The Bad Fat isn’t Bad and the Good Fat isn’t Good

President Eisenhower followed a low-cholesterol diet with military precision. But his cholesterol continued to climb. Even with exercise and strictly eating no foods with fat. He listened to the best medical advice of the day- and they were wrong.

President Eisenhower could not have been more frustrated. Following the advice of his cardiologist and General Thomas Mattingly, and the famed Paul Dudley White, Eisenhower was eliminating all cholesterol and fat from his diet. But every time they would take his blood level his cholesterol was higher.  He was no stranger to exercise, he gave up smoking in 1949, and days he would just have grapefruit with some melba toast.  The blood cholesterol would come back, higher than before. It was so frustrating that the White House physicians seeing him would make up numbers to tell him that it was getting better. But it didn’t. Eisenhower was crippled in retirement by his heart disease – determined to eat as prescribed, he ended his days as a cardiac cripple.

Lyndon B Johnson had a heart attack while he was a senator. General Thomas Mattingly was also his physician. Mattingly prescribed the same low fat diet that he had given to President Eisenhower. For months after his first attack Johnson followed it to the letter, shedding some 4o pounds and feeling better. But still his cholesterol was high.

LBJ, a heart patient, tried the “low cholesterol, low fat” diet, but realized his cholesterol didn’t change – so he gave it up. Remarkably, once he started eating the beef from his ranch his cholesterol decreased.

Johnson fell back into his old habits, and had another heart attack, which derailed his presidential ambitions for a while. Finally, in retirement Johnson started to follow the regime again – but noticed that when he started to eat beef from his ranch, his cholesterol went down. He came to his own conclusions, stopped trying to avoid beef- and enjoyed the bounties of his retirement. He enjoyed friends coming to the ranch, with frequent barbecues – often coming late for dinner.

For years America was told that saturated fat is bad for your heart. It was based on a faulty principle – that the fat in the arteries came from the fat in the blood which came from the fat in the diet. While it makes sense, it wasn’t until after Johnson and Eisenhower died that science discovered that dietary fat contributes only a small amount to blood lipid levels. The idea was popularized by Ancel Keys.

But in spite of evidence to the contrary, once a popular notion is in the press, it stays there. Which brings us to President Clinton. The president enjoyed his burgers, and when he had his heart attack he began to examine the notion that plant based diets would reverse heart disease. His disease arteries bypassed, he turned to Dr. Dean Ornish. Ultimately, Clinton became a vegan. Was it a wise choice? President Clinton is a smart fellow, but if he were to critically go through medical journals he might question his choice. ,

It has been 16years since Dean Ornish published his data showing a 3 per cent reduction in the plaques seen by coronary angiograms on a select group of patients who followed his Ornish diet and “lifestyle” plan. To be exact: the 28 patients who followed his plan had a 1.75% decrease in atherosclerotic plaque after one year and 3.1% decrease after five years. With the control group there was an increase of 2.3% in one year and 11.8% at five years.

In 16 years no one has reproduced that data. No one. Still, from one old paper Dean Ornish has made a career; first being the anti-Atkins, and riding the anti-cholesterol, low-fat band wagon with the same religious fervor as Keyes did thirty years before. Ornish has since become the lead health-blogger for Huffington Post, has influenced Bill Clinton – turning him into a vegan, and is favorably mentioned by Dr. Oz.

The difficulty is this: science has caught up with him, and we know a lot more about how atherosclerotic plaques form. We know that dietary lipids and their carriers are far less important that what the body makes. We know that the dietary component is far more related to the trigycerides – and triglycerides are raised much more by the grains and pastas that Ornish preaches on (in his trial, the “Ornish lifestyle” patients had a rise in their triglycerides).

What Ornish and his crew call a landmark paper, would not be accepted by the same journals today for a number of reasons:

(a) No one compares angiograms – a two-dimensional photograph of an artery – because they can be manipulated so easily and interpreted differently from one experienced radiologist or cardiologist to another. Depending on the angle you take the angiogram from, you can show a reduction in plaque by varying the recorder by a few degrees. Today intra-vascular ultrasound is the test of choice – this gives us a three dimensional view of the artery, from within the artery. The recent article in The New England Journal of Medicine, comparing lipid medications and their long-term effect on atherosclerotic plaque, is the most accurate measurement of plaque and its formation.

(b) We know about the science of lipids, plaque formation, and how we can manipulate those to provide a better answer for atherosclerosis that does not involve severe manipulations of a diet. For example, it appears it is the carrier proteins that cause the damage to the arteries – and more carrier proteins are made in response to certain stimuli (triglycerides being one).

(c ) There were deep and troubling issues with the groups of patients serving as controls. For example, we do not know how many pack-years of smoking were in one group or the other. This is not a minor flaw, as science understands the highly inflammatory changes that are made with smoking as opposed to those made with hyperlipidemia.

(d) Lipid lowering drugs were used in some, and not others – however, the drugs today are far better, and more targeted than before.

To this day when most talk about saturated fat we are given “alternatives” like margarine, olive oil, oils from nuts, seeds, and the like.  They are suppose to be better for us than “animal fat.” They are not.

We built pyramids – food pyramids, based on avoiding certain foods. We went out of our way to define the chemical nature of fats: polyunsaturated, monounsaturated, a trans-fats. We made charts so we could keep track of which fats were the “good fats,” so we could tell patients to eat these.

Monounsaturated fat Polyunsaturated fat
Olive oil Corn oil, Grapeseed oil
Avocados Fatty fish
Almonds, peanuts, macadamia nuts Walnuts, sunflower seeds, flaxseed
 

 

Then of course we had to tell people what was “bad” because it caused problems so we made tables like this:

Saturated fat Trans fat
Beef, lamb, pork Margarine (stick form)
Ice cream Fried foods (french fries, breading)
Milk, cream Crackers, popcorn, chips
Lard Shortening

 

But wait – then we had to tell what to change in their diet so we made tables like this one:

 

Less Healthy Better Choice
Beef that is corn-fed Beef that is grass-fed
Butter Olive oil
Standard eggs Eggs high in omega-3 fatty acids
Ice cream Frozen yogurt
Milk Fat-free milk, soy milk, almond milk
Shortening, lard Grape seed oil, canola oil, vegetable oil

Did I mention we were wrong?

In science we make a hypothesis – then we test the hypothesis – then based on our findings we refine things, test again, and somewhere we develop a theory that explains the nature of things. In this case – food.

When the USDA and Europeans looked at the data to make recommendations about fat, they cherry-picked the data about saturated fats. Meaning, in spite of studies showing that saturated fat did not increase heart disease, in spite of studies showing that polyunsaturated fats may be worse than saturated fats, they pressed through guidelines and recommendations that were based not on critical thinking, but the bias of the committee members.

Remember: in those days, everyone had the thought that the fat laden arteries of people with coronary artery disease came from butter, animal fat, and the like.

Heart artery plaque- low fat diet doesn’t prevent this

What do we do?

It turns out that saturated fat is not bad for a person, and the studies showing we should substitute with other fats were wrong.

Still the ideas of eating “healthy” for many people means avoiding red meat, avoiding saturated fats, even though the evidence for this is almost non-existent.

How We Live:

Which brings us to one simple fact: how we live is more important than how when we die- especially if the quality of life is less than satisfying. I doubt Eisenhower enjoyed his last days as much as Lyndon Johnson.

But let me bring one simple point: learn to cook. Appreciate fresh food. Yes, you can live on processed food but you cannot thrive.

 

REFERENCES:

In 2003, a meta-analysis of over 50 trials was published examining the relationship of dietary fat to serum cholesterol levels (Mensink RP, Zock PL, Kester AD, Katan MB. Effects of dietary fatty acids and carbohydrates on the ratio of serum total to HDL cholesterol and on serumlipids and apolipoproteins: a meta-analysis of 60 controlled trials. Am J Clin Nutr 2003;77:1146–55.).  The conclusion was that saturated fat increases the levels of low-density lipoprotein (LDL) and high-density lipoprotein (HDL) but without changing the ratio of total to the HDL cholesterol.   They concluded that using cholesterol alone as a marker of risk was unreliable. This was because if you replace the saturated fat with carbohydrates or tropical oils if you examine the effects on HDL and apolipoprotein B. They concluded that “… we can never be sure what such fats and oils do to coronary artery disease risk.” To translate that from doctor-scientist language: we can improve some laboratory markers, but really not by any mechanism that makes a difference from what we know.

While a systematic review of randomized trials showed that when saturated fats are replaced by polyunsaturated fats there is a reduction in the laboratory marker for risk of heart disease, there was no association with mortality from heart disease.  To emphasize this: the laboratory values of the patients studied improved, but their mortality didn’t. The review also showed that monounsaturated fat intake significantly increased cardiac events, but no effect from the intake of saturated or polyunsaturated fat. Let me emphasize that: Monounsaturated fats, by at least one study, not only didn’t improve issues with the heart- the patients in that study did worse.

When examining other prospective studies about the risk of saturated fat and cardiovascular disease, there has been a consistent lack of an association between fat intake and heart disease, stroke, or total cardiac events.

Cohort studies show that by replacement of saturated fats with unsaturated fats, or carbohydrates – and examining the hazard ratios for heart attacks and deaths from heart disease were as follows: 0.87 for polyunsaturated fat, 1.19 for monounsaturated fat, and 1.07 for carbohydrates.  For those not familiar with statistics, these are essentially no difference, and if these small statistical numbers are accepted than polyunsaturated fat shows an alarming trend. So here is a study that indicates (with as much precision as most studies these days) that polyunsaturated fats are worse for you than saturated fats.

There is a difference between protection against what we define as risk of heart disease and death from heart disease.  Risk reduction means that we lower the laboratory values of factors we associate with risk – but the end point is death.  In a meta-analysis published in 2010 (Ramsden CE, Hibbeln JR, Majchrzak SF, Davis JM. N-6 fatty acid-specific and mixed polyunsaturated dietary interventions have different effects on CHD risk: a meta-analysis of randomised controlled trials. Br J Nutr 2010;104:1586–600.) examined seven different trials, they found that there was a risk reduction but no change in mortality.  Another study (Skeaff CM, Miller J. Dietary fat and coronary heart disease: summary of evidence from prospective cohort and randomized controlled trials. Ann Nutr Metab 2009;55:173–201.  ) had eight trials found “There is probably no direct relation between total fat intake and risk of CHD (heart disease).

The advice of the USDA is reflected in places like WebMD, recounted in public service commercials, and recited as gospel by health care workers everywhere.  Giving false impressions about what an appropriate diet is.

 

Mummies & Eskimos with Heart Disease: it isn’t Modern Diets that are the Problem: The People of St. Paul

The recent study that came out showing that ancient people had heart disease, including a group of Alaska Natives whose mummified remains revealed that the perfect paleolithic diet did not protect from heart disease. Funny thing, Alaska Natives have known this for years. While some may want to say our diet is the ultimate, we have known it is just our way to survive – to live.   St. Paul is a small community of several hundred in the Pribilloff Islands. A remnant of the ancient people of Alaska, with only minimal changes from our paleolithic era.

Most people would never know about these islands were it not for the TV series, Most Dangerous Catch.  It is these islands that the crab fisherman come to process some of their crab. Viewers of the show will recognize the name of the place.

St George Island from St. Paul

In the distance is St. George, the smaller of the two islands. St. Paul is 7 miles wide, 14 miles long. Formed from volcanic activity.

Lonely islands, in the middle of the Bering Sea – but home to some of the most ancient people on earth. St Paul is a three hour flight from Anchorage. Sometimes the weather is so fierce that people have been unable to leave the island for several days.

Like their ancestors, these Alaska natives get their food from fishing. Halibut, crab, salmon, char, and the occasional seal. The only thing that has been introduced into their diet has been the reindeer herd on the island – that would provide a bit of our dinner that night. While there is a single grocery store, products from the lower-48 are expensive and not often used.

The recent Lancet article stated:

 

The presence of atherosclerosis in  pre-modern human beings suggests that the disease is an inherent component of human ageing and not  characteristic of any specific diet or lifestyle.

alaska Aleut

The Aleuts, or Unangan, peoples inhabit the western most part of Alaska – purple. The two little spots above the t in Alutiiq is where St. Paul Island is-

In the article they had studied   mummified remains of Alaska Natives, my ancestors. The Aleuts  live on the  islands in the western part of Alaska.   These islands, formed from mostly volcanic formation, to this day are rich in marine life, with abundant fish, seal, whales, and occasional berries.

I was last there when invited to a celebration in St. Paul because of their new clinic. A beautiful facility, staffed by physicians out of Anchorage. But this facility is vital to the community.

St Paul Seals

The island is a natural breeding ground for seals, who migrate here yearly. The Russians forced Aleuts to inhabit the island to harvest the seals

The island was originally uninhabited until the Russians arrived. Used primarily as a hunting area for natives, then the Russians discovered the great seal population they forcibly moved hundreds of Aleuts here to harvest the fur.  Those families still remain.

Why, you might ask, should you think about Aleuts?  Why do food scientists think about them? These were/are one of the great hunter-gathering societies, eating a diet of fish, meat – even getting their vitamin C, not from citrus, but from marine life. Those relatives, my ancestors, had a diet rich in omega-3 fatty acids, did not eat processed grains – in fact, they rarely had any food but what would be the ideal paleo-rich, non-processed, occasional berry (in season – fresh and local) diet.

For the study in Lancet, it was made possible to see what my ancestors ate because  the climate in these parts allows mother nature to mummify the body, making the bodies available to study.

St Paul

Main Street in St. Paul. They have one bar, one post office, one grocery store, and one church

This group was use to physical activity, without animals to transport them they relied on the kayak for whaling, fishing, and transportation to visit one another on other islands.  With Russians reporting that some of these peoples would go hundreds of miles in Kayaks.

kayak

Restoring an ancient Kayaks. Much larger than the individual ones used for modern sport

Kayak

A better view of how large these ocean going vehicles were

It has been postulated that the Eskimo (the Aleut are the same group as the Eskimo) would have the lowest incidence of coronary artery disease because of their diet. The hunter-gathering society had a “reported” low incidence – although as with many population studies have shown, you often find it when you look for it. For a more in depth discussion about population studies and how we have missed them see here. The Pima Indians, of Arizona, are called “the most studied group” in the world. It was once assumed they had no heart disease, and thus began an intensive study as to why they didn’t have heart disease- but as more studies were performed, turns out the Pimas, like many societies, have heart disease. In fact more of it than western societies. It is the same with the Eskimo health, whether from Greenland or other areas, when critically examined, this society has the same rate of heart disease as others.

Modern Man:

Some have speculated that the incidence of coronary artery disease among Eskimos is because of their interaction with modern man. The introduction of grains into their diets, tobacco, and machinery with less exercise. Not only did the study in Lancet article show that cardiac disease was present in those paleo-people, it is in line with laboratory studies of Aleuts showing they have the same markers for cardiac disease as the rest of us.

Smoking:

Aleut home Alaska Native Center

This is a modern representation of homes of the Aleuts. This from The Alaska Native Heritage Center in Anchorage, Alaska. A worthwhile place

While they did not have tobacco, all ancient peoples used fire. The Native Alaskas of the Aleutians  had homes built partially underground, and used community fires with smoke going out of a hole in the roof, or used fires to heat water that would heat the homes. This might have lead to increased exposure that would accelerate heart disease, but the dispersion of smoke from this would be hundreds of times less than exposure from those who inhale tobacco.

Seal oil was used for lamps. Which, like olive oil, burns quite brightly.

Today they use electricity.  So the second-hand smoke from fires and lamps is no longer a factor. They still eat a diet primarily of fish.  Still, as we found from this little clinic for a town of 400 people, there is  heart disease. Several times a year a person is evacuated out of this town to the city of Anchorage for advanced cardiac care.

One of the  mummified remains of an Aleut lady showed severe artery disease to the extent that if we saw this today she would undergo vascular surgery. This in a woman who was in her late 40′s to early 50′s. She may very well have died of a stroke.

 

St. Paul island birds

The people still get eggs, but they prefer the fresh ones from the cliff. Higher in omega-3 fatty acids than the ones from the chicken farms. These islands have some of the most unique birds in the world.

In fact, in the recent study published on-line by Lancet, they discovered atherosclerosis was prevalent in all areas of the world, over a 4000 year time span, and several continents, with peoples having ancient diets from rich in saturated fat, to near vegetarian, to pure paleo.

Exercise:

Exercise you say? Turns out that in ancient cultures, without the benefit of cars, bikes, or probably even animals- physical activity was normal- and lean and mean were simply natural. Like a six-pack, probably every ancient Alaska Native  person had one– but in their coronary arteries were plaques, that would make any modern, beer belly, sedentary modern human proud.

Diet:

These ancient ones didn’t have trans-fats, they didn’t have soda, they didn’t have wheat, they didn’t have dairy, they didn’t have cheese, but they did have heart disease. And today, they stil do.

Heart Disease:

The study showed that heart disease was found throughout ancient civilization. It wasn’t the diet that prevented it. In fact, probably was genetic like most of us thought all along. Like their ancestors before, the Aleuts of St. Paul have the same disease, virtually the same diet. Their lifestyle is better now, with indoor heat, better insulation. They still live a physical life. But one thing they need- much like many – is some statin drug like Lipitor  which works much better than their ancient diet, or any diet you can think of .

Ask an Alaska Native if their diet protected them from disease: they will tell you, it didn’t. Food wasn’t meant for medicine, food was meant to nourish the body. A lesson the ancient people knew – one that many doctors are still learning.

REFERENCES:

Atherosclerosis across 4000 years of human history: the Horus study of four ancient populations.Randall C Thompson, Adel H Allam, Guido P Lombardi, et.al. www.thelancet.com   Published online March 10, 2013

High prevalence of markers of coronary heart disease among Greenland Inuit. Jørgensen ME, Bjerregaard P, Kjaergaard JJ, Borch-Johnsen K.Atherosclerosis. 2008 Feb;196(2):772-8 PMID: 17306273

 

Mediterranean Diet: Heart Health – Not Just Yet

Mediterranean Diet Good For Your Heart?

Healthy Mediterranean Diet

This week most news outlets are touting the recent article in The New England Journal of Medicine about the Mediterranean Diet, and how it cut cardiovascular disease. But here is the rest of that story:

There was no significant reduction in heart attacks, there was no reduction in death from heart disease, but there was a small reduction in death from stroke. When you combine the strokes into a category of cardiovascular disease you have the difference the article noted.  To be clear, the study did not say a reduction in stroke, or a reduction in disability from stroke but just death from stroke.

There is a call for studies of diets to see how it affects heart disease, or cancer, or other diseases. But here is one that really didn’t show anything, and yet some are saying- hey, we need more.

What was not properly accounted for in the study was smoking, people who were taking statins, people who were taking blood pressure medicine,  and there was more obesity in the control group. There was no weight loss in the Mediterranean diet group.

Even the New York Times didn’t get this, their article said, “About 30 percent of heart attacks, strokes and deaths from heart disease can be prevented in people at high risk if they switch to a Mediterranean diet rich in olive oil, nuts, beans, fish, fruits and vegetables, and even drink wine with meals, a large and rigorous new study has found.”

In another part of the NYT article they said, ” Disease experts said the study was a triumph because it showed that a diet was powerful in reducing heart disease risk, and it did so using the most rigorous methods. “ 

The study did not show that the diet was “powerful” in reducing heart disease risk, and the most rigorous method used was statistical jockeying to add stroke deaths to heart issues to put it all under one statistical umbrella.

Plus, one group were required to drink a liter of olive oil a week (thats a lot of oil).

What was also missing from the study was any laboratory data, nothing showing a change in blood lipid chemistry (which may not matter). There was nothing in the data that showed changes in plaque formation. There was nothing in the data that showed inflammatory markers were lower.

Bottom line: you have a study that makes a lot of reaches, conclusions, and promises, but the facts are simply not there to support it. It also shows that the era of science journalism is gone.

Eating Healthier is better than not – in fact: Just Cook! :

Olive oil- buy local (US olive oils).

There are plenty of ways a person can eat healthy. And once someone begins to pay attention, and eat healthier they tend to think that their diet is the best of any. Diets become a religion for some people- proselytizing with the evangelical fervor of a Revival preacher.

What the report in the New England Medical Journal showed was this: eating healthier is a bit better than not.

A lot to love in this diet – what I like most, is it gets people into the kitchen, and cooking. There is nothing wrong with a diet that is rich in fruits, vegetables, whole grains, fish (and shellfish) with less emphasis on cattle raised on corn (grass fed is ok), and decreased portions, is probably best. Oh- and don’t forget the red wine.

 One of the New York Times columnists got it partially right. Mark Bittman, whose contributions to the food section of the NY Times are known for advocating cooking, healthy foods, and less red meat.  His column pointed out the flaws, as Bittman called physicians who were critical of the article. Bittman’s colum about this can be found by clicking here.  Bittman does credit Ornish with a diet showing a reversal of heart disease – which, sadly is simply not true (our review of Dr. Ornish here). Essentially, Ornish’s cardiac imaging was flawed – and his studies have not been reproduced.

What is the Mediterranean Diet – a Diet Plan

Breakfast: Greek yogurt. Fruit, fresh and whole. Granola made from fresh nuts, whole grains, and sweetened with blueberries. Fresh, whole wheat toast, or sourdough pancakes. Cucumbers with onions dipped in balsamic vinegar with some olive oil.  Tea or coffee

Mid-Morning snack: fresh fruits, nuts, or – dried fruits (that you have made).

Lunch: Fresh fish grilled or fried in olive oil. A hearty lentil soup. Fresh fish with pita bread.

Mid-afternoon snack: 1 banana or 1 apple, or some fresh fruit. A handful of nuts

Dinner: Chicken – baked or roasted, in a warm hummus salad. Fresh pita bread. Green beans blanched, then dressed with olive oil and mustard. Or pasta with a true Marinara sauce. One the island of Sardinia, I ordered pasta with Marinara sauce – besides tomatoes, in the sauce were fresh mussels, lobster, mackerel, and tuna — and it hit me – this is what marinara means- from the sea.

2 glasses of red wine.

Dessert: Poached pear with yogurt, or baked apple with nuts, fresh fruit salad

 Mediterranean Diet: What it consists of 

Vegetables and Fruits: the base of the Mediterranean pyramid. The bulk of food in this comes from these ingredients. Fruits form the basis of most deserts. This means fruits or vegetables with every meal- and for every snack, up to ten servings a day. These are not processed juices, these are something you can identify out of the garden. If you have dried fruits, that is acceptable, and prefer that you do them.

Grains: Whole grains, not processed wheats: quinoa, wheat berry, and sesame seeds. Perhaps my favorite of this is hummus, a great snack, all vegetable, that provides all the essential amino acids. It was this snack that allowed migration across the world.

Dairy: Greek yogurt, cottage cheese, are all used in this diet.

Fats: Primary source is olive oil in this diet, also grape seed oil

Pasta: A basis of high-carbohydrate, high fuel for people from the Mediterranean to China.

 

 

 

REFERENCE:
Primary Prevention of Cardiovascular Disease with a Mediterranean Diet. Estruch R,et. al. N Engl J Med. 2013 Feb 25.PMID: 23432189

 

The NYT article can be found here.

Food Can’t Cure You: It Can Kill You

Diet Does Not Cure Cancer

fresh produce healthy eating food mythsLet’s set the record straight on a silly, popular, and pervasive idea: Food cannot cure you—unless you have a specific deficiency: food cannot cure you of cancer, heart disease, or Alzheimer’s. But a proper diet, may delay some disease, or the effects of some disease.  It really frosts me when someone states this diet will keep you from getting some disease – at best such is misleading, at worst it can be catastrophic.

Food can kill you, and I see that everyday in my practice – people have an auto-destruct button- it is their mouths. And don’t think you can eat poorly and make up for it with taking supplements. If you eat a balanced diet you do not need to buy supplements, like vitamins, fish oil, calcium, or others.  Diets that are rich in these micronutrients may make a difference, the supplements themselves have never been shown to improve health, with the single exception of pregnancy.

Antioxidants are a prime example of false food claims. Every few months someone promotes supplements that contain antioxidants as beneficial to avoiding cancer, heart disease, Alzheimer’s, or macular degeneration of the eye. Scientists have tested to see if antioxidant  supplements prevented or improved heart disease or cancer. The use of antioxidants, in study after study,  made no difference. In fact, people who took antioxidants, like beta-carotene and vitamin E, didn’t live as long!. But that doesn’t stop some people from promotingsupplements. The sale of antioxidants continues to be pushed by physicians who spend more time in front of the camera than reading medical journals (I’ll call them TV doctors or TV MDs).

Micronutrients: A group of ingredients needed by humans that must come from food. Examples include calcium, iodine, antioxidants, iron, zinc, and vitamins.

Macronutrients: The major ingredients humans consume, including protein, fat, carbohydrate, amino acids, sugars, essential fatty acids, and alcohols.

The latest trend among cookbook authors is to list the macro- and micronutrients in their recipes with vague reference to how this is healthy. For example, you might hear “great for your prostate” or “promotes heart health,” even though science shows the nutrient just doesn’t work that way. While the recipes of those celebrity chefs are tasty, the list of micronutrients they put at the end is little more than word salad.

Even worse is the notion of eating certain foods instead of taking prescribed medicines. If your doctor prescribes a medication to lower your cholesterol, just eating more foods like salmon is NOT the same.

You may enjoy your glass of red wine—but don’t think it will save you from heart disease. To get enough resveratrol, the highly touted antioxidant in red wine, to reap any heart benefit, you would have to drink 2,000 bottles of wine in a day.

There is a long history of pitchmen (charlatans), from Graham (of the cracker) to Kellogg (of the cereal), who sought the fountain of youth through foods, supplements, and colonics. The trend in food promotion today is to highly tout and write about a chemical of the month—from antioxidants to the notion of “superfoods”—which often doesn’t hold up when tested by science.

Did you know:
Corn Flakes and Grape Nuts were once promoted a health food? Kellogg and Post were two competitors in Battle Creek Michigan who invented the cereals and marketed them as health foods.

To illustrate about  balanced diets, consider that in the 1500-1700’s many sailors died of scurvy, a disease that caused old wounds to open up, teeth to fall out, and a horrible death. Those sailors who had a balanced diet never got scurvy. It was discovered that scurvy was preventable by eating limes, which is why British sailors are called “limeys”. The ingredient in limes that prevents scurvy is vitamin C. The simple discovery—that a vitamin deficiency causes disease, began the idea that if we could isolate the vitamins and micronutrients we could prevent many other diseases.

But that does not mean a massive amount of vitamin C is better. Linus Pauling, the two-time Nobel Prize winner, believed that high doses of vitamin C would cure the common cold and prevent cancer. When I met Pauling, he was suffering from a cold; a few years later he died of prostate cancer. The more important lesson of vitamin C is this: Sailors who were fed a balanced diet did not suffer from scurvy.  

21st Century FOODS:
There are a lot of ways you can get food today. You can get foods from a restaurant that are made for you, you can get convenience food that you just heat in a microwave. There are also foods that have been processed and fortified so the manufacturer can claim you’ll get all your nutrition in a bar or a shake. You can even get your nutrition through an intravenous line (iv). Then there is the old fashioned way of whole foods that you put together and cook. We hope to show you that eating whole foods is simply better than eating fortified or convenience foods.

The disadvantage of whole foods is they have a short shelf life. Think of a ripe peach, it’s shelf life is only a few days.  Whole foods are quickly spoiled, can easily get bugs in them, mold, or become rancid. Many foods are processed so they have a longer shelf life. But when humans first started to process foods the processing removed some essential micronutrients, like vitamins- and people who ate a diet rich in process foods developed vitamin deficiencies. Vitamins are now put back into the processed foods– this is called “fortifying” foods. We do this with breads, cereals, juices, and infant formula.

The ability to chemically produce vitamins, and other micronutrients, had an impact in medicine. Putting nutrients into an IV has saved hundreds of thousands of lives. While people can survive on IV nutrition they cannot thrive on IV nutrition. Surgeons learned that it is better for  people to eat food, than to get nutrition from an IV. Think of IV nutrition as the ultimate convenience food.

Pikes Place MarketYou’ll see how it is better to be eating those foods that naturally contain nutrients, than to eat food that has been processed and requires fortification with micronutrients. This is the current state of affairs, and probably has to do with our limited knowledge of how certain micronutrients work together, how they absorb in humans, and perhaps there are more micronutrients to discover.

While we advocate the use fresh and local foods this is not always possible or reasonable. While Seattle has one of the oldest and best markets at Pike Street, a few miles away in the grocery stores you cannot get the same fresh ingredients. Many inner city folks only have processed foods to deal with. You have a unique advantage by getting and using them- and the advantage is taste and maybe better health (maybe). But if you miss the chance to get those foods, if you miss the chance to go to your local farmer’s market – you are missing out on some amazing local and tasty food.

Definitions:
Processed Foods: Any food that is modified in some way to be eaten
Fortified foods: Foods that have had vitamins and other micronutrients added
Convenience foods: Foods that have been processed and fortified for longer shelf life and pre-cooked or made easy to heat up to serve.

The nutritional information included on many recipes is little more than a wild guess. The cooking process changes the properties and concentrations of the nutrients in the foods, making any type of accurate analysis nearly impossible.

There is less fat and, thus, fewer calories in meat after you cook it.  Nutrients also change depending on how you cook the food: frying will be different than baking, which will be different than cooking sous vide.

Just adding up calories of the ingredients of a recipe won’t add up to the calories your body receives. If you cook with olive oil or butter, you won’t get 100 percent of the calories of that oil, only about 10 percent.

Cooking also changes how your body is able to process nutrients. Your body is able to get at more of the nutrients of cooked vegetables, even though the total nutrient count goes down. Cooking meat allows more proteins to be available for your body and also inactivates the animal’s hormones and other bioactive proteins.

Your genetic makeup determines how your body will process the food. One diet will not fit all.  Eskimo people can eat large quantities of fat and meat, but Eskimos cannot process simple sugars and carbohydrates the same way as a person of European descent.  On such a high fat diet Eskimos have low heart disease, until they have a western diet.  Scandinavian people easily process dairy products, but Mediterranean people do not process dairy effectively; dairy products for most Mediterraneans result in flatulence and weight gain. Science is just beginning to understand that our genetics plays a part in how we process certain foods. One diet will not fit all humans; one lifestyle will not fit all humans.

REFERENCES:

(1) Multiple studies showing that dietary supplements don’t reduce cancer risks, and may even increase it.  One has to feel sorry for people who take supplements thinking that they are doing something good for their health and yet the evidence is clear, and overwhelming- those who do not take supplements live longer. My concern always is that people eat unbalanced diets and seek to compensate by taking supplements.

J.Nati’l Cancer Instit Pub Med ID 22534785

(2) No association between dietary intake of vitamins, minerals, or fatty acids with colon cancer. Meaning- you can take all of those things and you still will get colon cancer at the same rate as if you didn’t take them. Even in the largest study looking at older men taking a multi-vitamin, while there was some decrease in some cancers – there was no decrease in mortality, death from cancer, or colon-rectal cancer.

Int J Cancer 2012 Pub Med ID 22139959

JAMA 2012

(3) Perhaps one of the most frustrating parts of anti-oxidants is that they work, in some level, in the laboratory with cells. But in clinical trials with people, they do not seem to work. Taking something that works in the lab, even with well worked out mechanisms in vivo, does not mean it works well in people. However, diets that are rich in anti-oxidants do benefit people, but not the supplements containing “anti-oxidants,” or the multi-level marketing programs selling anti-oxidants.

Molecules 2012 Pub Med ID 22418926

(4) Not only is there no evidence that antioxidant supplements prevent disease or ameliorate disease – there is evidence that some supplements increase mortality, especially Beta-carotene and vitamin E.

Cocharane Database Syst Rev 2012 Pub Med ID 22419320

(5)The agent in red wine is called resveratrol, which has been shown some benefit even with cancer. However, it does require higher doses than just a glass of wine. There are two ways of looking at this data – the use of resveratrol in a laboratory clearly has an effect, but to take 2000 bottles of wine to get that effect, makes one wonder if the effect on humans might be lost. Yet there is clearly a positive effect of those who have modest amounts of wine. 2000 bottles- I say, the journey of 2000 bottles of wine starts with a single glass – cheers.

J Diet Suppl 2012 Pub Med ID 22432802

(6)The intake of resveratrol in a dietary supplement doesn’t have any impact on DNA-stability  – which is how the higher dose works. It would take about 2000 bottles of wine to get the dose that has an effect.

Mutat Res 2012 Pub Med ID 2298176

(7) Scurvy is a miserable disease that is caused from a deficiency of vitamin C. Clinically sailors would get apathetic, bruise easily, old wounds and scars would open, and swollen legs.  In 1740 on one trip around the world the British Navy lost 1400 of the 1900 sailors, most to scurvy. James Lind was a navy surgeon who did experiments in 1747 and found that citrus fruits not only prevented but cured scurvy. Lind’s data was ignored by many, who felt scurvy was caused by the conditions of the life of a sailor. In addition, Lind suggested boiling down the lemons into juice. But when the juice was boiled it destroyed the vitamin C.  In 1794 when a 23 week trip to India, lemon juice was used daily and had no outbreak of scurvy made news throughout the British Navy. Among the British sailors in the West Indian colonies, found limes easier, and on that basis American sailors referred to the British Navy as “limeys.” Captain James Cook, on his journey to the Hawaian Islands, found that by providing sourkraut none of his sailors developed scurvy, and for that   It wasn’t until 1800, however, that lemons were used routinely in the British Navy.

Nutr Rev 2009 Pub Med ID 19519673

(8) The key of balanced diet discovered after years of unbalanced diets in the 16th and 17th century. Did you ever wonder about Eskimos and scurvy? Very little citrus fruit found in the far north, and yet there is no scurvy among Eskimos. It turns out that they get enough vitamin C through the meats that they eat – especially in the raw meats such as walrus (more about Eskimos and walrus tartar later).  To prove that you could avoid scurvy through a balanced diet, even before Vitamin C was synthesized in a laboratory, in 1928 anthropologists lived with the Eskimos and did not contract signs of scurvy.  Scurvy was not universal among sailors either – those who had a bit of a balanced diet, didn’t have this disease. While humans do not make vitamin C, and must get this micronutrient from diet, many animals do synthesize their own –and the highest concentrations in the liver of animals, lowest in muscles (typically we eat muscle as our source of protein). So while the Eskimo diet may not appear balanced to many, these people have been able to occupy this biologic niche on a diet primarily on foods that seem high fat.  The westernization of the Eskimo diet, has increased obesity and heart disease – those Eskimos moving to the city have higher levels of heart disease, cancers, and obesity.  When the traditional foods were examined, they also contained high levels of the micronutrients of Omega-3 Fatty acids, iron, phosphorus, zinc, copper, selenium, niacin, pantothenic acid, riboflavin, and vitamin B12. This has led some to claim that the diet of our ancestors, during the Paleolithic diet, is an ideal diet. In this case, the traditional diet of Eskimos would be high in fats, raw sea food products such as walrus, fish such as Arctic char, and seal oil. Not a diet that would be easy to follow for most in the United States. But remember, besides not having the lifestyle of the average Eskimo, we also do not have their genetic make-up, which makes them unique (see reference 15).

Clin Nutr 1992 Pub Med ID 16840004

Int J Circumpolar Health 2012 Pub Med ID 22818718

(9) Micronutrients were what chemists in the first half of the 20th century were trying to isolate to supplement processed foods.  The advantage of the processed foods is portability and stability. The processing of foods allowed humans to travel (bread for the west, and noodles for the Silk Road). But diets rich in some processed foods led to multiple micronutrient deficiencies, so chemists worked to isolate the micronutrients needed and return those nutrients to the processed foods to avoid deficiency. Beriberi is deficiency of vitamin B1 that was discovered when people ate diets high in white rice, but not brown rice.

In 1897, Dr. Christiaan Eijkman, a Dutch physician , demonstrated that beriberi is caused by poor diet, and that feeding unprocessed rice (instead of the white polished variety) to chickens helped to prevent beriberi. The following year, Sir Frederick Hopkins postulated that some foods contained “accessory factors”— necessary for the functions of the human body – we now call these vitamins. In 1901, Christiaan Eijkman in the Netherlands correctly interpreted beriberi  as a deficiency syndrome. Eijkman coined the term “vitamin.”

In 1929, Eijkman and Hopkins were awarded the Nobel Prize for Physiology or Medicine for this discovery. Hopkins later showed that margarine was inferior to butter because it didn’t contain vitamin A and D (ultimately margarine was supplemented with A and D, but it continues to be inferior).

These discoveries brought in the golden age of biochemistry with idea that we could isolate all the essential micronutrients, then put them back in processed foods, and led to finding the vitamins that were responsible for xerophthalmia, rickets, pellagra, scurvy, in addition to beriberi. By fortifying foods with these micronutrients led to reduction of widespread micronutrient disease in developing countries.

This worked with breads, cereals, juices, and infant formula. As much as we can get by with the processed foods with replacement of the micronutrients, there is a benefit to eating diets that are naturally rich in the essential ingredients. This may indicates that there are more micronutrients left to discover, as well as how these various ingredients are presented to our body makes a large difference in long-term health (see the next reference).

J Nutr 2012 Pub Med ID 22157539

Langenbecks Arch Surg 2007 Pub Med ID 17221268

(10) Cooking has an impact on what people can absorb and process from foods. The term we use is bioavailability- which is the amount of an ingested nutrient that is absorbed and available for use by the body. Another term we use is bioaccessibility, the amount of a nutrient that you eat that is available for absorption – and that has two components – how much can be released by the food matrix, and digestion. We use to determine the nutrients in a food from a chemists lab. The chemist would break down the food and determine the amount of micronutrients in that food. It turns out that people don’t absorb everything in food, and how you cook it changes how you absorb it. For example, if you take a carrot that is raw, a chemist can tell you how much vitamin A is in it. But that does not mean you will absorb all of that vitamin A. But if you feed the carrot to a person and measure how much vitamin A is in their blood and compare carrots that are cooked with raw carrots, it turns out that you get higher levels of vitamin A in the cooked carrots than in the raw carrots. This is how we know that people get more vitamins out of some cooked vegetables than raw, or how you get more when you cook some in certain oils than with others.

Another example is fructose in fruit. You can measure how much fructose is in banana – about 7 grams. But when you eat the banana only you might absorb less than half of that amount, the rest of the fructose is bound to fiber and isn’t available to be absorbed. In contrast with refined fructose, like a 20  ounce soda, would be the equivalent of eating 10 bananas (over half the fructose in a banana is not absorbed

Front Physiol 2012 Pub Med ID 22934067

Heat and cooking change the texture of beef and nutritional components. You have had the steak that is overcooked and dry, or the moist juicy steak. But heat not only changes the texture of the food – it also changes the macronutrients and micronutrients of the food.

J Agric Food Chem 2006 Pub Med ID 22062402

Throughout these references you will see a common theme: the supplement is not as good as the food. Omega-3 fatty acids are important, but taking fish oil capsules is not the same as eating fish. Think of the same thing with fortified food – it is like taking a supplement with a meal. You can sustain with these foods, but still there is something about whole foods we don’t YET understand.

(11) The Eskimo population has very low levels of an enzyme that is responsible for converting fat into usable energy (carnitine palmitoyltransferase). This is problematic with infants who are fasting because of illness, and the discovery of this has been an important therapeutic note for physicians who deal with Eskimo children. For if Eskimo children fast too long their blood sugar goes dangerously low and they can die. Sadly for the children, this is not an evolutionary advantage, but remember, in the remote arctic, infant mortality from disease is high anyway, having this enzyme does not change that. But this enzyme which accelerates the death from disease, is not a disadvantage, and may in fact me an advantage (decreasing the time of the disease, decreasing its ability to spread from one family to another). The evolutionary advantage of this enzyme is that it allows the Eskimo to store energy easily, and makes it difficult to take energy out of fat. In the western world, this means that Eskimos would store processed carbohydrates all too quickly, leading to obesity. But it also affects them into adulthood. This genetic anomaly, once thought to be rare, is common among aboriginal arctic people. But this points out how one cannot take one “diet” and assume it will work with all people. The genetics of diet are just starting to take be learned. For the adults, the ability to quickly store, and to make it difficult to utilize fat is evolutionary advantageous in this society – it allows them to survive famines particularly well. J Lipid Research 2012 Pub Med ID 22045927

24 Hour Flu Does Not Exist: Its Food Poisoning

 

Food Poisoning: Don’t Get Mis-Diagnosed

dr terry simpson arizona lap band

In the kitchen and in the Operating Room

You wake up feeling like you are hung-over, muscles hurt, then you realize you need to run to the bathroom. You call in sick to work, and spend the day in bed – quietly hoping your intestines will calm down and while you don’t feel like eating – you just want to keep down some water for a bit. The next day you wake up feeling fine- maybe a touch weak, but ok.  It isn’t the flu, you were poisoned.

No virus, influenza or otherwise, lasts for only 24 hours.  When flu season comes, that miserable virus will last 2 to 3 weeks. What does last for that period of time is food born illness. So  before we go into that– be sure to get vaccinated against the flu!

 

Kitchen Safety and Avoiding Food Poisoning

Food poisoning (technically we doctors call it foodborne illness) happens when we eat or drink something that is contaminated with bacteria, parasites, or viruses, or with some chemical that causes illness.

FACT: Every year 48 million people in the United States become ill from food, 128,00 are hospitalized, and 3,000 people die from foodborne illnesses. 

With chicken we worry about salmonella.However, if you are cooking above 130°F, the salmonella bacteria are unable to grow, as are all other common bugs. Still, food safety is important. Wash hands after handling raw meat, and wash all surfaces and utensils after they come in contact with raw meat. It is more likely that the raw meat will contaminate those surfaces and that those surfaces will pass the bugs onto other foods than you becoming sick from the meat directly.

For beef, the FDA states that it is safe when kept at a temperature of 130°F for 112 minutes or 140°F for 12 minutes. The temperature of a rare steak is between 130°F and 139°F in the center. By cooking the steak for 45 minutes at 136°F in a sous vide water oven, you will keep well within the recommended limits. Some cook the steak longer—two to four hours—but I find that 45 minutes for a 1-inch-thick steak works well. The fast grilling of a steak or standard cooking will also kill those bacteria.

Cross-Contamination

avoid food poisoning

Proper handling of poultry – includes washing all surfaces and utensils

The biggest issue with bacteria and food safety is cross-contamination. This means the bugs from one food are passively transferred to another food, where they grow. For example, if you wash some raw chicken in the sink where there is a cutting knife, you can contaminate that knife with bacteria. If you clean the knife insufficiently to rid it of the bacteria and then use it to cut some cooked eggs, these eggs can become the perfect place for bacteria to grow like crazy (especially if the eggs sit at room temperature). If you eat the eggs, you can get sick from the chicken (so the chicken came first). The lesson here is that if you wash raw poultry in the sink, be sure to have that sink cleaned out well to avoid cross-contaminating other utensils or serving dishes. Anytime you handle any raw meat or eggs, treat everything they touch as if it just came out of the toilet.

Do not use the same cutting board for raw and cooked meats. If you own only one cutting board, be sure to wipe it down with a bleach solution after cutting raw meat on it.

If you use a knife or fork or any instrument on raw meat, wash that utensil carefully. Essentially, consider raw meat to be contaminated, along with anything it touches: you, your clothes, your cooking utensils, your cutting boards, and your knives. Remember, when people get sick from the bacteria from raw meat, it is typically because of cross-contamination from other foods, from food workers improper techniques.

Refrigerate all foods promptly. If food is at room temperature for more than two hours, it may not be safe to eat. The bacteria that cause food poisoning typically do not produce an odor or change the texture of the food. Think about this the next time someone invites you to a buffet.

Make certain that your refrigerator is kept at 40°F or cooler, and that there is plenty of room for air to circulate in the refrigerator. Keep the freezer at or below 0°F.

Wash your hands carefully. I use a special soap made primarily from alcohol, the same type of soap surgeons use before scrubbing in the operating room. You can purchase this from most stores; one brand is Purell. Always wash after handling raw meat, poultry, fish, shellfish, produce, or raw eggs. Scrub and lather for at least for 20 seconds after handling any raw meat. An easy way to do that is to sing “Happy Birthday” to yourself twice while scrubbing your hands.

Wash all fruits and vegetables under running water before eating or cooking them. Use a vegetable brush to scrub melons and cucumbers, and then dry with a paper towel. Consider the vegetable brush contaminated, so sanitize it frequently.

It is better to throw out food than to be sick. Don’t be afraid to toss out any food that makes you suspicious.

How do “they” decide how much and how long to cook? Microbiologists have determined how much heat and time is needed to kill 90 percent of the bugs To kill 99 percent of the bugs you have to cook the food for twice as long (or increase the heat).

MYTH: You want to kill all those bugs!

Using a digital thermometer means never guessing

No, let’s not. First, it is probably impossible to do that. Second, the longer you cook something or the higher temperature you cook it, the more the heat will affect the flavor of the food. There are no guarantees that overcooking food will make it safe, or that under cooking food puts you in danger.

Because it is an average, the standards are much higher than commonly needed. Even if you were to kill 99.9999 % and someone’s thermometer was off, or the oven was not heating properly, then overcooking provides some safety but at the expense of flavor.

The entity responsible for this in the U.S. Department of Agriculture (USDA) is the Food Safety and Inspection Service (FSIS). As with most government bodies, it has a scientific advisory panel that makes recommendations. The advisory panel found that the FSIS figures for poultry were way too high. The FSIS recommends temperature and time enough to kill 99.99999 percent of the bacteria) but the panel recommended enough to kill 99.995 percent of the bacteria. At 122°F there are no bugs that are known to survive – on this planet.

“But on Chopped they reject under cooked food!”
I’m a huge fan of the Food Network. On the show Chopped you will see the judges reject food that they consider “under cooked” or “raw.” Are they crazy? Well, they might be (most chefs, like surgeons, get a bit nutty). But they sometimes are overdoing it when it comes to chicken or worrying about cross-contamination in a 20- to 30-minute contest. The funny thing is they will eat something that a chef has double-dipped. (The mouth has a far higher bacteria content, but if they would kiss it, they eat it!) The bottom line: over cooking foods ruins the flavor and texture. Pork can be pink, and chicken should not be cooked to an internal temperature of over 145 – and use a thermometer (guessing is never precise).

My favorite quote is from Chef Gordon Ramsay, who on his show “Hell’s Kitchen” will scream at the contestants when they under cook food (they usually under cook scallops or halibut on the stove top). He yells: “It’s raaaaaw!!!” Then tosses the food on the floor or in the trash.

It’s RAAAAW

REFERENCES:

(1) The loss from food borne illness in the United States is about 77 billion dollars a year.

J Food Prot 2012 Pub Med ID 22221364

(2) The time and temperature combinations for beef can be found from the Food Safety and Inspection Service guidelines. http://www.fsis.usda.gov/oa/fr/95033f-a.htm The part of their Chart is here: Min Internal Temp F 6.5 log lethality 7.0 log lethality 130 F 112 min 121 min 135 F 36 min 37 min 140 F 12 min 12 min 145 F 4 min 4 min 150 F 67 seconds 72 seconds The 6.5 log lethality means you are killing 99.99997 percent of the bugs (also called 6.5D) . A 7D lethality means you are killing 99.9999999 per cent of the bugs. If you have highly contaminated poultry (37,500 bacteria per gram of raw meat) then 3.5 ounces of meat would have 5.4 million Salmonella. To drop 7D means you would reduce 10 million pathogens to one bug. It takes about 105 Salmonella per gram of food to cause illness, less Salmonella than that cause no clinical symptoms. Thus, with worst case scenario you could kill just 99.999 per cent of the bacteria and not have symptoms (a 5D reduction).

Min Internal Temp F 6.5 log lethality 7.0 log lethality
130 F 112 min 121 min
135 F 36 min 37 min
140 F 12 min 12 min
145 F 4 min 4 min
150 F 67 seconds 72 seconds

The bacteria E. coli strain 0157 can cause illness with as little as 10 bacteria per gram of food. Thus a 6.5 D would not be adequate but a 7D would. As you increase the temperature, it decreases the time – it is a logarithm scale, which is why the drop in time with an increase in temperature. In low temperature cooking (Sous Vide), medium rare beef is typically cooked at 136 degrees for 45 minutes to an hour. That, combined with the searing of the surface at 400 degrees (most bacteria would reside on the surface of the meat) in addition to seasoning the surface of the meat with salt,which also kills bacteria, provides a large margin of safety. Most bacteria do not live above 120 degrees, and as you increase the temperature you kill more of them. At 102 degrees most bacteria can no longer reproduce- which is the protective nature of human fevers.

Sous Vide – its quite safe

(3) There are many ways of becoming contaminated by food workers. Most food illness comes from food workers, not from cooking. Another reason to cook and eat at home.

J Food Prot 2009 Pub Med ID 19205488

(4) Hand washing guidelines can be found at the CDC website. The keys are to not wear rings, jewelry, watches when handling raw food. Soap and water are fine- keeping the water running or turning on the water with a paper towel works. After any food preparation, and as often as needed, to remove contaminated residue. Remember, before handling food to wash also- consider your hands unclean. http://www.cdc.gov/nceh/vsp/cruiselines/handwashing_guidelines.htm

I like to hand wash by singing “Happy Birthday” twice – then I know I am done!

Parts of this post come from our new book coming out soon — (we hope) – called JUST EAT.

 

 

The Band Doesn’t Work When You Eat

The biggest challenge to taking patients from other lap-band surgeons is they don’t know how the lapband works. So, let me be very clear: The lap band does not work when you eat – the lapband works two hours after you eat. 


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