Overuse of Acetaminophen can cause Liver failure

 

Acetaminophen Caution and Guidance

Charles E. Argoff, MD

April 15, 2014

This is Dr. Charles Argoff, Professor of Neurology at Albany Medical College and Director of the Comprehensive Pain Management Center at Albany Medical Center in Albany, New York.

I want you to consider the following clinical situation. A 38-year-old woman presents to the emergency room in acute liver failure. She is accompanied by a family member, who reports that the patient has a history of chronic intractable headache and takes multiple medications for this; as best as the family member can tell, she takes butalbital, acetaminophen, and caffeine at least several times daily. She also uses hydrocodone with acetaminophen at least several times daily. She uses an over-the-counter preparation including acetaminophen, caffeine, and aspirin daily. In addition, she uses traditional over-the-counter acetaminophen every day.

This family member reports that during the past week, the patient has had a cold and has used an oral decongestant that also includes acetaminophen. Upon hearing this, the emergency room physician calculates an estimated total daily dose of acetaminophen for the past couple of months, including the past week, and estimates between 8 and 10 grams per day.

Do you think this is a rare case?

Unfortunately it is not rare. Let's look at some facts. Between 1998 and 2003, acetaminophen was the leading cause of acute liver failure in the United States, with 48% of these acetaminophen-related cases of liver failure being associated with accidental overdoses.^[1] Summarizing data from 3 different surveillance systems, there were an estimated 56,000 emergency department visits, 26,000 hospitalizations, and 458 deaths related to acetaminophen-associated overdoses per year from 1990 through 1998.^[2] A study from 22 medical centers in the United States that was completed in 2003^[1]and was confirmed in a separate study in 2007,^[3] demonstrated that a high percentage of instances of liver injury due to acetaminophen were related to unintentional overdoses. In other words, the patient took too much by mistake.

FDA Initiatives

As part of the US Food and Drug Administration's (FDA) Safe Use Initiative in 2011, the Acetaminophen Best Practices Task Force was created. The Task Force produced a white paper recommending complete disclosure of acetaminophen in all acetaminophen-containing products, a standard pharmacy warning label about liver damage for these medications, and specific wording on pharmacy container labels that is consistent with appropriate health literacy principles-- ie, these had to be specially designed so that people could [understand] them. On January 14, 2014, the FDA recommended^[1] that healthcare professionals discontinue prescribing and dispensing prescription combination drug products that contain more than 325 mg of acetaminophen per tablet, capsule, or other dosing form. Even before that, in 2011 the FDA had asked manufacturers of prescription combination drug products containing acetaminophen to limit the amount of acetaminophen to no more than 325 mg in each tablet, capsule, or other dosing method by January 14, 2014.

In this particular directive, the FDA noted that severe liver injury with acetaminophen had occurred in patients who took more than the prescribed dose of an acetaminophen-containing product within a 24-hour period, took more than 1 acetaminophen-containing product at the same time, and/or who drank alcohol while taking acetaminophen products. While noting also that acetaminophen is widely used in many over-the-counter products, including over-the-counter cold products, the FDA directive did not provide any regulatory action regarding these particular products. The FDA did advise that many consumers are often unaware that many products contain acetaminophen, and, therefore, consumers could easily take too much by accident. But no actions were taken in regard to over-the-counter products.

What can we do? We can advise patients not to exceed the acetaminophen maximum total daily dose. This is an active process on our part. We can advise our patients that severe liver injury can occur with the use of excessive amounts of acetaminophen. We can advise our patients to read the labels of the prescription and over-the-counter medications so that they do not take multiple acetaminophen-containing products at the same time. We can advise our patients not to drink alcohol while taking acetaminophen-containing products. We can advise our patients to seek medical help if they take more acetaminophen than directed or if they experience swelling of the face, mouth, and throat, difficulty breathing, itching, and a rash.

Thus, we can actively help reduce the accidental injury that acetaminophen can cause when taken in excessive quantities. As you see, this particular instance is not all that far from clinical scenarios that we may have encountered already. I hope this has been of some value to you. I am Dr. Charles Argoff. Thank you for your attention.

The Vitamin Deficiency That is Written All Over Your Face

HEALTHY LIVING, MOST POPULAR

by Sarah TheHealthyHomeEconomist April 7, 2013

Are wrinkles an inevitable fact of aging or could laugh lines and crow’s feet potentially indicate a more serious underlying health issue?

In 2011, researchers presented findings at a meeting of the Endocrine Society in Boston that revealed that women in their 40′s and 50′s who have extensive skin wrinkling are much more likely than their peers to have low bone mass.

Researchers noted the relationship between wrinkles and bone density in every single bone tested which included hip, heel, and lumbar (spine).   In addition, this relationship existed regardless of body fat percentage and age.

Epidemiological evidence of Asian women offers further health clues to the wrinkle mystery.

It is known that Japanese women have fewer wrinkles and less skin sagging that women of the same age living in North America.   These two groups of women vary greatly in diet and lifestyle, however.

Even when Japanese women living in Tokyo were compared with women from the Asian cities of Shanghai and Bangok, however, they showed the least visible signs of aging.

Diet and lifestyle factors for these three Asian groups of women are comparable except for one notable exception: the consumption of natto in Japan.

Tokyo residents frequently enjoy natto, a strong smelling food traditionally made from fermented soybeans for breakfast. Natto is loaded with menaquinone, Vitamin K2, and blood samples of the Tokyo women revealed high circulating levels of this fat soluble vitamin.

Further research which bolsters the notion that getting plenty of anti-wrinkle vitamin K2 in the diet makes for smoother facial features is found in the research of Korean scientists and was published in the journal Nephrology in 2008.

The rate at which the kidneys are able to filter the blood is an important measure of overall kidney function.  Researchers found that reduced renal filtration rate was associated with increased facial wrinkling.

What does decreased kidney filtration rate predict?

You guessed it – Vitamin K2 deficiency, according to American research published the year after the Korean study.

Testing has been limited so far on the true extent of Vitamin K2 deficiency in the western world, but so far, of those tested, 90% tested deficient in this critical nutrient.

The Anti-Wrinkle Vitamin: Foods High in Vitamin K2

If you want to make sure you’re getting plenty of Vitamin K2 for the most effective wrinkle prevention possible from the inside-out, know that it is an elusive nutrient and extremely difficult to obtain with a modern diet.   The highest sources of K2 are natto (fermented soybeans), goose liver, certain cheeses and animal fats like egg yolk, butter and lard which must come from grassfed animals.

Natto contains a whopping 1,103 mcg of K2 per 3 1/2 ounce portion which blows away every other food by a country mile.

The second highest food in Vitamin K2 is goose liver pate which has 369 mcg per 3 1/2 ounce portion.  While delicious and wonderful to eat, goose liver pate is very hard to find in most places.  It is also a very high end, gourmet food which makes the price out of reach for most.

Rounding out the top 3 foods highest in Vitamin K2 is none other than the humble Gouda cheese, which boasts 75 mcg per 3 1/2 ounce serving!  This compares to pastured egg yolks and butter, which each have about 15 mcg of K2 per 3 1/2 ounce portion.

How much of these K2 containing foods should you eat?  That part gets murky as the official recommended daily intake (RDI) of Vitamin K doesn’t distinguish between K1 and K2 despite their very different uses in the body.   The RDI for Vitamin K is only determined by the liver’s requirement for normal blood clotting factors, not the K2 needed for optimal bone and kidney health and wrinkle free skin.

The good news is that there is no known toxicity of Vitamin K2, so eating generously of Vitamin K2 rich foods as practiced by Traditional Societies and even potentially taking a supplement is considered wise by Vitamin K2 and the Calcium Paradox author, Dr. Kate Rheaume-Bleue, ND.

UPDATE

Recent research has shown that an Aboriginal sacred food is extremely high in vitamin K2, so high in fact that it is nearly as high as goose liver pate!  Click here for more information on this exciting discovery and where to source authentic emu oil from the genetically pure strain of birds that produce this nutrient dense fat.

Sarah, The Healthy Home Economist

Source: Vitamin K2 and the Calcium Paradox

Picture Credit

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10 Reasons You’re Always Cold & 4 Easy Ways To Re-Stoke Your Fire

JANUARY 31, 2014 / HEALTH / NO COMMENTS »

Written by: 

Amy Jo Gengler

Licensed Acupuncturist, Chinese Herbalist, Nutritional Consultant

717 Atlantic Ave. #2C

Boston, MA 02111

617.275.3488

flourishboston.com

Facebook:  flourishboston

Bio:

AMY JO GENGLER IS A LICENSED ACUPUNCTURIST, NUTRITIONAL COUNSELOR, FEARLESS COOK, COOKING AND HEALTH INSTRUCTOR & FOUNDER OF COOKING-DIVA.COM. SHE SPECIALIZES IN RESTORATIVE DIETS, SHARING HEAPS OF GREAT RECIPES, FOOD TIPS, AND ONLINE CLASSES TO GET YOU ON THE SUPERHIGHWAY TO VIBRANT HEALTH, GREATER FOOD CONSCIOUSNESS AND GAINING AUTONOMY IN YOUR KITCHEN. CONTACT HER VIACOOKING-DIVA.COM

"Eat food, not too much, mostly plants."  ~Michael Pollan

"It's always good to use the ideal as a reference point for where you are headed and what you want to accomplish."  ~Lonny Jarrett

"Soul strength comes from knowing, prior to thought, that the process is inherently good." ~Andrew Cohen

_______________________________________________________________________

Brrrrr-rrr-rrr! It’s January in Boston, and dare I say, it’s unbelievably cold outside? Each day on my walk to work, I can’t help but notice at least a handful of what I refer to as ‘true Bostonians’ walking down the street–these women holding a giant Dunkin’ iced coffee, wearing cropped pants & ballerina flats with bare feet, despite the 12″ of snow on the ground & bone-chilling wind tunnels. This astounds me, and this delicate southern flower’s hat is off to you ladies!

Despite my daily sightings of these bad-ass Bostonian chicks, I see ten times that amount of people in my practice suffering from symptoms caused by ‘cold’, such as: cold hands & feet, gas & bloating, constant runny nose, sinus issues, poor digestion, low back pain, low energy, foggy brain, poor circulation, and general lack of pizzazz. In Chinese Medicine, this is what we call ‘Yang Deficiency’.

Yang, as in ‘Yin & Yang’, and pronounced with an ‘ahhh’, like ‘long’, not an ‘eh’ like dang. Yang is the root of of our fire: digestive fire, drive, activity, action, force, sunlight, warmth, excitement and our general ability topounce. When the Yang gets smothered by cold things, many of the symptoms listed above will start to surface and it’s easy to feel like a wet blanket as your fire is slowly diminishing. Stoking the Yang back up, fortunately, doesn’t take much once you know how, and once you quit doing the things that are killing it. I do this all day long in my practice, so if you’re ready for more energy, more drive, warmth, and pounce-a-bility, call me for help and let’s get to work.

For now, I’ve compiled this list of 10 0f the most cold-inducing things that may be compromising your health, and a few home remedies for warming yourself back up. All of these cold items are particularly hard on the Spleen, and since we who practice Chinese Medicine believe that all disease starts in the gut, it’s important to keep the Spleen happy if you want to have strong immunity and age like a martial arts master.

1. ICED COFFEE   

Cold drinks are hard on the digestive fire, especially when it’s cold outside. I love a big ol’ iced tea in August, but drinking cold drinks in winter not only slows down your digestion, often leading to gas, bloating & low energy, but can also lead to more PMS, muscle pain, and contributes to infertility struggles and weight gain.

2. FRO-YO   

If there was one food-like product I could nix from humanity completely, this would definitely be a front runner. In terms of Chinese Medicine & general health, the combination of cold, diary (or ‘dairy’), and sugar is really just asking for trouble. This binds up the digestion due to the cold temperature + stagnating properties from food that creates phlegm in the body (dairy, sugar, gluten, chemicals).  However, the bigger elephant in the room is that Fro-Yo places shamelessly manipulate with their marketing. Somehow they have collectively convinced customers that Fro-Yo is ‘healthy’, and consequence-free, but unfortunately, it is highly processed and contains a shocking amount of chemicals all cleverly disguised in these cute & innocent little yogurt cups–with sprinkles, no less. Don’t believe the hype! Check out this great investigative report from foodbabe.com.

3. SALAD  

Of course salad, in and of itself, can have so many nutritive properties–especially when you add wonderful things like kale, avocado, nuts & seaweed. However, salad, being a raw food, is also hard on your digestion when eaten without something warm to help digest it. When food is cold to start with (like everything on this list), the Spleen (chiefly in charge of how we digest, and the first thing to freak out when not treated right) has to expend a lot of energy to warm up the food prior to digestion, often running out of fuel before the digestion process has finished. This is what leads to that 3pm energy slump, unexplained water weight, low energy, lethargy, sugar cravings, heaviness in the limbs, and inability to lose weight. Save the salads for summer, and instead, indulge yourself at the hot soup bar and warm, bubbly casseroles for now.

4. JUICING    

Wow, juicing has become wildly popular! How could it not, when it looks soooo beautiful, and so many authors, health coaches & bloggers are saying how amazing it is? Fresh juice is basically liquid Qi, and that is very intriguing. With it’s yummy concentrated flavors, it’s like sunshine in a glass. However, juicing, like all trends, must be taken with a grain of salt.

Juicing easily damages the digestion for a few main reasons: Juices are energetically cold and they are full of sugar, both of which damage the spleen and digestive fire. Unless you are consistently hot, with fast digestion, a red tongue, and tend to sweat quite easily, more than 8 oz of juice per day leads to what we call ‘damp’ conditions in Chinese Medicine. This manifests as a thick coat on the tongue, low energy, heavy limbs, runny nose, chronic sinus issues, gas & bloating and feeling cold all the time.

Seasonally speaking, Juicing is fantastic in the SPRING. And by spring I mean May, not January. Because juicing is so cooling, doing a juice cleanse when it is still cold outside will do more damage to your spleen and digestion, than good. It’s best to wait until it’s warm outside, and even then, if you still have any of these issues, try drinking some warming teas like ginger & cinnamon to counterbalance all of the cold & damp.

 

5. SMOOTHIES        

Closely related to juicing, is it’s frosty cousin–The Smoothie. Yet another fallacy pointing to ‘weight loss’, the smoothie often becomes a vessel for inducing diabetic episodes in many an innocent soul. Similar to juicing, the smoothie is also typically full of sugar, the main difference is that it’s even colder than juice with it’s primary ingredients being frozen, or the addition of ice–think blended popsicles. Again, similar to juicing, a little smoothie is fantastic in Miami in August, but other than that, please take my advice and give your spleen a break. For a delicious and much more nutritive, low-sugar alternative, check out my Favorite Kale Shake and try this at home.

6. COCONUT ICE CREAM   

Well…all ice cream, really. I find that the worst offenders are people who are addicted to Coconut Ice Cream, but all of it hurts you just the same. Coconut Ice Cream tends to fall in that same confusing category as Fro-Yo: It’s typically marketed to be healthier than regular ice cream, so we somehow twist this into thinking we should eat it every day….right? Especially for those with limited diets, who no longer eat dairy…the power of the coconut is strong! For now I will urge you to avoid the frozen section at the store at least until May. Eating any form of ice cream or sorbet–especially at night–is why you are freezing cold all the time, have constant sinus issues, stuffy ears or runny nose, foggy brain, low energy, and eventually will gain weight from sleeping on a cold stomach. If you need something sweet after dinner, try eating 1/2 an apple or perhaps a little chocolate.

7. ANTIBIOTICS   

By now you have probably read plenty about how controversial and polarizing Antibiotics are. One thing you should know is that Antibiotics (ABX) were one of the biggest revelations in health care, as we know it. Prior to their discovery in 1928, many people suffered dearly, and even died from many conditions that are considered easily treatable today such as salmonella, tuberculosis, syphilis, and some forms of meningitis. That being said, a sore throat or even a sinus infection are not enough reason to pummel your digestive tract with such severe medications.

Like everything on this list, ABX are very cold and produce ‘damp’ in the body. On the one hand, this is good because in fighting bacterial infections, they have the ability to dramatically cool down inflammation. On the other hand, they don’t have much regulatory ability, so they  also tend to cool the digestive tract too much, especially with repetitive use, and this is why they are a bit dangerous.

‘ABX Resistance’ is related to what I said earlier about Chinese Medicine stating that all health starts in the gut. Repeated ABX use can lead to resistance, often requiring stronger medicine each time one gets sick. According to Chinese Medicine principles, this is because we need a certain degree of healthy digestive fire to support a healthy immune system. All of the symptoms I am speaking of in this article (cold limbs, slow digestion, runny nose, chronic sinus issues, gas & bloating) are all signs of a weakening digestive system, which ultimately effects one’s immunity.

If you have never seen a Chinese Herbalist, what are you waiting for? You will be amazed at how effective Chinese Herbs are for all respiratory and digestive issues, including allergies, sinusitis, poor digestion, and just about everything else under the sun. They say that Western Medicine is the Study of What Makes You Sick, and Chinese Medicine is the Study of What Makes You Healthy. Building up a stronger body, stronger digestion and stronger immunity is never a bad idea, in my opinion, and this is where Chinese Medicine excels!

8. TOFU    

Tofu’s primary energetic is also cold and produces damp in the body, which isn’t that surprising if you’ve ever cooked with it. Ever noticed how squishy it is? It’s basically solidified soy milk. However, tofu is also quite versatile, and while bland in flavor by itself, tofu readily takes on the flavor of whatever it is cooked with. If you eat Tofu regularly, try adding some hot chili paste and curry for more warmth, then oven roasting it to dry it out a bit.

9. SUSHI   

Dear Gentle Readers, please understand I am truly sorry for this one, but I would rather tell you the whole truth so you can make educated decisions. Raw fish is very cold. Combatting this is perhaps why Sushi is often served with ginger, wasabi, saké, and miso soup–all warming items. I certainly don’t want to rain on your sushi parade because it IS one of the most beautiful and artful foods on earth, just make sure you partake in all of the warming items available to accompany your meal.

10. YOU LIVE IN BOSTON 

Yep, with a yearly average of 30+ days below freezing each year, living in Boston (and anywhere above 40* latitude) automatically predisposes you to being cold, inside and out. And while one can combat brutal weather by bundling up and wearing insulated boots, many of us need an extra boost to fight off the cold.

3 KEYS TO RE-KINDLE YOUR INNER GLOW

1. COOK YOUR VEGETABLES 

Make sure to cook all of your vegetables and pass on the raw foods, salad, juices & smoothies until it’s warm enough to break a sweat outside. Check out the Diva’s recipe collection and my Pinterest page for great ideas & cooking inspiration.

2. KEEP IT SPICY 

Use more warming spices in your food like Ginger, Cinnamon, Chiles, Black Pepper, Garlic, Fennel & Cloves. One easy way to do this is to eat more Indian food and drink more Chai. Just watch out for refined sugar in your chai–opt for honey instead, which is also gently warming.

3. TAKE A GINGER BATH 

Taking a warm or hot bath will always beat a hot shower, especially in winter. And on those days when you can’t get warmed up, adding some freshly steeped Ginger water to your bath will change everything. Heat about 4 cups of water on the stove. Once it has come to a boil, add 1/2 cup to 1 1/2 cups of freshly grated or chopped Ginger, turn off the heat, and cover it with a lid. Let steep for 3-5 minutes, then strain the Ginger out, adding the Ginger water to a bathtub full of hot water. Soak as long as it stays warm enough, and enjoy the toasty warmth.

 4. SEE A CHINESE HERBALIST 

Chinese Medicine Practitioners offer the most unique, effective and affordable solutions to 99% of all health problems. We are trained to treat each patient as a ‘whole person’, rather than just addressing this or that symptom in isolation. Because of this approach, you should expect a steady and consistent improvement of all aspects of your health, when you check in regularly with someone who practices Chinese Medicine (acupuncture, too!). If you live in the Boston area, schedule an appointment with AJ here.

Personal Note:

While I agree with most of the things being said in this article, I do think that we can adapt certain things to make them less "cold" on our system.

For instance, you can keep eating your salads as long as you add a cooked protein to it, or combine it with a cup of soup or a hot beverage. That way, the warm element will help bring the cold element up to body temperature and help facilitate digestion.

Likewise with juices or smoothies, adding a nice piece of ginger to it, will bring up its energetic temperature to something warmer and therefore better tolerated by our digestive tract.

However, If you do have a cold or "yang deficient" constitution, you want to avoid those cold foods, juices, etc....in the winter time. Save those for when you are in warmer climates....

Anita

blogs.kqed.org

5 Foods that Boost Immunity and May Help Prevent Colds and Flu

Cold and flu season is upon us and as the old adage goes, “An ounce of prevention is worth a pound of cure.” We all know that it is much better to avoid getting sick than to try to shake a bug once it has taken hold. Unfortunately, even with the best personal hygiene, such as frequent hand washing, it can be difficult to avoid germs. That is why it is so important to have a strong immune system.
The immune system is made up of cells and proteins that fight off foreign invaders like viruses and bacteria and prevent infection. These cells work together as a team and they have a long memory. Ideally this coordinated defense prevents an illness before it takes hold. But even if you do get sick, the immune system remembers the virus and can fight it off more effectively in the future. Luckily for us, diet has a big impact on immune function, and optimizing nutrition is one of the most important things we can do to boost our defenses.

Here are five foods or food groups that benefit the immune system.

Chicken soup with egg noodles. Photo: Wendy Goodfriend

Chicken soup and other foods high in protein

Grandma was right, high quality complete proteins are essential for the immune system to function. The truth is that all of our immune cells and antibodies are made up primarily of proteins. When we don’t get enough dietary protein or we are unable to absorb the protein from our diets the immune system suffers. The nice thing about chicken soup is that it is both a complete protein, meaning that it contains all of the essential amino acids, and it is easy to digest because the meat has been cooked until it is soft and falling apart. However vegetarians and chicken soup haters need not despair, all high protein foods are helpful. Meat, eggs and beans are also good sources.

Maitake mushroom surrounded by Trumpet and button mushrooms. Photo: Wendy Goodfriend

Medicinal mushrooms

Many medicinal mushrooms are also edible and delicious. They can be sauté roasted and added to soups or gravies, but they should not be eaten raw. Shiitake and Maitake mushrooms are commonly available at stores and farmers markets around the Bay Area. These fungi are immune super foods with properties ranging from increasing white blood cell numbers to supporting anticancer effects. Most people agree that the medicinal components of these mushrooms are best absorbed when they are extracted in hot water. This means that soups or teas are the ideal way to eat them. In fact certain mushrooms like Reishi are so hard and woody that they cannot be eaten directly but are commonly simmered in broth and then removed. However they are prepared, mushrooms add both health benefits and a rich, savory flavor to any dish.

Tangerines, Cara cara and navel oranges. Photo: Wendy Goodfriend

Tangerines, kiwis and other foods high in vitamin C

Vitamin C is a powerful immune tonic. It increases white blood cell numbers and improves the function of these important immune cells.
It is an essential nutrient meaning that humans cannot make their own; they must consume it in food or supplements. It is best absorbed in small frequent doses, which is easy to do this time of year when oranges, tangerines and kiwis abound. Vitamin C is heat sensitive, and it can be destroyed by cooking. The best way to eat foods rich in vitamin C is fresh and raw.

Heads of Garlic. Photo: Wendy Goodfriend

Garlic

We often use garlic for colds and flus because it has direct anti-viral properties. But garlic is also a potent regulator of the immune system. Garlic doesn’t just stimulate immune cells it also reducesinappropriate inflammation so the immune system can focus on the real invaders. For its antimicrobial properties garlic must be consumed raw and freshly crushed. For example fresh, crushed garlic can be mixed with honey for sore throats. But for immune balancing, dried and aged extracts have been frequently researched. Based on those studies, soups, sautés and sauces should all be beneficial.

Raw Khitchari Kraut and organic yogurt. Photo: Wendy Goodfriend

Yogurt, Sauerkraut and other cultured foods

We are not sterile creatures. There are bacteria that populate our skin, nasal passages, genitalia and most importantly our gastrointestinal tract. We are coming to realize that the difference between having the right bacteria in our guts and the wrong bacteria can be the difference between health and disease. That is why beneficial bacteria (AKA probiotics) are so important in the human diet. These probiotics don’t just improve the health of the gut. They directly improve gut and systemic immunity. One of the best ways to consume probiotics is in cultured foods such as yogurt, kefir, sauerkraut, and miso. Because these beneficial foods contain live bacteria and yeast they should not be cooked or excessively heated.
Below is one of my favorite warming winter soups. It is incredibly delicious with Chantrelle mushrooms. However, Shiitake and or Maitake also give it a lovely flavor with an added immune kick. Be sure to use unpasteurized miso and add it at the end for a live cultured food.

Creamy Mushroom Soup with Fresh Shiitakes

Makes 6-8 servings

Ingredients:
• 1 medium onion diced
• 2 cloves of garlic, peeled and minced
• 4 cups of shiitake mushrooms, stems removed and sliced (you may use other mushrooms if desired such as maitake or oyster)
• 3 tablespoons of extra virgin olive oil
• 1 teaspoon salt
• 6 cups of water
• 1 cup of cashews
• 2 tablespoons of chickpea miso

Instructions:
1. Heat the olive oil in a heavy bottom stockpot. Add the onion and sauté it over medium-low heat for 5 minutes or until it begins to brown. Stir it frequently to prevent it from burning.
2. Add the garlic and continue to sauté for 1 minute stirring frequently.
3. Mix in the mushrooms, and sauté for five more minutes.
4. Add 3 cups of water and 1/2 teaspoon of salt to the pot and stir well, scraping the bottom with a wooden spoon to remove and caramelized vegetables.
5. Cover the pot and allow it to simmer for 10 minutes.
6. While the soup is simmering place the cashews and 1 cup of water in a blender. Make sure the lid is secure and start the blender on low, slowly increasing to the highest speed. While blending gradually add 1 more cup of water, 1/4 cup at a time every time the mixture gets too thick to process. You should end up with a smooth cashew cream at the end. In small blenders this often works better in two batches. The cashews will puree more easily if they are presoaked in water to cover overnight. If you do this be sure to drain and rinse them well before making cashew cream.
7. Pour the cashew cream into the soup pot while stirring and mix it well. Rinse the blender out with 1/2 cup water and add that to the pot as well. The cashew cream will thicken as it comes to a simmer, so stir the soup frequently during this step. Once the cream has thickened and the soup has come back to full simmer, remove it from the heat.
8. In a small bowl dissolve the miso into the last 1/2 cup of water.
9. Stir the miso into the soup and taste it. Add the last 1/2 teaspoon of salt if desired.
10. Serve the soup warm.

* Note: None of the information in this article is intended to diagnose, or treat any disease or health condition.