Melatonin and kids; genetics and childhood cancer; healthier mac and cheese; reducing anxiety: Upstate Medical University's HealthLink on Air for Sunday, July 31, 2022

Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," the poison center's medical director addresses the huge rise in cases of children ingesting melatonin.

Vincent Calleo, MD: ... Melatonin certainly is used in the pediatric population, but normally that's done under the guidance of a pediatrician or a family medicine doctor who's helping to take care of the patients. ...

Host Amber Smith: A pediatric oncologist talks about the role of genetics in children's cancers.

Gloria Kennedy, MD: ... Most of the things that we think of as genetic cancers are an inherited predisposition, so an inherited, increased risk that still then would require an additional factor to turn it on and to actually cause the cancer to happen. ...

Host Amber Smith: And a registered dietician nutritionist shares a healthy recipe for macaroni and cheese.

All that, and a visit from The Healing Muse, right after the news.

This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith. On this week's show, we'll explore the role genetics plays in childhood cancer. Then, a dietitian walks us through a nutritious recipe for macaroni and cheese. But first, why are so many children ingesting melatonin?

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." Melatonin is a hormone produced in our brains in response to darkness, and it helps with the timing of our circadian rhythms and sleep. Synthetic melatonin is also available as a dietary supplement, sold over the counter, and it's popular with people seeking sleep aids.

But recently there's a concern about the use of melatonin in children. Here to explain is Dr. Vincent Calleo. He's the medical director of the Upstate New York Poison Center. Welcome back to "HealthLink on Air," Dr. Calleo.

Vincent Calleo, MD: Thanks, Amber. It's great to be back

Host Amber Smith: A report from the Centers for Disease Control and Prevention noted more than a 500% increase in the number of pediatric ingestions of melatonin over 10 years, from 2012 to 2021.

And it said the increase was primarily because of an increase in unintentional melatonin ingestions in children under age 5, and I wonder, have you seen the same trend at the Upstate New York Poison Center?

Vincent Calleo, MD: We have been seeing a significant increase in the number of unintentional pediatric exposures to a number of different medications and substances.

But one of the ones that we have seen a pretty large increase in is the unintentional ingestion of melatonin in the children that fall into that age range. Now, if I'm taking a look at the exact percentages, I don't know if the ones that we've seen at the Upstate New York Poison Center have been quite as large as a 530-and-some-odd percent increase over the last several years, but that number certainly has gone up quite a bit.

Host Amber Smith: Why is there such an increase, then? Because I know there's an increase in the use of melatonin overall. Is it just that there's more of it out there in homes?

Vincent Calleo, MD: I don't know the exact answer to that question because I think there are probably a bunch of answers, but much like you alluded to, I think that one of the biggest reasons that there may be an increased number of exposures is simply because there's more of it around, right? It's just a law of statistics. The more that there is something around, the more likely it is that it could potentially be ingested by a small child.

And the other thing too, that I think people always need to remember, is that there are a lot of different formulations of melatonin out there. And some of them actually look like gummies. And for that reason, a lot of times children are more likely to seek something that looks like a common treat that they may have.

Host Amber Smith: So some of these are accidental. Are you seeing intentional ingestion of melatonin? Are parents giving younger kids, under age 5, melatonin to help them sleep?

Vincent Calleo, MD: We definitely do get calls, occasionally, when parents will give some of the medication to their children to help them sleep, if maybe they're concerned a child may have ingested an extra one. And I think melatonin certainly is used in the pediatric population, but normally that's done under the guidance of a pediatrician or a family medicine doctor who's helping to take care of the patients. Now, I can't say for sure that there aren't cases out there where parents are giving children melatonin without being told by their physician. But I think for the most part, most parents tend to err on the side of caution and at least ask a pediatrician or their family medicine provider, whether it's safe to give this medication to a child.

Host Amber Smith: Now I understand it's a small number, but some children who ingested melatonin required hospital intensive care. And some even died. What were the symptoms that they were in need of medical care? How would a parent recognize a bad reaction?

Vincent Calleo, MD: So when we start to think about that report that came out not too long ago, it was nice in that it looked at thousands and thousands of cases over the course of about nine to 10 years. And so I think from that end, we have a large number that we draw from, but, amber, much like you already spoke to, there were a few cases, sadly, of children that required some intensive hospitalization and a couple that even resulted in death.

Now, the problem with the study that was done is that it doesn't actually have the ability to take a look at the individual case reports for the children that had those more serious outcomes. So I really applaud the authors who put in a lot of work in order to get this data and, through no fault of their own, unfortunately, it sounds like it was a little bit unrealistic for them to get the exact case reports that take a look at the data as to, say, what may have caused the child to have a bad outcome, whether it was just the melatonin or whether the child may have been otherwise sick before that or had other medical problems that may have significantly led to their poor outcome.

In terms of answering your other question -- what can families watch out for? -- one of the things that melatonin can typically do is cause children to get more sleepy than normal. So if you start to see a child have a significant change in their mental status, where they're acting much different than normal, if you see the child, and it looks like they're having a harder time breathing or not breathing as much as they normally do, those are some of the more worrisome signs, and if families are ever concerned, I do urge them to seek immediate medical attention.

Host Amber Smith: I thought melatonin was considered safe for most people, especially if it's short-term use. But technically it's not a medication, so the FDA (Food and Drug Administration) doesn't have the same oversight that it would over, like, aspirin, right?

Vincent Calleo, MD: That's correct. So melatonin right now is considered to be a supplement, and as a supplement, the FDA doesn't have that same degree of, regulatory oversight that we see with other medications that are FDA approved. Overall, I think melatonin is a very safe medication, and we get many, many, many calls to the poison center every year for ingestions of only melatonin.

And in addition to that, melatonin along with other substances, and the vast majority of the time, people do tend to do pretty well with melatonin. So it is overall, I think, a relatively safe medication, but much like with any substance, including even things like water, too much of a good thing can result in something bad, right?

You know, in toxicology, one of the mantras that we live by is "the dose makes the poison." So if you take enough of anything, there's a chance that it could cause toxicity or significant harm. So normally though, in a therapeutic setting or one where it's taken at the recommended dose, normally it does tend to be a pretty safe medicine.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Dr. Vincent Calleo. He's the medical director for the Upstate New York Poison Center. And just a reminder that you can reach the poison center 24 hours a day at 800-222-1222.

Now, back to melatonin. Can you describe for me how melatonin works in the body? What does it do that helps us sleep?

Vincent Calleo, MD: Without getting, really technical with it, essentially, the way that melatonin works is your body naturally makes melatonin, and that does help to regulate your circadian rhythm and your sleep cycles. One of the reasons why we think that giving exogenous melatonin, or melatonin that you take by mouth, as a supplement is that if your body is running a little bit low in that hormone, taking extra melatonin may help to regulate that amount and raise it a little bit.

And by doing so may help to reestablish your ability to fall asleep a little bit more naturally and get into that induced sleep state. So that's the long and short of it. Unlike a lot of different medications that can affect your sleep cycle and develop some dependence, we don't think that, for the most part, the majority of people that take melatonin end up developing a dependence to it, just because of the way that it works a little bit differently than something like a benzodiazepine or some other medicines that people take more regularly. In fact, one of the things that melatonin is frequently touted as is a non-habit-forming sleep aid. And so by hopefully replacing the amount of melatonin in the body, you may be able to help regulate your circadian rhythm a little bit more.

And for that reason, it can help you to establish a better sleep pattern.

Host Amber Smith: So it might help you fall asleep. Does it help you stay asleep?

Vincent Calleo, MD: To be quite honest with you, Amber, I think it probably depends a little bit on the individual person. I think that there's a chance that it may help you to stay asleep some, but when I really start to think about it, the primary thing that I think about is helping to regulate getting you into a more healthy sleep cycle and help induce sleep a little bit more than staying asleep once you've already fallen asleep.

Host Amber Smith: What are the expected side effects? Does it make you feel drowsy, or is there a sensation that people will get from taking it?

Vincent Calleo, MD: Usually what'll happen is people will oftentimes describe feeling a little bit more relaxed in a wakeful state. And in theory, that's really what oftentimes helps people actually fall asleep from there.

When you start to think about taking too much of it, people will describe feeling maybe a little bit lightheaded or a little bit dizzy. They may feel a little bit drowsy, which, again, is not unexpected. When you start to think about some of the more severe side effects for taking far too much, sometimes you can see some more severe effects, like slurred speech, ataxia or, kind of walking around and bumping into things or having a decrease in your coordination. And some people have even described having hallucinations at larger amounts. Now, again, I think the number of people that have those more severe side effects are very, very low compared to the number of people that take the supplement. But at the same time, those are things that have been reported in the (medical) literature.

Host Amber Smith: Is it meant to be taken every day or every night, like a vitamin, or do you just take it if you're having trouble getting to sleep and you need some help sporadically?

Vincent Calleo, MD: I think that really depends on the individual person, and both for pediatric patients and for adults that take melatonin, I always recommend talking with your primary care provider in trying to establish a good trend, in order to help establish a better sleep cycle. Sleep is an incredibly complex field of study that, in all honesty, I don't think anyone has a great understanding of. There are some people that spend their entire career studying sleep and sleep cycles, and they still don't have all the answers.

So to go back to your original question, Amber, as to whether it's meant to be taken regularly or just on occasion, I think that really depends on the individual, and I would strongly encourage them to talk with their health care provider in order to help establish not just a safe, and effective treatment regimen with melatonin, but sometimes, and oftentimes even more importantly, establishing good sleep or healthy habits that can really help to optimize the ability to fall asleep without using any sort of medication and to help with that, too.

Host Amber Smith: Does melatonin interact with certain medications? Are there things, if you're taking them as a prescription, that you shouldn't take (with) melatonin?

Vincent Calleo, MD: I'm sure there are things out there that melatonin can interact with. And I would always recommend, particularly for elderly individuals or people who take other medications for things like anxiety or depression or for sleep, I would always recommend taking that at the recommendation of your primary care provider because I'm sure there probably are some medications where it could interact a little bit more strongly. When I start to think about the relative degree when I consider all the medications out there, it's not one of the ones that's higher on my list that I think has a high degree of very significant interactions with other medications.

But with that being said, always talking with your primary care provider, when you're thinking about whether you want to use this and looking at your medication list can help to decrease the likelihood of having a bad reaction or some sort of medication interaction between that and another substance.

Host Amber Smith: We started out talking about the use in children, particularly young children, under age 5, and, you talked about the importance of speaking with your pediatrician first. Are there special concerns about the use in senior citizens, older people?

Vincent Calleo, MD: When I look at age in the relative spectrum of caring for patients, I really think there are two different extremes.

On the one hand you have the young, pediatric patients. And on the other hand, you have the elderly, geriatric patients, both of whom tend to fall into slightly more unique categories than the majority of people that we think of as the traditional teenagers or early to mid-adulthood age ranges. So as the body starts to age, the way that different enzymes work does start to change, particularly as we're thinking about the way that the liver works, the way that the kidneys work and a number of different other functions in the body. Those things do change as people age.

So to answer your question as to whether we get a little bit more concerned regarding use in elderly patients, I'd say the answer is certainly yes. For one thing, like we just talked about before, there is always a potential for there to be a medication interaction with another substance. And as people age, the likelihood of them being on additional medications does go up pretty significantly. So I always worry that if we're adding in too many things, you end up to have that proverbial too many cooks in the kitchen type thing going on, where if you have extra medications that are being added in, sometimes it does get a little bit tricky to know exactly how each one is going to interact.

It's hard enough to sometimes figure out how two medicines will interact. And then when you go ahead and you have nine or 10, it makes it a lot more challenging. So, much like for the pediatric patients that we discussed earlier, I would say for anyone who's a geriatric patient in particular, they should be making sure they're speaking with their primary care provider or their geriatrician in order to help make sure that the medicine they're taking is not going to have an interaction with melatonin, should they choose to try and take it.

Host Amber Smith: What sorts of questions does the poison center get from callers about melatonin? Do you ever hear from people with questions?

Vincent Calleo, MD: Yeah, we certainly do. And one of the more common things that we see is in the pediatric patient population. Much like we talked about earlier in the interview, frequently families will call and say, "My child got into the melatonin gummies and took two or three extras. Is it going to be safe for my child to stay at home, or do they have to go to the emergency department?"

Now, in the majority of cases, most children are going to do pretty well at home, provided they don't take other medications and that they didn't get into any other substances and they're otherwise pretty healthy.

Every case we consider on an individual basis, so it's hard to make a blanket statement as to whether it's safe for any child to stay home under any circumstance after taking melatonin. But I'd say the majority of calls we get for home medication exposures to things like melatonin with young pediatric patients, we're normally able to keep them at home if the situation is appropriate.

And fortunately, we have a highly trained staff of specialists in poison information who've been trained for a long period of time as to how to "risk stratify" who's going to be safe to stay home and who needs to seek immediate medical attention.

So that's really, I think, probably the most common thing that we see, are the calls to the poison center regarding accidental exposures to home doses of melatonin from pediatric populations.

Host Amber Smith: Well, Dr. Calleo, I thank you for making time for this interview.

Vincent Calleo, MD: It's my pleasure. And Amber, if anyone ever has any questions for us, I always remind folks that we can be reached at the poison center toll free at that 1-800-222-1222 number, and we're there 24/7, 365 (days a year). We're safe. We're fast. We're confidential. And we strongly encourage anyone to call with any questions or concerns they may have.

Host Amber Smith: My guest has been Dr. Vincent Calleo. He's the medical director of the Upstate New York Poison Center. I'm Amber Smith for Upstate's "HealthLink on Air."

Should we test the genes of adults who survived childhood cancer? -- Next, on Upstate's "HealthLink on Air."

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

As scientists continue to make discoveries about genetic causes of cancer, genetic testing is being used for medical care more frequently. Today, I'm talking about this trend with a pediatric oncologist from Upstate. Dr. Gloria Kennedy is an assistant professor of pediatrics. Welcome to "HealthLink on Air," Dr. Kennedy.

Gloria Kennedy, MD: Well, thanks for inviting me, Amber.

Host Amber Smith: Now, a lot of progress has been made in cancer treatment for children just during your career, but cancer still remains the second leading cause of death after accidents in children ages 1 to 14. How much have the overall survival rates for childhood cancers improved in the last few decades?

Gloria Kennedy, MD: When I started, in the early '90s, the overall survival rate for pediatric cancers was about 70%. And now it's up to 85%.

Host Amber Smith: So that's significant.

Gloria Kennedy, MD: Yeah, I think it's a significant improvement. We've seen bigger strides in certain conditions than others, but, in general, everything has gone up a little bit.

Host Amber Smith: Now of the childhood cancers, how many of them have a genetic cause?

Gloria Kennedy, MD: There are some pediatric cancers that we know have specific genetic causes, but those tend to be few in number. An example would be retinoblastoma, which is a tumor of the back of the eye that's usually seen in very young children. We know that this runs in families and is associated with the RB1 gene, especially if it's related to multiple lesions or lesions in both eyes, then it is usually genetically caused. But for most things, we don't have a clear genetic cause of childhood cancers.

Host Amber Smith: The ones that are related to a gene, some of those are inherited from the family, the mother and the father, but some of them are acquired mutations that just spontaneously develop?

Is that right?

Gloria Kennedy, MD: Yes. All cancer would be from a mutation. So something has to affect the cell of origin to turn it from a normal, healthy cell into a cell that continues to grow out of control and becomes a tumor and a cancer. Sometimes there are inherited things that can make you more at risk for an additional hit, if you will, that then transforms that cell. In fact, most of the things that we think of as genetic cancers are an inherited predisposition, so an inherited, increased risk that still then would require an additional factor to turn it on and to actually cause the cancer to happen.

Host Amber Smith: And I realize we're talking about a subset of children who develop a childhood cancer, but in that subset, do parents or doctors typically know that a child has a genetic mutation that increases their risk of cancer before they're diagnosed with it?

Gloria Kennedy, MD: It depends on the family, so in some families, if the cancer has happened previously, then they might have been diagnosed. Say, for instance, retinoblastoma, that I mentioned before: There are families that know they carry that gene, and if so, the child, as soon as they're born, really can start having eye exams and monitoring for that.

In other situations, not necessarily inherited, but the child could be born with a condition that puts them at increased risk for developing a cancer. For example, neurofibromatosis Type 1, or a kind of overgrowth syndrome called Beckwith-Wiedemann syndrome, or even Down syndrome can cause an increased risk for a childhood cancer.

So those kinds of things would be known to the pediatrician, and they could inform the parent and at least be monitoring for them. Whether or not you do more intensive screening really depends on the specific condition.

Host Amber Smith: Currently when a baby is found to have cancer, is genetic testing a standard recommendation for the baby or for the siblings or the parents in that family?

Gloria Kennedy, MD: Yes and no. There's two types of genetic testing that we can talk about. One would be somatic testing. So that's genetic testing on the tumor itself, or in case of leukemia, on the leukemic cells, and that is always done. It's done to confirm diagnoses, it's done to guide us with treatment -- in some form or another, we do genetic testing on the cancer.

But in terms of an inherited risk, that comes from the germline testing, so that would come from genetic testing on the patient's healthy cells, and that's not so standard that we do that all the time. It depends on if there's a strong family history of cancer or the specific type of tumor that the child has, whether or not we would do that germline testing.

Host Amber Smith: But the test on the tumor or the cancer cells themselves -- that will tell you as the physician, a lot of information that will guide how you recommend to treat the child, right?

Gloria Kennedy, MD: Yes, definitely.

Host Amber Smith: Is genetic testing advised for siblings? If you have a baby that has an inherited cancer, and I recognize those are rare, but if you do find that, does that child's sibling need to be tested as well or looked at to see whether they're at an increased risk?

Gloria Kennedy, MD: That's an interesting question. We've always kind of known that because some cancers, even if it's a small number, run in families, that siblings probably have about seven times the risk of the general pediatric population of developing a malignancy, but even seven times a very small number is still going to be a very small number.

So it's not something that we have routinely done, but again, I think in most of the situations, the most appropriate thing as we do get better and more consistent about doing germline genetic testing is to test the patient. And then if we have a positive, then we can do what they call cascade, or downstream, testing on their brothers and sisters, their parents, other family members as appropriate.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Dr. Gloria Kennedy. She's a pediatric oncologist at Upstate.

A study funded by the National Institutes of Health recently suggested that the genetic testing of the siblings of newborns who are found to have mutations in any one of 11 genes, that are most commonly associated with childhood-onset cancers, could reduce deaths from these rare cancers by about 50%. So I know we're still talking about small numbers here, but do you think testing for these 11 specific mutations would be a good idea? Just routinely?

Gloria Kennedy, MD: This NIH paper wasn't really a study. It was a modeling, so they did this very sophisticated computer modeling, saying, "What if ... ?" "What if we added these 11 cancer predisposition genes to our newborn screening that's done for some genetic conditions already?" If we added that on to the panel and their numbers calculating that they would screen 3.7 million newborns to save the lives, basically, of 15 siblings, it was very interesting how they did that.

They calculated a risk-benefit ratio using the cost of cancer care and the cost of this genetic testing added onto the newborn screen and said that it was financially a good move to do this. But they didn't really calculate into this other costs, the costs of stress on the families, of having this diagnosis, and then, the costs of taking time off from work and doing all this surveillance screening on the siblings for the potential of a cancer developing.

Because, like I said, having the gene, it's not a one-to-one correlation. It's not like having the gene for sickle cell disease and knowing that you're going to have sickle cell disease. Having this genetic cancer predisposition is not the same as having it cause a cancer. And so there's a lot of worry screening, other things that would be inflicted on these families that I think is very hard to quantitate and without any definite medical benefit. To each particular family, it's hard to impose that on them. There's already just a whole ethical conundrum about doing genetic testing on children under 18 and their parents deciding for them about having that information, and so this is like taking that out to the nth degree.

Host Amber Smith: Do you think there'd be any value in testing the genes of adults who survived childhood cancer, now that genetic testing is more readily available? Would that be of any use?

Gloria Kennedy, MD: Yes, definitely. And we are offering this to our survivors. We've always known that they were at increased risk for a number of different things. Being a survivor is by no means saying that these kids are out of the woods. They're close enough to the edge that they can see the sun, but they're still in the woods. So when they finish treatment, we're surveilling them to make sure that the disease is not going to come back.

And then when we get past the time that we're worried about recurrence, we're still very focused on following them up to look at late effects, and a second malignancy is often one of the late effects that we're looking for. And these can be caused by the treatment that the children have to cure them, and it could be a second primary malignancy caused by whatever underlying conditions, whether it be genetic or lifestyle, that triggered their first cancer could cause the second cancer.

So, definitely, if we had more genetic information on our survivors, we could narrow that down and know specifically what things we need to worry about, based on whatever, if they have a genetic mutation. But for all of them, we're very focused on trying to improve their lifestyle choices, things that can help to protect them from cancer in general: diet, exercise, not smoking, using sunscreen, all of those things.

Host Amber Smith: So if someone survived cancer as a child or a young adult, how concerned should they be that their baby might develop cancer, either the same kind that they had or another one? Is that something that they need to be mindful of as they enter into parenthood?

Gloria Kennedy, MD: We used to tell survivors that there was no increased risk for their children, and a fairly large study did support this. But in reality, for each individual survivor, it really depends on whether that survivor did have a genetic predisposition that triggered their cancer in the first place, and therefore whether or not they could potentially pass it on to their child, so that's another reason to be testing the survivors, that then we could give them specific information for their situation, as opposed to just the statistics for survivors as a whole.

Host Amber Smith: Do people with a genetic predisposition to cancer, does that predispose them to some other, noncancerous diseases?

Gloria Kennedy, MD: Yes. So, depending on the particular gene mutation, they could have other tumors, non-malignant tumors, that they're at risk for and maybe ones that would require treatment, even though they're not cancer.

Host Amber Smith: In the next several years, as you look out toward the years ahead of you, what changes would you most likely expect to see regarding genetics and childhood cancer, or what would you hope for?

Gloria Kennedy, MD: Well, I think our understanding of cancer genetics is exploding right now, and the cost of even large genetic screening panels is coming down, and I think it's going to become more and more routine to do genetic testing, not only on all tumor types, but to also more frequently offer germline, or testing on the patient's healthy cells, to look for these inherited predispositions.

Host Amber Smith: Well, Dr. Kennedy, I really appreciate you making time for this interview.

Gloria Kennedy, MD: Thank you.

Host Amber Smith: My guest has been pediatric oncologist Dr. Gloria Kennedy. I'm Amber Smith for Upstate's "HealthLink on Air."

Next on Upstate's "HealthLink on Air" -- macaroni and cheese can be healthy.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." Nutrition is important all the time, but it can be especially challenging for someone who is in cancer treatment. So today I'm talking with Katie Krawczyk. She's the Upstate Cancer Center's registered dietician nutritionist, and she agreed to share a macaroni cheese recipe that's easy to prepare and maybe a little more nutritious than you might expect. Welcome back to "HealthLink on Air," Ms. Krawczyk.

Katie Krawczyk: Hi, Amber. Thanks for having me.

Host Amber Smith: Now today I wanted you to talk to us about one of the most popular comfort foods, macaroni and cheese. It's something people may crave, and you have some ideas for how to make a version that's more nutritious than opening up a box, but it's still pretty easy to prepare. I know you need three pans -- a pot for the pasta, a saucepan, and a sauté pan or deep skillet, right?

Katie Krawczyk: Yep, and then also a casserole dish to bake this in the oven.

Host Amber Smith: And a large bowl to mix everything?

Katie Krawczyk: Yep. And during the recipe, I can kind of shed light into ways to maybe cut down on those dishes as an option.

Host Amber Smith: Perfect. Let's start with a shopping list. What are the items that people need to have ready?

Katie Krawczyk: The first ingredient is a half a pound of pasta, preferably a whole-wheat pasta -- it's going to offer a little bit more fiber and texture to this dish. And you can use any shape. It can be the medium shells, a rotini, elbow or ziti.

The next ingredient is 4 tablespoons of butter,

1/4 cup of flour,

2 cups of milk.

Host Amber Smith: Let me ask you about the milk. Does it need to be cow's milk? Or can it be an alternative? And, does it matter the fat content? Does it need to be whole milk or low fat?

Katie Krawczyk: No, this is a very forgiving recipe. You do not need to use cow's milk. You can use any milk of your liking, could be almond or soy or any other lactose-free milk. Just make sure it's the unflavored. You don't want chocolate or vanilla in this dish, of course.

Host Amber Smith: All right. But you do have some spices in there?

Katie Krawczyk: Yes, you can use fresh or a dried grated nutmeg, 1/2 a teaspoon,

salt and pepper, just to taste, roughly a 1/2 a teaspoon of each,

Katie Krawczyk: 2 teaspoons of grated Parmesan cheese,

1/2 a tablespoon of olive oil,

half of a small cauliflower that should be chopped,

1 1/2 cups of fresh spinach.

Host Amber Smith: Now, let me ask you, on the spinach, baby spinach, regular, or does it matter?

Katie Krawczyk: Any type of spinach will work here. You can even use a frozen spinach.

Host Amber Smith: All right. And if you use regular spinach, do you need to cut off the stems?

Katie Krawczyk: Nope. Once those are sauteed, those get nice and soft, along with the leaves.

Host Amber Smith: And then there's got to be cheese in here, right?

Katie Krawczyk: Yep. Last but most important is half a cup of mozzarella cheese, shredded.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host Amber Smith. I'm talking with Katie Krawczyk. She's the registered dietitian nutritionist who works at the Upstate Cancer Center, and she's walking us through preparation of macaroni and cheese. Listeners can find this recipe connected to this interview on our website at upstate.edu/informed.

So for the directions, the pasta's supposed to cook in boiling water until it's barely al dente, meaning that it still has a bit of a bite. Do you get the water boiling and then add the pasta? Or can the pasta be in the pot as the water comes to a boil?

Katie Krawczyk: You want to get the water to a full boil before adding that pasta. And when we say al dente, usually the package will give you an estimated time frame for what that would be. So it'd be at the lower end of that cooking time.

Host Amber Smith: And what about, I know some people like to put salt in their boiling water. Does that do anything? Should you, or should you not do that?

Katie Krawczyk: You can add a little bit of salt here. There's room within the recipe to add it a little bit later and that's just to taste. Oftentimes I don't add salt at this time. I just cook the pasta within the water. But I know that's a little bit kind of procedurelike for some families to add it to their pasta while it cooks.

Host Amber Smith: Or oil? Will the pasta get sticky if you don't put oil in it?

Katie Krawczyk: Not at this time. Once it, when it's boiling, you don't have to add oil.

Host Amber Smith: All right. While that's boiling can you walk us through how to make the rest of the dish?

Katie Krawczyk: Sure. And don't forget, we're going to preheat our oven to 350 at this time.

And then, so while that pasta's cooking, in our other skillet, you're going to warm up the skillet, heat the olive oil. You're going to add some chopped cauliflower and sauté it until it's soft, which is going to take around 10 minutes. Just before that's soft and around that 10-minute mark, you want to add the spinach to that same skillet with the cauliflower, until it's wilted, which will happen pretty quickly, within two to three minutes.

And then, at this time, if you want to season it with that salt and pepper, you can do so.

Host Amber Smith: So, let me back up and ask you about the cauliflower, cutting it up. How small should the pieces be?

Katie Krawczyk: They should really be like bite-size pieces.

Host Amber Smith: OK. Do you melt this over medium or medium high? Where would you put the temperature?

Katie Krawczyk: Medium heat to sauté.

Host Amber Smith: OK. So that takes care of the vegetables. Do you add anything more to this pan or?

Katie Krawczyk: Nope, at this time, that's the only thing that will go in that pan.

Host Amber Smith: OK. So that's the vegetables. What about the sauce?

Katie Krawczyk: Now the cheese sauce ... again, I mentioned you can possibly cut down on a pot here. So at this time, your pasta's likely done cooking. So you can remove that from the pot, drain it in a colander, leave it in that colander, return that pot to the stove where we can make our cheese sauce, or also known as a roux.

Host Amber Smith: Okay. Let me ask you about the pasta one more thing: when you bring the pasta into the colander, does it need to be rinsed or cooled?

Katie Krawczyk: No, it does not. You can just drain and leave it there.

Host Amber Smith: OK. All right. So tell me more about this roux.

Katie Krawczyk: OK, the roux or the cheese sauce, we're going to start with that saucepan. We're going to melt butter, and then we're going to add some flour. And using a whisk, we're going to stir it into the butter for about one to two minutes, until the mixture turns to a very light golden brown. Then we're going to whisk in the milk, any milk of your choice, a little bit at a time, and the sauce will gradually start to thicken, and keep whisking until that milk has been all incorporated. This is over, still, that medium heat. And then we're going to reduce the heat and allow it to just simmer a little bit. You can stir throughout, gently, until that whole mixture is smooth and thick.

Host Amber Smith: So I get a little scared with cooking with milk, because it can burn pretty quickly on the stove top, right?

Katie Krawczyk: Yeah. So you do want to keep an eye on it. Pay attention and continue to kind of stir every minute or so throughout.

Host Amber Smith: And so it'll thicken naturally on its own?

Katie Krawczyk: Yeah. Thicken while stirring.

Host Amber Smith: OK. When do you add the spices?

Katie Krawczyk: Once that has thickened, you can add the nutmeg and the cheese.

Host Amber Smith: And just, as they say, fold in the cheese?

Katie Krawczyk: Yep. Continue to stir or fold in.

Host Amber Smith: Now does it stay on the same heat temperature, or do you move the pan off to the side?

Katie Krawczyk: You can keep it on the heat as we add that cooked pasta from your colander. Add that to your roux or cheese sauce. And then also add in your vegetables, the cauliflower, spinach and the rest of the cheese, if needed. Stir that up, and then you're going to pour that whole mixture into your casserole dish. And then that is going to go into the oven to bake for 20 to 25 minutes, or until that top is golden brown.

Host Amber Smith: So everything ultimately ends up in that one pan, and then you put it in the casserole dish?

Katie Krawczyk: Yes, exactly.

Host Amber Smith: Well, what does the cauliflower and the spinach do to the taste of the cheesy mac and cheese flavor? What does it do to that?

Katie Krawczyk: That's going to add a little bit of texture, a little bit of variety to what's coming in on that fork, which oftentimes patients are looking for something that just sounds a little bit different to them, to kind of spark their appetite. And again, it's adding a little bit extra fiber and a serving of vegetables for the day. So you're getting that combination of not only your cheese and shells, but also that crunch from the cauliflower and spinach.

Host Amber Smith: And I know we put in a cup and a half of spinach, seems like a huge amount, but it shrinks down considerably. So it is not going to overwhelm this casserole dish. It's still going to look like macaroni and cheese, right?

Katie Krawczyk: Right. That raw spinach can be kind of a big volume, but that cooks down to be very nicely incorporated.

Host Amber Smith: Now let me ask you on the casserole dish, does it need to be greased or olive-oiled before you put all of this in it?

Katie Krawczyk: Yeah, that will help with the washing afterward, to grease your casserole dish first, before adding in that full mixture.

Host Amber Smith: And then, do you need to cover it with foil while it's baking, or does it just go in the oven uncovered?

Katie Krawczyk: You don't need to cover it with foil. If you do notice while it's baking that it's turning too brown to your liking on the top, that cheese, you can cover it, but you shouldn't need to cover it.

Host Amber Smith: And how long does it bake for?

Katie Krawczyk: For about 20 to 25 minutes And again, just kind of watch that top. When it turns golden brown, that means it's good. You can remove it from the oven.

Host Amber Smith: So what do you like about this recipe, as a dietitian, for someone who's in cancer treatment?

Katie Krawczyk: I like that it adds, it kind of sneaks in that serving of vegetables. And it's something just a little bit different than your typical mac and cheese. It's a little bit more hearty, where it may give patients a little bit more, stimulate your appetite as something different to try.

Host Amber Smith: How does it work in terms of leftovers? Because if you have this huge casserole pan, can you have it for dinner and then have some for lunch the next day or two?

Katie Krawczyk: Absolutely. That's another good thing about this dish, is you put in the work once. You bake it. But it can be utilized for leftovers the next day, for lunch or dinner, just reheating in the microwave.

Host Amber Smith: Could it be prepped ahead of time or even baked ahead of time and then frozen so that you would have a casserole ready to thaw and cook later?

Katie Krawczyk: Yes. You can even take it step by step of doing some things ahead of time, such as boiling the pasta, and then putting that in the refrigerator with a little bit of olive oil so it doesn't stick. And you can saute the vegetables first, or you can even, there's an option to use frozen vegetables instead of fresh, where that would take away some of that cooking time. You can also steam or microwave the cauliflower first. That will allow the saute time to be cut in half. And then to freeze it, you can take them out, put the whole casserole in the freezer, or you can put it into individual portions and freeze it that way into Tupperware.

Host Amber Smith: And then you have it ready for when you need it.

Katie Krawczyk: Yep.

Host Amber Smith: This has been very nice of you to walk us through how to put this macaroni and cheese together, and I appreciate you making time for that.

Katie Krawczyk: I hope that patients will utilize this recipe and find it comforting. And it's generally accepted by the whole family. So not only patients maybe going through treatment, but it is a good dish for everybody.

Host Amber Smith: My guest has been registered dietitian nutritionist Katie Krawczyk from the Upstate Cancer Center. I'm Amber Smith for Upstate's "HealthLink on Air."

here's some expert advice from psychiatrist Dr. Nayla Khoury from Upstate Medical University. How can someone reduce anxiety?

Nayla Khoury, MD: I would say, first and foremost, checking the facts about what is making one feel anxious. Right now in this day and age, there are a lot of things to be anxious about: the pandemic, dual pandemics, war. But the question to really ask oneself in a moment of suffering with anxiety is, is this anxiety serving me right now? So worry has a purpose. It helps us to plan. It helps us to prevent. And, we want to be able to turn it off when we need to, to be able to sleep and enjoy ourselves and calm down and engage with our families.

So if it's the case that the anxiety's not serving you, then there's a number of things that one can do. You can use either your body, your mind or relationships and behaviors to reduce anxiety. In terms of the body, we can engage the parasympathetic nervous system, which is the hormone response in our body that is activated when we're calm and when we're doing things we enjoy. And so that can be activated by taking deep breaths, which sounds really simple and is not easy to do. Some people find yoga, or different types of exercise, helps them to access the breath, particularly the exhale, to be able to find a sense of calm. Some people find changing their behaviors. In this day and age, for many people being constantly on their phone, looking at the news, is a source of great anxiety. So even for myself, I have to remind myself to turn off, to unplug, that I don't need to be constantly checking every moment of the day.

Similarly, when certain things are making us anxious, if it's not something that in fact should make us anxious, then we want to try to approach that thing slowly and with support so it doesn't have as much threat. So while many people have restricted their life because of the pandemic, they may want to slowly begin to leave their house again and find ways where they can manage the risk, but also prove to themselves that the world is not a scary place, even though there are lots of scary things.

And then lastly, connecting with supportive relationships. So whether that be a friend, a colleague, a counselor, I would say if anxiety is overwhelming, if someone is feeling like they can't function or having thoughts of suicide, even, those are reasons to seek professional help for anxiety. So there's a lot we can do for ourselves. And it's also a great thing to ask for help when we need it.

Host Amber Smith: You've been listening to psychiatrist Dr. Nayla Khoury from Upstate Medical University.

And now, Deirdre Neilen, editor of Upstate's literary and visual arts journal, The Healing Muse, with this week's selection.

Deirdre Neilen, PhD: Jamie Wendt is an author of a poetry collection called "Fruit of the Earth." She gave us a beautiful portrait of a father-daughter relationship in her poem entitled "Fathers."

Father and daughter stitch their shoulders

together in the hospital room after

her mother/his wife escapes her body. How

does the lover's loss listen

to the 16-year-old's piercing silence?

They each break inside a future, without.

One of them places hands on knees,

bends a body, vomits into a bucket. One of them curls

fists, opens bluish lips as skin turns ashen, a rapid pulse. Life

is a conscious effort in a hospital room.

The daughter inhales antiseptic, the waxy polished floor,

yellow skin fainting to musty gray, tumor scented.

What do the eyes of a grown man

see at the loosening fatigue of his daughter?

Her wordless stare, her arms and legs collapsing

like an old, wild and silent tree.

Who is she?

Can he be a father alone? How does a man do that?

Children have lost fathers to wars. It is 1949.

His fingertips pace across the floral wallpaper.

Losing a devoted mother is a fairy tale,

a haunted, meat-infested forest

ripe and full of honeybees.

In a few years, she will marry

the young truant man who swing dances, tells embarrassing jokes.

Sitting at home at the curtained window, a father

digs a grave for the rest of his life.

Plans a wedding. Pays bills.

Keeps perfume bottles on his desk like gold.

Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York.

Next week on "HealthLink on Air," how checkpoint inhibitors are successfully fighting cancer.

If you missed any of today's show or for more information on a variety of health, science and medical topics, visit our website at healthlinkonair.org. Upstate's "HealthLink on Air" is produced by Jim Howe, with sound engineering by Stephen Shaw. This is your host, Amber Smith, thanking you for listening.