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Olive Oil Hunter News #250

Black Dal Recipe, Spotlight on Black Lentils, How to Store Lentils, Sorbitol and The Liver, and More Muscle, Younger Brain

When it comes to dark leafy greens, kale occupies a heightened position thanks to its wide range of nutrients. And yet, shockingly, researchers have found that the body doesn’t absorb as many of them as hoped…unless you eat it with a healthy fat source, like extra virgin olive oil. I’m also sharing the trick to make this hearty green more tender, which also involves olive oil. It’s another reason why these two ingredients are a match made in heaven.

Black Dal

  • Indian black dal Black Dal

    If you’re new to lentils, this flavorful recipe makes a great introduction. I’ve streamlined the number of spices used in traditional recipes because garam masala already incorporates the essentialscoriander, black pepper, cardamom, cinnamon, cloves, ginger, and nutmeg, among others. This makes a hearty meatless meal, a soup, or a side dish—scoop it up with a piece of your favorite Indian bread.

    Ingredients

    • 2 cups black lentils
    • 3 tablespoons extra virgin olive oil, plus more for drizzling
    • 1 small onion, minced
    • 2-inch piece ginger, minced
    • 2 garlic cloves, minced
    • One 6-ounce can tomato paste
    • 2 teaspoons garam masala
    • 1/2 teaspoon cayenne pepper
    • 1 cinnamon stick
    • 1 cup homemade or store-bought low-sodium chicken or vegetable broth
    • 2 tablespoons unsalted butter
    • 1/2 cup heavy cream
    • Optional garnish: chopped fresh cilantro

    Directions

    Step 1

    Rinse the lentils, and then put them in a stockpot or Dutch oven. Add enough cold water to cover them by 2 or 3 inches. Bring to a rolling boil and cook for 5 minutes, then lower the heat to a simmer. Cook for about 45 minutes, stirring occasionally, until the lentils are tender but still hold their shape. (If the water level gets too low, add more water as needed to keep them covered). Drain if needed and transfer to a bowl.

    Step 2

    Rinse the pot and heat over medium-high heat. When it’s hot, add the olive oil and onions; cook until they become translucent, and then add the minced ginger and garlic and cook until fragrant. Push the vegetables to the sides of the pot and add the tomato paste in the center. Cook, stirring constantly, until the paste deepens in color, then mix into the vegetables. Add the garam masala, cayenne pepper, cinnamon stick, broth, and cooked lentils. Simmer for 15 minutes, stirring frequently, to infuse the lentils with the spices. Then stir in the butter and cream and simmer for 2 minutes. Serve with a drizzle of olive oil and a sprinkle of cilantro if desired.

    Yields 6 main servings, 6 side servings

Healthy Ingredient Spotlight: Black Lentils

Healthy Ingredient Spotlight

Black Lentils

Lentils belong to the broader family of legumes, which includes beans and dried peas. But unlike those others, lentils don’t need an overnight soak in water, so there’s less prep needed. Also available in red, green, and yellow, lentils are rich in protein, fiber, and iron, along with dozens of other nutrients. Because of their deep color, round shape, and tiny size, black lentils are often called caviar or beluga lentils. Black dal traditionally uses urad dal, a mung bean that’s not a true lentil, though it is a legume. However, black lentils—which you can find at specialty markets or online—work extremely well for dal and many other recipes.

dried lentils
Quick Kitchen Nugget: How to Store Lentils

Quick Kitchen Nugget

How to Store Lentils

Like other legumes, lentils keep best in a cool, dry cabinet, either in their original packaging or a tightly sealed glass container. They’re most flavorful (and take less time to cook) when used within a year of packaging. Before cooking, check them for any debris, like tiny stones, and rinse with cold water, then drain.

For Your Best Health: Sorbitol and The Liver 

For Your Best Health 

Sorbitol and The Liver 

Sweeteners such as aspartame, found in Equal packets, sucralose (Splenda), and sugar alcohols are widely promoted as healthier options than foods made with refined sugar (glucose). Many people turn to them hoping to reduce health risks linked to sugar and cut calories. But new scientific evidence is now calling that into question. Recent findings suggest that the sugar alcohol sorbitol in particular may not be as harmless as it is often assumed to be.

The findings come from a study published in Science Signaling that builds on years of research from the laboratory of Gary Patti, PhD, at Washington University in St. Louis into how fructose affects the liver and other organs. Dr. Patti, the Michael and Tana Powell Professor of Chemistry in Art & Sciences and a professor of genetics and medicine at WashU Medicine, has previously shown that fructose processed by the liver can be diverted in ways that fuel cancer cell growth. Other studies have linked fructose to steatotic liver disease, a condition that now affects about 30% of adults worldwide.

One of the most unexpected results of the new study is that sorbitol is essentially “one transformation away from fructose,” according to Dr. Patti. Because of this close relationship, sorbitol can trigger effects similar to those caused by fructose itself.

Using zebrafish as a model, Dr. Patti and his team showed that sorbitol, commonly found in low-calorie candies and gums and naturally present in stone fruits, can be produced inside the body. Enzymes in the gut can generate sorbitol, which is then transported to the liver and converted into fructose.

The team also discovered that the liver can receive fructose through multiple metabolic routes. Which pathway dominates depends on how much glucose and sorbitol a person consumes as well as the specific mix of bacteria living in their gut.

Most earlier studies of sorbitol metabolism focused on disease states such as diabetes, where high blood sugar leads to excess sorbitol production. Dr. Patti explained that sorbitol can also be created naturally in the gut after a meal, even in people without diabetes.

The enzyme responsible for making sorbitol does not bind easily to glucose, meaning glucose levels must rise significantly before the process begins. That is why sorbitol production has long been linked to diabetes. However, the zebrafish experiments showed that glucose levels in the intestine can become high enough after you eat to activate this pathway even under normal conditions. “It can be produced in the body at significant levels,” said Dr. Patti. “But if you have the right bacteria, turns out, it doesn’t matter.”

Certain Aeromonas bacterial strains are able to break down sorbitol and convert it into a harmless bacterial by-product. When these bacteria are present and functioning well, sorbitol is less likely to cause problems. “However, if you don’t have the right bacteria, that’s when it becomes problematic. Because in those conditions, sorbitol doesn’t get degraded, and as a result, it is passed on to the liver,” he said.

Once sorbitol reaches the liver, it is converted into a fructose derivative. This raises concerns about whether alternative sweeteners truly offer a safer option than table sugar, especially for people with diabetes and other metabolic disorders who often rely on products labeled as sugar-free.

At low levels, such as those typically found in whole fruits, gut bacteria are usually effective at clearing sorbitol. The trouble begins when the amount of sorbitol exceeds what these microbes can handle. This overload can happen when large amounts of glucose are consumed, leading to an increased production of sorbitol from glucose, or when the diet itself contains high levels of sorbitol. Even individuals with helpful bacteria may run into problems if their intake of glucose and sorbitol becomes too high, since the microbes can be overwhelmed.

Avoiding both sugar and sugar substitutes has become increasingly difficult, as many processed foods contain several forms of sweeteners at once. Dr. Patti said he was surprised to learn that his own favorite protein bar contained a significant amount of sorbitol.

Further research is needed to understand exactly how gut bacteria clear sorbitol. What is becoming clear, however, is that the long-held assumption that sugar alcohols, also known as polyols, are simply eliminated without harm may not be accurate. “We do absolutely see that sorbitol given to animals ends up in tissues all over the body,” he said. The overall message from the research is that replacing sugar is not as simple as it may seem. As Dr. Patti put it, “there is no free lunch” when it comes to sugar alternatives, and many metabolic pathways can ultimately lead back to liver dysfunction.

Fitness Flash Icon: More Muscle, Younger Brain

Fitness Flash

More Muscle, Younger Brain

New research shows that people who have more muscle and a lower visceral fat-to-muscle ratio tend to show signs of a younger biological brain age. This conclusion comes from a study recently presented at the annual meeting of the Radiological Society of North America. Visceral fat refers to the fat stored deep in the abdomen around key internal organs.

“Healthier bodies with more muscle mass and less hidden belly fat are more likely to have healthier, youthful brains,” said senior study author Cyrus Raji, MD, PhD, Associate Professor of Radiology and Neurology in the Department of Radiology at the Mallinckrodt Institute of Radiology at Washington University School of Medicine in St. Louis. “Better brain health, in turn, lowers the risk for future brain diseases, such as Alzheimer’s.”

Brain age is an estimate of how old the brain appears biologically, based on its structure as seen through an MRI. A whole-body MRI can track muscle mass, which serves as a marker for efforts to reduce frailty and strengthen overall health. Estimated brain age from structural scans may also shed light on risk factors for Alzheimer’s disease, including muscle loss.

“While it is commonly known that chronological aging translates to loss of muscle mass and increased hidden belly fat, this work shows that these health measures relate to brain aging itself,” Dr. Raji said. “It shows muscle and fat mass quantified in the body are key reflectors of brain health, as tracked with brain aging.”

Exercise for brain health

The study evaluated 1,164 healthy adults across four research sites using whole-body MRI. Participants had a mean chronological age of 55.17 years. Imaging included T1-weighted MRI sequences, which highlight fat as bright and fluid as dark, providing a clear view of muscle, fat, and brain tissue. An artificial intelligence (AI) algorithm measured total normalized muscle volume, visceral fat (hidden belly fat), subcutaneous fat (fat under the skin), and predicted brain age.

The data indicated that individuals with a higher visceral fat-to-muscle ratio had higher predicted brain age. Subcutaneous fat showed no meaningful association with how old the brain appeared. “The participants with more muscle tended to have younger-looking brains, while those with more hidden belly fat relative to their muscle had older-looking brains,” Dr. Raji said. “The fat just under the skin wasn’t related to brain aging. In short, more muscle and a lower visceral fat-to-muscle ratio were linked to a younger brain.”

Dr. Raji explained that focusing on building muscle and reducing visceral fat are realistic and actionable goals. Whole-body MRI and AI-based brain age estimates can offer clear benchmarks for programs designed to lower visceral fat while maintaining or increasing muscle. He also noted that the results highlight the close connection between physical health and brain health.

“This research has validated widely held hypotheses about the association between body composition biomarkers and brain health and provides a foundation for those biomarkers to be included in future trials of various metabolic interventions and treatments.”

Commonly prescribed glucagon-like peptide-1 (GLP-1) weight loss medications, including Ozempic, are effective at reducing body fat but may also contribute to muscle loss. Dr. Raji suggested that the study’s findings could help guide the development of next-generation therapies. These future treatments may aim to reduce visceral fat more than subcutaneous fat while protecting muscle mass.

“Losing fat—especially visceral fat—while preserving muscle volume would have the best benefit on brain aging and brain health based on insights from our work,” he said. “Thus, our study can inform future treatments by promoting research that quantifies MRI of body fat, muscle, and brain age, which can help determine the optimal dosing regimens for GLP-1s to achieve the best outcomes in body and brain health.”

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Hydroxytyrosol from Olives Is a Neuroprotective Agent

One of the most powerful polyphenols in olive oil is hydroxytyrosol. Consuming hydroxytyrosol is linked to benefits in neurological, cardiovascular, and metabolic health, and the compound has demonstrated anti-inflammatory, anti-cancer, neuro-protective, and immuno-protective effects. A recently published scientific review in the journal Foods examines the growing body of evidence supporting the characterization of hydroxytyrosol as a “functional food,” with emphasis on its effects on neurological and cognitive processes.

What is it?

Hydroxytyrosol (hi-droxy-TY-roh-sol), abbreviated as HXT, is a phenol, a natural chemical that is both water-soluble and attracted to fats, which means that it can pass through cell membranes. Its chemical structure also explains its strong antioxidant and anti-inflammatory properties. HXT occurs mainly in olives—olive oil, fruit, leaves, and pulp—as well as in red and white wines.

What does HXT do in the brain?

HXT interacts with the brain and its vascular (blood vessel) system in 3 ways: 1) as an antioxidant and anti-inflammatory agent, HXT helps prevent damage to cerebral blood vessels and improves their function; 2) lab studies show that, by reducing oxidation and inflammation, HXT helps maintain the proper functioning of the blood-brain barrier (BBB), a crucial filter inside the brain’s blood vessels that controls what substances enter and exit the brain; 3) in studies in humans, consuming HXT in the form of high-phenolic EVOO resulted in less “leakage” across the BBB and, as reflected in participants’ performance on cognitive tests, improved connectivity between brain regions.

HXT and its metabolites (the components of a substance that are formed when metabolic processes, such as digestion, break it down) are able to cross the BBB to interact with specific brain processes, enhancing protective activity and dampening inflammatory activity that is linked to depression and cognitive decline.

How much HXT is needed to obtain its benefits?

In studies in humans, the above benefits were observed with an HXT intake ranging from 7 to 15 mg/day. In terms of EVOO, this translates to a daily consumption of about 25 to 50 ml of high-phenolic olive oil, or ~2 to 3 tablespoons. Table olives—regardless of their color or brining—also provide an excellent source of HXT.

What’s next for HXT?

This body of promising evidence has intensified interest in the development of HXT-enriched foods and other ways of delivering this health-promoting compound. HXT is highly bioavailable, which means that, after it is consumed and digested, it is readily absorbed and transported by the body. So, for now—perhaps for always—the most effective, efficient, and delicious way to obtain the neuroprotective benefits of HXT is “food-first,” via high-phenolic EVOO.

Reference: Martínez-Zamora Z. Foods 2025;14(21):3624.

Olive Oil Hunter News #208

Avocado Tuna Salad Recipe, Spotlight on Canned Tuna, Safer Avocado Slicing, HDL Cholesterol and Brain Health, and Moderate Exercise and Appetite

Move over avocado toast—avocado tuna salad is the new must-have dish. My recipe incorporates olive oil and cannellini beans for even more toothsome goodness. In fact, it’s loaded with ingredients that help boost good HDL cholesterol, which has many health benefits. For one, HDL may protect the brain’s gray matter, according to new research done at UT Southwestern Medical Center. I’m also sharing a finding from Murdoch University in Australia that moderate-intensity exercise may help decrease appetite in people trying to lose weight.

Avocado Tuna Salad

  • Tuna avocado salad Avocado Tuna Salad

    This twist on tuna salad forgoes mayo for creamy, nutrient-dense avocado (the avocado should be ripe but still somewhat firm). This recipe is also great made with grilled tuna—the next time a fillet is on the dinner menu, consider making a little extra to enjoy this dish for lunch the next day.

    Ingredients

    • 3 tablespoons extra virgin olive oil, plus more for drizzling
    • 1 tablespoon fresh lime juice
    • 1 tablespoon chopped fresh flat-leaf parsley
    • 1/4 teaspoon fine sea salt 
    • 1/2 teaspoon freshly ground black pepper
    • 1 Hass avocado, cut into chunks
    • One 5-ounce can chunk light tuna, drained and flaked, or the equivalent amount of grilled tuna 
    • 1 cup cherry tomatoes, halved
    • 3/4 cup canned cannellini beans, rinsed and drained
    • 2 tablespoons minced red onion
    • 4 cups mixed spring greens, arugula, and/or baby spinach

    Directions

    Step 1

    In a large bowl, whisk the olive oil and lime juice. Whisk in the parsley, salt, and pepper. Place half the avocado chunks in the bowl and mash them into the dressing. Gently fold in the rest of the chunks, the tuna, tomatoes, beans, and red onion. 

    Step 2

    Divide the greens between two bowls and top with equal amounts of the tuna and drizzles of olive oil.

    Yields 2 servings

Healthy Ingredient Spotlight: Update on Tuna

Healthy Ingredient Spotlight

Update on Tuna

Canned tuna

Because of its availability and low price, canned tuna is the most consumed fish in the US. But recent recalls (due to defects in the cans themselves) and concern over mercury levels in fish may have you wondering how safe it is to eat tuna and how often.

The type of tuna matters. When Consumer Reports (CR) analyzed popular brands, their scientists found that chunk light and skipjack tuna have roughly a third of the mercury found in albacore, with some even greater variations by brand. Bumble Bee, Chicken of the Sea, StarKist, and Safe Catch Wild Elite had the lowest amounts of mercury and were deemed safe to eat up to three times a week, compared with albacore that on average should be limited to once a week. 

Where the tuna was caught matters too. CR reported that “experts who study mercury contamination in fish have found that levels of it in different oceans appear to be linked to different practices and policies in the nations nearby. For instance, mercury contamination in tuna caught in the Pacific Ocean is on the rise, but levels are dropping in tuna from the Atlantic Ocean,” said Nicholas Fisher, PhD, a distinguished professor in the School of Marine and Atmospheric Sciences at Stony Brook University in New York. ​​“In China and India, they burn a lot of coal for electricity, and when you burn coal, you release a lot of mercury into the air, which eventually rains down; so mercury levels have been increasing somewhat in the Pacific,” Dr. Fisher added. “Whereas in the Atlantic, we’ve shown that the levels have declined a little bit, primarily because of efforts made in North America … to sort of scrub the mercury from coal-fired plants in the US and Canada.” 

Quick Kitchen Nugget: Safer Avocado Slicing

Quick Kitchen Nugget

Safer Avocado Slicing

You’ve probably seen chefs on TV piercing an avocado pit with the tip of a knife and then twisting it out. As impressive as this maneuver might look, it’s extremely dangerous, for fingers and the palm of your hand. According to a study published in The American Journal of Emergency Medicine, there were an estimated 50,413 avocado-related knife injuries from 1998 to 2017 in the US. An analysis of data from the US Consumer Product Safety Commission found there are roughly 24 avocado-related hospital visits per day!

There’s even a name for this common injury: avocado hand. It happens when the knife slices through the fleshy part of the avocado and into your hand or fingers. This can lead to tendon, nerve, blood vessel, or muscle injury that could permanently affect the ability to use your hand. According to experts at University of Utah Health, here’s the right way to cut an avocado and remove the pit: 

  • Choose a ripe avocado and place it on a cutting board.
  • Use a butter knife and cut it in half lengthwise.
  • Twist the avocado to pull apart the halves.
  • Remove the pit by putting your index and middle finger between the pit and flesh and placing your thumb on the back to push and pop out the pit.
  • Remove the flesh from the skin with a spoon.
For Your Best Health: HDL Cholesterol and Brain Health 

For Your Best Health

HDL Cholesterol and Brain Health 

High-density lipoprotein (HDL), or good cholesterol, may play a vital role in conserving healthy brain matter in middle-aged adults, according to the first study to investigate a potential link between HDL function and brain volume. The research was done at UT Southwestern Medical Center and published in the Journal of Clinical Medicine. 

“Our study has identified a novel role of HDL cholesterol function in maintaining gray matter volume in the brain, which is important for cognitive function in middle-aged adults,” said the study’s first author, John Giacona, PhD, assistant professor of applied clinical research and internal medicine in the School of Health Professions at UT Southwestern.

The research involved 1,826 participants between the ages of 35 and 70 enrolled in the multiethnic, population-based Dallas Heart Study, a longitudinal study now in its 25th year. First, fasting lipoprotein concentrations were assessed using nuclear magnetic resonance. Participants were then tested for cognitive function, and their brain matter volume was measured using brain magnetic resonance imaging. Initial assessments took place between 2000 and 2002, and participants were reassessed between 2007 and 2009.

Professor of internal medicine in the division of cardiology Anand Rohatgi, MD, and his team at UTSW’s Clinical Heart and Vascular Center measured HDL function in this study. Their findings revealed that higher concentrations of small-particle HDL—but not larger particles or total HDL concentration—were linked with greater gray matter volume and higher cognitive capacity.

Foods rich with omega-3 fatty acids

“Previous research has shown conflicting evidence regarding the concentration of HDL cholesterol in development of dementia or brain atrophy,” said senior author Wanpen Vongpatanasin, MD, professor of internal medicine and director of the hypertension section in the division of cardiology at UTSW. “However, the concentration of HDL cholesterol may not reflect their function.”

HDL decreases the amount of low-density lipoprotein LDL, or bad cholesterol, in blood vessels by transporting the excess to the liver, where it gets broken down. “In addition, HDL particles exist in many sizes, which may be linked to their function,” Dr. Vongpatanasin said. “We now need to understand exactly how the small HDL particle, which can cross the blood-brain barrier, may have a beneficial role in maintaining brain health.” 

This finding led the researchers to note that HDL cholesterol function or levels of small HDL particles may be used as markers for a population at risk of developing cognitive decline, though additional studies would be required to confirm the connection. 

According to the UMass Chan Medical School Center for Applied Nutrition, to increase your HDL you should increase the amount of physical activity you do, lose weight if needed, quit smoking if you smoke, and aim to increase omega-3 fatty acids in your diet with foods like fatty fish (such as light tuna, salmon, trout, and sardines), freshly ground flaxseed, walnuts, and dark, leafy greens. 

Fitness Flash: Moderate Exercise and Appetite

Fitness Flash

Moderate Exercise and Appetite

A recent study from researchers at the Murdoch University Health Futures Institute in Australia found that moderate-intensity exercise can significantly influence appetite-related hormones and perceptions in obese men. It provides new insights into how exercise can aid appetite control and weight management.

According to one of the study authors, Timothy Fairchild, PhD, associate professor at Murdoch’s School of Allied Health, the study confirms their previous work showing the benefits of incorporating regular exercise into daily routines for individuals looking to manage their weight and improve their overall health.

“People understand that exercise helps burn energy. A lot of people assume that exercise also increases hunger and energy intake afterwards,” said Dr. Fairchild. “We have previously shown, using high-intensity exercise, that this is not the case. This latest study shows that even moderate-intensity exercise can have immediate and beneficial effects on appetite control in males with obesity.”

The study not only assessed food intake and appetite but also measured changes in hormones, which help regulate appetite. “Despite a strong focus on weight loss drugs in society at present, this study shows that lifestyle factors still have a strong and relevant role in helping people to live their healthiest life,” Dr. Fairchild added. “In fact, the hormones which have been shown to increase after exercise are the same hormones which the most successful weight loss drugs are mimicking. The added benefit of exercise is that you also receive the physical and mental health benefits of exercise.”

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Eating a Mediterranean-Style Diet Improved Brain Health in US Hispanic and Latino Adults

Background: Cognitive decline—worsening memory and more frequent memory loss or confusion—affects 10% of all US adults aged 45 and older. Incidence is higher—11.4%—among Hispanic and Latino Americans. In some cases, cognitive decline may be an early sign of dementia.

Close adherence to the Mediterranean diet (MeDi) is associated with a reduced risk of dementia and cognitive decline. The MeDi emphasizes fresh fruits, vegetables, whole grains, beans, legumes, nuts, low to moderate amounts of dairy, eggs, fish, and poultry, and olive oil as the primary fat source.

Researchers have attributed the MeDi’s brain benefits to its cardiovascular effects, such as lower blood pressure, reduced diabetes risk, and improvements in blood vessel function and cholesterol levels. The first large-scale study of the MeDi in Hispanic and Latino Americans investigated whether the MeDi’s brain benefits are independent of its cardiovascular effects.

Preliminary findings from this 10-year study of 2,774 participants (44% men, 56% women; average age 64 at follow-up) were presented at the recent conference of the American Stroke Association, February 5–7, 2025.

Methods: At an initial visit, each participant reported their food intake during the previous 24 hours and received a score (0 to 9), indicating how closely their diet corresponded to the MeDi. Average MeDi score was 5. Ten years after the baseline visit, investigators obtained a brain scan via MRI (magnetic resonance imaging) for each participant.

The main outcome evaluated in the study was white matter integrity (WMI) and volume. The white matter of the brain (as opposed to the gray matter) consists of bundles of nerve fibers that, crucially, communicate information to different parts of the brain. WMI and volume are markers of the strength of those connections in the brain. MRI scans provide clear, detailed cross-sections of the brain, showing white matter and gray matter.

To account for the impact of cardiovascular benefits, the study also asked participants about multiple practices associated with heart health: regular exercise; healthy diet; not smoking; weight maintenance; and maintaining healthy blood pressure, blood sugar, and cholesterol levels.

Results: Participants with higher MeDi scores had stronger connections between regions of the brain (preserved WMI) compared to those with lower MeDi scores. With each point higher in MeDi score, participants’ MRI scans also showed less structural damage to the blood vessels of the brain. After factoring in heart-health practices, the researchers determined that cardiovascular effects alone did not account for all the significant brain benefits of the MeDi.

Conclusion: Eating a Mediterranean-style diet improved brain health and preserved structural integrity in a high-risk population. Even small adjustments in food intake, closer to the MeDi, could help protect against cognitive decline and dementia. The brain benefits of the MeDi extend beyond its well-known cardiovascular effects—more research is needed to identify the brain-protective mechanisms involved.

References: 1. Trifan G, Moustafa B, Issan C, et al. Stroke. 2025(56);Supp 1:Abstract 100. 2. Mediterranean-style diet linked to better brain health in older Hispanic and Latino Adults. February 5, 2025. 3. Wooten KG, McGuire LC, Olivari BS, et al. MMWR Morb Mortal Wkly Rep. 2023;72:249–255.