October 2020 Issue
Cannabis & CBD Edibles
By Janice Newell Bissex, MS, RDN, FAND
Today’s Dietitian
Vol. 22, No. 8, P. 48
This common mode of administration will give clients another option to help manage a variety of health conditions.
The legalization of medical cannabis in California in 1996 paved the way for more and more states to legalize cannabis for both medical and recreational adult use and cracked open the door for much-needed medical research. A survey found that 66% of Americans support the legalization of cannabis. Its medical use is now legal in 33 states, while adult recreational use is permitted in 14 states.1,2 The 2018 Farm Bill removed hemp from Schedule I status and legalized its growth and production, making the compound cannabidiol (CBD) widely available nationwide.1
Research has shown that cannabis and CBD may be helpful in managing a variety of conditions, including pain, depression, anxiety, inflammatory bowel disease, seizure disorders, insomnia, inflammation, and posttraumatic stress disorder.3,4 There are many different modes of administration, but not all delivery methods work equally well for all people and conditions.
The most common ways to use CBD and cannabis are oil tinctures placed under the tongue, softgels and edibles, topical creams applied to the skin, and inhalation via vape pen, pipe, or smoking a joint. Other delivery methods include transdermal patches applied to the wrist or ankles, water-soluble tinctures added to a beverage, and rectal and vaginal suppositories. Each form of delivery has varying times of onset, duration, and optimal therapeutic uses. This article will focus on cannabis and CBD edibles.
Rise in Popularity
Edibles, sometimes referred to as ingestibles, have become an increasingly popular method of cannabis and CBD consumption. People who are interested in exploring the therapeutic benefits of cannabis may be averse to smoking but willing to try gummies, brownies, or a pill instead. The largest growing market for cannabis products consists of baby boomers and older adults, so it isn’t surprising that edibles, such as gummies and softgels, have gained popularity. Edibles are discreet and inconspicuous, with no associated smell or smoke, and don’t require any additional equipment.
The sales numbers are telling, with the percentage of cannabis sales from edibles growing from 2.5% in 2016 to 13.7% in 2018.5 There was an estimated $1 billion in edibles sales in 2017.6 With 12% of adults reporting using cannabis on a daily basis, these numbers are expected to climb. Edibles may be a particularly good choice for cancer patients, athletes, patients in palliative care, individuals with lung disease or asthma, elderly patients, those with gastrointestinal issues such as Crohn’s disease and ulcerative colitis, and individuals with chronic pain.
CBD and THC Edibles
Edibles are available with CBD, tetrahydrocannabinol (THC), or both. Which product or cannabinoid ratio to choose depends on the desired effect. There’s dramatic synergy among the cannabinoids, terpenes, and flavonoids in cannabis and hemp. Each individual component of the plant may provide therapeutic benefits on its own, but when combined together the so-called entourage or ensemble effect is dramatic. For this reason, it’s best to choose broad- or full-spectrum whole plant products vs isolates.
CBD is a compound (cannabinoid) found in cannabis and hemp plants. In recent years, CBD has gained popularity for its purported health benefits and therapeutic effects. Many people find that CBD helps manage pain, inflammation, anxiety, muscle spasms, insomnia, inflammatory bowel disease, irritable bowel syndrome, migraines, neurodegenerative disorders, and much more.
THC is another cannabinoid found in cannabis and hemp plants. It’s best known for its intoxicating effects—too much will get you “high” or “stoned”—but it has anti-inflammatory, antispasm, antinausea, analgesic, and bronchodilator effects. It also can help stimulate appetite and relax muscles.
Gummies have cornered the edibles market. In 2019, gummies accounted for 43% of sales within the cannabis edibles market, compared with chocolates at 12% and mints at 3%.7 Other types of edibles on the market today are raw honey, lollipops or hard candy, beverages, and baked goods, such as cookies, muffins, and brownies. Cookbooks are becoming increasingly popular as consumers start to experiment with different ways to cook and bake with cannabis.
Advantages and Disadvantages of Ingesting Cannabis
Cannabinoids (CBD and THC) that are consumed have a 6% to 10% bioavailability rate.8 Individual physiological factors, such as absorption, metabolism, and excretion rates, and rates of metabolism and excretion can affect the bioavailability of cannabinoids from person to person. Consuming an ingestible after a meal or with a food containing fat, such as nuts or avocado, will increase absorption and availability.
It’s important to note that edibles have a significantly delayed onset time vs smoking, ranging from 30 minutes to a few hours compared with just minutes after inhalation.9 This is because edibles must travel through the digestive tract and undergo first pass metabolism by the liver before reaching the bloodstream. The effects from an edible can last six to 12 hours (sometimes as long as 24 hours) compared with one to three hours with smoking. So edibles can be an advantage for people with chronic pain, as the therapeutic effect lasts longer with the slower onset time.
THC edibles may have a more intoxicating effect when compared with other methods of consumption. There are two reasons for this. First, liver metabolism results in some of the delta-9 THC being converted to the more potent 11-hydroxy THC. This form of THC crosses the blood-brain barrier more easily and results in an increase in intoxication.
Second, given the delayed onset time, individuals may get impatient when they don’t feel any effect and might be tempted to take an additional dose (or bite). Health professionals should caution against this, noting that if someone overingests, the high may become too strong later on to the point of being uncomfortable. It’s always best to wait two hours before taking another bite/dose of a THC-containing edible to first determine the impact of the initial dose.
Dosing and Safety Considerations
Dosing of edibles depends on the individual. Some people may find relief with just 1 to 2 mg of THC or CBD, while others may require 25 mg or more. Be mindful that THC edibles typically are sold in 10-mg doses at dispensaries. This is a high amount of THC for many people and wouldn’t be recommended for someone new to cannabis or for older adults.
Edibles affect everyone differently, based on several factors: the type and potency of the edible, individual tolerance and body chemistry, and what and how much was eaten before consuming.10 Up to 1 in 5 people may not respond at all to cannabis or CBD edibles due to genetic factors. In contrast, alcohol users may hyper-respond when ingesting edibles. First-time users should know the potency of the edible and experiment with a maximum starting dose of 2 to 5 mg THC (labeled when purchased from dispensaries). It’s generally recommended to start low and go slow to find the dose that works best.
Cannabis and Drug Interactions
Other safety considerations are drug interactions. The cytochrome P450 enzyme system in the liver metabolizes about one-half of all prescription medications. This enzyme also breaks down cannabis and CBD, so it’s possible that the blood levels of certain medications may be impacted by ingestibles.11 If a patient is taking a drug such as warfarin (Coumadin) or certain antiarrhythmics with a narrow therapeutic window, it’s best to proceed with caution when using edibles. A general guideline to follow: If grapefruit is contraindicated with a medication, there may be an issue of a drug interaction with ingested CBD or cannabis.12 In these cases, a topical that doesn’t typically enter the bloodstream or a tincture that’s absorbed directly into the blood without liver involvement may be better choices.
As always, it’s important for clients to inform their health care providers about any supplements or botanicals they may be taking, including CBD and cannabis.
Legal Issues
Clients also need to concern themselves with the legalities of cannabis and CBD edibles. CBD can be extracted from both hemp and cannabis; however, CBD products derived from cannabis remain federally illegal. In addition, the FDA hasn’t conferred Generally Recognized as Safe status to CBD and states that “it is currently illegal to put into interstate commerce a food to which CBD has been added.” Regulations are ever-changing and often vary state to state, so it’s best to check the FDA website for updated information.13
Culinary Considerations
Once clients have educated themselves about the legalities, dosing and safety considerations, and possible drug interactions regarding edibles, they also can consider cooking with cannabis as part of their wellness routine. When using a tincture, clients can add a few drops to their favorite foods and beverages (ie, salad dressings, smoothies, or baked goods). To reap the most therapeutic benefit, it’s important to be careful when applying heat. High heat (over 350˚ F) may result in the loss of terpenes, the aromatic compounds that work synergistically with cannabis to boost the therapeutic effects.
Home-grown cannabis or hemp can be used to make infused oil or butter for use in recipes. The dried flower must be decarboxylated (activated) first. This process naturally occurs when smoking or vaping cannabis. There are appliances on the market that also will decarboxylate cannabis flower and enable clients to make infused oils. The challenge clients will have when making their own infused oils is determining dosing.
Here’s one method clients can use to decarboxylate their own cannabis or hemp flower for use in cooking using a standard oven, from Leafly.com.14
1. Set oven temperature to 225˚ F and place the oven rack in the middle position. Ovens are hotter at the top and cooler at the bottom, so placing it in the middle will ensure decarboxylation at the ideal temperature.
2. Cut a piece of aluminum foil to the size of a baking sheet and lightly crumple it, then lay it across the baking sheet. This will minimize the direct contact of the cannabis to the baking sheet, which conducts heat better than aluminum foil and will get hotter than the air in the oven.
3. Lightly break up the cannabis until it’s about the size of a grain of rice (too fine of a grind increases the risk of burning). Spread the cannabis across the aluminum foil, then lightly lay another piece of aluminum foil on top. Place the baking sheet in the oven and bake for 45 minutes.
4. After 45 minutes, remove the baking sheet from the oven, and let it cool for 30 minutes at room temperature. The cannabis should look lightly toasted and golden brown.
5. When it’s cool enough to handle, carefully put the decarboxylated cannabis into a storage container to use for future cooking. (The odor created by decarboxylating cannabis is quite pungent.)
Emily Kyle, MS, RDN, CLT, HCP, owner of Emily Kyle Nutrition, LLC, a communications and consulting company in Rochester, New York, has a helpful tutorial on how to make cannabis-infused coconut oil available at emilykylenutrition.com/cannabis-coconut-oil. This oil can be incorporated into a variety of recipes.
Implications for RDs
When discussing edibles with clients and patients, it’s important to recommend they incorporate fat when cooking with cannabis or using an edible. Cannabinoids are fat-soluble, so they’re better absorbed when consumed with a fat source or after a meal. Baked goods should be stored in a cool, dry place to avoid degradation of the cannabinoids and terpenes, and may be frozen for later use. Gummies, while popular, may not be the best choice since the duration of effect is shorter due to the lack of fat to aid in absorption. Consuming gummies with a handful of nuts will help with absorption and lengthen the effect.
Both THC and CBD may help stimulate appetite, so there’s potential for increasing food intake and body weight in clinical populations, such as in people with HIV-associated wasting syndrome, anorexia nervosa, or cancer-associated cachexia. It also may be a useful tool for older adults who experience a decrease in appetite and body weight. THC increases ghrelin, the “hunger hormone,” which boosts appetite and may promote fat storage. CBD may influence the areas of the brain that regulate food intake and enhance eating pleasure.15 Despite stimulating appetite, the average BMI of daily cannabis users is about 3% lower than the general population.16
When discussing cannabis and helping clients choose a CBD or cannabis product, it’s best to steer them towards products that are organically grown, since cannabis and hemp are bioaccumulator plants that draw toxins from the soil. Clean extraction methods avoid the use of solvents and preserve the components of the plant.17
Consumers should ask CBD companies for independent lab testing of their products to ensure that what’s listed on the label is accurate. Studies by the FDA and the American Medical Association found that 70% of CBD products on the market were mislabeled, with some containing zero CBD.18,19 If clients are concerned about potential employer drug testing, it’s important to note that CBD products legally may contain up to 0.3% THC, which may be enough to trigger a positive drug test.
Four out of five doctors approve of medical cannabis, but 90% don’t feel confident prescribing it. Surprisingly, only 10% of medical schools include cannabis education, and few dietetics internships teach about the benefits of medical cannabis.20 Clients are looking for credible information, and RDs are in a unique position to offer nonjudgmental advice and counseling about the medical benefits of cannabis and CBD, in particular as it relates to gastrointestinal issues, inflammatory bowel disease and irritable bowel syndrome, pain, blood sugar control, and cancer treatment side effects.
Cannabis has been used medicinally for centuries with no reported cases of overdose.21 According to the World Health Organization, “Across a number of controlled and open-label trials of the potential therapeutic effects of CBD, it is generally well tolerated, with a good safety profile.” Dietitians need to be aware that more and more people are turning to cannabis and CBD to obtain relief for a variety of medical conditions. Therefore, it’s incumbent on all RDs to listen and learn to better assist clients. Edibles are a convenient and discreet way to consume cannabis and CBD, but they’re not appropriate for everyone. My hope is that RDs will join the effort to reduce the stigma and be open to cannabis and CBD as viable options in the treatment of many debilitating health conditions.
— Janice Newell Bissex, MS, RDN, FAND, is a holistic cannabis practitioner at Jannabis Wellness, and a professor at John Patrick University of Health and Applied Sciences in South Bend, Indiana.
References
1. 2018 Farm Bill. United States Senate Committee on Agriculture, Nutrition, & Forestry website. https://www.agriculture.senate.gov/2018-farm-bill. Accessed July 1, 2020.
2. State medical marijuana laws. National Conference of State Legislatures website. http://www.ncsl.org/research/health/state-medical-marijuana-laws.aspx. Updated March 10, 2020. Accessed July 1, 2020.
3. Patel J, Marwaha R. Cannabis Use Disorder. Treasure Island, FL: StatPearls Publishing; 2019.
4. Kinnucan J. Use of medical cannabis in patients with inflammatory bowel disease. Gastroenterol Hepatol (N Y). 2018;14(10):598-601.
5. Winstock AR, Maier LJ. Cannabis edibles - booming business and harm reduction. Global Drug Survey website. https://www.globaldrugsurvey.com/gds-2019/gds2019-cannabis-edibles-booming-business-and-harm-reduction/. Accessed July 1, 2020.
6. BDS Analytics. The tasty future of cannabis edibles. https://bdsa.com/wp-content/uploads/2018/10/The-Tasty-Future-of-Cannabis-Edibles-BDS-Analytics-Cannabis-Industry-Report-Infographic.pdf. Published 2018. Accessed July 1, 2020.
7. Daurer G. Industry Report: Cannabis Gummies. Company Week website. https://companyweek.com/article/data-dive-gummies-rule-the-edibles-market. Published March 24, 2020. Accessed July 5, 2020.
8. Ohlsson A, Lindgren JE, Wahlen A, Agurell S, Hollister LE, Gillespie HK. Plasma delta-9 tetrahydrocannabinol concentrations and clinical effects after oral and intravenous administration and smoking. Clin Pharmacol Ther. 1980;28(3):409-416.
9. Methods of cannabis consumption. Safe Cannabis Guide website. https://www.safecannabisuse.com/dosing. Accessed July 1, 2020.
10. Atakan Z. Cannabis, a complex plant: different compounds and different effects on individuals. Ther Adv Psychopharmacol. 2012;2(6):241-254.
11. Devitt-Lee A. CBD-drug interactions: role of cytochrome P450. Project CBD website. https://www.projectcbd.org/medicine/cbd-drug-interactions/p450. Updated September 8, 2015. Accessed July 1, 2020.
12. Kossen J. How does cannabis interact with other drugs? Leafly website. https://www.leafly.com/news/health/cannabis-cannabinoids-drug-interactions. Published March 23, 2017.
13. FDA regulation of cannabis and cannabis-derived products, including cannabidiol (CBD). US Food & Drug Administration website. https://www.fda.gov/news-events/public-health-focus/fda-regulation-cannabis-and-cannabis-derived-products-including-cannabidiol-cbd. Updated August 3, 2020. Accessed July 5, 2020.
14. Williams K. Decarboxylation 101: how to decarb in an oven. Leafly website. https://www.leafly.com/news/lifestyle/decarboxylation-101-oven. Published July 9, 2019. Accessed July 5, 2020.
15. Soria-Gómez E, Bellocchio L, Reguero L, et al. The endocannabinoid system controls food intake via olfactory processes. Nat Neurosci. 2014;17(3):407-415.
16. Beulaygue IC, French MT. Got munchies? Estimating the relationship between marijuana use and body mass index. J Ment Health Policy Econ. 2016;19(3):123-140.
17. Mead A. The legal status of cannabis (marijuana) and cannabidiol (CBD) under U.S. law. Epilepsy Behav. 2017;70(Pt B):288-291.
18. Warning letters and test results for cannabidiol-related products. US Food & Drug Administration website. https://www.fda.gov/newsevents/publichealthfocus/ucm484109.htm. Updated November 2, 2017. Accessed July 1, 2020.
19. Bonn-Miller MO, Loflin MJE, Thomas BF, Marcu JP, Hyke T, Vandrey R. Labeling accuracy of cannabidiol extracts sold online. JAMA. 2017;318(17):1708-1709.
20. Evanoff A, Quan T, Dufault C, Awad M, Jean L. Physicians-in-training are not prepared to prescribe medical marijuana. Drug Alcohol Depend. 2017;180:151-155.
21. Wiese B, Wilson-Poe A. Emerging evidence for cannabis’ role in opioid use disorder. Cannabis Cannabinoid Res. 2018;3(1):179-189.