Getting a Grip on Our Toxic World

In an interesting presentation at the 2018 Integrative Healthcare Symposium in New York City, Joseph Pizzorno, ND, a leading expert on toxicity and chronic disease, discussed some interesting and useful points.  The first is we live in a toxic world. The EPA’s data estimates that there are 84,000 chemicals used in commerce currently.  This is an approximate quadrupling over the past 40 years, and the trend is expected to accelerate over the next 30-35 years.

Most troubling is the large group that are poorly broken down in the environment, termed persistent organic pollutants (POPs).  POPs include many chemicals and insecticides.  These tend to persist in the body for decades and are more associated with triggering chronic disease.  While humans have highly functional detoxification mechanisms, they are not infinite in their capacity.

An example of a food related toxin is BPA or bisphenol A, a component in plastics that are heavily used in the food supply.  BPA has been used to line cans to prevent exposure of the contents and the metal surface as well as in water bottles and other containers.  BPA is a xenoestrogen, meaning a chemical that comes from outside the body and mimics the effects of estrogen.  These estrogen-mimicking, hormone-like properties raise concern about its suitability in some consumer products and food containers. 

The difficulty with these chemicals is that they are approved after only shorter-term safety testing and yet their toxic effects occur primarily after long-term exposure to repeated small amounts.  The reality is that we typically do not learn of the potential dangers of these products until they have been in use for 10-15 years.

Some of the most informing research about BPA has come from studies of the Agouti mouse.(1)  This mouse has a gene that when activated during gestation causes most of the pups to be born with a yellow coat and very prone to developing obesity and metabolic disease.  The identical litter twins in whom the gene does not activate are born lean and disease resistant. The mice shown are identical twins, one with the Agouti gene activated (yellow) and the other with it present but not activated.

This research manipulated BPA exposure as well as nutrient exposure to see how these factors would affect the number of mice in a given litter that would have the Agouti gene activated.  When the mothers were exposed to BPA in amounts typical to that of typical human exposure, the percentage of the litter with the gene activated was significantly increased.  When the mother was given nutrients such as vitamins B12, B6 and folate used in an important process called methylation which helps with detoxification, the litter is biased towards more of the mice being born with the gene inactive.

The author of this research summarized that this knowledge helps to understand the effect of nature (genetic make-up) and nurture (environmental influence of genetic activation) on disease risk.  Toxins interact with the patterns of human gene activation which is highly influential on disease risks.

So how do we protect ourselves from long-term toxicity.  Dr. Pizzorno gave some clues to help with those answers.  The first way is to minimize exposure.  That may seem difficult but his analysis of where our toxic exposure comes from shows that a few steps can make a big difference.  By far, our biggest toxic exposure comes from food.  He estimates that 60% of our exposure is through that route.  This can range from pesticide residues on commercial produce to additives in processed food to chemicals used in packaging.

The number of chemicals and potential toxins in our environment and food supply is staggering.  Protecting ourselves must come from a combined effort of minimizing exposure and maximizing inherent detoxification mechanisms.

There are several steps involved in minimizing exposure to toxins.  There is important merit to eating organic.  This minimizes exposures to a broad range of chemicals such as pesticides and herbicides used in commercial growing.  I had a vivid lesson as to how much this is an issue.  About 35 years ago a friend who managed a large orchard complex and packing plant got a call about a problem at the plant.  He invited me to go along when he went to investigate this.

Large wooden crates of apples were brought to one end of the processing/packaging line and dumped into a bin of water.  They floated to the other end of the tank in about 30 seconds and went onto a belt under a blow dryer.  Hardly enough to remove chemical residues.  The next step was spraying with wax, a step that I could only think was sealing in any chemical residues.  When I asked how many applications of different chemicals were applied over the season, the stunning answer was about 25.

Other layers of protection include avoiding processed and packaged food as much as is possible.  Walk the isles of any grocery store and read the ingredient lists.  Some things such as synthetic dyes are recognized as chemicals. A general rule is that those you do not know what they are, are likely to be chemicals. Most people begin to appreciate that about 20-30% of most highly processed foods are chemicals. 

Packaging adds other concerns regarding toxic exposure.  BPA is a classic example of a packaging-based toxin.  Microwave in the bag vegetables are another example.  Heat can leech organic compounds from plastic packaging.

Given all the care possible, there will still be exposure which means it is important to have detoxification mechanisms highly functional.  These mechanisms are dependent on a high nutrient diet as discussed above.  The same considerations about eating “cleaner” food ensures higher nutrient density.  The levels of the essential nutrients have been shown to be about 30% greater in organic produce.  The >15,000 phytonutrients such as flavonoids, many of which are highly involved in helping our detoxification, have been shown to be about 70% denser in organic produce.

Toxicity is an important disease contributing concern. Although the sources are many, food is the top concern.  The often expressed concern about eating healthier is that it is a little more expensive.  This is only true in the short-term.  Nothing is more expensive than dealing with long-term, chronic illness.

1)   Dolinoy DC.  The agouti mouse model: an epigenetic biosensor for nutritional and environmental alterations on the fetal epigenome.  Nutr Rev. 2008 Aug; 66(Suppl 1): S7–11.

The 15 Cupcake Diet

Most are Surprised They are Eating It

Asking questions often creates a great teaching moment.  One of my favorite questions to patients who are eating the typical Western/U.S. diet is, “How healthy do you think you would be eating 15 chocolate cupcakes each day?”  The answer is typically not very healthy at all.

Establishing that reality makes it easy to transition into what may be wrong with their diet that is causing their health problems.  The sugar content of the Western diet is equivalent to that in 13-15 cupcakes.  The problem is that our “cupcakes” wear disguises.

Humans historically ate no added sugar for the vast majority of our 6-million-year existence.  As humans learned to find or extract dense sugar from plants our consumption has exploded especially in the past 100 years.  A whole food diet containing 40-50% carbohydrate provides about 30-35 grams of sugars.  The current U.S. average is over 200 grams/day, or 6-8 times our historic norms.  It is the primary mechanism driving both the obesity and diabetes epidemics which in turn drive several other problems such as vascular disease and Alzheimer’s disease.

The reality is that the major ill effect of the food we eat is not that it contains chocolate or that it is in the shape of a cupcake, rather it is the sugar content.  Given that, it does not matter if the sugar is added to a cupcake, fruit in the bottom yogurt, in bread, cereal, soup or any other of the majority of foods it is added to. 

The seriousness of this problem is the longer-term disease patterns that our sugar consumption is causing.  It is thought to be the dominant contributor to the obesity and diabetes epidemics and to the development of cardiovascular disease.  A review of all of the studies looking at the association between sugar intake and cardiovascular disease risk concluded the following: “Associations between added sugars and increased cardiovascular disease risk factors among US children are present at levels far below current consumption levels. Strong evidence supports the association of added sugars with increased cardiovascular disease risk in children through increased energy intake, increased adiposity, and dyslipidemia. Thus, there is consistent evidence that cardiovascular risk increases as added sugars consumption increases.” (1)

A 2010 study points out the “increased dyslipidemia” the above study referred to.  The study found that 1 in 5 children already show abnormal blood lipid patterns, and they are highly related to weight.

This data is typical of that used by a noted group of scientists to suggest that the youth of today will likely have a diminished life expectancy compared to prior generations.

Fixing the problem requires an informed consumer.  A great exercise is to read every label of everything you eat for 2 weeks.  First look at the grams of sugar a serving contains. Most whole food, natural carbs contain 1-5 grams of natural sugar per serving.  Any amount greater than that should elicit an investigation as to where the sugar is in that food item.  This is found in the ingredient list.

Watch out for the “sleight of hand trick” that is often done with serving size.  Many labels now simply have changed the serving size downward to make the content of sugar look less than a functional serving size.  For example, cola contained 52 grams of sugar in a 16 oz serving about 15 years ago.  Now it contains 28 grams appearing to be healthier;  that is until you notice that they simply redefined the serving size as 8 ozs so that the same 16 oz bottle or can actually is yielding 56 grams of sugar.  Think honestly about how much your actual serving is when you consume it. 

Look at what an item is made of, not how it appears on the packaging. The following 2 labels demonstrate this idea well.  They are the ingredients from a chocolate cupcake and from a “heathy” cereal bar.  The words chocolate and cherry have been hidden to not bias your selection.  Which is which?  The first ingredients are added sugars with the rest being the same just in different order.  These include artificial flavor, refined white flour, propylene glycol (cousin to ethylene glycol or antifreeze) and some artificial color. Both contain 18 grams of sugar per serving. 

The answer to which is the cupcake is that from a content perspective they both are just with a different look (cherry vs chocolate and bar vs muffin shaped).  A small cup of fruit in the bottom yogurt contains about 24 grams of added sugar, or “1 1/3  cupcakes worth”.  A popular commercial tomato soup contains 13 grams of added sugar, or “two-thirds of a cupcake worth”.

Another sad part of our national 13-15 cupcake diet is that the added sugar is done only to increase consumption.  Sugar activates a strong evolutionarily derived desire to eat more.  It is thought that this was a signal when food was always in short supply to prefer those that impart high energy.  However, in this time of constant food availability it drives excessive energy consumption.

Some very innovative studies by a group of French researchers has examined the strong drive to consumption that sugar imparts.(2) The study used lab rats who had access to cocaine for 3-4 days to habituate to it.  Subsequently they had access to both the cocaine and to intensely sweet sugar water.  After another 3-4 days most gave up the cocaine in favor of the sugar water.  The researcher’s comments on the outcome of their study tells the story best; “Our findings clearly demonstrate that intense sweetness can surpass cocaine reward, even in drug-sensitized and -addicted individuals.”

There are many forces that create the environment that allows our food to be unhealthy in spite of the significant adverse health effects that result.  At this point an informed consumer insures the best plan and outcome.  Think about just how healthy someone could be consuming 15 cupcakes per day.

1.  Vos et al.  Added Sugars and Cardiovascular Disease Risk in Children: A Scientific Statement From the American Heart Association.  Circulation. 2016;134.
2.   Lenoir M, Serre F, Cantin L, Ahmed SH (2007) Intense Sweetness Surpasses Cocaine Reward. PLoS ONE, 2007;2(8): e698.
    http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0000698

Perhaps the Final Nail in the Low-Fat Coffin

For the past 50 years the basis of nutritional advice from the medical community has been “eat a low-fat diet”.  During that time the obesity epidemic, the diabetes epidemic and growing concerns about a shortening in U.S. life expectancies has occurred. In addition, an increase in cardiovascular disease rates has occurred in 34-54 aged women and no further decrease in the rates for middle aged men.(1)

At some point it is prudent to say that if the desired effect of a policy is not occurring, the policy must be flawed.  This is the case with the low-fat diet.  The results have proven this concept highly flawed at great expense to our national health.

The idea of a low-fat diet as protection against cardiovascular and other chronic disease originated in the 1950’s based on some seriously flawed research by Ancel Keys, PhD.  He examined the carbohydrate and fat ratios in relation to cardiovascular disease rates from “all of the research” published world wide up to that time.  The infamous Seven Countries Study concluded that the analysis from the seven countries reported that higher fat consumption correlated with higher cardiovascular disease rates and began the unquestioned era of the low-fat diet as disease prevention.

Unfortunately, Key’s study did not come under independent analysis for the next 50 years.  When it did, it was revealed that he had “cherry picked” the available research including only 7 of the 22, or less than 33%, of the available studies.  Examination of Key’s data 50 years later found that the majority (66%) of the research he actually had available supported exactly the opposite of his conclusion.  Keys was opening a health spa/retreat which was to be based on the low-fat diet and biased his study to support its concept.

Several studies throughout the late 1900s and early 2000s actually demonstrated that the low carbohydrate/higher healthy fat diet actually out-performed the low-fat diet, but these studies failed to change longstanding medical advice patterns.  It however, has begun to soften very recently and perhaps a large, well done newer study will finally change this flawed advice.(2) 

The study called PURE examined the relationship between dietary patterns and disease and mortality rates from 18 countries from 2003- 2013. Subjects were divided in to groups, according to the carbohydrate/fat ratios of their diets. The data showed that compared to those consuming the lowest carbohydrate/higher fat diets, each increase level of higher carbohydrate and lower fat consumption was associated with higher cardiovascular disease rates and increased total mortality rates. Compared to those consuming the lowest carbohydrate, those in the highest quintile had a striking 30.8 % increased risk of cardiovascular disease and a 75.6 % increased risk of total mortality.

The conclusions of the authors of this new study tell the whole story; “In conclusion, we found that a high carbohydrate intake was associated with an adverse impact on total mortality, whereas fats including saturated and unsaturated fatty acids were associated with lower risk of total mortality and stroke.”

“Low-fat” had to result in “high carbohydrate”.  Humans had historically consumed only about 35-40% of their energy from carbohydrate.  In the last 100 years this has ballooned to 55-60%, an almost doubling while our metabolic “wiring” has not changed.  We have been trying to consume a diet that is incompatible with our physiology and the results been unfortunate.  Change needs to occur.  

Our blind faith that medical advances can outstrip the negative effects of human dietary behavior is proving wrong.  Unquestionably, medical therapy does help delay the adverse effects of poor diet, but it does not prevent the eventual outcome.  Good medical care can push back the complications of diabetes and overweight/obesity.  This is tempered by the fact that the average age of onset of many diseases such as diabetes have plunged.  While diabetes treatment may push back the development of complications of the disease by 15 years, the age of onset has dropped 16 years since 1970.  That math affects mortality plain and simple.

The authors final conclusion says it all: “Global dietary guidelines should be reconsidered in light of the consistency of findings from the present study, with the conclusions from meta-analyses of other observational studies and the results of recent randomised controlled trials.”  Low-fat/high carb was a grand experiment whose unfortunate outcome has cost a high price.  Time to put the final nail in and move on.

1.    Ford, E. S. et al.  Coronary Heart Disease Mortality Among Young Adults in the U.S. From 1980 Through 2002: Concealed Leveling of Mortality Rates .J Am Coll Cardiol 2007;50:2128-2132.     
2. Deghan et al.  Associations of fats and carbohydrate intake with cardiovascular disease and mortality in 18 countries from five continents (PURE): a prospective cohort study.  Lancet, 2017; 390: 2050–62.

A Simple Step to Improve Diet, Weight and Mental Health

Human behavior can be a funny thing.  At times it is so complex, yet some very seemingly simple things can change it in positive ways.  A new study looking at one simple logistical factor about eating has demonstrated this point well.  The complex part of human behavior examined was trying to change eating and activity behavior to a healthier pattern. 

Almost endless government and other organizational guidelines have had little success in that area.  The same for public service messages, public health programs and more.  

This is where a very simple answer has performed better.  The study looked at the relationship between eating meals as a family during adolescence and in those who became parents during the next 17 years.  Participants were from mixed socioeconomic and racially/ethnically diverse households.

Both those who had regular family meals as adolescents and maintained that as young parents, and those who began the practice as young parents ate healthier foods, participated in more healthy weight-related behaviors such as exercise and had higher psychological well-being scores compared to those who reported never eating family meals together.

It appears that the family mutual support group reinforced by the simple practice of eating meals as a family has profound positive effects on health behaviors that a mountain of guidelines and policies have not accomplished.  Human behavior has always tended to have a “tribal” nature which is highly influential on all parties.  Try regularly getting your tribe together for meals.  It is not just an old custom but also a healthy behavior.

Berge et al.  Intergenerational transmission of family meal patterns from adolescence to parenthood: longitudinal associations with parents’ dietary intake, weight-related behaviours and psychosocial well-being. Public Health Nutrition, 2018;21:299-308. 

Why We use Whole Food Nutritional Supplements

The vast majority of nutritional supplements available are synthetically made.  Only a small number of companies offer supplements made primarily from whole foods in spite of several advantages associated with them.  I thought it would be appropriate to discuss the differences and particularly how these differences translate into different health outcomes.

First, it may be surprising to many that most supplements are synthetic.  This practice actually originated several decades ago from concerns about whole food sourced nutrients, concerns that we now know were unfounded.  These concerns centered around the idea that plant nutrient content can vary according to the conditions the plants are grown in.  With reasonable varying growth conditions, plant nutrient levels remain within a reasonable range.

To eliminate this varying but reasonable nutrient range, the idea of making nutrients synthetically emerged.  Unfortunately, it generates far greater variability in nutrient content and health impact than what it was supposedly trying to avoid.  The variations from whole food nutrient content that synthetic supplements create include:

•  They are incomplete micronutrients.
• They are devoid of the phytonutrients that always appear with micronutrients in whole food.

Incomplete micronutrients

There are 28 essential micronutrients such as vitamins and minerals.  This means that humans cannot make them from other food substances and that they must be obtained directly from food.  However, different micronutrients are “complexes” containing multiple parts.  Vitamin E is an example containing 8 tocopherols.

Unfortunately the FDA decided since the biggest piece of this 8 piece complex was alpha tocopherol that for the purpose of making a supplement, only alpha tocopherol could be included and yet it could be called “vitamin E”.  A tipoff that a supplement is a synthetic is that there will be a second term in the name which describes the synthetic form such as “d-alpha tocopherol succinate”.  This is 1 piece of the 8-piece complex made synthetically.

The collective group of tocopherols generate the health effects.  For example, different tocopherols in the group have different antioxidant properties and different abilities to suppress HMG CoA reductase, the enzyme that increases cholesterol production in the liver.  The best balance of these effects appears to come from the whole complex of tocopherols.

Devoid of phytonutrients

Vitamins and minerals do not appear in nature by themselves but rather they always appear in complexes with several phytonutrients.  For example, ascorbic acid which is part of vitamin C complex always appears with the phytonutrients called phenolic compounds such as flavonoids.  Much of the benefit attributed to vitamin C is now thought to come from these phenolics.

The FDA has allowed synthetic ascorbic acid to now be called “vitamin C” even though it is devoid of this group of phenolics that always appear with it in whole food.  While there are 28 essential micronutrients in whole food, there are about 16,000 known phytonutrients all which impart health benefits.

Several of the large studies on the impact of nutritional supplements have suggested that they provide no significant health benefits.  Most notable were 2 different arms of the Physicians Health Study which look at many health outcomes related to several lifestyle factors.  The studies used 400 IUs of synthetic alpha-tocopherol and 500 mgs synthetic ascorbic acid over a 10-year period. The conclusions of these two studies were:

“In this large, long-term trial of male physicians, neither vitamin E nor vitamin C supplementation reduced the risk of major cardiovascular events.”

“In this large, long-term trial of male physicians, neither vitamin E nor C supplementation reduced the risk of prostate or total cancer.”

These results are in contrast to many studies that look at obtaining these nutrients in greater amounts from whole food diets which have shown consistent improved health outcomes, outcomes which have been attributed to their nutrient content.

So, what generated the stark difference in the clinical trials that have looked at the benefits of nutrients in disease prevention and treatment?  It appears to be the difference in the effects between whole food complexes and isolated synthetic nutrients.  Whole food supplements are natural, complete nutrient complexes with superior health benefits. 

Sesso et al.  Vitamins E and C in the prevention of cardiovascular disease in men: the Physicians' Health Study II randomized controlled trial.  JAMA, 2008;300(18):2123-33.

Gaziano et al.  Vitamins E and C in the prevention of prostate and total cancer in men: the Physicians' Health Study II randomized controlled trial.  JAMA, 2009;301(1):52-62

The Possible End to Increasing Life Expectancy

One of the more controversial papers ever to be published in the prestigious New England Journal of Medicine projected that “the steady rise in life expectancy which had occurred over the past 2 centuries may soon come to an end.”  They ended the conclusion commenting that the youth of today may live less healthy and shorter lives than their parents.   As would be expected this paper sparked a large volume of letters to the editor criticizing this projection.  

While the authors based their projection on some very sound data, the real validation could only come with time.  As my favorite philosopher, Yogi Berra once said when asked to predict on Thursday who would win a golf tournament which ended Sunday, “ask me Sunday night.  I am a lot better at predicting the past than I am the future.”

While “Sunday night” is not here on this striking prediction about our children’s longevity, the preliminary data appears to be supporting this grim projection.  The primary basis of this projection was the ever growing rate of obesity and its relationship to increased rates of the chronic diseases such as diabetes, heart disease, cancer and many others.

As projected, overweight and obesity trends have continued upward across all population groups.  Currently about 9% of children 5 years of age and under are obese, and this rises to 20.5% between 12 and 19 years.  The increasing trend continues throughout adulthood.  Currently 38% of U.S. adults are obese and 74% are overweight.

Diabetes is perhaps the best leading edge indicator of the disease trends that may accompany the overweight and obesity change.  It is now projected that the 14.3% of the U.S. population have diabetes an increase of approximately 300% since 1990.  The real emphasis comes from the fact that fully 38%, or about 1 of every 3 persons in the U.S., is pre-diabetic with a high percentage expected to convert to full diabetes over time.

Pre-diabetes is a misleading term in some ways. Normal fasting blood glucose is 70-99 mg/dL.  Diabetes is a fasting glucose of 140 or greater.  Pre-diabetes is that zone of abnormal glucose from 100-139.  My take on pre-diabetes is that just as the first trimester of pregnancy is not “pre-pregnant” but is early pregnancy, the better term is early diabetes.

These trends are fueled by the general belief by most that no matter what they do to themselves, some medical innovation will bail them out.  At least some knowledgeable healthcare scientists seem to accept that the rate at which we can become diseased is beginning to outpace the ability to maintain chronic disease.  One trend that supports this concept is another important statistic, healthy longevity.  It is defined as age of onset of the first chronic disease.

Even as longevity has increased over the past 60 years, healthy longevity has decreased more dramatically.  This is what the authors of the NEJM paper referred to as “our children living less healthy lives than their parents”. Many treatments for chronic disease do not completely prevent the complications that often shorten life but rather they delay them.  The diabetic today has their disease longer than previous generations.

The average onset of type II diabetes was 52 years of age 40 years ago.  It is now 41 years of age.  While improvements in diabetes treatment have delayed the onset of complications, the earlier ages of onset may begin to override treatment based complication delays. 

One of the most striking papers I have read was a commentary by an endocrinologist at the University of Texas.  He had been in practice 30 years and commented that in his early years they would see perhaps only a couple of new onset cases of type II diabetes in adolescents each year.  Now they see several new cases every week.  This phenomenon was why the terminology when I was in graduate school, adult onset diabetes, was changed to type II diabetes.

This paper making these projections that received so much criticism in 2005 is being looked at as evolving reality in 2017.  Sad but true.

There is little disagreement that the primary driver of the chronic disease epidemic is diet based.  Likewise, the most effective solution will also be diet based.  Perhaps one of the best health investments we can make is to get some help from a nutritional health professional in understanding and optimizing our diet as well as that of our families.

Olshansky et al.  A Potential Decline in Life Expectancy in the United States in the 21st Century.  New England Journal of Medicine, 2005:352;11.

If We Had This Drug, I Would Be on It

One of the largest studies on the reduction of chronic disease risk and mortality was recently published in The Lancet.  The study looked at the use of a particular treatment and the reduction of cardiovascular disease risk, stroke risk, as well as the risks of cardiovascular, non-cardiovascular and overall mortality.  The study was very comprehensive involving 135,335 individuals aged 35 to 70 years without cardiovascular disease from 613 communities in 18 low-income, middle-income, and high-income countries in seven geographical regions: North America and Europe, South America, The Middle East, South Asia, China, Southeast Asia, and Africa.

The results shown to the left were fairly striking with the treatment reducing the risks uniformly for all of the followed measures.  The vertical black line is the risk in the non-treatment group.  That is arbitrarily called “1” in a comparative study.

The graphic shows the risk reductions circled in red compared to those not taking the treatment regularly.  The red line shows the risk reduction to 0.7 which means a 30% reduction.  For cardiovascular events (CV disease) the reductions were all about 20%.  The mortality reductions were more dramatic, all being more than 30%.

The conclusion is that this treatment resulted in broad reductions in disease rates and deaths for the leading cause in developed and less developed countries.  The results occurred regardless of age, income status or country of residence.

Participation in this treatment would not take much persuasion if this drug existed, was widely available and relatively inexpensive.  While it meets all of those criteria, it has been and continues to be a hard sell to the population at large.  This is because the “drug” used in the study was actually “more than 3 servings per day of fruits, vegetables and legumes”. 

To give some perspective on these results, the results of similar clinical trials using statin drugs on total cardiovascular mortality have found risk reductions varying between 0 and 12%.  Seems like one could do twice as much just by eating enough fruits and vegetables daily.

The irony of all of this is that virtually every guideline out there supports this “therapy”, yet the minority of the population follow this in practice.  The breakdown seems to occur for many reasons.  Medical practice has become largely “this drug for that problem” with insufficient time spent or emphasis on implementing this very effective prevention.  This is driven by time restraints in patient care, patients preferring a pill over lifestyle change, and intense pharmaceutical advertising biasing opinions.

The bottom line is that you can’t fight data and in this case, it is convincing.  We are in the era of chronic lifestyle related disease and the biggest piece of lifestyle appears to be diet.