surgery on the stomach or vagus nerve
  • medications, particularly anticholinergics and narcotics (drugs that slow contractions in the intestine)
  • gastroesophageal reflux disease (rarely)
  • smooth muscle disorders such as amyloidosis and scleroderma
  • nervous system diseases, including abdominal migraine and Parkinson's disease
  • metabolic disorders, including hypothyroidism

Diagnosis of Gastroparesis

The diagnosis of gastroparesis is confirmed through one or more of the following tests.
  • Barium x ray. After fasting for 12 hours, you will drink a thick liquid called barium, which coats the inside of the stomach, making it show up on the x ray. Normally, the stomach will be empty of all food after 12 hours of fasting. If the x ray shows food in the stomach, gastroparesis is likely. If the x ray shows an empty stomach but the doctor still suspects that you have delayed emptying, you may need to repeat the test another day. On any one day, a person with gastroparesis may digest a meal normally, giving a falsely normal test result. If you have diabetes, your doctor may have special instructions about fasting.
  • Barium beefsteak meal. You will eat a meal that contains barium, thus allowing the radiologist to watch your stomach as it digests the meal. The amount of time it takes for the barium meal to be digested and leave the stomach gives the doctor an idea of how well the stomach is working. This test can help detect emptying problems that do not show up on the liquid barium x ray. In fact, people who have diabetes-related gastroparesis often digest fluid normally, so the barium beefsteak meal can be more useful.
  • Radioisotope gastric-emptying scan. You will eat food that contains a radioisotope, a slightly radioactive substance that will show up on the scan. The dose of radiation from the radioisotope is small and not dangerous. After eating, you will lie under a machine that detects the radioisotope and shows an image of the food in the stomach and how quickly it leaves the stomach. Gastroparesis is diagnosed if more than half of the food remains in the stomach after 2 hours.
  • Gastric manometry. This test measures electrical and muscular activity in the stomach. The doctor passes a thin tube down the throat into the stomach. The tube contains a wire that takes measurements of the stomach's electrical and muscular activity as it digests liquids and solid food. The measurements show how the stomach is working and whether there is any delay in digestion.
  • Blood tests. The doctor may also order laboratory tests to check blood counts and to measure chemical and electrolyte levels.
To rule out causes of gastroparesis other than diabetes, the doctor may do an upper endoscopy or an ultrasound.
  • Upper endoscopy. After giving you a sedative, the doctor passes a long, thin tube called an endoscope through the mouth and gently guides it down the esophagus into the stomach. Through the endoscope, the doctor can look at the lining of the stomach to check for any abnormalities.
  • Ultrasound. To rule out gallbladder disease or pancreatitis as a source of the problem, you may have an ultrasound test, which uses harmless sound waves to outline and define the shape of the gallbladder and pancreas.
Treatment
The primary treatment goal for gastroparesis related to diabetes is to regain control of blood glucose levels. The best treatment is to use a superior nutritional wellness protocol such as the Super Meal Model Diet for Diabetics.
Changing your eating habits can help control gastroparesis. Your doctor or dietitian may prescribe six small meals a day instead of three large ones. If less food enters the stomach each time you eat, it may not become overly full. In more severe cases, a liquid or pureed diet may be prescribed. Liquid meals provide all the nutrients found in solid foods, but can pass through the stomach more easily and quickly. In that case, raw juicing, smoothies, and wholefood supplements can help tremendously to obtain the necessary nutrients.  Consequently, we recommend the Death to Diabetes ebook and the  Power of Juicing ebook.

Your doctor may recommend that you avoid high-fat and high-fiber foods. Fat naturally slows digestion—a problem you do not need if you have gastroparesis—and fiber is difficult to digest. Some high-fiber foods like oranges and broccoli contain material that cannot be digested. Avoid these foods because the indigestible part will remain in the stomach too long and possibly form bezoars.

To summarize:
  • Eat smaller meals more frequently.
  • Eat low-fiber forms of high-fiber foods, such as well-cooked fruits and vegetables rather than raw fruits and vegetables.
  • Choose mostly low-fat foods, but if you can tolerate them, add small servings of fatty foods to your diet.
  • Avoid fibrous fruits and vegetables, such as oranges and broccoli, that may cause bezoars.
  • If liquids are easier for you to ingest, try soups and pureed foods.
  • Drink water throughout each meal.
  • Try gentle exercise after you eat, such as going for a walk.
Some people with gastroparesis may be unable to tolerate any food or liquids. In these situations, doctors may recommend a feeding tube (jejunostomy tube) be placed in the small intestine.
Feeding tubes can be passed through your nose or mouth or directly into your small intestine through your skin. The tube is usually temporary and is only used when gastroparesis is severe or when blood sugar levels can't be controlled by any other method.
If treatment doesn't help control your nausea, vomiting or malnutrition, you may consider gastroparesis surgery. During surgery, the lower part of the stomach may be stapled or bypassed to help improve stomach emptying.

Gastric electrical stimulation (GES): Another possible treatment for more serious cases may require a gastric pacemaker, which uses an electric current to provide electrical gastric stimulation  to cause stomach contractions. Working much like a heart pacemaker, this stomach pacemaker, consisting of a tiny generator and two electrodes, is placed in a pocket that surgeons create on the stomach's outer edge. Stomach pacemakers have been shown to improve stomach emptying and reduce nausea and vomiting in some people with gastroparesis, but more studies are needed.

Here is a link to an external website that provides a more structured approach to eating smaller meals for treating gastroparesis:
http://www.gicare.com/diets/Gastroparesis.aspxOther treatments include insulin, oral medications, and, in severe cases, feeding tubes and intravenous feeding.
It is important to note that in most cases treatment does not cure gastroparesis -- it is usually a chronic condition. Treatment helps you manage the condition so that you can be as healthy and comfortable as possible.
Insulin for blood glucose control
If you have gastroparesis and you are on insulin, your food is being absorbed more slowly and at unpredictable times. To better control blood glucose, levels your doctor may recommend that you:
  • take insulin more often
  • take your insulin after you eat instead of before
  • check your blood glucose levels frequently after you eat and administer insulin whenever necessary
Your doctor will give you specific instructions based on your particular needs.

Medication for Gastroparesis

Several drugs are used to treat gastroparesis. Your doctor may try different drugs or combinations of drugs to find the most effective treatment.
  • Metoclopramide (Reglan). This drug stimulates stomach muscle contractions to help empty food. It also helps reduce nausea and vomiting. Metoclopramide is taken 20 to 30 minutes before meals and at bedtime. Side effects of this drug are fatigue, sleepiness, and sometimes depression, anxiety, and problems with physical movement.
  • Erythromycin. This antibiotic also improves stomach emptying. It works by increasing the contractions that move food through the stomach. Side effects are nausea, vomiting, and abdominal cramps.
  • Domperidone. The Food and Drug Administration is reviewing domperidone, which has been used elsewhere in the world to treat gastroparesis. It is a promotility agent like metoclopramide. Domperidone also helps with nausea.
  • Other medications. Other medications may be used to treat symptoms and problems related to gastroparesis. For example, an antiemetic can help with nausea and vomiting. Antibiotics will clear up a bacterial infection. If you have a bezoar, the doctor may use an endoscope to inject medication that will dissolve it.

Hope Through Research on Gastroparesis

NIDDK's Division of Digestive Diseases and Nutrition supports basic and clinical research into gastrointestinal motility disorders, including gastroparesis. Among other areas, researchers are studying whether experimental medications can relieve or reduce symptoms of gastroparesis, such as bloating, abdominal pain, nausea, and vomiting, or shorten the time needed by the stomach to empty its contents following a standard meal.

Points to Remember about Gastroparesis

  • Control your blood glucose levels to prevent gastroparesis.
  • Gastroparesis may occur in people with type 1 diabetes or type 2 diabetes.
  • Gastroparesis is the result of damage to the vagus nerve, which controls the movement of food through the digestive system. Instead of the food moving through the digestive tract normally, it is retained in the stomach.
  • The vagus nerve becomes damaged after years of poor blood glucose control, resulting in gastroparesis. In turn, gastroparesis contributes to poor blood glucose control.
  • Symptoms of gastroparesis include early fullness, nausea, vomiting, and weight loss.
  • Gastroparesis is diagnosed through tests such as x rays, manometry, and scanning.
  • Treatments include changes in when and what you eat, changes in insulin type and timing of injections, oral medications, a jejunostomy, parenteral nutrition, gastric pacemakers, or botulinum toxin.
  • Change your diet to an alkaline-based diet such as  the Super Meal Model Diet for Diabetics
  • Eat more nutritious liquid meals that can pass through the stomach more easily and quickly, i.e. raw juices, smoothies. Get the Power of Juicing ebook.
References (for Gastroparesis):
  1. ^ "Spotlight on gastroparesis," unauthored article, Balance (magazine of Diabetes UK, no. 246, May-June 2012, p. 43.
  2. ^ "Gastroparesis - Your Guide to Gastroparesis - Causes of Gastroparesis". Heartburn.about.com. Retrieved 2012-02-10.
  3. ^ "Gastroparesis: Causes". MayoClinic.com. 2012-01-04. Retrieved 2012-10-09.
  4. ^ "Epocrates article, registration required". Online.epocrates.com. Retrieved 2012-10-09.
  5. a b "Summary for Oley Foundation by R. W. McCallum, MD". Oley.org. Retrieved 2012-10-09.
  6. ^ "Gastroparesis: Symptoms". MayoClinic.com. 2012-01-04. Retrieved 2012-10-09.
  7. ^ Mirtazapine for Severe Gastroparesis Unresponsive to Conventional Prokinetic Treatment
  8. http://www.aetna.com/cpb/medical/data/600_699/0678.html
  9. G-PACT Gastroparesis Patient Association
  10. Overview from NIDDK National Institute of Diabetes, Digestive, and Kidney Diseases at NIH
  11. Overview at Mayo Clinic
  12. Overview at University of Chicago Hospitals
  13. Patient Perspective at the icarecafe

The Power of Garlic

Native to central Asia, garlic is one of the oldest cultivated plants in the world and has been grown for over 5000 years. Ancient Egyptians seem to have been the first to cultivate this plant that played an important role in their culture.

Garlic (Allium sativum) began to find its way into other cultures and everyday life of ancient civilizations such as Greece, Rome, Northern Europe and China. Although it was native to Central Asia, the medicinal purposes and properties of garlic eventually became known throughout the known world and celebrated in pre- and recorded history.

Almost everyone is aware of the power and health benefits of garlic. In folklore, garlic was attributed with the ability to bring good luck, protect against evil forces, serve as an aphrodisiac, repel scorpions and ward off/repel sorcerers, werewolves, warlocks and vampires (mostly because of its odorous quality), among other things.

Beyond its alleged fantastical abilities, garlic was recognized in ancient cultures and those following them to possess certain medicinal powers (see Pizzorno & Murray, 1996; Wikipedia, 2010; Zimmerman, 2010).
For example, garlic was used to treat such conditions as bladder infections, bacterial infections from wounds, respiratory disorders, intestinal disorders and conditions such as diarrhea, dysentery and flatulence, worms, skin diseases, hysteria, diphtheria, vaginitis, among other ailments. It was also used to increase strength and life-energy (i.e., chi), improve blood circulation and provide protection against the plague during the Middle Ages (see Pizzorno & Murray, 1996; Wikipedia, 2010; Zimmerman, 2010).

Garlic was not only bestowed with sacred qualities and placed in the tomb of Pharaohs, but it was given to the slaves that built the Pyramids to enhance their endurance and strength. This strength-enhancing quality was also honored by the ancient Greeks and Romans, civilizations whose athletes ate garlic before sporting events and whose soldiers consumed it before going off to war.

Garlic was introduced into various regions throughout the globe by migrating cultural tribes and explorers. By the 6th century BC, garlic was known in both China and India, the latter country using it for therapeutic purposes.

Throughout the millennia, garlic has been a beloved plant in many cultures for both its culinary and medicinal properties. Over the last few years, it has gained unprecedented popularity since researchers have been scientifically validating its numerous health benefits.

Currently, China, South Korea, India, Spain and the United States are among the top commercial producers of garlic.

Health Benefits of Garlic

Various garlic health benefits and medicinal properties have long been claimed and it has been used extensively in herbal medicine (phytotherapy). It's been considered by many to be a herbal "wonder drug", with a reputation in folklore for preventing everything from the common cold and flu to the Plague!

Modern science has shown that garlic is a powerful natural antibiotic, albeit broad-spectrum rather than targeted. The bacteria in the body do not appear to evolve resistance to the garlic as they do to many modern pharmaceutical antibiotics. This means that its positive health benefits can continue over time rather than helping to breed antibiotic resistant "superbugs".

Studies have also shown that garlic - especially aged garlic - can have a powerful antioxidant effect. Antioxidants can help to protect the body against damaging free radicals.
Cardiovascular Benefits

Most of the research on garlic and our cardiovascular system has been conducted on garlic powder, garlic oil, or aged garlic extracts rather than garlic in food form. But despite this research limitation, food studies on garlic show this allium vegetable to have important cardio-protective properties. Garlic is clearly able to lower our blood triglycerides and total cholesterol, even though this reduction can be moderate (5-15%).

But cholesterol and triglyceride reduction are by no means garlic's most compelling benefits when it comes to cardio-protection. Those top-level benefits clearly come in the form of blood cell and blood vessel protection from inflammatory and oxidative stress. Damage to blood vessel linings by highly reactive oxygen molecules is a key factor for increasing our risk of cardiovascular problems, including heart attack and atherosclerosis.
Oxidative damage also leads to unwanted inflammation, and it is this combination of unwanted inflammation and oxidative stress that puts our blood vessels at risk of unwanted plaque formation and clogging. Garlic unique set of sulfur-containing compounds helps protect us against both possibilities—oxidative stress and unwanted inflammation. 

In addition to the ability of garlic to help prevent our blood vessels from becoming blocked, this allium vegetable may also be able to help prevent clots from forming inside of our blood vessels. This cardiovascular protection has been linked to one particular disulfide in garlic called ajoene. Ajoene has repeatedly been shown to have anti-clotting properties. It can help prevent certain cells in our blood (called platelets) from becoming too sticky, and by keeping this stickiness in check, it lowers the risk of our platelets clumping together and forming a clot.

Equally impressive about garlic is its ability to lower blood pressure. Researchers have known for about 10 years that the allicin made from alliin in garlic blocks the activity of angiotensin II. A small piece of protein (peptide), angiotensin II helps our blood vessels contract. (When they contract, our blood is forced to pass through a smaller space, and the pressure is increased.) By blocking the activity of angiotensin II, allicin form garlic is able to help prevent unwanted contraction of our blood vessels and unwanted increases in blood pressure.

More recently, however, researchers have found that garlic supports our blood pressure in a second and totally different way. Garlic is rich in sulfur-containing molecules called polysulfides. It turns out that these polysulfides, once inside our red blood cells (RBCs), can be further converted by our RBCs into a gas called hydrogen sulfide (H2S). H2S helps control our blood pressure by triggering dilation of our blood vessels. When the space inside our blood vessels expands, our blood pressure gets reduced. (H2S is described as a "gasotransmitter" and placed in the same category as nitric oxide (NO) as a messaging molecule that can help expand and relax our blood vessel walls.) Interestingly, our RBCs do not appear to use processed garlic extracts in the same way that they use polysulfides in food-form garlic.

Garlic's numerous beneficial cardiovascular effects are due to not only its sulfur compounds, but also to its vitamin C, vitamin B6, selenium and manganese. Garlic is a very good source of vitamin C, the body's primary antioxidant defender in all aqueous (water-soluble) areas, such as the bloodstream, where it protects LDL cholesterol from oxidation. Since it is the oxidized form of LDL cholesterol that initiates damage to blood vessel walls, reducing levels of oxidizing free radicals in the bloodstream can have a profound effect on preventing cardiovascular disease.

Garlic's vitamin B6 helps prevent heart disease via another mechanism: lowering levels of homocysteine. An intermediate product of an important cellular biochemical process called the methylation cycle, homocysteine can directly damage blood vessel walls.

The selenium in garlic can become an important part of our body's antioxidant system. A cofactor of glutathione peroxidase (one of the body's most important internally produced antioxidant enzymes), selenium also works with vitamin E in a number of vital antioxidant systems.
Garlic is rich not only in selenium, but also in another trace mineral, manganese, which also functions as a cofactor in a number of other important antioxidant defense enzymes, for example, superoxide dismutase. Studies have found that in adults deficient in manganese, the level of HDL (the "good form" of cholesterol) is decreased.

Anti-Inflammatory Benefits Across Body Systems
Our cardiovascular system is not the only body system that may be able to benefit from garlic's anti-inflammatory properties. There's preliminary evidence (mostly from animal studies, and mostly based on garlic extracts rather than whole food garlic) that our our musculoskeletal system and respiratory system can also benefit from anti-inflammatory compounds in garlic. Both the diallyl sulfide (DAS) and thiacremonone in garlic have been shown to have anti-arthritic properties. And in the case of allergic airway inflammation, aged garlic extract has been show to improve inflammatory conditions (once again in animal studies).

Even more preliminary is research evidence showing that some inflammatory aspects of obesity may be altered by sulfur-containing compounds in garlic. Specifically, there is one stage in development of the body's fat cells (adipocytes) that appears to be closely related to status of our inflammatory system.

Fat cells cannot become fully themselves unless they are able to progress from a preliminary stage called "preadipocytes" to a final stage called "adipocytes." One of the sulfur compounds in garlic (1,2,-vinyldithiin, or 1,2-DT) appears able to lessen this conversion of preadipocytes into adipocytes, and the impact of 1,2-DT appears to be inflammation-related. Even though very preliminary, this research on 1,2-DT is exciting because obesity is increasingly being understood as a disease characterized by chronic, low level inflammation and our inflammatory status is precisely where garlic's 1,2-DT has its apparent impact.

Antibacterial and Antiviral Benefits
From a medical history standpoint, the antibacterial and antiviral properties of garlic are perhaps its most legendary feature. This allium vegetable and its constituents have been studied not only for their benefits in controlling infection by bacteria and viruses, but also infection from other microbes including yeasts/fungi and worms. (One particular disulfide in garlic, called ajoene, has been successfully used to help prevent infections with the yeast Candida albicans.)

Very recent research has shown the ability of crushed fresh garlic to help prevent infection by the bacterium Pseudomonas aeruginosa in burn patients. Also of special interest has been the ability of garlic to help in the treatment of bacterial infections that are difficult to treat due to the presence of bacteria that have become resistant to prescription antibiotics. However, most of the research on garlic as an antibiotic has involved fresh garlic extracts or powdered garlic products rather than fresh garlic in whole food form.

Overgrowth of the bacterium Helicobacter pylori in the stomach—a key risk factor for stomach ulcer—has been another key area of interest for researchers wanting to explore garlic's antibacterial benefits. Results in this area, however, have been mixed and inconclusive. While garlic may not be able to alter the course of infection itself, there may still be health benefits from garlic in helping to regulate the body's response to that infection.

Cancer Prevention
While not as strong as the research evidence for cruciferous vegetables, research on the allium vegetables—including garlic—shows that these vegetables have important anti-cancer properties. Interestingly, high intake of garlic (roughly translated as daily intake of this food) has been found to lower risk of virtually all cancer types except cancer of the prostate and breast cancer.

However, moderate intake of garlic (roughly translated as several times per week) has been repeatedly found to lower risk of only two cancer types—colorectal and renal cancer. This difference between "high" versus "moderate" garlic intake may be a real difference that suggests we all need to eat more garlic if we want to maximize its cancer-related benefits. Or it may be a difference that is more related to research complications involving the options given to research participants when reporting their food intake. Still, garlic has a consistent track record with respect to general anti-cancer benefits, and there are good research reasons for classifying garlic as an "anti-cancer" food.

The allyl sulfides found in garlic may play a key role in its cancer-prevention benefits. These garlic compounds are able to activate a molecule called nuclear erythroid factor (Nrf2) in the main compartment of cells. The Nrf2 molecule then moves from the main compartment of the cell into the cell nucleus, where it triggers a wide variety of metabolic activities.

Under some circumstances, this set of events can prepare a cell for engagement in a strong survival response, and in particular, the kind of response that is needed under conditions of oxidative stress. Under other circumstances, this same set of events can prepare the cell to engage in programmed cell death (apoptosis).

When a cell recognizes that it has become too compromised to continue functioning in a healthy manner with other cells, it stops proceeding through its own life cycle and essentially starts to dismantle itself and recycle its parts. It's critical for a cell to determine whether it should continue on or shut itself down, because cells that continue on without the ability to properly function or communicate effectively with other cells are at risk of becoming cancerous. The ability of garlic's allyl sulfides to activate Nrf2 suggests that garlic may be able to help modify these all-critical cell responses and prevent potentially cancerous cells from forming.

One especially interesting area of research on garlic and cancer prevention involves meat cooked at high temperatures. Heterocyclic amines (HCAs) are cancer-related substances that can form when meat comes into contact with a high-temperature cooking surface (400Ë?F/204Ë?C or higher). One such HCA is called PhIP (which stands for 2-amino-1-methyl-6-phenylimidazopyridine). PhIP is thought to be one reason for the increased incidence of breast cancer among women who eat large quantities of meat because it is rapidly transformed into DNA-damaging compounds.

Diallyl sulfide (DAS), one of the many sulfur-containing compounds in garlic, has been shown to inhibit the transformation of PhIP into carcinogens. DAS blocks this transformation by decreasing the production of the liver enzymes (the Phase I enzymes CYP1A1, CYP1A2 and CYP1B1) that transform PhIP into activated DNA-damaging compounds. Of course, your best way to prevent formation of PhIP is not to bring your meat into contact with a 400Ë?F/204Ë?C cooking surface in the first place. But this area of research still bolsters our view of garlic as an allium vegetable with important cancer-preventive properties.

Garlic and Iron Metabolism
Recent research has shown that garlic may be able to improve our metabolism of iron. When iron is stored up in our cells, one of the key passageways for it to be moved out of the cell and returned into circulation involves a protein called ferroportin. Ferroportin is protein that runs across the cell membrane, and it provides a bridge for iron to cross over and leave the cell. Garlic may be able to increase our body's production of ferroportin, and in this way, help keep iron in circulation as it is needed.

For a small vegetable, garlic (Allium sativum) sure has a big, and well deserved, reputation. And although garlic may not always bring good luck, protect against evil, or ward off vampires, characteristics to which it has been assigned folklorically, it is guaranteed to transform any meal into a bold, aromatic, and healthy culinary experience. Garlic is a member of the Lily family and is a cousin to onions, leeks and chives.

Garlic is arranged in a head, called a "bulb," which averages about 2 inches in height and diameter and consists of numerous small separate cloves. Both the cloves and the entire bulb are encased in paper-like sheathes that can be white, off-white, or have a pink/purple hue. Although garlic cloves have a firm texture, they can be easily cut or crushed. The taste of garlic is like no other—it hits the palate with a hot pungency that is shadowed by a very subtle background sweetness. While elephant garlic has larger cloves, it is more closely related to the leek and therefore does not offer the full health benefits of regular garlic.

Fresh, dried and powdered garlic are available in markets throughout the year, however, fresh varieties from California are in season from June through December.

For maximum flavor and nutritional benefits, always purchase fresh garlic. Although garlic in flake, powder, or paste form may be more convenient, you will derive less culinary and health benefits from these forms.
Purchase garlic that is plump and has unbroken skin. Gently squeeze the garlic bulb between your fingers to check that it feels firm and is not damp.

Avoid garlic that is soft, shriveled, and moldy or that has begun to sprout. These may be indications of decay that will cause inferior flavor and texture. Size is often not an indication of quality. If your recipe calls for a large amount of garlic, remember that it is always easier to peel and chop a few larger cloves than many smaller ones. Fresh garlic is available in the market throughout the year.

Store fresh garlic in either an uncovered or a loosely covered container in a cool, dark place away from exposure to heat and sunlight. This will help maintain its maximum freshness and help prevent sprouting, which reduces its flavor and causes excess waste. It is not necessary to refrigerate garlic. Some people freeze peeled garlic; however, this process reduces its flavor profile and changes its texture.

Depending upon its age and variety, whole garlic bulbs will keep fresh for about a month if stored properly. Inspect the bulb frequently and remove any cloves that appear to be dried out or moldy. Once you break the head of garlic, it greatly reduces its shelf life to just a few days.

Tips for Enjoying and Preparing Garlic
The first step to using garlic is to separate the individual cloves. An easy way to do this is to place the bulb on a cutting board or hard surface and gently, but firmly, apply pressure with the palm of your hand at an angle. This will cause the layers of skin that hold the bulb together to separate.

Peel garlic with a knife or alternatively, separate the skin from the individual cloves by placing a clove with the smooth side down on a cutting board and gently tapping it with the flat side of a wide knife. You can then remove the skin either with your fingers or with a small knife. If there is a green sprout in the clove's center, gently remove it since it is difficult to digest.

Enhancing the Health-Promoting Properties of Garlic
Chopping or crushing stimulates the enzymatic process that converts the phytonutrient alliin into allicin, a compound to which many of garlic's health benefits are attributed. In order to allow for maximal allicin production, wait at least 5 minutes before eating or cooking the garlic. Also observe this 5-minute "time out" period before adding any high acidic ingredient to the garlic (for example, lemon juice). Ingredients with a pH below 3.5 can also deactivate the enzymatic process.

Since crushing and chopping are the food preparation steps that activate garlic's enzymes, these steps can help you obtain many of garlic's special benefits. For example, research has shown that microwaving or boiling garlic in uncrushed, whole clove form will deactivate its enzymes, preventing these enzymes from working. For this reason, we recommend that you chop or crush the garlic cloves prior to heating.

According to research on garlic preparation methods, it only takes 60 seconds of microwaving whole cloves to lessen some of garlic's health benefits. By contrast, many of garlic's health benefits (including its anti-cancer properties) are preserved if the whole cloves are crushed and allowed to sit for 10 minutes prior to cooking.

The Healthiest Way of Cooking Garlic
We recommend using raw garlic in many of our recipes. If it is a cooked dish you are preparing and you cannot tolerate raw garlic, add chopped garlic towards the end of the cooking time to retain maximum flavor and nutrition. Too much heat for too long will reduce the activity of the health-promoting sulfur compounds that have formed by letting it sit for 5-10 minutes; it will also make garlic bitter. Therefore expose garlic to heat for as little time as possible (5-15 minutes).

Side-Effects of Garlic
Even garlic isn't a perfect wonder drug. Apart from garlic breath there are other possible side effects, especially if used to excess.

Raw garlic is very strong, so eating too much could produce problems, for example irritation of or even damage to the digestive tract.

There are a few people who are allergic to garlic. Symptoms of garlic allergy include skin rash, temperature and headaches. Also, garlic could potentially disrupt anti-coagulants, so it's best avoided before surgery. As with any medicine, always check with your doctor first and tell your doctor if you are using it.

Important: Research published in 2001 concluded that garlic supplements "can cause a potentially harmful side effect when combined with a type of medication used to treat HIV/AIDS".

Five Forms of Garlic

Raw Fresh Garlic
History teaches that fresh raw garlic provides healthful benefits but consuming it comes with a pungent odor. It also has the potential to cause indigestion if consumed in large quantities with the intention of experiencing its medicinal effects. That being said, one of the health benefits of eating raw fresh garlic (assuming it is consumed in large amounts and can be tolerated gastro-intestinally) is its cardiovascular protective effects such as lowering blood cholesterol levels, inhibiting the aggregation of blood platelets and dissolving blood clots (see Borek, 2000; Kleijnen et al., 1989).

In addition to its cardiovascular protective effects, raw garlic cloves once they are ground or sliced can be applied topically on wounds. Allicin, a by-product of the enzymatic catalyzing of alliin by alliinase, has the ability to kill bacteria and prevent infections. Yet, while it possesses anti-bacterial-anti-infection potential, allicin can also damage external and internal tissue on contact, thereby, limiting its topical application and internal consumption (Kyolic, 2010a).

Thus, although raw fresh garlic does provide cardiovascular when consumed in large quantities and anti-bacterial-anti-infection benefits when applied topically, fresh raw garlic comes with the unpleasant side-effects of offensive odor, indigestion and tissue damage, all of which diminishes its medicinal benefits.
However, consuming garlic, especially in large amounts to achieve therapeutic benefit, is problematic because of its pungent odor which tends to linger on the breath and skin and, thereby, acts as a social deterrent and because of its potential to cause gastrointestinal problems, including indigestion. It well-established that once garlic cloves are cut or crushed the enzyme alliinase catalyzes the chemical reaction converting alliin to allicin.

Allicin was once believed to be the compound giving garlic its medicinal properties. However, scientific studies have established that allicin is an unstable, reactive/oxidative compound. It is responsible for garlic’s strong odor and capacity to trigger digestive discomfort. In addition, allicin lacks bioavailability once inside the body.

Garlic Essential Oil
Garlic essential oil is produced when fresh garlic is crushed and subjected to steam distillation. It is important to point out that garlic oil is constituted more of vegetable oils and only a small fraction of the garlic’s health-producing oil-soluble sulfides and virtually no water-soluble sulfur compounds.

According to Borek (2000), garlic oil is diluted approximately 200-fold with vegetable oils being used to diminish the overpowering odor of volatile oil-soluble sulfides found in garlic. The pungent odor of the crushed garlic would be too overwhelming for health consumers, if commercially produced garlic oil consisted only of garlic. Thus, garlic oil is not a robust and useful source of garlic’s health-giving effects.

Garlic Oil Macerate
Garlic oil macerate is produced in two forms both of which are packaged in soft gel capsules. One product form is a mixture of garlic flavoring powder mixed with vegetable oil. This form is similar to garlic powder packaged in tablets and capsules. Another product form of garlic oil macerate is grounded raw garlic in vegetable oil. This form has a potent garlic odor because it contains oil-soluble compounds (allicin break down products) and residual alliin. Both product forms of garlic oil macerate are high in fat. Consequently, they are not suitably healthy for use as a dietary supplement on a daily or regular basis.

Garlic Powder
Garlic powder is made when garlic cloves are sliced or crushed then oven-dried and pulverized into powder. Drying the garlic at high temperatures (i.e., above 158 F) inactivates the enzyme alliinase, which is responsible for converting alliin into allicin (see Borek, 2000).

Allicin was believed to be the compound in garlic responsible for its medicinal values. As it turns out, allicin is a highly volatile, oxidative compound produced when garlic is sliced or crushed causing the cells to rupture. Furthermore, allicin lacks bioavailability and decreases to non-detectable amounts in the body after a short period of time. It is only beneficial when it is applied topically.

Just as it protects the garlic plant when it is injured from insects and fungi, allicin when applied externally to the skin will protect against fungi and bacteria. However, the internal use of allicin for medicinal purposes is subject to question (see Kyolic, 2010b).

No garlic powder product or any other garlic supplement product is capable of containing allicin because of its chemical instability. Furthermore, garlic powder contains not only inactivated alliinase but also only a small or residual amount of alliin because more than half of it is lost during the manufacturing process.

While some garlic powder products contain alliin and alliinase, the claim that these products possess “allicin yield” or “allicin activity” is suspect because there is no compelling clinical evidence to support the hypothesis that alliinase will convert alliin to allicin once in the body (see Kyolic, 2010b). Thus, while mass produced, commercial garlic powder serves an effective food flavoring agent, it does not provide any known scientifically supported medicinal benefits.

Aged Garlic Extract
AGE is a form of garlic created using extraction and a proprietary process of aging. Long before it is subjected to extraction and aging process, the garlic is grown on selected farms following strictly controlled organic conditions. No chemical fertilizers, herbicides or pesticides are used in the farming of the garlic.

The garlic is harvested, cleaned, sliced and stored in stainless steel tanks under carefully controlled conditions without the use of a heating process. The garlic is stored in the stainless steel tanks for up to 20 months in an aqueous ethanol solution, which helps to extract and age the garlic compounds.

The proprietary aging process produces an odorless preparation and converts the harsh, unstable organosulfur compounds in garlic (e.g., allicin) into milder and more beneficial compounds including water-soluble, sulfur-containing, antioxidant rich amino acids such as S-allylcysteine (SAC), S-allyl mercaptocysteine (SMAC) and Maillard reaction products.

It is worth noting that SAC has a 98% absorption rate into the blood giving it robust bioavailability. SAC is the key compound in AGE and is used to standardize it (see Borek, 2000; Kyolic 2010b; Kyolic 2010c). It is also worth noting that the entire production process in making AGE (i.e., Kyolic)  is subject to 250 stringent quality checks to ensure its safety and efficacy, all of which conforms to international GMP (Good Manufacturing Practice) guidelines (see Kyolic 2010c).

The chemical conversion brought about the aging process results in eliminating the pungent odor of the garlic and providing AGE with its various health–promoting benefits, without the unpleasant side effects (i.e., offensive odor and potential indigestion) of fresh raw garlic.

AGE also contains small amounts of oil-soluble organosulfur compounds, along with flavanoids and selenium, among other health-giving nutrients. Generally speaking, oil-soluble sulfur compounds tend to be odorous, while water-soluble compounds are odorless. Furthermore, water-soluble compounds are such that they are more stable and safer than oil-soluble compounds (see Kyolic, 2010d).

Conclusion
Garlic, as a whole food, has an illustrious history of medicinal use and benefits. It holds a prestigious ranking among foods to help prevent disease and promote health and well-being in cultures around the world.

Raw fresh garlic, garlic oil, garlic macerate and garlic powder are traditional ways in which garlic has been consumed in different cultures. Their contributions to the culinary arts are well-known and enjoyed.

However, when it is compared to these more traditional forms of garlic, AGE is superior in that it is (1) less harsh and irritating to bodily tissues, (2) less distressing to the digestive system, (3) less pungent and socially offensive, (4) less caloric (especially compared to garlic oil products) (5) less constituted of oil-soluble compounds and more comprised of water-soluble compounds and (6) less bound to folklore and more supported by science with respect to its health-promoting effects.

Therefore, if one is seeking to capitalize upon or otherwise take advantage of the health-giving gifts of AGE, then the Kyolic brand would be an intelligent and informed dietary supplement choice. Currently, as of 2009, there are 650 peer-reviewed studies on Kyolic AGE.

The various scientifically supported health-giving effects of AGE will be explored in an upcoming issue of Healthful Hints. Particular attention will be devoted to AGE’s cardioprotective effects, liver protective and detoxification effects, immune enhancement and anti-infection effects, anti-oxidative and radioprotective effects, anti-stress and anti-fatigue effects, anti-cancer and cancer-preventive effects and anti-aging effects.
Given all of its scientifically supported health benefits, Kyolic Aged Garlic Extract can play an important role in successful aging.

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