‘Green Gold' Review: How the Avocado Grew on Us
An odd quirk of the avocado, Persea americana to botanists, is the clockwork performed by its blossoms. They undergo a complicated sequence of opening, closing and reopening that keeps each flower's male and female sex organs from operating on the same day. Among two large categories of cultivated strains, group A trees bear flowers that are functionally female in the morning and male the next afternoon. Meanwhile, group B's flowers are female in the afternoon and male the next morning.
Unreliable pollination had long baffled commercial avocado growers until, on May 5, 1923, the botanist A.B. Stout had the game-changing idea of setting up cameras in a California orchard. His photographs solved the mystery by capturing the discrepancy between A and B's blossoming schedules, thus suggesting the wisdom of planting trees from both groups in close proximity.
The lesson doesn't seem to have great priority in today's industrial-scale avocado production, at least as depicted by Sarah Allaback and Monique F. Parsons in 'Green Gold,' a trenchant chronicle of the fruit's commercial and cultural exploitation from the late 19th century to the present. The authors' enlightening picture draws on a wide range of material—plant pathology studies, avocado-association yearbooks, Super Bowl commercials, leading figures' field notes and more.
The book broadly centers on two 'mother trees' while saluting 'the people who nurtured them, for money and love.' In 1911 Carl Schmidt, an American investigator scouting for avocado specimens in Mexico, observed a tree bearing splendid crops near Atlixco in Puebla state. He was sufficiently impressed to take cuttings from the tree and bring them back for grafting in an Altadena, Calif., nursery, where the strain received the varietal name El Fuerte (Spanish for 'the Strong One').
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With geographic differences in mind, the NASEM committee limited its scoping review to studies of Lyme IACI in the US, which it considered to be 'Lyme-associated chronic illness with otherwise unexplained symptoms that persist for at least 6 months following antibiotic treatment for either proved or presumed infection with B spp that cause Lyme disease.' (That definition is less stringent than the IDSA's 2006 research case definition of Post-Treatment Lyme Disease Syndrome (PTLDS), which requires an initial Lyme disease diagnosis meeting the surveillance case definition used by the CDC.) European studies are not always generalizable to the US because borrelial species associated with Lyme disease in Europe — and the clinical features of Lyme disease — can differ from those found in the US, said Maloney, who lives and has practiced in a Lyme-endemic area of Minnesota. Maloney, a family physician, became involved in CME in 2007 after treating patients 'who didn't always present as a Lyme patient was supposed to present,' such as patients with arthritis but no history of an erythema migrans rash. 'I read the medical literature and found that things that were presented as black and white and well worked out were not,' she said, 'and had many shades of gray.' The NASEM report only briefly discussed tick-borne coinfections, noting that little is known about how they do or do not affect the development, diagnosis, treatment, and prognosis of Lyme IACI — and that research is needed. Evidence on Pathogenesis, Diagnosis, Incidence The committee's scoping review identified 23 articles addressing potential mechanisms of disease, most of which were not evaluated in prospective studies. In addition to pathogen persistence — and persistence of bacterial remnants — proposed mechanisms for Lyme IACI include immune dysregulation and autoimmunity, central nervous system dysfunction, metabolomic changes, and gut dysbiosis. All are important to consider, Fallon and Maloney emphasized in interviews. Another 27 studies covered the diagnosis of Lyme IACI. Four described direct detection methods that need to be replicated and developed into clinically useful assays; 15 described indirect detection methods using a wide range of potential biomarkers (eg, autoantibodies and other immune markers, metabolite or microbiome signatures, and CNS imaging); and the remaining eight evaluated clinical questionnaires or evaluation scales. (Only two of the eight questionnaires and scales were validated but for monitoring disease progress and not for diagnostic purposes.) Pediatric patients have been scarce in Lyme IACI research, according to the report. Only one of the 27 papers covering diagnosis focused on the pediatric population, for instance, and only three included children along with adults. Moving Forward Lyme IACI is a broad and inclusive name, NASEM experts believe, that encompasses different terms used over the years to describe persistent symptoms (including chronic Lyme and persistent Lyme). The name also acknowledges the heterogeneity and different diagnostic histories of patients, they said, including those with missed and delayed diagnoses. The development of formal consensus research definitions that 'address the different strata of the broad range of people living with Lyme IACI,' the report noted, will make it possible to more accurately determine population prevalence and to conduct impactful research. The PTLDS definition has provided standardization but is a 'subset' of Lyme IACI and excludes many individuals, Kester said in the webinar. Thus far, limited research has suggested that 10%-20% of the approximately 476,000 patients who contract Lyme disease each year develop persistent symptoms after standard antibiotic treatment, the NASEM report said. In addition to its call for consensus definitions, the NASEM report called on the National Institutes of Health (NIH) and CDC to define standard tools and metrics — including patient-focused outcome measures — and said that patient registries and biobanks are valuable and have been underutilized thus far. Clinical studies, it emphasized, should be 'well-designed, randomized trials with appropriate control groups.' Maloney said possible reliance on RCTs is concerning, considering the heterogeneity of the Lyme IACI population and the need for subgroup analyses. 'I worry that [researchers] will not be able to amass the number of patients necessary, even with an expanded definition,' she said in the interview, adding that evidence-based medicine encompasses more than RCTs. She also worries that 'with NIH funding being slashed, tick-borne disease research is not going to get the attention it needs.' NIH funding for Lyme disease research has increased in recent years, but according to a per-patient funding analysis by the Center for Lyme Action, research on West Nile (with an estimated 2566 new diagnoses in the US in 2023) has been funded at 75 times the rate of Lyme disease. In another comparison, the $50 million granted for the study of Lyme disease in 2022 represented < 2% of the public funds invested in HIV/AIDS, according to the Center. Understanding persistent symptomatology was part of a strategic tick-borne disease research plan that was developed by the NIH in 2019. In 2023, NIAID funded seven projects addressing persistent symptoms slated to run through 2028, with first-year funding of $3.2 million. (The NIH did not respond to a query from Medscape Medical News about the future of these and other projects relating to Lyme IACI.) With private funding from the Steven & Alexandra Cohen Foundation, the Clinical Trials Network for Lyme and other Tick-Borne Diseases, coordinated by Fallon, has a slate of small studies underway of therapies that address potential mechanisms of Lyme IACI: tetracycline, transcranial direct current stimulation with cognitive retraining, vagus nerve stimulation, mast cell treatment, and pulse-dosed ceftriaxone). (Network researchers have been using research classification criteria for Lyme disease that are intended to allow for more inclusive and generalizable studies. In a paper published this year, they describe their proposed research classification system, with criteria for Lyme disease at different levels of diagnostic certainty: Well-defined, probable, possible, and uncertain.) Fallon said he is hopeful that the NASEM's recommendations can be implemented. 'Everyone's committed to reducing tick-borne illnesses, and there's a strong interest in [the Administration] in addressing chronic illness,' he said, noting 'it's not just Lyme disease — the coinfections are causing major problems.' Practice Today In practice, meanwhile, Fallon said he and others can help patients by utilizing approaches and therapies 'in our current armamentarium, drawing upon rheumatology, neurology, psychiatry' and other fields. 'I tend to see patients who have had chronic [neuropsychiatric] symptoms for a long time and have received quite a lot of courses of antibiotics,' he said. 'I focus on some of the treatments we know are helpful for people with neuropsychiatric symptoms. For example, there are some psychiatric medications that can help reduce arthritis pain, reduce neuropathies, help improve energy.' Physicians trained in integrative medicine and functional medicine bring 'a broad, comprehensive approach to examination' that can be helpful in Lyme IACI, said Fallon, whose team at Columbia's Lyme and Tick-Borne Diseases Research Center includes an integrative medicine physician. 'They may look at some of the other organisms that may be complicating the course of illness, for instance. They may look for other causes of persistent symptoms such as endocrine problems or mold problems…that can complicate recovery,' he said. 'And they frequently use herbals, which can be helpful.' In its statement, ILADS urged adoption of 'a dual-path strategy [of investing] in long-term research while also expanding access to care based on current best practices.' This includes treatments 'with emerging or empirical evidence that have shown benefit in some patient populations and carry an acceptable risk profile when monitored responsibly.' Many patients improve, the statement said, 'with tailored therapies, including antimicrobial, immune-modulating, and symptom-targeted treatments, especially when the treatments are guided by a clinician who listens to the patient and tracks outcomes over time.' The NASEM committee, comprised of 14 experts from various disciplines, including one patient, heard from over 35 invited speakers representing patients, clinicians, researchers, funders and more. Their work was sponsored by the Steven & Alexandra Cohen Foundation and was recommended by the US Department of Health and Human Services Tick-Borne Diseases Working Group (TBDWG) that was established by Congress in 2016. (Maloney was a member of this group.) The TBDWG produced three reports that addressed persistent symptomatology, among many other issues, before concluding its work in 2022.
