Plaquology

Plaquology: A new term.

Plaquology: def: (plaque-: atherosclerotic plaque; -ology: study of.) The study of atherosclerotic plaque, originating in the early 21st century during the time period when the material underlying atherosclerosis gained recognition as a measure superior to "risk factors" for cardiovascular disease. Previous to the plaque concept, blood measures of cholesterol and adverse lifestyle habits, such as smoking and sedentary lifestyle, alone had been used to predict potential for cardiovascular events. With acceptance of the concept of plaque measurement, the concept of risk factors was abandoned.


Look it up in the current Oxford Dictionary of the English Language, or Webster's Dictionary, and I'm afraid that you still won't find plaquology . . . but you should.

I'm currently rewriting many parts of the Track Your Plaque book. The rewriting process has caused me to review just how much we've learned these past few years. One of the phenomena that fascinates me is that we now have non-medical people--teachers, software people, engineers, bankers, bed and breakfast owners, retired businesspeople, etc.--all discussing the finer points of coronary atherosclerotic plaque--plaquology--what constitutes plaque, what triggers plaque inflammation, how to quantify potential for plaque rupture or plaque quiescence, what effect various treatments have on plaque composition and behavior, etc.

We now have a legion of Plaquologists!

I'm very proud of our Plaquologists. Having devoted themselves to the study of plaque, their level of knowledge now exceeds that of 99% of practicing physicians, including my colleagues, the cardiologists. While cardiologists spend their day squashing/cutting/vaporizing plaque, they are no more experts in plaquology than a carpenter is an expert in trees. More often than not, cardiologists view plaque as just something that gets in their way, rather than the quantifiable, modifiable, reversible material that we can exert control over.

One of the software tools currently in the works for the Track Your Plaque website is a certification process. Members will be able to gain a "certification" in various topics relevant to plaquology, such as plaque quantification, lipoprotein testing, and nutritional supplements.

How about a Doctor of Plaquology?

Thyroid perspective update

Since the publication of the extraordinary HUNT Study relating the entire spectrum of thyroid function and heart issues, I have been vigorously and systematically examining thyroid function in numerous patients.

While there's no news in relating flagrant low thyroid function with triggering heart disease in several forms, the cut-off between low thyroid and normal thyroid has been a matter of dispute for decades.

In the early 20th century, low thyroid function wasn't diagnosed until someone gained 40 lbs, displayed extravagant amounts of edema (water retention) in the legs and huge bags under the eyes, hair fell out in clumps, and often eventually proved fatal. At autopsy, these unfortunates also showed advanced and extensive quantities of coronary atherosclerotic plaque.

Low thyroid is usually diagnosed on the basis of the blood test, thyroid stimulating hormone, or TSH. TSH is a pituitary gland hormone responsible for stimulation of thyroid function. When thyroid function flags, the pituitary increases TSH release. Thus, a high TSH signals lower thyroid hormone levels.

The difficulty is in distinguishing normal thyroid function from low thyroid function judged by TSH levels. As the years have passed, in fact, the cut-off for "normal" TSH has drifted lower and lower.

The HUNT Study, I believe, clinches the argument: A TSH of 1.5 or lower, perhaps even 1.0 or lower, is desirable to eliminate the excess cardiovascular risk provided by an underactive thyroid, not to mention feel better: more energetic, clearer thinking, greater well-being.

Having now applied this renewed appreciation for thyroid, I have come to believe that:

--Low thyroid function, even subtle levels, are rampant and far more common than ever previously thought. In my office practice, the case could be made that several people per day are marginally or mildly hypothyroid (low in thyroid).
--Restoration of optimal thyroid levels facilitates correction of lipid measures, especially LDL cholesterol and, to a lesser degree, lipoprotein patterns dependent on the insulin axis such as triglycerides and small LDL. It's a lot happier way to correct lipids than statins.

I don't discount the value of feeling better. People who feel better--more energetic, more upbeat, clearer thinking--tend to do better in health overall. If thyroid restoration is a part of that equation, then greater attention should be paid to this facet of health on our way to optimal heart health.

Though I sometimes feel like an endocrinologist dispensing desiccated thyroid (rarely the synthetic T4), I believe that this has been a previously neglected and important part of our effort to achieve coronary plaque stabilization and reversal.

Accidental Health


"I shall never have smallpox for I have had cowpox; I shall never
have an ugly pockmarked face."

Such was the idle comment made by a milkmaid to Edward Jenner in 1768 when Jenner was 19, a remark that later prompted his investigations into using isolates of cowpox injected into humans as the first vaccination against the devastations of the European epidemic of smallpox.

(A caricature of Jenner administering cowpox vaccine to people, causing them to sprout bovine appendages. Image courtesy Wikipedia and the Library of Congress.)

When I look back, something similar has happened here.

Although the Track Your Plaque program is intended to stop and reverse coronary plaque using the only available means of tracking coronary plaque, i.e., heart scans, an unintended panel of benefits follow:

--People lose weight, often dramatically
--People gain greater energy
--Thinking is clearer, emotions more stable
--Sleep is deeper
--Bone density increases
--Physical strength and coordination improve
--Winter blues dissipate
--Blood sugar drops dramatically
--Blood pressure drops

Cholesterol (lipid) panels also settle to values that most physicians deem impossible or impractical, given our target of 60:60:60, i.e., LDL 60 mg/dl or less, HDL 60 mg/dl or higher, triglycerides 60 mg/dl or less. And medications are not always necessary to achieve these values. (When I show these values to my colleagues, they declare them flukes, unobtainable only in select people with high doses of medications.)

I didn’t set out to find the next weight loss solution, nor the key to boundless energy. My goal was "simpler": create a program of heart health. I am, after all, a cardiologist.

I was so intently focused on achieving incremental improvements over the steps leading to heart disease prevention that I failed to recognize the profound phenomena that accompanied it: people were quicker, smarter, thinner, and healthier.

In other words, I believe that we have inadvertently created a program of super health and performance.

Ironically, most people don't want to talk about heart disease, let alone reversal of heart disease. They do want to talk about getting thinner, feeling more energetic, living longer, better cholesterol values, etc.

Perhaps there's a lesson in this.

Livin' La Vida Low Carb interview


I recently provided an interview for Livin' La Vida Low Carb's irrepressible Jimmy Moore.

Jimmy runs a fun set of blogs, webcasts, and the like to broadcast this message of reducing carbohydrates in the diet. He credits his 210 lb weight loss to a strict low-carbohydrate and exercise program.

For the interview, just go to The Livin' the Vida Low Carb Show, Episode 185, or click here.

And click here for Part 2


For more of Jimmy Moore's spin on the entire low-carbohydrate diet experience, he maintains several popular blogs, including Carb Wire and The Livin' La Vida Low-Carb Blog.

Wheat withdrawal: How common?

In response to the recent Heart Scan Blog poll,

Have you experienced fatigue and mental fogginess with stopping wheat, i.e., "wheat withdrawal"?

the 104 respondents said:


Yes, I have experienced it: 26 (25%)

No, I stopped wheat and did not experience it: 65 (62%)

I'm not sure: 3 (2%)

I haven't tried it but plan to: 7 (6%)

I haven't tried it and don't plan to: 3 (2%)



So 25% of respondents reported experiencing the fatigue and mental fogginess of wheat withdrawal. This is similar to what I observe in my practice.

I counsel many patients to consider the elimination of wheat, as well as cornstarch products, in an effort to regain control over:

--Weight
--Appetite
--Low HDL
--High triglycerides
--Small LDL
--High blood sugar
--High blood pressure

All of these issues respond--often dramatically--to elimination of wheat and cornstarch.

Why would there be undesirable effects of eliminating wheat?

One clear issue is that elimination of wheat and other sugar-equivalents deprives your body of glucose. Your body then needs to resort to fatty acid metabolism to generate energy. Apparently, some people are inefficient at this conversion, having subsisted on carbohydrates for the last few decades of their lives. However, as fatty acid metabolism kicks in, energy generation improves. That is my (over-)simplified way of reasoning it through.

However, are there other explanations behind the mental fogginess, drop in energy, and overwhelming sleepiness? Some readers of this blog have suggested that, since opioid-like sequences (i.e., amino acide sequences that activate opiate receptors) are present in wheat, perhaps withdrawal from wheat represents a lesser form of opiate withdrawal. I find this a fascinating possibility, though I know of no literature devoted to establishing a cause-effect relationship.

Whatever the mechanism, I find it very peculiar that this food widely touted by the USDA, American Heart Association, and other agencies actually triggers a withdrawal syndrome in approximately 25% of people. Spinach does not trigger withdrawal. Nor does flaxseed, olive oil, almonds, and countless other healthy foods.

Then why would whole wheat grains be lumped with other healthy foods?

Treat the patient, not the test

"Treat the patient, not the test."

That is a common "pearl" of medical wisdom often passed on during medical training.

It refers to the fact that we should always view any laboratory or imaging test in the context of the live, human patient and not just treat any unexpected value that doesn't seem to make sense.

I raise this issue because it recently came up on a discussion on the Track Your Plaque Forum. A Member with a high heart scan score of around 1100 was advised by his doctor that it should be ignored, because he'd prefer to treat the patient, not the test. The patient is apparently slender, physically active, and entirely without symptoms, with favorable cholesterol values as well. The high heart scan score didn't seem to jive with the appearance of the patient, as viewed by this doctor.

This common phrase is meant to impart wisdom. It is a reminder that we treat real people, not just a jumble of laboratory values.

But the unspoken part of the equation is that judgment needs to be applied. A well looking person who shows an unexpected rise in white blood cell count could just have a screwy result, or could have leukemia. Liver tests (AST, ALT) that top 400 could represent a fluke, or dehydration incurred during a long workout, or hepatitis from a long ago blood transfusion.

Yes, treat the patient. But don't be an idiot and entirely dismiss the signficance of an unexpected laboratory or imaging test. A heart scan score of 1100 should be as readily dismissed as discovering a white blood cell count of 90,000 (normal is less than 12,000), or a 5 cm mass in the lung. The absence of symptoms or the failure of conventional risk factors to suggest causation is insufficient reason to dismiss the concrete findings of a test.

In this particular person, dismissing the significance of the heart scan finding by suggesting that the doctor should treat the patient, not the test, is tantamount to:

--Colossal ignorance
--Malpractice
--A certain sentencing of the hapless patient to future major heart procedures, heart attack or death (20-25% likelihood every year, or a virtual certainty over the next 5 years).

There is an ounce of wisdom in this old medical pearl. But there's also plenty of room for a knuckleheaded doctor to misconstrue and abuse its meaning for the sake of covering up his/her ignorance, laziness, or lack of caring.

Does high cholesterol cause heart disease?

How often does someone develop coronary heart disease from high cholesterol alone?

Believe drug industry propaganda and you'd think that everyone does. Physicians have bought into this concept also, driving the $27 billion annual sales in statin cholesterol drugs.

In my experience, I can count the number of people who develop coronary disease from high cholesterol alone on one hand. It happens--but rarely.

That's not to say that cholesterol is not an issue. That rant populates many of the kook websites and conversations on the internet that argue that high cholesterol is a surrogate for some other health issue, or that it is part of a medical conspiracy.

The problem with conventional measurement of cholesterol is that it ignores the particle size issue: whether particles are large or small. Small LDL are flagrant causes of coronary atherosclerotic plaque. Large LDL is a rather meager cause. Simple cholesterol measurement also ignores the presence of other factors that lead to heart disease, like lipoprotein(a) and vitamin D deficiency.

Conventional total and LDL cholesterol do not distinguish between large and small particles, nor reveal the presence of other hidden patterns. An LDL cholesterol of 150 mg/dl, for instance, may contain 100% large LDL--a relatively good situation that by itself is unlikely to cause heart disease, or it might contain 100% small LDL--a very bad situation that is likely to cause heart disease. Just knowing that LDL is 150 mg/dl tells you almost nothing. In 2008, most people have some mixture of the two, particularly with the proliferation of "healthy whole grains" in the American diet, foods that trigger formation of small LDL.

The imprecision and uncertainty of conventional total and LDL cholesterol has provided ammunition for some to discount the entire cholesterol concept. And they are right to a degree: cholesterol by itself is indeed a lousy predictor of heart disease. But small LDL is a very reliable predictor of potential for heart disease. Dismissing the entire concept because the standard measurement stinks is not right, either.

It is therefore an unfortunate oversimplification to say that high cholesterol causes heart disease or that it doesn't. It can--but not always, depending on size and other factors. In my view, it is therefore irreponsible to treat total or LDL cholesterol without knowledge of particle size. I've seen this play out many times: Someone with an LDL cholesterol of 150 mg/dl but all large still gets prescribed a statin drug by his/her doctor. Or someone with an LDL of 100 mg/dl--generally "favorable" by most standards--is not treated but it is all small and the person is truly at high risk. (Also, knowledge that all LDL particles are small does not mean that statins are the preferred agent. In my view, they are not.)

Are humans meant to be omnivores?

Are humans meant to be omnivores?

Does the ideal human diet include animal products like meat, fish, cheese, eggs, and dairy products?

Or should the ideal diet be devoid of all animal products?a vegetarian diet?

Though the argument is distorted by modern food processing methods (e.g., factory farming, long-term administration of antibiotics), convenience foods, and pseudo-foods crafted by food manufacturers, there are, obviously, proponents of both extremes.

The Atkins’ diet, for instance, advocates unrestricted intake of animal products, regardless of production methods or curing (sausage and bacon). At the opposite extreme are diets like Ornish (Dr. Dean Ornish’s Program for Reversal of Heart Disease) and the experiences of Dr. Colin Campbell, articulated in his studies and book, The China Study, in which he lambasts animal products, including dairy, as triggers for cancer and heart disease.

So which end of the spectrum is correct? Or ideal?

For the sake of argument, let's put aside philosophical questions (like not wanting eat animal products because of aversion to killing any living being) or ethical concerns (inhumane treatment of farm animals, cruel slaughtering practices, etc.). Does the inclusion of animal products provide advantage? Disadvantage?

The traditional argument against animal products has been saturated fat. If we accept that we’ve demoted the saturated fat question to a place far down the list of importance (though this is yet another argument to discuss another time), several questions emerge:

• If humans were meant to be vegetarian, why do omega-3 fatty acids (mostly from wild game and fish) yield such substantial health benefits, including dramatic reduction in sudden death from heart disease?

• Why would vitamin K2 (from meats and milk, as well as fermented foods like natto and cheese), obtainable in only the tiniest amounts on a vegetarian diet, provide such significant benefits on bone and cardiovascular health?

• Why would vitamin B12 (from meats) be necessary to maintain a normal blood count, prevent anemia, keep homocysteine at bay, and lead to profound neurologic dysfunction when deficient?


Omega-3 fatty acids and vitamins K2 and B12 cannot be obtained in satisfactory quantities from a pure vegetarian diet. The consequences of deficiency are not measured in decades, but in a few years. The conclusion is unavoidable: Evolutionarily, humans are meant to consume at least some foods from animal sources.

That's not to say that we should gorge ourselves on animal products. Gout (excessive uric acid) and kidney stones are among the unhealthy consequences of excessive quantities of meats in our diets.

It pains me to say this, since I’ve always favored a vegetarian lifestyle, mostly because of philosophical concerns, as well as worries about the safety of our factory farm-raised livestock and rampant inhumane practices.

But, stepping back and objectively examining what nutritional approach appears to stack the odds in favor of optimal health, I believe that only one conclusion is possible: Humans are meant to be omnivorous, meant to consume some quantity of animal products in addition to vegetables, fruits, nuts, and other non-animal products.

The question is how much?

Are you wheat-free?

According to the recent Heart Scan Blog poll, Are you wheat-free?, the 173 respondents said:

Yes, I am free of wheat products.
87 (50%)

No, I include wheat products in my diet.
73 (42%)

I'm not sure.
1 (0%)

I think you're nuts.
12 (6%)


That's kind of what I expected.

There are people who have eliminated wheat and experienced nothing except a feeling of deprivation. These people are in the minority. Though the poll was not set up to reflect this (i.e., asked who tried it and experienced no perceptible benefit), in my experience, this applies to about 20% of people. Little happens with elimination of wheat beyond modest weight loss. Those are the people who generally think I'm nuts.

Or, these people may have been brainwashed by "official" agencies like the USDA, the American Diabetes Association, and American Heart Association and the constant marketing of (high markup) grain products like Cheerios and Shredded Wheat . Some people are really uncomfortable going against the "grain" of popular public opinion.

Then there are the people who try to eliminate wheat and fail. They can't deal with the overwhelming fatigue, mental fog, and moodiness that comes with withdrawal from wheat, the phenomenon of converting from a sugar-burning metabolism to a fat-burning metabolism. Although wheat withdrawal usually runs its course in 2-5 days, some people find it intolerable. (That would be another fun poll to run: Have you experienced wheat-withdrawal?) Occasionally, the withdrawal is replaced by endless cravings, a phenomenon that applies to only about 10% of people. These are the true "wheat addicts." These are the people who eliminate wheat, lose 40 lbs, then regain it when they have one cracker and the floodgates of impulse control crumble.

Then there are the majority, 50% in the poll, though more like 70% in my face-to-face experience. Why is my experience skewed? Well, the people I deal with every day come because of coronary disease in some form (abnormal heart scan score, for instance) or because of lipid or lipoprotein abnormalities. So my experienced is skewed towards people who are likely to have something abnormal, such as high triglycerides or small LDL particles, both of which are created by including wheat in the diet.

This last group also shows unexpected effects of wheat elimination: substantial weight loss, dramatic reductions in blood sugar and triglycerides, increase in HDL, reductions in small LDL, reduction in c-reactive protein and other inflammatory measures. Appetite shrinks considerably. Not uncommonly, improved well-being, reduction in bowel complaints like cramping or "irritable bowel syndrome" is experienced, some rashes clear, occasionally arthritis will improve. See below for some of the testimonials to this experience.

When I first set out to advise people to eliminate wheat, I did it because I reasoned that it would be a quick and simple way to get people to reduce blood sugars and help correct the ubiquitous metabolic syndrome that afflicts nearly 50 million Americans now. And it did indeed accomplish that simple goal. But I did not expect all the other benefits to develop, the dramatic weight loss, improved well-being, reduction in hunger, etc.

I view wheat elimination as an easy-to-remember, digestible way to obtain enormous health benefits in a coronary plaque-control program, one that works for most--but not all--people. And I relate this experience not to sell you something, but to simply relate what I see as the truth, a way that is contrary to conventional advice yet works enormously well.



Unsolicited testimonials of people who have successfully been wheat-free:

Barbara W said:

It's true! We've done it. My husband and I stopped eating all grains and sugar in February. At this point, we really don't miss them any more. It was a huge change, but it's worth the effort. I've lost over 20 pounds (10 to go)and my husband has lost 45 pounds (20 to go). On top of it, our body shapes have changed drastically. It is really amazing. I've got my waist back (and a whole wardrobe of clothes) - I'm thrilled.

I'm also very happy to be eating foods that I always loved like eggs, avocados, and meats - without feeling guilty that they're not good for me.

With the extremely hot weather this week in our area, we thought we'd "treat" ourselves to small ice cream cones. To our surprise, it wasn't that much of a treat. Didn't even taste as good as we'd anticipated. I know I would have been much more satisfied with a snack of smoked salmon with fresh dill, capers, chopped onion and drizzled with lemon juice.

Aside from weight changes, we both feel so much better in general - feel much more alert and move around with much greater flexibility, sleep well, never have any indigestion. We're really enjoying this. It's like feeling younger.

It's not a diet for us. This will be the way we eat from now on. Actually, we think our food has become more interesting and varied since giving up all the "white stuff". I guess we felt compelled to get a little more creative.

Eating out (or at other peoples' places) has probably been the hardest part of this adjustment. But now we're getting pretty comfortable saying what we won't eat. I'm starting to enjoy the reactions it produces.


Weight loss, increased energy, less abdominal bloating, better sleep--I've seen it many times, as well.


Dotslady said:

I was a victim of the '80s lowfat diet craze - doc told me I was obese, gave me the Standard American Diet and said to watch my fat (I'm not a big meat eater, didn't like mayo ... couldn't figure out where my fat was coming from! maybe the fries - I will admit I liked fries). I looked to the USDA food pyramid and to increase my fiber for the constipation I was experiencing. Bread with 3 grams of fiber wasn't good enough; I turned to Kashi cereals for 11 years. My constipation turned to steattorrhea and a celiac disease diagnosis! *No gut pains!* My PCP sent me to the gastroenterologist for a colonscopy because my ferritin was a 5 (20 is low range). Good thing I googled around and asked him to do an endoscopy or I'd be a zombie by now.

My symptoms were depression & anxiety, eczema, GERD, hypothyroidism, mild dizziness, tripping, Alzheimer's-like memory problems, insomnia, heart palpitations, fibromyalgia, worsening eyesight, mild cardiomyopathy, to name a few.

After six months gluten-free, I asked my gastroenterologist about feeling full early ... he said he didn't know what I was talking about! *shrug*

But *I* knew -- it was the gluten/starches! My satiety level has totally changed, and for the first time in my life I feel NORMAL!



Feeling satisfied with less is a prominent effect in my experience, too. You need to eat less, you're driven to snack less, less likely to give in to those evil little bedtime or middle-of-the-night impulses that make you feel ashamed and guilty.



An anonymous (female) commenter said:

My life changed when I cut not only all wheat, but all grains from my diet.

For the first time in my life, I was no longer hungry -no hunger pangs between meals; no overwhelming desire to snack. Now I eat at mealtimes without even thinking about food in between.

I've dropped 70 pounds, effortlessly, come off high blood pressure meds and control my blood sugar without medication.

I don't know whether it was just the elimination of grain, especially wheat, or whether it was a combination of grain elimnation along with a number of other changes, but I do know that mere reduction of grain consumption still left me hungry. It wasn't until I elimnated it that the overwhelming redution in appetite kicked in.

As a former wheat-addicted vegetarian, who thought she was eating healthily according to all the expert advice out there at the time, I can only shake my head at how mistaken I was.




Stan said:

It's worth it and you won't look back!

Many things will improve, not just weight reduction: you will think clearer, your reflexes will improve, your breathing rate will go down, your blood pressure will normalize. You will never or rarely have a fever or viral infections like cold or flu. You will become more resistant to cold temperature and you will rarely feel tired, ever!



Ortcloud said:

Whenever I go out to breakfast I look around and I am in shock at what people eat for breakfast. Big stack of pancakes, fruit, fruit juice syrup, just like you said. This is not breakfast, this is dessert ! It has the same sugar and nutrition as a birthday cake, would anyone think cake is ok for breakfast ? No, but that is exactly the equivalent of what they are eating. Somehow we have been duped to think this is ok. For me, I typically eat an omelette when I go out, low carb and no sugar. I dont eat wheat but invariably it comes with the meal and I try to tell the waitress no thanks, they are stunned. They try to push some other type of wheat or sugar product on me instead, finally I have to tell them I dont eat wheat and they are doubly stunned. They cant comprehend it. We have a long way to go in terms of re-education.

Yes. Don't be surprised at the incomprehension, the rolled eyes, even the anger that can sometimes result. Imagine that told you that the food you've come to rely on and love is killing you!



Anne said:

I was overweight by only about 15lbs and I was having pitting edema in my legs and shortness of breath. My cardiologist and I were discussing the possible need of an angiogram. I was three years out from heart bypass surgery.

Before we could schedule the procedure, I tested positive for gluten sensitivity through www.enterolab.com. I eliminated not only wheat but also barley and rye and oats(very contaminated with wheat) from my diet. Within a few weeks my edema was gone, my energy was up and I was no longer short of breath. I lost about 10 lbs. The main reason I gave up gluten was to see if I could stop the progression of my peripheral neuropathy. Getting off wheat and other gluten grains has given me back my life. I have been gluten free for 4 years and feel younger than I have in many years.

There are many gluten free processed foods, but I have found I feel my best when I stick with whole foods.



Ann has a different reason (gluten enteropathy, or celiac disease) for wanting to be wheat-free. But I've seen similar improvements that go beyond just relief of the symptoms attributable to the inflammatory intestinal effects of gluten elimination.



Wccaguy said:

I have relatively successfully cut carbs and grains from my diet thus far.

Because I've got some weight to lose, I have tried to keep the carb count low and I've lost 15 pounds since then.

I have also been very surprised at the significant reduction in my appetite. I've read about the experience of others with regard to appetite reduction and couldn't really imagine that it could happen for me too. But it has.

A few weeks ago, I attended a party catered by one of my favorite italian restaurants and got myself offtrack for two days. Then it took me a couple of days to get back on track because my appetite returned.

Check out Jimmy Moore's website for lots of ideas about variations of foods to try. The latest thing I picked up from Jimmy is the good old-fashioned hard boiled egg. Two or three eggs with some spicy hot sauce for breakfast and a handful of almonds mid-morning plus a couple glasses of water and I'm good for the morning no problem.

I find myself thinking about lunch not because I'm really hungry but out of habit.

The cool thing too now is that the more I do this, the more I'm just not tempted much to do anything but this diet.

No more canned foods

If you haven't already caught the news, it's time to eliminate canned foods and exposure to plastics that contain the chemical, bisphenol A (BPA). A worrisome and unexpected association with heart disease and diabetes has been found.

This issue has been debated for some years ever since scientists at the NIH detected BPA in the blood samples of 93-95% of Americans, with consumer protection advocates calling for more research or even the outright banning of BPA , while industry representatives have argued that the data fail to conclusively prove adverse health effects.

Well, the argument has been tilted heavily in favor of increased consumer protection with the publication of a study in the Journal of the American Medical Association by Dr. Iain Lang and associates at the University of Exeter, UK, and the University of Iowa. Their study, released Sept. 17, 2008, Association of urinary bisphenol A concentration with medical disorders and laboratory abnormalities in adults, persuasively demonstrated a 40% increased incidence of coronary heart disease, heart attack, and diabetes with increasing exposure to BPA (as judged by urine levels) among the nearly 1500 adults aged 18-74 years. People with coronary heart disease had double the blood level of BPA compared to those without.

In addition, higher urine levels of BPA were associated with abnormalities of two liver tests, GGT and alkaline phosphatase.

Interestingly, although much of the debate over adverse health effects of BPA have centered around concern over cancer and reproductive risks, an association with cancer did not hold. (No analysis for reproductive issues was conducted in these adults, since most of the concern is for children exposed through polycarbonate baby bottle use. Some BPA critics have raised questions like low birth weight developing from exposure.) No relationship to thyroid disease was identified, also.

The editorial accompanying the study added some sharp commentary:

"Subsequent to an unexpected observation in 1997, numerous laboratory animal studies have identified low-dose drug-like effects of BPA at levels less than the dose used by the US Food and Drug Administration and the Environmental Protection Agency to estimate the current human acceptable daily intake dose (ADI) deemed safe for humans. These studies have shown adverse effects of BPA on the brain, reproductive system, and--most relevant to the findings of Lang et al--metabolic processes, including alterations in insulin homeostasis and liver enzymes. . . For example, when adults rats were fed a 0.2 microgram/kg per day dose of BPA for 1 month (a dose 250 times lower than the current ADI), BPA significantly decreased the activities of antioxidant enzymes and increased lipid peroxidation, thereby increasing oxidative stress. When adult mice were administered a 10 microgram/kg dose of BPA once a day for 2 days ( a dose 5 times lower than the ADI), BPA stimulated pancreatic beta cells to release insulin."

This study, piled on top of the worrisome literature that precede it, are enough for me: No more tin cans (which are lined with BPA), no more hard plastics labeled with recycling code #7 or #3, no more polycarbonate water bottles (the hard ones, often brightly colored). Microwaveable-safe may also mean human-unsafe, as highlighted by this damning assurance from the Tupperware people that BPA is not a health hazard.

The National Toxicology Program also issued these advice in response to the Lang study to reduce BPA exposure (reported by the Washington Post) :

· Don't microwave polycarbonate plastic food containers. Polycarbonate may break down from overuse at high temperatures and release BPA. (Manufacturers are not required to disclose whether an item contains BPA, but polycarbonate containers that do usually have a No. 7 on the bottom.)

· Reduce use of canned foods, especially acidic foods such as tomatoes that can accelerate leaching of BPA from plastic can linings. Opt for soups, vegetables and other items packaged in cardboard "brick" cartons, made of safer layers of aluminum and polyethylene plastic (labeled No. 2).

· Switch to glass, porcelain or stainless-steel containers, particularly for hot food or liquids.

· Use baby bottles that are BPA-free; in the past year, most major manufacturers have developed bottles made without BPA.
Do you work for the pharmaceutical industry?

Do you work for the pharmaceutical industry?

In response to my post, Lovaza Rip-off, I received this angry comment:


Very high triglycerides, as you all know, is a very serious and life-threatening condition. Therefore, it is very important that any medication you take for treatment must be FDA proven and scientifically backed. This is true for a few reasons. First, there have been zero studies done to show the effects of Costco brand fish oil pills on patients with high triglycerides. So, you cannot assume, simply because the pills you are taking "claim" to have a certain amount of Omega 3 in the them, that they actually do (supplement labeling is self-submitted by the company, and not regulated by any external or 3rd party agency).

Secondly, the other components in fish oil, and maybe in Costco brand (no one knows because it isn't on the label) can actually inhibit the bioavailablity of Omega 3, most notably, Omega 6. And, nowhere on the Costco label does it tell you how much Omega 6 is in it. We also cannot underestimate the importance of purity with these compounds: a top selling brand of fish oil found stores like CVS was recently recalled because it was found to have large amounts of fire retardant in it! These supplements are NOT regulated by the FDA.

Thirdly, be careful when you compare costs. The cost of hospitalization due to acute pancreatitis (a risk of very high triglycerides) far outweighs the cost of taking Lovaza for even several years. If you have a real disease, you need a real drug. And, until Costco does a prospective long-term clinical trial to show that it lowers triglycerides, it should not be used in place of Lovaza.

Finally, I am a living example of how taking a high-potency supplement form of Omega 3 barely lowered my triglycerides, yet within 2 weeks of being on Lovaza there was a significant difference. I am now at my goal. So, before you knock a company, that, in my opinion, has saved my life, please do your research and do not mislead people into thinking that an Omega 3 is an Omega 3 is an Omega 3. If your insurance covers the most potent, the most pure, and the ONLY proven Omega 3 pill on the market, you should be thankful.



The comment was posted anonymously, so I don't know who it came from. But I can tell who I think it is: Someone who works for the drug industry.

This is a common phenomenon: Large corporations are fearful of the comments that are generated on internet conversations and other media. On the internet, there are actually people whose job it is to do "damage control." I suspect this came from one of them.

Why bother? Surely there are better things to do? Well, that's easy. There are billions of dollars at stake. Lovaza, in particular, is sold on the perception that it is somehow superior. If word gets out that maybe you can achieve the same results at a fraction of the cost . . .

Perhaps the "commenter" should also question whether omega-3 fatty acids can come from eating fish.

As part of my cardiology practice, I provide consultation on complex hyperlipidemias, or unusual lipid abnormalities. I have many patients with something called familial hypertriglyceridemia, a genetic condition that permits triglyceride levels of 500, 1000, even many thousands of mg/dl, levels that, as the anonymous commenter points out, can be dangerous.

I virtually never prescribe Lovaza for these people. In their treatment program, I use simple fish oil supplements, such as that from Costco, Sam's Club, or other retailers. I have not witnessed a single failure in treating these people and reducing triglycerides. People with lesser triglyceride abnormalities likewise respond very nicely to inexpensive fish oil that we can buy at the health food store. (I do rely on useful services like Consumer Reports and www.consumerlab.com to reassure us that no pesticide residues, mercury, or other contaminants are in the brands we use.) Excellent, high-quality fish oil supplements are sold by Carlson, Life Extension, Barlean's, even the Members' Mark brand from Sam's Club.

So, the notion that only prescription fish oil is capable of reducing triglycerides is, in a word, nonsense.

Take that back to your CEO.

Comments (30) -

  • Jenny

    3/24/2009 7:18:00 PM |

    The drug industry seems to have put a full time anonymous troll at work  replying to posts my blog.

    They always appeal to authority, along the lines of "How dare you say .... I'm a medical professional and what you are saying is dangerous...." They don't seem to get the part about how no one is going to believe their authority since they're posting anonymously.

    I occasionally post one of their screeds as my forum regulars enjoy bashing them. But my blog policy is that I don't make anonymous posts public if they are without merit.

  • Anonymous

    3/24/2009 8:26:00 PM |

    I wonder if that person continues to eat the foods that raised his triglycerides in the first place while taking the drug.  I suppose he considers himself smart and ahead of the game? Hah!!! Mother nature always wins!

  • Dr. William Davis

    3/24/2009 9:46:00 PM |

    Hi, Jenny--

    Good for you to stand up to them.

    I agree: They're very clever about crafting their comments to make you feel small. I find it funny. Here we are, David vs. Goliath, and they resort to deception, subterfuge, and smear to make their points.

    Anonymous (above): Excellent point! I failed to mention how effective diet is for high triglycerides.

  • Michael

    3/25/2009 12:57:00 AM |

    The argument that the vitamin industry is self-regulated and answers to nobody is genuine.  Look what happened to the financial industry with self regulated derivative products!  Given a choice between lab-tested Lovaza and an off-the-shelf fish oil that has no oversight for their claims ... I'll have to go with the Lovaza.  My triglycerides were 800+ ... now they are 300.  My physician said, with triglycerides that high, I can't take the chance of getting a dud bottle of vitamins.

  • Michael

    3/25/2009 1:03:00 AM |

    Re:  "I wonder if that person continues to eat the foods that raised his triglycerides in the first place while taking the drug."

    So you've set up a hypothetical situation and trash the person on the basis of your assumption/wondering?  And that makes you smarter than ... who?

  • Andrew

    3/25/2009 3:27:00 AM |

    lol OUCH, Dr. Davis.

    I think the CEO's Mama is going to feel that one.

    Excellent reply.  Although, I do think that one positive thing that can be taken away from what the "anonymous" person wrote is that it is very true that supplements are not regulated.  It is extremely important that everyone researches where their supplements come from and if they do meet some kind of quality control standards.

  • Anonymous

    3/25/2009 3:29:00 AM |

    I was thinking the same thing, what is he eating that nothing less than a prescription(?) drug has any effect?

    Regarding purity...  What?  Like no one else has ever had any recalls?

    What about all of the drugs that garnered FDA approval and were then recalled due to long term effects that did not show up in trials?

  • Anonymous

    3/25/2009 4:12:00 AM |

    I agree that person was probably affiliated with Big Pharma in some way.

    In early 2006, my triglycerides were 432mg/dl with no supplements. After taking four Life Extension Super Omega-3 capsules (which yields 2.4 grams of EPA/DHA) once daily and absolutely NO changes in my diet or added exercise, my triglycerides dropped to 157mg/dl when I retested a little over 3 months later, so I know their fish  oil works at reducing triglycerides. Life Extension brand costs me about 63 cents per day at that dosage and it has a 5 star rating from the International Fish Oil Standards. Here is a snip it from their website:

    "The International Fish Oil Standards (IFOS) is an international program concerned with the quality of omega 3 products, as it relates to the international standards for purity and concentration established by the World Health Organization and the Council for Responsible Nutrition."

    http://www.lef.org/Vitamins-Supplements/Health-Nutrition-Awards/Fish-Oil-Supplements.htm

    http://www.nutrasource.ca/ifos_new/index.asp?section=ifosfaq

    I also like the fact the Life Extension fish oil has sesame lignans & olive fruit extract in it as well.

  • Anonymous

    3/25/2009 1:56:00 PM |

    Supplements are not FDA regulated?  It kinda ruins your point when you make a completely false comment like this.

    Here are two FDA websites that describe exactly how they indeed do regulate the supplement industry:

    http://www.cfsan.fda.gov/~dms/supplmnt.html

    http://www.cfsan.fda.gov/~dms/dscgmps6.html

    Oh, to be a complete buffoon....

  • JPB

    3/25/2009 2:42:00 PM |

    I have noticed that any time I leave a comment that challenges any part of the current dogma that inevitably someone claiming to be a doctor steps up to tell me that I don't know what I am talking about....

  • Anonymous

    3/25/2009 2:53:00 PM |

    I eat tons of saturated fat and sometimes I take my fish oil but my trigs are 104  because I dont't eat any sugar or starch. Why take drugs when you can control the entire spectrum of cholesterol values and other health issues with diet?

    People you dont' need to take any drugs. You've been brainwashed big time.

  • mtflight

    3/25/2009 7:49:00 PM |

    OOps Dr. Davis, I accidentally published my last comment before proofing it and messed up a link. here it is as it was intended (post this one instead of the other one please).

    I can think of one instance where fish oil won't reduce triglycerides / VLDL:  in the presence of antioxidants.

    I know it sounds strange, but the mechanism by which VLDL/triglyceride reduction takes place depends on peroxidation products of n-3 polyunsaturated fatty acids.  

    It was noticed that when people take antioxidants with their fish oil, for instance vitamin E, the plasma TG/VLDL reductions did not take place.  I experienced this first hand... and I was baffled why the fish oil was "not working" at reducing my triglycerides.

    In a nutshell, the liver determines the presence of peroxidized [hopefully glycated as well] polyunsaturated fatty acids (PUFA), is not ideal for release into circulation, so through a process dubbed PERPP, the VLDL particle that never was is aborted and is instead kept inside the liver.

    The article is called "Hold The Antioxidants and Improve Plasma Lipids?" by Ronald L. Krauss, M.D. Ph.D. can be read at
    PubMed or
    The Journal of Clinical Investigation

    Peter genially deconstructs the described process in detail at AGE RAGE and ALE: VLDL degradation and Fish Oil

    So probably the best way to reduce triglycerides is to cut out the wheat/starch/sugar/honey/fructose.

    I still take fish oil (with antioxidants) but I eat low-carb so my triglycerides are below 100.

    R.L. Krauss is one of the researchers responsible for recognizing that small dense LDL  are the atherogenic LDL.  yet as an advisor to the AHA, well... not much progress there, unfortunately.

    Thanks for your blog Dr. Davis!

    Alex

  • moblogs

    3/25/2009 11:17:00 PM |

    ...And if they don't work for the industry, they probably should and collect their commission! Smile

    It just shows desperation. You can paste posters and ads everywhere but when it comes down to it, you can never beat word of mouth which will always help you achieve minimal cost and max. benefit. And word of mouth just expanded with the net.

    People like to help each other. Industries don't.

  • Shreela

    3/26/2009 2:14:00 AM |

    Dr. Davis: Did you and Jenny compare IP addresses between your emailer and her commenters by any chance?

    I searched for the following keyword combinations:

    fish oil recall
    cvs fish oil fire retardant
    cvs fish oil recall
    cvs omega fire retardant recall
    cvs fish oil PBDE recall
    cvs fish oil PCB recall

    I would hope that news of the nation's number 1 chain pharmacy having a very popular supplement recalled because of toxic contamination would be heavily represented in search results. But NO!

    Except that last keyword combo's first result did have "lab tested for contaminants", and surprise, CVS's fish oil caps passed (and they sourced Consumer Lab, so extra cred for their article):
    http://www.supplementgenius.com/2008/08/09/50-fish-oil-supplements-get-lab-tested/

    One of the emailer's other claims intrigued me, so I searched these keyword combos:

    omega 6 inhibits bioavailablity of omega 3
    omega 6 decrease bioavailablity of omega 3

    I haven't found much on omega 6 affecting bioavailability of omega 3 yet, but I did find a 97 study about "inadequate intake of vitamin E results in a decreased absorption of omega-3" at least.

  • Andrew

    3/26/2009 8:04:00 AM |

    "Here are two FDA websites that describe exactly how they indeed do regulate the supplement industry:

    http://www.cfsan.fda.gov/~dms/supplmnt.html

    http://www.cfsan.fda.gov/~dms/dscgmps6.html"

    Sadly, that's not really regulation.  

    From the FDA website:
    "Generally, manufacturers do not need to register their products with FDA nor get FDA approval before producing or selling dietary supplements.* Manufacturers must make sure that product label information is truthful and not misleading."

    It's the classic case of police oversight (actively looking for violators) vs. fire-alarm oversight (only responding when an alert has been raised).  So while it's true that regulation exists, it's not where it needs to be.

    If you have time, check out the documentary "Bigger, Faster, Stronger."  They show how absurdly easy it is to produce, promote and sell supplements that are complete and total garbage.

  • Trinkwasser

    3/26/2009 7:08:00 PM |

    Who needs fish oil supplements when you can eat the whole fish???

    In all seriousness there may be quality control issues with supplements, but I *decimated* my trigs simply by not eating excess carbs. I can't think of a way that something you don't eat could be adulterated

  • Dr. William Davis

    3/26/2009 9:43:00 PM |

    Hi, Shreela--

    Sorry, but it didn't even occur to me. We'll have to do that next time (and I'm sure there will be a next time).

  • Dr. William Davis

    3/26/2009 9:44:00 PM |

    Remember: We take fish oil to accomplish more than reduce triglycerides.

    It also reduces cardiovascular events, accelerates clearance of post-prandial abnormal particles, and modifies plaque composition.

  • Nameless

    3/27/2009 6:45:00 AM |

    My cardiologist tried to prescribe me Lovaza over the fish oil I normally take, using the argument that OTC brands may have mercury in them. I of course declined her offer, and tried to tell her that OTC brands are rather unlikely to have mercury.

    But it got me interested in the differences, if any, between Lovaza and OTC fish oil. I originally contacted GlaxoSmithKline, which was a waste of time, no response. So I went right to the source, Pronovo, the company that actually makes Lovaza for Glaxo. I had two questions, why are transfats listed as being in the product, and what about oxidation, which is the real potential problem with fish oils, not mercury contamination.

    Response from Pronovo for the transfats question:
    However I can assure you that Lovaza has never contained partially hydrogeneated oil. This is simply a mistake. I agree, it is not good marketing - and we are working on it.

    -- Okay, weird answer, but I guess it's believable... kinda. I still don't see why they wouldn't have fixed it by now though. It's sort of like marketing Lipitor -- now with extra trans-fats!

    And regarding oxidation, which i consider the main issue with fish oils, they say that Lovaza is stable at room temperature, even after its opened. They went on to say they don't recommend refrigerating it, as the shelf life may not have been determined in refrigerator conditions.

    Huh? To the best of my knowledge, after fish oil has been opened it's always been considered safest to refrigerate it, to limit potential oxidation. If a liquid is used, it's even more important. And the higher the percentage of omega 3s, the greater the potential for oxidation. So why wouldn't it be suggested to refrigerate Lovaza?

    The only reason I can come up with relates to the last thing they said to me:

    Anyway, you can store Lovaza toghether with other medications. I gues this may be considered a
    good thing when it comes to patient compliance.

    ---

    And then I thought about how pharmacists store medications. Or say, mail order places, which ship 3 month supplies, where they will ship using their own bottles -- meaning they had to use open Lovaza bottles. So this basically means patients will be getting fish oil that has been sitting around for god knows how long, open, and non-refrigerated... and then finally shipped in the Medco (or whatever mail order) bottles, to be used for the next 3 months. And this whole time the fish oil has been exposed to air with no refrigeration.

    So how is Lovaza better than OTC fish oil again? At least I can count on OTC fish oil being sealed and not exposed to air when I buy it.

  • Dr. William Davis

    3/27/2009 1:04:00 PM |

    Hi, Nameless--

    The pharmacist opening the bottle of Lovaza hadn't occurred to me. Excellent point.

    Yet another reason to avoid using this overpriced product.

  • mtflight

    3/27/2009 4:10:00 PM |

    We're missing this:

    the peroxidation is what allows the liver to abort the production of VLDL/triglycerides and through the subsequent delipidation cascade the other particles that would result. See my post above!

    The plaque composition and reduction of cardiovascular events "probably" due to it affecting the omega balances (6:3) and therefore the eicosanoid production.

    I take generic, enteric-coated fish oil. The one I buy has some tocopherols (to prevent peroxidation).

  • Anonymous

    3/27/2009 6:18:00 PM |

    The anon poster made a grave mistake fish oil is not a "drug" it is a food!

  • Nameless

    3/27/2009 6:47:00 PM |

    The only advantage to Lovaza I can see, assuming the patient gets sealed bottles of the stuff, is the reduction in pills daily. And I guess that'd be good for those with stomach issues where they can't tolerate too many pills a day. Although even there we are only talking about like 1 or 2 less capsules daily.

    What would be interesting are studies comparing high dose capsules vs low dose in patients, and see if there is any difference in outcomes. I am curious if Dr. Davis has noticed any difference between patients on fish oil with higher omega 3 content (ex: 600mg/capsule vs 300mg/capsule). In theory, the additional non-EPA/DHA fats in the capsule of lower strength fish oils could have some negative effects. But without studies, who knows?

    Same with the forms of fish oil, which tend to be ignored. Are ethyl esters as effective as triglyceride forms? The current studies are mixed... some show no difference, some show the triglyceride  form of Omega 3s absorbing a lot better.

    For Lovaza to back up any of their claims, they need to do a head-to-head study with a good OTC fish oil, say like Carlson's or Nordic Naturals. But we know that'll never happen. Generic Lovaza may hit the market by years end too, depending on what the courts rule, which will be weird. Companies like the ones I mentioned above, or Meg-3, could cash in by licensing with a drug maker and just reselling their OTC fish oil as a new 'drug'. Which would completely obliterate any notion that Lovaza is different than OTC fish oils too.

  • Anne

    3/28/2009 12:40:00 PM |

    I am prescribed Lovaza, though it's called Omacor here in the UK. I used to buy my fish oils from the health food store and it was costing me around £25 ($36) per month - obviously fish oils are much dearer in the UK - so I asked my cardiologist to prescribe me Omacor and he did. My prescriptions are free of charge under the National Health Service so I'm now getting my fish oils for free.

    I was very puzzled that the manufacturers say not to store Omacor in the refrigerator and on pressing them, saying that in the summer I could not be sure that the temperature in my house would stay under 25 C they conceded that I could store the Omacor in the fridge: "If you feel that a temperature rise may affect your Omacor, then it is possible to store the product in the fridge."  !

    Anne

  • Trinkwasser

    3/30/2009 3:10:00 PM |

    Has anyone found differences between brands (or between the same brand at different times, they may come from different sources) in their palatabily?

    I tend to feel bloated and get fishy belches with the capsules I've tried (not Costco or Lovasa but various OTC and mail order types) which doesn't happen with the whole fish, except for elderly mackerel or stale kippers. You don't know how old the capsules might be or how they've been stored.

    My theory is, by reducing the carbs and Omega 6s a lower dose of Omega 3s will probably work. I'll let you know if I'm right or not after I'm dead (grins)

  • Bill

    3/31/2009 5:21:00 PM |

    Michael said: "The argument that the vitamin industry is self-regulated and answers to nobody is genuine."

    Comment: Some easily identifiable companies self-regulation is far superior than the FDA's regulation of drug companies Michael considering the FDA's record on such matters. If one were to take the time to look for reliable providers of high-quality supplements they would be far ahead of the game and have zero the risk of the myriad of side effects caused by pharmaceutical drugs which are often times rehashed toxic byproducts of the manufacturing process put in pill form instead of being paid for to dispose of.

    Michael said:" Look what happened to the financial industry with self regulated derivative products!"

    Comment: Relevance?

    Michael said: "Given a choice between lab-tested Lovaza and an off-the-shelf fish oil that has no oversight for their claims ... I'll have to go with the Lovaza.

    Comment: Have at it Michael and take with it the dozens of risks for side effects that go with it vs. the safety of the fish oil supplements.

    Michael said: "My triglycerides were 800+ ... now they are 300. My physician said, with triglycerides that high, I can't take the chance of getting a dud bottle of vitamins."

    Comment: Just what you would expect from a doctor who is PROGRAMMED to view vitamins or other nutritional supplements as worthless from YEARS of programming efforts by Big Pharma and virtually no classes on Orthomolecular medicine which has been widely studied for decades upon decades with great results and few risks at even high levels of dosing to deal with serious nutritional deficiencies (aka-"chemical" imbalances).

    Chalk another one up to the propoganda machine Michael - you seem to have bought in hook line and sinker or maybe you're just a paid propogandist?

    In health and in truth,
    Bill

  • cAPSLOCK

    4/5/2009 7:45:00 PM |

    Anne... I must pick at a nit.  Yu said:

    My prescriptions are free of charge under the National Health Service so I'm now getting my fish oils for free.

    They are far from free.  I understand you do not seem to have to pay for them, but we are all paying, even on this side of the sea, for the "free percriptions" folks receive.

  • Anne

    4/7/2009 7:44:00 AM |

    Hi Capslock,

    The money I am charged in my taxes goes towards the cost of the National Health Service so from that point of view my prescriptions are not free, but I am paying my taxes regardless of whether I buy the fish oils from the health food store or get them at no cost on prescription. Since the fish oils are *extremely* expensive from the health food store and since I pay my  taxes this seems the best deal to me.

    Anne

  • Anne

    4/9/2009 7:04:00 AM |

    Hi Capslock, a PS to my previous message - I'm thinking you must be thinking that the UK system is similar to the American one and that only low income people don't pay prescription charges ? No, everyone under 18 and over 60 gets their prescriptions free, and anyone who has one of certain chronic conditions gets them free too, doesn't matter what your income is or even if you're a millionaire !

    If I did pay for my prescriptions then the maximum charge for anyone is £7.20 per prescription, no matter the price of the medicine, no matter the income of the patient....and £7.20 for a prescription of Omacor fish oils is still much cheaper than buying fish oils from the health food store !

    Anne

  • Fda Regulatory Affairs

    4/17/2009 11:40:00 AM |

    Thanks for this informative post

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