The Balance of Work and Rest

June 29, 2009

This month has been extra busy for me.  Usual excuse for having neglected this website for almost a month!!!! 

 After attending the Annual Endocrine Society Convention in Washington DC…  before I overcame my jet lag, I had a scheduled lecture on Diabetes Management in Tagaytay attended by around 250 doctors nationwide.  Then another scheduled lecture within that week in Manila attended by another 250 doctors from Asian Countries in Dusit Hotel.  Immediately after my lecture , I had a scheduled meeting  with the Board of the American Association of Clinical Endocrinologists Philippine Chapter for our joint international meeting in Mactan Shangrila with AACE US in August.  

Then…. I have to go back to Cebu by that day because it was going to be Fathers Day the nxt day and I promised myself to spend that day with my wife and kids!  And boy did we have FUN!  

Without asking permission from my kids ( which am sure they wont say YES)  the next day I have to fly back again to Manila to attend another meeting then flew back to Cebu the next day to give another lecture Tuesday night in Marriot Hotel. 

And in between those scehdules were scheduled meetings with the Pharma Industries Product Managers and National Sales Managers.  WHEW!!!!

Finally the weekend came!  Rewarding myself with a weekend in Shangrila Mactan with my Saturday off and spending that day for leisure was worth the break I needed.  Spending time with my kids and pampering myself with a massage were rejuventaing enough for another week of work!

I guess in life… to enjoy one’s work, one has to balance it with fun and rest!  If one has time to spend work with and for others…so much more of a reason that one should and MUST  FIND time for yourself and your family!  I guess it’s an OBLIGATION rather than a LUXURY!

For me…money should NOT be the sole purpose of living but we USE money to provide a better life for you and your loved ones!  Therefore to achieve that purpose is to prioritize yourself above money and to make sure one has the Best of HEALTH to be able to achieve what you want to pursue in life.  Never should WEALTH take over HEALTH!

The balancing act in life  maybe difficult but if practiced in ones life… this can lead to a more productive , Healthy and FUN environment for yourself and your loved ones. 

And if possible…balance your work with rest and fun everyday and every moment you can! 

Enjoy Your Day Folks… and Glad that AM BACK!

Posted in General Health Tips | 1 Comment »

How To Lower Cholesterol Levels Naturally

June 3, 2009

Here’s one interesting article from the Harvard Health Publications HealthBeat on ways we can do to lower cholesterol naturally without meds:

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15 tips for lowering your cholesterol naturally

Many factors contribute to the development of heart disease or stroke. Genes and gender play a role, but for most of us, what we eat is an important factor as well. The good news is that a few small changes to your diet can help lower your cholesterol, which in turn will lower your risk for heart disease and stroke. Here are 15 heart-healthy eating tips to help you in the fight against high cholesterol.

1. Eat meat sparingly. Relegate meat to a minor part of your diet instead of making it the centerpiece of most meals. Trim off fat and skin from meats and poultry. Avoid fatty cuts of beef, pork, and lamb; instead choose lean meats, or substitute fish or skinless white-meat poultry. When dining out, choose a smaller portion of meat, or meatless pasta or fish dishes.

2. Opt for low-fat dairy products. Avoid dairy foods that contain whole milk or cream; instead, use low-fat or nonfat versions.

3. Watch the snacks. Choose low-fat snacks (homemade popcorn, carrots, dried fruits, or fresh fruits) instead of high-fat ones (potato chips and candy bars). Avoid store-bought bakery products unless they are explicitly low in saturated fats and free of trans fats.

4. Cut down on saturated fat in cooking. Use liquid cooking oils rather than butter or margarine. Use nonstick pans. Instead of frying your food, bake, broil, roast, steam, or stew. Discard drippings, and baste with wine or broth.

5. Avoid palm and coconut oils. Most vegetable oils are unsaturated, but these two contain mostly saturated fat. Choose canola, sunflower, safflower, corn, soybean, olive, and peanut oils.

6. Reduce dietary cholesterol. Strive to eat less than 200 mg of dietary cholesterol a day. Limit eggs to no more than four egg yolks per week; two egg whites can replace a whole egg in most recipes. Limit lean meat, fish, and poultry to no more than 6 ounces per day (a 3-ounce portion is about the size of a deck of playing cards). Stay away from cholesterol-rich organ meats, such as liver, brains, and kidneys.

7.  Increase complex carbohydrates and fiber. Emphasize foods with complex carbohydrates—such as fruits and vegetables, whole-grain products, and legumes (dried beans and peas)—that are low in calories and high in fiber. Eat more water-soluble fiber, such as that found in oat bran and fruits. This type of fiber can significantly lower your blood cholesterol level when eaten in conjunction with a low-fat diet.

8. Eat fruits and vegetables. To protect your heart, eat plenty of fruits and vegetables.

9. Go for nuts. Nuts are associated with a lower risk of heart disease. They’re a healthful and filling source of protein, but go easy on them; they have lots of calories, so too much could cause weight gain.

10. Add fish to your diet. Countries with high fish consumption have a lower risk of death from all causes as well as from cardiovascular disease. Like nuts, oily fish contain the essential fatty acids known as omega-3s and omega-6s. Since our bodies can’t make these, we have to eat foods that contain them to gain their benefits, which include improved cholesterol levels.

11. Reduce salt intake. High blood pressure is a major risk factor for cardiovascular disease. Diets high in salt increase risk of hypertension.

12. Avoid trans fats. According to the Institute of Medicine’s Food and Nutrition Board, there are no redeeming qualities to trans fats, and no safe levels. They raise LDL cholesterol and lower HDL cholesterol. The National Cholesterol Education Program urges people to eat as little as possible. Avoid or eat only very small quantities of foods that list hydrogenated oil or partially hydrogenated oil among their first ingredients. These products contain a lot of trans fat.

13. Drink alcohol only in moderation. Regular, moderate drinking can reduce the risk of cardiovascular disease, but heavy drinking negates the benefits. Moreover, the advantages aren’t strong enough to recommend alcohol for anyone who doesn’t already drink. For those who do, the Dietary Guidelines for Americans recommend no more than one drink a day for women, and one or two drinks a day for men.

14. Read labels carefully. Avoid prepared foods that list any of the following among the first few ingredients: meat fat, coconut or palm oil, cream, butter, egg or yolk solids, whole milk solids, lard, cocoa butter, chocolate or imitation chocolate, or hydrogenated or partially hydrogenated fat or oil. Watch out for fast foods and other unlabeled products; when you don’t know what you’re getting, eat sparingly.

15. Change strategies. If three months of healthy eating doesn’t bring your total and LDL cholesterol levels into the desired range, consult your physician and a dietitian. If the numbers still don’t budge after six months, it may be time to consider medication.

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Simple measures we can at home to avoid getting th compications associated with a high cholestrol level in the blood.  High cholesterol levels have been shown to increase ones risk to suffer from stroke and heart attack. 

The good news is , we now have ways to control and lower the cholestrol levels by taking care of what we eat and through medications.

Be Health Smart and Check the Labels!

Posted in General Health Tips, Healthy Practice Tips, Lifestyle Measures, Medical News Bits, Nutrition Health Tips, Personal Thoughts, Tips To Protect Your Heart | 9 Comments »

Intelligence Equates Fitness!

May 29, 2009

I found this very interesting article and I find it rather amusing… linking inteligence to physical fitness.   This is the first time I have read such a study published in the journal Intelligence and I want to share the information to all….

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We suggest that an over-arching ‘fitness factor’ (an index of general genetic quality that predicts survival and reproductive success) partially explains the observed associations between health outcomes and intelligence. As a proof of concept, we tested this idea in a sample of 3654 US Vietnam veterans aged 31–49 who completed five cognitive tests (from which we extracted a g factor), a detailed medical examination, and self-reports concerning lifestyle health risks (such as smoking and drinking).

As indices of physical health, we aggregated ‘abnormality counts’ of physician-assessed neurological, morphological, and physiological abnormalities in eight categories: cranial nerves, motor nerves, peripheral sensory nerves, reflexes, head, body, skin condition, and urine tests. Since each abnormality was rare, the abnormality counts showed highly skewed, Poisson-like distributions. The correlation matrix amongst these eight abnormality counts formed only a weak positive manifold and thus yielded only a weak common factor.

However, Poisson regressions showed that intelligence was a significant positive predictor of six of the eight abnormality counts, even controlling for diverse lifestyle covariates (age, obesity, combat and toxin exposure owing to service in Vietnam, and use of tobacco, alcohol, marijuana, and hard drugs).

These results give preliminary support for the notion of a superordinate fitness factor above intelligence and physical health, which could be further investigated with direct genetic assessments of mutation load across individuals.

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This study showed that being healthy is linked to being more intelligent.  And this relationship is linked to a certain genetic “fitness factor” that regulates both the health fitness  to that of brain intelligence.  

In other studies, the relationship was believed to be more of a “cause and effect” relationship where by being more intelligent means more likely to live a healthy lifestyle by eating the right kind of food and knowing the benefits of exercise.  Unfortunately, this cause and effect relationship may not be that simple after all because I know of intelligent people who may not be at their best of fitness level.

On the other hand, the researchers further noted that the lower intelligence predicted health problems more than deviant lifestyle factors like smoking or alcohol intake.

All these date suggest that there indeed is the existence of a genetic ‘fitness factor’ that influences both health fitness and the way our brains work!

Look Smart By Being Fit!!!!

Posted in Exercise and Activity Tips, General Health Tips, Lifestyle Measures, Medical News Bits, Personal Thoughts | 3 Comments »

The Alcohol Paradox

May 16, 2009

 I came across a short review on the paradox of alcohol from the Harvard Newletter which I want to share.  Its concise and full of facts worth reading.

We may not know it but alcohol can have good benefits too… to Health.

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Drinking increases “good” HDL cholesterol, reduces factors in blood that make it more likely to clot, and may directly affect blood vessels, keeping the linings smooth and pliable and thus less vulnerable to atherosclerosis. European researchers reported interesting findings in 2008 that show a connection between alcohol intake and higher blood levels of omega-3 fats. Indeed, temperate tippling has been associated with everything from greater bone density to less risk for Alzheimer’s disease and vascular dementia, as well as protection against heart disease and stroke.

Moderation is paramount when it comes to alcohol, because drinking too much is patently ruinous. Triglycerides and blood pressure go up. Binge drinking can lead to stroke. Moderation is flexibly defined, but the American Heart Association guidelines are often cited: for men, one to two drinks a day; for women, just one. A drink is defined as a 12-ounce beer, 4 ounces of wine, or 1.5 ounces of 80-proof liquor.

Women do need to worry about alcohol increasing breast cancer risk. Alcohol may drive up estrogen levels, and estrogen seems to play an integral part in the development of many breast cancers. However, at moderate amounts (the drink-a-day level), the risk is small. Folic acid may help offset the breast cancer risk posed by alcohol, so women who drink are encouraged to get an extra 400 micrograms per day.

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Just like anything we do and eat:  Do and Eat the amount that is not more than what can harm you! 

The line between the good and the  bad effects can be so thin that you may not know it…you are already crossing the line!

So They Say:  DRINK MODERATELY!   Now you know what it means!

Posted in General Health Tips, Lifestyle Measures, Medical News Bits | 2 Comments »

WHY Breastfeed?

May 8, 2009

Go to fullsize imagehat breastfeeding is best for babies…now we know its also good for mothers as well.  Good news for those who believe in the benefits of breastfeeding based on a new study publsihed in the recent journal of Obsetrics and Gynecology, May 2009: 

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OBJECTIVE: To examine dose-response relationships between the cumulative number of months women lactated and postmenopausal risk factors for cardiovascular disease.

METHODS: We examined data from 139,681 postmenopausal women (median age 63 years) who reported at least one live birth on enrolling in the Women’s Health Initiative observational study or controlled trials.

RESULTS: Dose-response relationships were seen; in fully adjusted models,

  • women who reported a lifetime history of more than 12 months of lactation were less likely to have hypertension , diabetes, hyperlipidemia, or cardiovascular disease than women who never breast-fed, but
  • they were not less likely to be obese.

In models adjusted for all above variables and BMI, similar relationships were seen. Using multivariate adjusted prevalence ratios from generalized linear models,

  • we estimate that among parous women who did not breast-feed compared with those who breast-fed for more than 12 months, 42.1% versus 38.6% would have hypertension, 5.3% versus 4.3% would have diabetes, 14.8% versus 12.3% would have hyperlipidemia, and 9.9% versus 9.1% would have developed cardiovascular disease when postmenopausal.
  • Over an average of 7.9 years of postmenopausal participation in the Women’s Health Initiative, women with a single live birth who breast-fed for 7-12 months were significantly less likely to develop cardiovascular disease  than women who never breast-fed.

CONCLUSION: Among postmenopausal women, increased duration of lactation was associated with a lower prevalence of hypertension, diabetes, hyperlipidemia, and cardiovascular disease.

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What this study showed is that women who breastfed for more than one year throughout their lifetime were 10% less likely to have a heart attack or stroke.  But what’s important is that these breastfeeding women were also less likely to develop the dreaded metabolic syndrome: 20% less likely to develop of diabetes, 12% less likely to have hypertension and 19% less leklely to develop high cholesterol. 

How long should one breastfeed top get the effect?  Well, even women who had breastfed for only one month had lower rates of diabetes, high blood pressure and high cholesterol.

Why do benefits result with breastfeeding? 

Well most likely women who breastfeed their babies are more careful with their health in terms of food habits and lifestyle.  Likewise the hormone oxytocin produced during breastfeeding have the capacity to relax the vessels that may play a role in delaying plaque buildup in the vessel walls.

There you go guys…

Breastfeeding is Good for Our Health!

Posted in General Health Tips, Healthy Practice Tips, Lifestyle Measures, Medical News Bits | Leave a Comment »

L-Carnitine and Weight Loss…

April 28, 2009

Go to fullsize imageIve seen my friends drinking juice with L carnitine thinking that by doing so…they are enjoying the taste plus the calories from the juice while the Carnitine burns the fat that makes them lose weight.  This would be an ideal setting and definitely one that will earn the founder of this promise of weight loss while enjoying the food will win the Novel Prize Winner in Science….

All in the game of marketing and the problem is…these products are winning high in sales because people are easily fooled by marketing.  Just like our kids are fooled into eating fried chicken because they’re healthy!

Carnitine is an important nutrient.  It is one that helps the body turn fat into energy.  So marketing the product from this basis : enjoy the taste of juice while burning your fat and lose weight…is one marketing that is really stretching the facts too lame!  Unfortunately people buy the ads as if they are the truth!

Lastly beware of websites from companies selling the product…claiming facts regarding carnitine and products that they sell… because bias in reporting data is always evident.   Be vigilant when searching for them in the internet.  Always check the source and its realiability of the findings including the institution that claims the facts!!

The truth of L carnitine is that at present and quote from the University of Maryland website: NO PROOF!

 “Although L-carnitine has been marketed as a weight-loss supplement, there is no scientific evidence to date to show that it improves weight loss. A recent study of moderately overweight women found that L-carnitine did not significantly alter body weight, body fat, or lean body mass. Based on the results of this one small study, claims that L-carnitine helps reduce weight are not supported at this time.”

Dont Be Fooled… Enjoy Water instead!
 

 

 

Posted in General Health Tips, Medical News Bits | 10 Comments »

Licking Speeds Up Wound Healing….

April 15, 2009

Call it reflex but the moment something feels painful or see blood in our fingers or hands, we immediately bring that finger into our mouth to lick it!  We feel better and we think it stops the bleeding.

Now science tells us indeed we were right all along.  A recent study published online by FASEB showed that licking a wound can indeed speed up wound healing:

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Wounds in the oral cavity heal much faster than skin lesions. Among other factors, saliva is generally assumed to be of relevance to this feature. Rodent saliva contains large amounts of growth factors such as epidermal growth factor (EGF) and nerve growth factor (NGF).

In humans, however, the identity of the involved compounds has remained elusive, especially since EGF and NGF concentrations are 100,000 times lower than those in rodent saliva.

Using an in vitro model for wound closure, we examined the properties of human saliva and the fractions that were obtained from saliva by high-performance liquid chromotography (HPLC) separation.

  • We identified histatin 1 (Hst1) and histatin 2 (Hst2) as major wound-closing factors in human saliva.
  • In contrast, the D-enantiomer of Hst2 did not induce wound closure, indicating stereospecific activation. Furthermore, histatins were actively internalized by epithelial cells and specifically used the extracellular signal-regulated kinases 1/2 (ERK1/2) pathway, thereby enhancing epithelial migration.

This study demonstrates that members of the histatin family, which up to now were implicated in the antifungal weaponry of saliva, exert a novel function that likely is relevant for oral wound healing.

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Now we know why nature tells us to lick our wounds…why dogs and cats do it too!!!!  This study also explains why mouth sores heal easily even if we dont do anything to them.

Hopefully in the future, this will help scientists develop new and better ways to help heal the wounds especially among those with diabetes or poor circulation that require the most aggressive way of treating the wounds to avoid complications like amputation.

For now…if you can lick it… go for it!!!!

Posted in Medical News Bits, Personal Thoughts | 1 Comment »

Meat Is Not NEAT!

April 7, 2009

Go to fullsize imageIt is easier to convince a child to eat meat than to eat veggies.  This scenario is given.  We are exposed to too many ads on meat whether chicken meat or beef meat on TV and newspapers.  It is therefore a challenge to parents to introduce other varieties of food that we deem healthier to the next generation.  It may take us some time to be successful but a little step can indeed go a long way overtime!

Now comes another study to support the concept that meat is really not neat!  Published in the latest edition of  Archives of Internal Medicine:

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Background  High intakes of red or processed meat may increase the risk of mortality. Our objective was to determine the relations of red, white, and processed meat intakes to risk for total and cause-specific mortality.

Methods  The study population included the National Institutes of Health–AARP (formerly known as the American Association of Retired Persons) Diet and Health Study cohort of half a million people aged 50 to 71 years at baseline. Main outcome measures included total mortality and deaths due to cancer, cardiovascular disease, injuries and sudden deaths, and all other causes.

Results  There were 47 976 male deaths and 23 276 female deaths during 10 years of follow-up.

  • Men and women in the highest vs lowest quintile of red (HR, 1.31 [95% CI, 1.27-1.35], and HR, 1.36 [95% CI, 1.30-1.43], respectively) and processed meat (HR, 1.16 [95% CI, 1.12-1.20], and HR, 1.25 [95% CI, 1.20-1.31], respectively) intakes had elevated risks for overall mortality.
  • Regarding cause-specific mortality, men and women had elevated risks for cancer mortality for red (HR, 1.22 [95% CI, 1.16-1.29], and HR, 1.20 [95% CI, 1.12-1.30], respectively) and processed meat (HR, 1.12 [95% CI, 1.06-1.19], and HR, 1.11 [95% CI 1.04-1.19], respectively) intakes.
  • Furthermore, cardiovascular disease risk was elevated for men and women in the highest quintile of red (HR, 1.27 [95% CI, 1.20-1.35], and HR, 1.50 [95% CI, 1.37-1.65], respectively) and processed meat (HR, 1.09 [95% CI, 1.03-1.15], and HR, 1.38 [95% CI, 1.26-1.51], respectively) intakes.
  • When comparing the highest with the lowest quintile of white meat intake, there was an inverse association for total mortality and cancer mortality, as well as all other deaths for both men and women.

Conclusion  Red and processed meat intakes were associated with modest increases in total mortality, cancer mortality, and cardiovascular disease mortality.

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This study further confirms the relationship between red meat and cancer, heart and overall risk of death.  Likewise, the study also showed that fish or intake of white meat was associated with a reduction in the risk of death.

Translating the data to common language…it means…

Over 10 years, those that eat meat equivalent to a quarter-pound hamburger can increase ones risk to die from cancer by 22 percent and the risk to die from heart disease by 27 percent. 

Bottom Line is:

Cut The Red Meat… Enjoy Fish in time for the Lenten Season….

Posted in General Health Tips, Healthy Practice Tips, Medical News Bits, Nutrition Health Tips, Personal Thoughts, Tips To Protect Your Heart | 5 Comments »

Take a Nap…Its Good for your Memory!!!

April 2, 2009

It is now known that being sleep deprived means…risking yourself to suffer from chronic illnesses including diabetes and heart disease.  Now comes an interesting observation published in Sleep Journal that links sleep to memory….

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Study Objectives:

In this study we examined the benefit of a daytime nap containing only NREM sleep on the performance of three declarative memory tasks: unrelated paired associates, maze learning, and the Rey-Osterrieth complex figure. Additionally, we explored the impact of factors related to task acquisition on sleep-related memory processing. To this end, we examined whether testing of paired associates during training leads to sleep-related enhancement of memory compared to simply learning the word pairs without test. We also examined whether strength of task acquisition modulates sleep-related processing for each of the three tasks.

Subjects and Procedure:

Subjects (11 male, 22 female) arrived at 11:30, were trained on each of the declarative memory tasks at 12:15, and at 13:00 either took a nap or remained awake in the sleep lab. After the nap period, all subjects remained in the lab until retest at 16:00.

Results:

Compared to subjects who stayed awake during the training retest interval, subjects who took a NREM nap demonstrated enhanced performance for word pairs that were tested during training, but not for untested word pairs. For each of the three declarative memory tasks, we observed a sleep-dependent performance benefit only for subjects that most strongly acquired the tasks during the training session.

Conclusions:

NREM sleep obtained during a daytime nap benefits declarative memory performance, with these benefits being intimately tied to how well subjects acquire the tasks and the way in which the information is acquired.

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In short…. 

For a sharper memory… taking a nap can definitely help!

“Not only do we need to remember to sleep, but most certainly we sleep to remember,” . The main message of the investigator and researcher Dr. William Fishbein, a cognitive neuroscientist at the recent meeting of the Society for Neuroscience.

So my friends… take a rest in between work…enjoy life… take it easy…

AND remember to take care of your brain because just like anything else in life…it needs to rest to function better!

Posted in General Health Tips, Lifestyle Measures, Medical News Bits | 4 Comments »

Can I Eat Eggs Everyday? Yes You Can!!!!

March 28, 2009

New studies have been made to refute the previous claims that eggs can increase ones cholesterol. 

A recent article published in the International Journal of Obesity showed that the previous notion of limiting eggs because they can increase cholesterol is no longer an acceptable fear.  In fact eggs can help one lose weight!

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Objective:

 To test the hypotheses that an egg breakfast, in contrast to a bagel breakfast matched for energy density and total energy, would enhance weight loss in overweight and obese participants while on a reduced-calorie weight loss diet.

Design:

Otherwise healthy overweight or obese participants were assigned to Egg (E), Egg Diet (ED), Bagel (B) or Bagel Diet (BD) groups, based on the prescription of either an egg breakfast containing two eggs (340 kcal) or a breakfast containing bagels matched for energy density and total energy, for at least 5 days per week, respectively. The ED and BD groups were suggested a 1000 kcal energy-deficit low-fat diet, whereas the B and E groups were asked not to change their energy intake.

Results:

After 8 weeks, in comparison to the BD group,

  • the ED group showed a 61% greater reduction in BMI,
  • a 65% greater weight loss ,
  • a 34% greater reduction in waist circumference (P<0.06) and
  • a 16% greater reduction in percent body fat (P=not significant).
  • No significant differences between the E and B groups on the aforementioned variables were obtained.
  • Further, total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol and triglycerides, did not differ between the groups.

Conclusions:

  The egg breakfast enhances weight loss, when combined with an energy-deficit diet, but does not induce weight loss in a free-living condition. The inclusion of eggs in a weight management program may offer a nutritious supplement to enhance weight loss.
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It is however to be emphasized that in this study, the egg diet was part of a calorie restircted diet suggesting that eating eggs as part of a low calorie diet can help one lose weight.  
  • But the added bonus of the study is the fact that eggs did not have any effect on the blood cholesterol level suggesting that it is really the intake of Saturated fat in the diet found in pastries, cakes and cookies that is harmful to the body!
  • The results of the study  were further confirmed in a similar finding from the University of Surrey research group which showed a similar no effect on cholesterol level with intake of 2 eggs per day for 6 to 8 weeks.
Hopefully…these two studies can now end the debate as to whether eggs are safe to eat or not.  Enjoy!!!!!

Posted in General Health Tips, Healthy Practice Tips, Lifestyle Measures, Medical News Bits, Nutrition Health Tips, Personal Thoughts, The Truths on Obesity | 213 Comments »

How Safe Are Artificial Sweeteners….

March 25, 2009

One topic that has never died down during these years is the safety of artifical sweteeners.  The problem stems from internet messages and information being propagated by unknown sources regarding the dangers of these products.  As an endocrinologist, I have been recommending these sweeteners to my patients as they actually help stave off the craving for sugar without necessarily increasing the sugar load.

But how much is enough for these sweeteners?

Recently the Mayo Clinic organization published views on this controversy and recommendations.

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The Food and Drug Administration (FDA) has approved the following low-calorie sweeteners for use in a variety of foods. The FDA has established an “acceptable daily intake” (ADI) for each sweetener. This is the maximum amount considered safe to eat each day during your lifetime. ADIs are intended to be about 100 times less than the smallest amount that might cause health concerns.

Artificial sweetener ADI* Estimated ADI equivalent** OK for cooking?
Aspartame (NutraSweet, Equal) 50 milligrams (mg) per kilogram (kg) 18 to 19 cans of diet cola No
Saccharin (Sweet’N Low, SugarTwin) 5 mg per kg 9 to 12 packets of sweetener Yes
Acesulfame K (Sunett, Sweet One) 15 mg per kg 30 to 32 cans of diet lemon-lime soda*** Yes
Sucralose (Splenda) 5 mg per kg 6 cans of diet cola*** Yes

*FDA-established acceptable daily intake (ADI) limit per kilogram (2.2 pounds) of body weight.
**Product-consumption equivalent for a person weighing 150 pounds (68 kilograms).
***These products usually contain more than one type of sweetener.

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How about the safety of these products?

Although this is one product has been bombarded with bad publicity probably because of its popularity being present in almost any low calorie foods to diet sodas… the National Cancer Institute and other major health oragnizations including the American Diabetes Association and the US FDA continue to refute these claims… as so far,  there’s no scientific evidence that any of the artificial sweeteners approved for use in the United States cause cancer and that there are now numerous studies to confirm that artificial sweeteners are safe for the general population.

I for one contnue to use aspartame or splenda for my coffee eevry morning or in the afternoon. I am a user and a believer in these low calorie sweeteners that as long as used properly and not in excess of what is recommended…then it is safe!

Enjoy The Sweetness of Health!

Posted in General Health Tips, Medical News Bits, Nutrition Health Tips, Personal Thoughts, The Diabetes Facts | 2 Comments »

The Nutritional Benefits of Pulses

March 22, 2009

Just gave a lecture to a group of food technologist, media personnel and nutritionist on the Nutritional Benefits of Pulses upon the invitation of the United States Department of Agriculture at the USDA Culinary Theater. Fortunately the Philippines now has access to the USDA products of pulses which have been neglected sources of healthy nutrients especially fiber.

I have been a proponent of healthy foods in my website. I am an advocate of healthy lifestyle for a healthy mind. And I am not hesitant to help promote products that are healthy and nutritious.

Pulses are actually edible seeds of legumes. Legumes include the peas, chickenpeas, beans and lentils. The good thing about them is that they are rich in fiber and have low glycemic index. As such, they therefore can be great partners to what we know as healthy diet.

A cup of cooked peas for example can be packed with fiber and yet very low in glycemic index meaning, the capacity to increase the blood sugar upon ingestion is very low. The combination of these properties provide one an ideal food that can be both filling and nutritious. As a result therefore, one gets to enjoy a food that can less likely contribute to weight gain which we know can lead to more serious chronic illnesses like diabetes, high blood pressure and stroke.

Several studies have now shown that obesity can lead to serious problems, and pulse based diet has been shown to help curb obesity in certain populations. Anything that can help us decrease the prevalence of obesity in this country and the world is really a welcome addition to our need to find more ways to combat this epidemic. Likewise, intake of pulses in certain regions of the world have been shown in epidemiological studies to result in long life span like the Japanese or the Swiss and reduce the risk of colon Cancer due to their pre-biotic properties. However long term studies need to be done to confirm this finding.

We don’t go to groceries and easily grab peas or beans in the aisle. We still need to be educated more about these foods and the USDA has led the way in this regard and I am pleased to be part of it. I myself am a fan of peas and beans.

I have started to educate my kids about the nutritious benefits of eating veggies and slowly and slowly, they’re learning to enjoy the greens more each day. So the next time you go grocery shopping… take a second look at Pulses. They are HEALTHY AND NUTRITIOUS!!!

Posted in General Health Tips, Lifestyle Measures | 1 Comment »

Can Vitamin C Help Prevent GOUT?

March 19, 2009

Go to fullsize imageGood news for patients at risk of developing gout because a very common remedy and very affordable at that has been shown to help prevent gout.

A new study published in the latest edition of Archives of Internal Medicine showed a relationship linking higher intake of Vitamin C to lower risk of developing gout:

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Background  Several metabolic studies and a recent double-blind, placebo-controlled, randomized trial have shown that higher vitamin C intake significantly reduces serum uric acid levels. Yet the relation with risk of gout is unknown.

Methods  We prospectively examined, from1986 through 2006, the relation between vitamin C intake and risk of incident gout in 46 994 male participants with no history of gout at baseline. We used a supplementary questionnaire to ascertain the American College of Rheumatology criteria for gout. Vitamin C intake was assessed every 4 years through validated questionnaires.

Results  During the 20 years of follow-up, we documented 1317 confirmed incident cases of gout. Compared with men with vitamin C intake less than 250 mg/d, the multivariate relative risk (RR) of gout was 0.83  for total vitamin C intake of 500 to 999 mg/d, 0.66  for 1000 to 1499 mg/d, and 0.55 (0.38-0.80) for 1500 mg/d or greater. The multivariate RR per 500-mg increase in total daily vitamin C intake was 0.83 . Compared with men who did not use supplemental vitamin C, the multivariate RR of gout was 0.66  for supplemental vitamin C intake of 1000 to 1499 mg/d and 0.55 (0.36-0.86) for 1500 mg/d or greater.

Conclusions  Higher vitamin C intake is independently associated with a lower risk of gout. Supplemental vitamin C intake may be beneficial in the prevention of gout.

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 What the study patients took were supplements of 1,500 mg daily.  What is interesting to note is that for every increase in Vitamin C intake of 500 mg per day, the risk of developing gout was decreased by 17%.

Likewise, those who took the 1500 mg supplemental form of Vitamin C had a 45% lower risk of developing gout than those who took lower doses of Vitamin C.  On the other hand those that took 1000 mg ov Vitamin had a 34% lower risk of developing gout!

It is known that Vitamin C can decrease the levels of uric acid oin the blood by increasing its excretion in the urine.

Does this mean,. we now go ahead and grab more Vitamin Cs in the market? I guess we need to wait for more studies to confirm this finding. 

But to those who continue to believe in Vitamin C and its role in preventing colds, this is one good news!

For me… getting the Vitmain Cs from fruits would be a better option.  Remember one orange can give you 70 mg of Vitamin C already.  Plus the ther benefits of fruit intake!

Posted in General Health Tips, Healthy Practice Tips, Medical News Bits | 4 Comments »

Reduce Your Risk for Diabetes Through Weight Loss: The Impact of Weight Loss Surgery

March 9, 2009

Go to fullsize imageWeight gain and Obesity play very important roles in the development of chronic diseases like Diabetes, High blood pressure and complications like Stroke and Heart Attack.  One therefore has to incorporate proper lifestyle and good behavior through daily physical acitvity to help avoid developing these conditions.  However there are certain inidividuas where weight loss through these behvioral methods no longer are enough to provide the weight loss one desires and therefore for ” medical” reasons, one resorts to drastic measures like Bariatric surgery.

But do they work in decreasing the risk? or do they help patients improve disease outcomes?

Now comes s study published in the American Journal of Medicine, March 2009  to show that weight loss indeed can work wonders to diabetes and that bariatric surgery can help:

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  • 621 studies from 1990 to April of 2006 were analyzed:  78.1% of diabetic patients had complete resolution and diabetes was improved or resolved in 86.6% of patients as the result of bariatric surgery.
  •  Gastric banding yielded 56.7% resolution, gastroplasty 79.7%, gastric bypass 80.3% and BPD/DS 95.1%.
  •  After more than 2 year post-operative, the corresponding resolutions were 58.3%, 77.5%, 70.9%, and 95.9%.
  • The Percent excess weight loss was 46.2%, 55.5%, 59.7% and 63.6%, for the type of surgery performed suggesting that BPD yielded the best result.

Concluding that:

  • 82% of patients had resolution of the clinical and laboratory manifestations of diabetes in the first 2 years after surgery, and
  • 62% remained free of diabetes more than 2 years after surgery (80% and 75% for the total group).

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The study for me tells us one thing: that weight loss indeed can work wonders.  However lets not all resort to surgery to achieve improvement in our risk for diseases as surgery also entails risks! 

While proper diet and physical activity are completely free and easy to do…all they need are the Two D’s to succeed: DETERMINATION and DISCIPLINE!

Posted in General Health Tips, Medical News Bits, The Diabetes Facts, The Truths on Obesity, What's New in Diabetes | 3 Comments »

Chewing Nuts and Weight Loss

March 3, 2009

I recommend munching on nuts like almonds or cashew for snacks among my patients becuase of their monounsaturated fat content.  The problem however with nuts is the tendency to overeat and the difficulty of stopping.

We are told that chewing ones food more often than swallowing right away after chewing 2x can have a dramatic effect on satiety and weight. More often than not, we chew our food only few times then swallow then grab some more food until we feel so bloated.  Thus it is often my principle to chew food properly and do it more times to allow my brain to inform my body that I am full!

Here’s one study that I found interesting published recently in the Journal of Clinical Nutrition.  This study looked at the number of times one chew the nuts and measure their level of satiety.

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Background: Epidemiologic and clinical data indicate that nuts can be incorporated into the diet without compromising body weight. This has been attributed to strong satiety properties, increased resting energy expenditure, and limited lipid bioaccessibility.

Objective: The role of mastication was explored because of evidence that the availability of nut lipids is largely dependent on the mechanical fracture of their cell walls.

Design: In a randomized, 3-arm, crossover study, 13 healthy adults (body mass index, in kg/m2: 23.1 ± 0.4) chewed 55 g almonds 10, 25, or 40 times. Blood was collected and appetite was monitored during the following 3 h. Over the next 4 d, all foods were provided, including 55 g almonds, which were consumed under the same chewing conditions. Complete fecal samples were collected.

Results: Hunger was acutely suppressed below baseline (P < 0.05), and fullness was elevated above baseline longer (P < 0.05) after 40 chews than after 25 chews. Two hours after consumption, fullness levels were significantly lower and hunger levels were significantly higher after 25 chews than after 10 and 40 chews (P < 0.05). Initial postingestive glucagon-like peptide-1 concentrations were significantly lower after 25 chews than after 40 chews (P < 0.05), and insulin concentrations declined more rapidly after 25 and 40 chews than after 10 chews (both P < 0.05). Fecal fat excretion was significantly higher after 10 chews than after 25 and 40 chews (both P < 0.05). All participants had higher fecal energy losses after 10 and 25 chews than after 40 chews (P < 0.005).

Conclusion: The results indicate important differences in appetitive and physiologic responses to masticating nuts and likely other foods and nutrients. 

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For me the significance of this study boils down to one: Chewing ones food more often is healthier for the body in terms of early satiety and therefore better for weight control.  This study really justifies the concept of chewing food slowly around 20 times or more before swallowing to allow your body to register that food has entered and that you’re full.  By practicing this behavior, one also is able to control the appetite and therfore results in better regulation of weight! 

So if you love nuts…chew them properly…chew them more than 40 x if you want… they’re not only healthy snack alternatives but better for weight loss too.

Posted in General Health Tips | 8 Comments »

Take Action on Your Weight!!! The Risks Associated with Being Overweight…

February 28, 2009

Go to fullsize imageBeing overweight needs immediate action!  Thats why when I registered a BMI of 25.6 with a fasting blood sugar of 96, I decided to take action and become healthier with my diet and physical activity.  Being overweight carries with it chronic diseases like diabetes, high blood pressure and cholesterol problem.  Not mentioning stroke and heart attack as endpoints!

For year 2009: Its NOW a Global Call to action as more and more children and adolescence are gaining weight.  There’s no time to sit back and relax on this matter as inaction means DISASTER in the long run for these children!

A recent study published in www.bmj.com showed that obese adolescents have the same risk of premature death in adulthood as people who smoke more than 10 cigarettes a day!!!!   This is indeed a scary thought.

Those who are overweight have the same risk as less heavy smokers.

BMI is a measure of your weight according to your height.  For Caucasians, a BMI of >25 if already overweight but for Asians, a lower BMI of 23 is considered abnormal already.

What if one is underweight?

Being underweight carries with it a better prognosis  as it carries with it no increased risk, irrespective of smoking status.  However, if you are also too thin with a a body mass index of less than 17; then it carried with it the same risk of premature death as being overweight.

The study suggests therefore that being OBESE and Overweight at the age of  18 carries the same risk of premature death as being too thin!  Both conditions stem from poor nutrition either too much or too little.

Its not late to start and do something for yourself or for our kids…. NOW!

Life is short..Take time to Take Care of your HEALTH!

Posted in General Health Tips, Healthy Practice Tips, Lifestyle Measures, Medical News Bits, Personal Thoughts, The Truths on Obesity | 1 Comment »

High Blood Sugar Predicts Death in Heart Attack Patients

February 26, 2009

Just a note for all of the readers with family members who are diabetics.  This is just to make you aware that control of sugar is of paramount importance even at the time of hospitalization especially due to heart attack.

This new study published in Archives of Internal Medicine, Feb 2009 shows that the relationship between fasting blood sugar on admission and its ability to predict outcome of death within 6 months of the acute attack.

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Background  Elevated blood glucose level at admission is associated with worse outcome after a myocardial infarction. The impact of elevated glucose level, particularly fasting glucose, is less certain in non–ST-segment elevation acute coronary syndromes. We studied the relationship between elevated fasting blood glucose levels and outcome across the spectrum of ST-segment elevation and non–ST-segment elevation acute coronary syndromes in a large multicenter population broadly representative of clinical practice.

Methods  Fasting glucose levels were available for 13 526 patients in the Global Registry of Acute Coronary Events. A multivariate logistic regression analysis was used for assessing the association between admission or fasting glucose level and in-hospital or 6-month outcome, adjusted for the variables from the registry risk scores.

Results 

  • Higher fasting glucose levels were associated with a graded increase in the risk of in-hospital death (odds ratios [95% confidence intervals] vs <100 mg/dL: 1.51 [1.12-2.04] for 100-125 mg/dL, 2.20 [1.64-2.60] for 126-199 mg/dL, 5.11 [3.52-7.43] for 200-299 mg/dL, and 8.00 [4.76-13.5] for 300 mg/dL).
  • When taken as a continuous variable, higher fasting glucose level was related to a higher probability of in-hospital death, without detectable threshold and irrespective of whether patients had a history of diabetes mellitus.
  • Higher fasting glucose levels were found to be associated with a higher risk of postdischarge death up to 6 months.
  • The risk of postdischarge death at 6 months was significantly higher with fasting glucose levels between 126 and 199 mg/dL (1.71 [1.25-2.34]) and 300 mg/dL or greater (2.93 [1.33-6.43]), but not within the 200- to 299-mg/dL range (1.08 [0.60-1.95]).

Conclusions  Short-term and 6-month mortality was increased significantly with higher fasting glucose levels in patients across the spectrum of acute coronary syndromes, thus extending this relation to patients with non–ST-segment elevation myocardial infarction. The relation between fasting glucose level and risk of adverse short-term outcomes is graded across different glucose levels with no detectable threshold for diabetic or nondiabetic patients.

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Better still…. across the spectrum of diabetes management that good control should always be practiced.  

No ifs or buts…its the RULE!

Reduction in short term complications, the sense of well being…plus reduction of long term complications like stroke and heart attack…are more than enough for any diabetic in the family to make sure that good control should always be practiced.  

Ths study tells us that up to the time of the acute event, high sugar continues to present itself as a menace.  And that high sugar should not be relegated as a mere stress effect but for me should be aggressively treateed as metabolic effects can have lasting impact on ones health and are irreversible!

Be aggressive as high sugar may not manifest any symptoms until its late!

Posted in Medical News Bits, The Diabetes Facts, Tips To Protect Your Heart, What's New in Diabetes | 9 Comments »

Can Daily Intake of Eggs Be Healthy?

February 23, 2009

Go to fullsize imageControversies continue to surround whether eggs can cause harm if taken daily or not. Debate among the experts continue with assumptions that cholesterol in the diet actually has little effect on blood cholesterol.  No doubt that intake of saturated fat can increase the level of blood cholesterol and risk a patient to develop heart attack and stroke.  The relationship of Egg intake to disease continues to be debatable.

Now comes a new study publsished in the Diabetes Care , this February 2009  that for sure will add fuel to the ongoing controversy:

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OBJECTIVE—Whereas limited and inconsistent findings have been reported on the relation between dietary cholesterol or egg consumption and fasting glucose, no previous study has examined the association between egg consumption and type 2 diabetes. This project sought to examine the relation between egg intake and the risk of type 2 diabetes in two large prospective cohorts.

RESEARCH DESIGN AND METHODS—In this prospective study, we used data from two completed randomized trials: 20,703 men from the Physicians’ Health Study I (1982–2007) and 36,295 women from the Women’s Health Study (1992–2007). Egg consumption was ascertained using questionnaires, and we used the Cox proportional hazard model to estimate relative risks of type 2 diabetes.

RESULTS—During mean follow-up of 20.0 years in men and 11.7 years in women, 1,921 men and 2,112 women developed type 2 diabetes. Compared with no egg consumption, multivariable adjusted hazard ratios for type 2 diabetes were 1.09 (95% CI 0.87–1.37), 1.09 (0.88–1.34), 1.18 (0.95–1.45), 1.46 (1.14–1.86), and 1.58 (1.25–2.01) for consumption of <1, 1, 2–4, 5–6, and 7 eggs/week, respectively, in men (P for trend <0.0001). Corresponding multivariable hazard ratios for women were 1.06 (0.92–1.22), 0.97 (0.83–1.12), 1.19 (1.03–1.38), 1.18 (0.88–1.58), and 1.77 (1.28–2.43), respectively (P for trend <0.0001).

CONCLUSIONS—These data suggest that high levels of egg consumption (daily) are associated with an increased risk of type 2 diabetes in men and women. Confirmation of these findings in other populations is warranted.

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The question arises: whether it is the intake of egg that increased the risk to develop diabetes.  Or is it the relationship of the high fat diet associated with the egg intake that increased the risk.  It is known that high cholesterol and saturated fat intake can increase a patients risk to develop diabetes.

So when the study participants’ daily cholesterol intake was assessed, it showed a relationship related to diabetes risk!!!  When the researchers factored this relationship in, the association between egg intake and diabetes weakened suggesting that a cholesterol-rich diet might promote diabetes.  This also suggest that a person who may like eggs may also eat other fatty foods that will result in increasing the risk to deveolp the disease.

So a not so good news for egg lovers who have family history of diabetes.  This is one food that one may have to limit for now until more studies will show the relationship to be otherwise.

But for the others who have no risk of developing diabetes…I suggest that eggs should remain to be enjoyed as long as one should not exceed 3-5 eggs per week.  This recommnedation will stay for now. 

But do … Watch out in this site if new developments come in about eggs because for sure I will be the first to know and you will be the first to be informed !!!!

Posted in General Health Tips, Lifestyle Measures, Medical News Bits, What's New in Diabetes | 3 Comments »

Is There Any Benefit in Taking A Multivitamin?

February 12, 2009

Go to fullsize imageI used to take one multivitamin pill per day.  I know of others who take tons of vitamins because they make them feel “better”. Or just a habit difficult to change. Or better still, relatives in the US send us with big bottles of these Vitamins as presents.  But are they USEFUL? 

Ever since, I already doubted the usefullness of these vitamins UNLESS one is not eating properly or is very choosy with food that predisposes one to deficiency of certain vitamins that we usually get from food.  But for people that have problems of the Opposite, that is… controlling the intake, I suggest you might as well spend your money on something else that’s healthy and has important benefit on ones health.

The latest issue of the Archives onf Internal Medicine published this recent study looking at the effectiveness of taking multivitamins.

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Background  Millions of postmenopausal women use multivitamins, often believing that supplements prevent chronic diseases such as cancer and cardiovascular disease (CVD). Therefore, we decided to examine associations between multivitamin use and risk of cancer, CVD, and mortality in postmenopausal women.

Methods  The study included 161 808 participants from the Women’s Health Initiative clinical trials (N = 68 132 in 3 overlapping trials of hormone therapy, dietary modification, and calcium and vitamin D supplements) or an observational study (N = 93 676). Detailed data were collected on multivitamin use at baseline and follow-up time points. Study enrollment occurred between 1993 and 1998; the women were followed up for a median of 8.0 years in the clinical trials and 7.9 years in the observational study. Disease end points were collected through 2005.

We documented cancers of the breast (invasive), colon/rectum, endometrium, kidney, bladder, stomach, ovary, and lung; CVD (myocardial infarction, stroke, and venous thromboembolism); and total mortality.

Results  A total of 41.5% of the participants used multivitamins. After a median of 8.0 years of follow-up in the clinical trial cohort and 7.9 years in the observational study cohort, 9619 cases of breast, colorectal, endometrial, renal, bladder, stomach, lung, or ovarian cancer; 8751 CVD events; and 9865 deaths were reported. Multivariate-adjusted analyses revealed no association of multivitamin use with risk of cancer (hazard ratio [HR], 0.98, and 95% confidence interval [CI], 0.91-1.05 for breast cancer; HR, 0.99, and 95% CI, 0.88-1.11 for colorectal cancer; HR, 1.05, and 95% CI, 0.90-1.21 for endometrial cancer; HR, 1.0, and 95% CI, 0.88-1.13 for lung cancer; and HR, 1.07, and 95% CI, 0.88-1.29 for ovarian cancer); CVD (HR, 0.96, and 95% CI, 0.89-1.03 for myocardial infarction; HR, 0.99, and 95% CI, 0.91-1.07 for stroke; and HR, 1.05, and 95% CI, 0.85-1.29 for venous thromboembolism); or mortality (HR, 1.02, and 95% CI, 0.97-1.07).

Conclusion  After a median follow-up of 8.0 and 7.9 years in the clinical trial and observational study cohorts, respectively, the Women’s Health Initiative study provided convincing evidence that multivitamin use has little or no influence on the risk of common cancers, CVD, or total mortality in postmenopausal women.

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In short … wanna live long?  Live a healthy lifestyle.  There are other ways to better living not simple taking of pills as a shortcut or better still … lets take a walk and think again.

Pills or exercise?  I know your answers…keep it to yourselves.  You choose … it’s your life!

Posted in General Health Tips, Medical News Bits, Nutrition Health Tips | 2 Comments »

The New Way To Exercise and Get Results….

February 9, 2009

Go to fullsize imageGood news to those who just dont have the time to exercise.

A new study published online by the BMC, 2009 showed a new way to exercise that will have the same or better impact on our body’s metabolism than previously thought.

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Background

Classic, long duration aerobic exercise reduces cardiovascular and metabolic disease risk but this involves a substantial time commitment. Extremely low volume high-intensity interval training (HIT) has recently been shown to cause similar improvements to aerobic performance, but it has not been established whether HIT has the capacity to improve glycemic control.

Methods

Sixteen young men  performed 2 weeks of supervised HIT comprising of a total of 15 min of exercise (6 sessions; 4-6 x 30-s cycle sprints per session). Aerobic performance (250-kJ self-paced cycling time trial), and glucose, insulin and NEFA responses to a 75-g oral glucose load (oral glucose tolerance test; OGTT) were determined before and after training.

Results

Following 2 weeks of HIT, the area under the plasma glucose, insulin and NEFA concentration-time curves were all reduced (12%, 37%, 26% respectively, all P<0.001). Fasting plasma insulin and glucose concentrations remained unchanged, but there was a trend towards reduced fasting plasma NEFA concentrations post-training (pre: 350 +/- 36 v post: 290 +/- 39 mumol * l-1, P=0.058). Insulin sensitivity as measured by the Cederholm index was improved by 22.5% (P<0.01). Aerobic cycling performance was improved by ~6% (P<0.01).

Conclusions

The efficacy of a high intensity exercise protocol, involving only ~250 kcal work each week, to substantially improve insulin action in young sedentary subjects is remarkable. We feel this novel time-efficient training paradigm can be used as a strategy to reduce metabolic risk factors in young and middle aged sedentary populations who otherwise would not adhere to a classic high volume, time consuming exercise regimens

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In this study short burst of intense exercise activity lasting for like 30 seconds resulted in improvement of parameters that can have an impact in preventing chronic illnesses. 

The subjects used exercise bikes which we can easily buy in sports stores… performed a quick sprint insturcted to do it at their highest possible intensity for around 30 seconds.  The results showing significant improvements in exercise parameters biochemically suggest that any highly vigorous activity carried out in few minutes in a few days per week should achieve the same protective metabolic improvements. 

This is definitely good news to those who just cant find the right time and place to do their exercise workout.  This is one of the first studies to document that short bouts of exercise can be as effective in improving metabolic parameters as the usual recommendations of moderate exercise for 30 minutes most days of the week. 

Now my friends… no more excuses!!!

Posted in Exercise and Activity Tips, General Health Tips, Healthy Practice Tips, Lifestyle Measures, Medical News Bits | 5 Comments »

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