Let food be thy medicine and medicine be thy food.
Who said anything about medicine? Let's eat!
Who hasn't seen or heard Hippocrates' famous quote about letting food be your medicine and your medicine your food? If you have Facebook friends who are the least bit into "natural" medicine or living, you've almost certainly come across it in your feed, and if you're a skeptic who pays the least bit of attention to what's going on in the quackosphere you will almost certainly have seen it plastered on a picture as a meme, either using a picture of Hippocrates or pictures of plates of green, leafy vegetables, or both. I like to view the worship of "food as medicine," to cite Hippocrates (if he or his followers even said it), as one of the best examples out there of the logical fallacy known as the appeal to antiquity; in other words, the claim that if something is ancient and still around it must be correct (or at least there must be something to it worth considering).
Of course, just because an idea is old doesn't mean it's good, any more than just because Hippocrates said it means it must be true. Hippocrates was an important figure in the history of medicine because he was among the earliest to assert that diseases were caused by natural processes rather than the gods and because of his emphasis on the careful observation and documentation of patient history and physical findings, which led to the discovery of physical signs associated with diseases of specific organs. However, let's not also forget that Hippocrates and his followers also believed in humoral theory, the idea that all disease results from an imbalance of the "four humors." It's also amusing to note that this quote by Hippocrates is thought to be a misquote, as it is nowhere to be found in the more than 60 texts known as The Hippocratic Corpus (Corpus Hippocraticum).
But Hippocratic doctors clearly saw a difference between food and medicines. In fact, food was considered as a material that could be assimilated after digestion (e.g. the air was also food) and converted into the substance of the body. For example, food was converted into the different parts of the body such as muscles, nerves, etc. By contrast, the concept of medicines at the time was a product which was able to change the body's own nature (in terms of humor quality or quantity) but not be converted into the body's own substance. Thus a food wasn't considered a medicine. A possible root of the food-medicine confusion is the following cryptic phrase found in the work On Aliment: "In food excellent medication, in food bad medication, bad and good relatively".3 This text is nowadays attributed to the Hellenistic period, but was considered to be Hippocratic in Antiquity by Galenus in particular.
Now, it is certainly true that Hippocrates and his followers used diet to treat many illnesses, it's not really clear what sort of success they had. However, this ancient idea that virtually all disease could be treated with diet, however much or little it was embraced by Hippocrates, has become an idée fixe in alternative medicine, so much so that it leads its proponents twist new science (like epigenetics) to try to fit it into a framework where diet rules all, often coupled with the idea that doctors don't understand or care about nutrition and it's big pharma that's preventing the acceptance of dietary interventions. That thinking also permeates popular culture, fitting in very nicely with an equally ancient phenomenon, the moralization of food choices (discussed ably by Dr. Jones a month ago).
Let food be thy medicine and medicine be thy food?
This idée fixe that diet can fix everything even leads respectable doctors to write stories that are in some ways balanced but in other ways maddeningly credulous, like this story published last week in The New Republic by Dr. Sushrut Jangi, an Instructor in Medicine at Beth Israel Deaconess Medical Center, entitled "The Nutrition Gap." You can tell right away that there are going to be…problems…with the article by its summary:
In America, where the pharmaceutical industry is king, many doctors dismiss nutritional therapies as quack medicine. But many patients disagree, and they're taking matters into their own hands—sometimes to the detriment of their health. Can food cure disease? And are doctors ready to think outside the pillbox?
Yes, the trope is there, that pharma rules all and nutritional therapies are dismissed as quackery. Of course, one has to distinguish between different nutritional therapies because many nutritional "therapies" promoted by alternative medicine are quackery. Unfortunately, Dr. Jangi can't quite bring himself to do that properly. Before I get to the most egregious examples of that failing, first I must in all fairness acknowledge one thing that he gets right, and that's his pointing out that there is a "nutrition gap in America, a disconnect between how patients and clinicians perceive diet," a gap that has "been largely filled by opportunists like Gwyneth Paltrow and Dr. Mehmet Oz, obscuring many meaningful advances in understanding how nutrition influence health." Right on! There are so many quack nutritional therapies out there, so many diets, so many claims, and so little science to back them up that it's no wonder that it's hard for a nutritional therapy to break through.
As is usually the case with articles like this, Jangi begins with a human interest anecdote, about a woman who is identified only as Helen who unexpectedly developed multiple myeloma at an age far younger than the disease usually strikes. Multiple myeloma is a cancer of plasma cells, immune cells that make antibodies. Because of this, as the disease progresses, multiple myeloma can cause kidney failure due to it secretion of excess antibodies and components of antibodies, proteins that can damage the kidney at high concentrations. It can also cause bone pain and fractures due to its secretion of a factor that activates cells that break down bone. Life expectancy can vary considerably, depending on age and how aggressive the tumor is. Survival rates have been increasing steadily, however, over the last 15 years, particularly in younger patients like Helen. Indeed, given improvements in treatment, after the initial treatment with chemotherapy, it is possible that one day in the not too distant future multiple myeloma could be treated as a chronic disease, as Dr. Jangi himself points out.
If you've been reading this blog and stories like this long enough, you'll know what's coming next:
…Helen began to wonder if this was her fault—if she had done something wrong. Still a young woman, married, employed, with two children at home, she exercised regularly, never smoked, rarely drank, and hardly ever got a cold. What in my life, she wondered, was to blame?
Helen's doctors encouraged her to look forward. Her hematologist, at Massachusetts General Hospital in Boston, explained that her bone marrow had become overgrown by cancerous immune cells, and that the treatment required high doses of chemotherapy. The doctor described the litany of consequences from the powerful medications: hair loss, infections, and a probable bone marrow transplantation. Helen sat in the clinic of the busy Boston hospital, surrounded by expert oncologists with their novel clinical trials in dismay. She faced either the threat of a serious, potentially life-limiting disease or a heavy-duty regimen of drugs that she felt would similarly poison her body. "There had to be another way," she said. "I didn't want chemotherapy."
Helen did choose another way, based on her suspicion about why she had fallen sick in the first place. "It had to be my diet," she told me. So, against all professional medical advice, she started an experiment on herself.
Humans crave explanation, as I have pointed out so many times before. When someone as young as Helen is diagnosed with a life-threatening disease that's pretty uncommon to begin with but very uncommon in patients her age, the natural thing for her to do is to look for possible explanations, just as, for example, the mother of Tiffany Frantz did when Tiffany was diagnosed at age 21 with breast cancer. She ended up incorrectly blaming her daughter's keeping her cell phone in her bra. Also, as I've said so many times before about so many other patients, I don't blame Helen for being afraid. High dose chemotherapy followed by stem cell rescue (i.e., a bone marrow transplantation) is a brutal, brutal regimen that requires prolonged hospitalization and guarantees some nasty side effects. I understand, at least as much as anyone who hasn't himself been faced with such a choice. However, there is little good evidence connecting diet with elevated risk for multiple myeloma, other than one study in which risk correlates with obesity and negatively correlates with cruciferous vegetables and fish. In such an uncommon disease, rare in her age group, the likelihood that the small absolute risk reduction from a dietary change would have made any difference is exceedingly small. In any case, before too long we learn that Helen headed for the Mexican border and went to Baja to begin "nutritional therapy for her cancer." That therapy? You guessed it: Gerson.
Here's where Jangi goes off the rails. For one thing, I hate it when Gerson therapy is just described as "nutritional" therapy or "dietary therapy." So vague. So bland. It doesn't tell you just exactly what the Gerson protocol involves. It's something I've discussed in detail; so I don't feel a need to go into great detail, but let's just briefly recap what the Gerson protocol involves:
- Thirteen glasses of fresh, raw carrot/apple and green-leaf juices prepared hourly from fresh, organic fruits and vegetables.
- Three full plant-based meals, freshly prepared from organically grown fruits, vegetables and whole grains. A typical meal will include salad, cooked vegetables, baked potatoes, Hippocrates soup and juice.
- Fresh fruit and vegetables available at all hours for snacking, in addition to the regular diet.
The Gerson therapy requires enormous amounts of these fruits and vegetables to make these juices and meals, up to 20 lbs. per day or even more, as well as these supplements:
- Potassium compound
- Lugol's solution
- Vitamin B-12
- Thyroid hormone
- Pancreatic enzymes
To top all this off (I know, old joke), the Gerson therapy involves coffee enemas, lots and lots and lots of coffee enemas, usually five a day. To be fair, Jangi does describe some of this and how it took three weeks at the Gerson Clinic to learn the protocol, which she followed for two years. She even quoted Helen as saying, "I was actually pretty exhausted that whole time." However, instead of making the Gerson protocol sound quacky (which it is), he makes it sound downright rational (which it isn't). For instance, he portrays poor Max Gerson as persecuted, having come up with his idea as the "pharmaceutical industry entered its golden era":
While in Germany, Gerson had created a regimen devoid of processed foods and had published several cases of patients forever cured of migraines, arthritis, and even forms of tuberculosis. He surprised himself most when, in 1928, a patient with cancer of the bile ducts asked for his diet. Initially, he refused, but caved to her persistence. Six months later, he announced her cure. Two more cancer cures followed.
Dr. Jangi desperately needs to read Peter Moran's excellent deconstruction of Max Gerson's "50 cases" that he used as evidence that his protocol could cure cancer. Seriously. There is no excuse to portray Gerson's nonsense this way, no excuse at all, much less to go on to write:
But Gerson ran into resistance when he began applying his dietary regimen at Gotham Hospital in New York City in the 1940s. Suspicious of his methods, the Journal of the American Medical Association asked for copies of Gerson's data. When he failed to provide the reputed medical journal the requested information, the editors responded. In a widely read 1946 JAMA article, editor Dr. Morris Fishbein (who actually made much of his reputation busting medical flimflammery) denounced the Gerson diet as lacking significant evidence in the treatment of cancer. In a follow-up editorial in 1949, Fishbein published a criticism of Gerson's approach in a review entitled "Frauds and Fables," labeling Gerson a charlatan.
Gee, Jangi writes this as though what Dr. Fishbein did were a bad thing! Or that it were a bad thing that the American Medical Association and the American Cancer Society blacklisted the Gerson regimen and insurance companies stopped providing compensation for the therapy! It wasn't. None of it was. In fact, the whole tone of Dr. Jangi's article is irritating to the extreme to anyone who knows the actual history of Max Gerson and his "alternative cancer cure," painting Gerson as an unfairly persecuted visionary who was driven unjustly from his country. Heck, Jangi even uses the word "persecution" when he observes that after Gerson's death his daughter Charlotte "founded a place to administer his therapies at a hospital near Tijuana, free from the persecution of American medical societies." She's still there, decades later. None of this stops Jangi from making Gerson sound like the brave maverick doctor persecuted by the medical establishment who just didn't see his genius. Oh, sure, ten patients were admitted to hospitals in Southern California with Campylobacter fetus sepsis, believed to be a side effect of the liver injections that accompany the older versions of the therapy, none of them cured of cancer. And there were a bunch of other complications and fatalities, too, as documented in this article.
Of course, that doesn't seem to bother Jangi as much as this:
In 1992, JAMA published a "special communication" again denouncing the therapy. "The poisons in processed foods that proponents of the Gerson therapy say cause cancer have never been identified," they wrote, disputing the idea that a diet of fruits and vegetables could prevent the process of cancer development. "This makes the Gerson therapy impossible to accept," they wrote.
I can't get an article from JAMA that old through my institutional subscription, so I can't evaluate it for myself in context. However, the many criticisms of the Gerson protocol from that era and before that I have read generally emphasize its extreme biological implausibility given how it is based on an idea of how cancer forms from the early 1900s that had long since been shown to be incorrect; the lack of evidence, basic science or clinical trial, that it works; and the harm caused to patients. It's well-accepted that diet can decrease the risk of certain cancers; what's not well-accepted, mainly because there is little or no good evidence, is that dietary interventions can impact the progression and course of cancer. Remember, that is what Gerson claimed, that a radical diet, a boatload of supplements per day, and coffee enemas could cure cancer. Indeed, a deceased proponent of the Gerson protocol, Jess Ainscough, reported that over the two years she did the Gerson protocol she had consumed 8,760 glasses of juice, 1,460 baked potatoes, 1,460 bowls of Hippocrates soup, 33,580 supplements, and 174 shots of castor oil, while giving herself 2,920 coffee enemas. Two years include 730 days; so you can do the math yourself.
In other words, the reason the Gerson protocol is viewed as quackery (at least by physicians who even know what it is in the first place) is quite simple. It is quackery. Max Gerson was not some poor, misunderstood, persecuted visionary. He was a dangerous quack, and his daughter continues to carry on that quackery. Yet the average reader only gets a very minimal inkling of this possibility, if any at all, from Dr. Jangi's article.
Food versus medicine
As much as the whole Gerson business irked me, what really frustrated me about this article is that there are some insights in there. This could have been a good article explaining to the lay public what is known and what isn't known about nutrition and disease and why it's difficult to evaluate such treatments. He takes a stab at that when he points out how difficult it is to do randomized controlled studies of dietary interventions because it's almost impossible to blind them and they require one group to make a major change to their lifestyle that could take years before an effect is observed. Still, such studies have been done, such as the study of the Mediterranean diet published in the NEJM in 2013 that showed a Mediterranean diet supplemented with extra-virgin olive oil or nuts reduced the incidence of major cardiovascular events by 30% in high risk patients.
Jangi also mentions work by Gary Wu, the associate chief of research in the Division of Gastroenterology at the University of Pennsylvania, who has studied elemental diets—a regimen composed of components of food in its simplest form—as a treatment for inflammatory bowel disease. His results suggest that the therapy works almost as well as TNF inhibitors, although Jangi didn't make a couple of important things clear. First, as far as I can tell, there has as yet not been a randomized controlled trial. The most recent clinical study by Dr. Wu I could find was a prospective observational study. He also neglects to note that these "elemental diets" are liquid diets that sometimes have to be administered through a feeding tube. They're not exactly great as far as lifestyle goes. They're not "normal" in the sense that they don't allow the patient to eat what most would refer to as "real" food. They're also nothing new. These sorts of diets have been studied in inflammatory bowel disease and other gut disorders on and off for a long time. I remember endless debates in my ICU rotations in the 1990s over whether using elemental diets, parenteral nutrition, diets with medium chain triglycerides, or various other tube feeding formulas best prevented and/or healed gut dysfunction in critically ill patients.
Oh, and Dr. Jangi falls a bit for the magical thinking so many are layering on the emerging field of epigenetics. Ugh. (Click the links if you want to see why his brief discussion of epigenetics is a misfire.) He also greatly exaggerates the promise of substances like curcumin, whose reality (in my not so humble opinion) hasn't really lived up to the hype of several years ago, citing a seven year old article.
One area that could also have used a bit more explanation is the recent FDA guidelines about whether a human study can be conducted without an investigational new drug application (IND). It's a topic that I might have to take the time to do an entire post about after reading the entire draft guidelines and looking up some analyses. Basically, he has a germ of a point when he writes:
But recent guidance from the FDA similarly requires that foods being tested for the management of illness also mandate submission of an IND if those foods are to be studied in humans, a significant hurdle for academics and researchers who cannot invest in such a potentially expensive gamble. Consequently, nutritional therapies have a hard time reaching the stage of serious clinical trials. They never receive the FDA's blessings and stagnate in the dark corner of the local vitamin shop, lost to the mainstream.
On the one hand, I can understand the FDA's rationale if the intent of the food use is to treat a disease; in that case, it is arguably being used as medicine. On the other hand, what about diets that don't necessarily involve what the FDA refers to as "medicinal foods" (e.g., curcumin for cancer prevention or treatment), such as exclusion diets for inflammatory bowel disease, or, for that matter, the Mediterranean diet, which doesn't include any specific single "medicinal food" but rather broad types of foods in certain proportions? One also can't help but wonder whether this confusing morass has a lot to do with how dietary supplements were handled 20 years ago by the DSHEA of 1994? For instance, I have seen supplement manufacturers complain that these guidelines make it possible for the same supplement to be considered simultaneously a drug if it's in a clinical trial after an IND is obtained and a supplement. Of course, I rather suspect that they doth protest a bit too much because they don't want to do clinical trials anyway when the DSHEA lets them sell their supplements with minimal regulation. Why would they want to dive into this morass, when it could only hurt their profits? Be that as it may, requiring an IND makes sense when it's a defined supplement or manufactured diet (such as the aforementioned elemental diet) but makes a lot less sense for diets like the Mediterranean diet.
In the end, Dr. Jangi sweeps around again to his human interest element, Helen. Happily, she is still alive and doing well six years later:
Yet her appearance, however glowing, belied her five-year struggle—her trip to Baja, to various clinics, hospitals, and rehabilitation centers; her inner conflicts between her own philosophies and those offered by conventional doctors and alternative practitioners; blood-test results that made her question her decision to forgo chemotherapy. Yet nutrition continued to be a centerpiece of her life. A volunteer at her children's elementary school, she saw what other children were eating and worried about her own kids' health. At home, her family followed her lead in dietary change. "Now my husband and children eat real food," she said, citing almond-flour pancakes, oatmeal, honey, whole grain breads, bananas, berries, kale, spinach, red carrots, and grass-fed meats.
I really wish that Dr. Jangi had read a bit about these alternative cancer cure testimonials before featuring Helen so prominently. I found what is almost certainly her blog, given her timeline. It wasn't hard, but since Dr. Jangi didn't want to reveal who she is I will honor that. What I did learn is that she was into alternative therapy from the beginning, given that she went to her naturopath to evaluate her initial complaints that ultimately led to her being diagnosed. Thankfully for her, her naturopath was one of the more reasonable ones and noticed that a lot more was going on than he could handle. After she finished Gerson therapy (which she described as the "two hardest years of my life"), her disease was merely "stable," as she described it, and she was clearly disappointed. In the process she had had to have all her amalgam fillings removed, which left her with extreme sensitivity to hot and cold.
So she moved on to the Gonzalez protocol, where she takes 160 supplements per day, fewer coffee enemas than the Gerson protocol, and a lot of the same other woo, given the considerable overlap between Gerson's protocol and Dr. Gonzelez's protocol. There's also the usual stuff on there about how big pharma has no interest in "natural, safe, effective healing" as there is no way for them to "patent a nutritional product and reap large profits." She also doesn't vaccinate her children (a decision that Nicholas Gonzalez fully supported, telling her that childhood diseases "served a purpose"). Her disease has waxed and waned, and at one point it must have alarmed Gonzalez enough that he sent her to an oncologist who wanted to begin chemotherapy but was going to start her on Revlimid, a drug related to thalidomide, which has been found to be effective treating multiple myeloma. Overall, though, there are lots of posts about her IgA (she has IgA myeloma) going up and down and various dubious markers drawn by Gonzalez similarly going up and down. She keeps saying she's getting better, but somehow the tumor never seems to go away and there's always a story about her numbers "going in the wrong direction." Her IgA level seems to bounce between 6,000 and 7,000. (Normal is 70-400.) The most parsimonious explanation is that Helen is fortunate enough to have an indolent tumor that is not really progressing much, despite her having a higher-risk subtype. It is, after all, known that there is a "clear heterogeneity amongst patients with myeloma as some individuals have a slow disease pace and can live decades and others have rapid disease progression, unresponsiveness to multiple therapies and short survival."
Dr. Jangi clearly hasn't dealt with alternative medicine cancer cure testimonials, as I have. All you have to do is to look at the comment section, where alt-med believers have descended to castigate big pharma and tout their alternative cures.
In the end, I can't help but reiterate my disappointment. There is so much to discuss with respect to diet and cancer, but Dr. Jangi decided to structure his story around a run-of-the-mill alternative medicine cancer cure testimonial that didn't tell anywhere near the whole story, much less enough to judge whether Helen is doing better than she should be expected to do. She is then represented as an example of a "nutrition gap" in which doctors and patients believe very different things about nutrition when in fact, all you have to do is to read her blog to see that she is an alt-med True Believer, hardly typical of the average person interested in nutrition and health. Then, the whole story is bolstered with alt med tropes that border on conspiracy mongering, in which pharmaceutical companies rule and doctors' organizations ruthlessly suppress research into diet and health. There is promise in using dietary manipulations as medicine ("let food be your medicine") for a variety of conditions; doctors have been doing it since Hippocrates. It does no one any favors to use a sympathetic portrait of an unfortunate alt-med true believer to stand in for the disconnect between what people think about food and health and what doctors think about it.
ADDENDUM: A nice article: The new religion: How the emphasis on ‘clean eating’ has created a moral hierarchy for food.
There have been whole conference devoted to the "Food as Medicine" trope. They feature such alt-med starts as Mark Hyman (who has been shilling hard for an organic store called Thrive Market) and Aviva Romm, a "pro-safe vaccine" doctor.
What is amazing about these people is that their confidence they can treat disease is inversely related to the responsibility they have for actually treating sick people. None of these quacks works in a hospital or ER. None of them work with anything but the rich and likely, worried well. Yet, they have the hubris to tell those on the front lines how they should do their jobs.
What is amazing about these people is that their confidence they can treat disease is inversely related to the responsibility they have for actually treating sick people. None of these quacks works in a hospital or ER.
Sounds like Dunning-Kruger in action.
I was surprised to hear that the Gerson protocol is that old, and was debunked so long ago. But perhaps I shouldn't be, given how tenaciously so many alt-med types cling to the even more ridiculous, older, and more thoroughly debunked idea of homeopathy. Anybody who has taken high school chemistry--presumably including all doctors--should know that homeopathy is bunk. Gerson therapy isn't so obvious, although I wonder why anybody would voluntarily submit to multiple daily coffee enemas. We know the Gerson protocol is bunk because doctors have observed it to be bunk, not because it contradicts scientific principles that any educated layman should know--doctors, of course, should know better.
The opposite may actually be truer. Insufficient food nutrition can damage health. Lack of key nutrients, lack of sufficient calories, etc. can open broad pathways for disease to travel. This may help the converse paradigm take hold without the evidence to support it.
"What is amazing about these people is that their confidence they can treat disease is inversely related to the responsibility they have for actually treating sick people. None of these quacks works in a hospital or ER."
What surprises me even more is that there are so few restaurant owners.
And I am waiting for the days when one will get a burger prescription according to tumor microarray as part of a personalized cancer treatment.
Reading the Gershon requirements, I kept wondering what that was going to do to a person's plumbing. Thirteen vegetable smoothies a day and I wouldn't be able to get off the toilet.
a gap that has “been largely filled by opportunists like Gwyneth Paltrow and Dr. Mehmet Oz, obscuring many meaningful advances in understanding how nutrition influence health.”
Didn't Gwyneth Paltrow recommend a diet of steamed clams or something?
Now I'm confused, I thought she was some gluten-free vegan and the only clam she has steamed was her own?
Now I’m confused, I thought she was some gluten-free vegan and the only clam she has steamed was her own?
Far be it from me to interrupt comment threads with tasteless jokes.
Tasteless maybe, but not a joke I fear.
FACT:There are people alive today who were able to strengthen their bodies enough to fight Cancer using Gerson Therapy.
Bill Clinton's doctor has proven that his heart disease was REVERSED through diet.
Chemotherapy is considered a success if it increases your survival rate by 2.5%. Doctors will radiate you to give 10-12 weeks to linger in misery.
Want to see proven results in 8 weeks? watch https://www.youtube.com/user/ForksOverKnives
Um, no. Bill Clinton's doctor didn't actually prove that.
It's true that heart disease can be improved through diet, but that doesn't change how much its power is exaggerated.
As for the "2% gambit" chemotherapy lie, it's just that, a lie:
Tawana- Yes, you can reverse heart disease through diet. But that doesn't mean diet can cure everything.
And anyone can post a Youtube video. I wouldn't be surprised if the Flat Earth society has a Youtube channel.
As I mentioned to Orac's "friend", it's beyond stupid that her children are not vaccinated. Plasma cell myeloma causes suppression of the other immunoglobulins, resulting in an immunocompromised state. Gonzales is committing malpractice by endorsing this choice.
Regarding the "horrors" of stem cell transplantation: my brother went this route to treat mantle cell lymphoma,which is another malignant lymphoma that is regarded as incurable. He did undergo a few weeks of nasty effects, but it gave him an additional three years of comfortable living with his family. He was able to work and travel. Compare this to the years of all-consuming juicing,supplements and multiple daily coffee enemas that don't do a damn thing.
I know what I would choose.
The image Orac posted above had me laughing:
I see so much of the same veggie porn wherever I alight whilst reading woo. Yes, the rainbow-hued cornucopia of phytochemicals that will supplant chemotherapy, CVD drugs and arthritis meds.
If you eat enough berries, you'll no longer suffer knee pain and cruciferous vegetables will prevent and cure cancer; appropriate foods will restore your depleted hormones or life energies.This wisdom from the garden of earthly delights is illustrated with artfully arranged fruits and vegetables almost as PROOF of their efficacy as cure-alls.
AND where do I see this stuff? The alt media sites like PRN/ Gary Null ( e.g. health retreat raw vegan meal artistry), Natural News, Mercola, Green Med Info as well as antivax sites like TMR and the Vaccine Machine facebook page-
that last one displays especially egregious examples compleat with mottos like " MYchoice for disease prevention" or suchlike, usually credited to 'Raw for Beauty' IIRC.
In addition, sites like Natural News show attractive models drinking the OBVIOUSLY pure ambrosia of lusciously rich green smoothies rife with healing nutrients from superfood (tm) galore. And if juicing isn't healthy enough for you, you can buy dried powdered vegetables and fruits OR supplements that contain these same concentrated natural treasures bore by Gaia herself.
These products are BETTER than actual fruits and vegetables because they have all of that space-taking water squeezed out fo them so that they are PURER and DENSER.
And so you will be as well: you are what you eat after all..
Water, fiber, heat-sensitive vitamins, who needs 'em.
Oh, I just can't resist..
A man walks into his doctor's office. The man has carrots sticking out of his ears, beans in his nose, bread in his hair. He says, "Doc, what's wrong with me?"
The doctor replies, "You're not eating right."
What surprises me even more is that there are so few restaurant owners.
Restaurant owners, unlike the alt-med types who are pushing this stuff, are constrained by the reality that they have to attract enough paying customers to cover their rent and overhead. So you might find a few restaurants of this kind in big cities with a substantial woo-prone population: New York, the Bay Area, parts of SoCal, London, and maybe a few others. But most parts of the world, fortunately, do not have a high enough concentration of food-woo types to support such a restaurant. Especially if, as I suspect, the sort of person who would be prone to food woo is unlikely to be the sort of person who would want to own a restaurant.
This may help the converse paradigm take hold without the evidence to support it.
You bring up a logical fallacy that isn't emphasized enough. Too many people assume that if a statement of the form "If A, then B" is true, its converse (if B, then A) is also true. But as anyone familiar with science or mathematics can tell you, the converse does not always hold. It's the contrapositive (if Not B, then Not A) that must be true if the original statement is true. I don't know if there is a name for this fallacy--it seems common enough that it ought to have a name, possibly even in Latin.
Science is slow and people are impatient to feel better. This leaves the door open to good and bad advice from quacks.
Currently, my mother's on a big "fermented foods" kick, buying lots of dill pickles, kimchi, fancy cheese, and such, for the purpose of helping digestion. I have no idea whether that helps or not, but I can't say I object to her tastes this time.
- as an aside-
I notice that Eric mentions the 4 loci of evil of the Western World- I usually only list 3 but after seeing 'Love and Mercy' the other night, I'll concur with LA being added- it belongs!. but I digress-
Those places have, as well as a woo-prone population and Gwyneth Paltrow living there, substantial, entrenched drug cultures going back to (at least ) the 1960s .Earlier really.AS well as sponsoring the avant garde.
The idea that what you ingest can transform you magically from run-of-the-mill everyday average to ultra healthy or supremely enlightened is dreadfully important in those climes.
GF - point her towards kimchee. If nothing else it will keep people from wanting to get close to her, thus reducing the likelihood of contagion.
I have a friend who is heavily into food-woo. In my facebook feed he is often linking memes related to Gerson and GAPS and all the other 'food as cure-all' tropes.
A while back he linked one with the statement that 'nature has provided a natural food to cure every disease". This of course got a lot of approving responses.
I simply responded "Which one cures Huntington's?"
Never got a response. Not sure my point was even comprehended.
GF@19: I don't know of anything that fermentation in general helps. But for those of us without the lactase persistence gene (that would be most people who are not of European ancestry, and some who are--my family does have this gene), fermented milk products (i.e., cheese and yogurt) and ghee (butter with the milk solids strained out) are the only dairy products that can be eaten without a substantial likelihood of causing severe gastrointestinal distress.
Cheese and yogurt making are of course beyond my skill. I have a recipe for kimchi which I tried once, and was dissatisfied with the results (in case you were wondering: it wasn't spicy enough for me). But I do make my own pickles when picking cukes are in season (July and August, where I live). It's not that difficult, they taste as good as store-bought, and they're cheaper.
I'll admit, some of those "superfood" things sound good at first reading. I think that for a lot of us on the ground, it's the mistaken idea that if beautiful people are consuming this stuff, then it must make you beautiful; and people do conflate "beautiful" with "healthy" a lot. As #17 above pointed out, beautiful people drinking green smoothies =/= you'll be beautiful if you drink geen smoothies, too, but it's really hard to get people to believe that, which Adams, Food Babe, et.al. are definitely relying on.
At the sickest point of my life, when I was easily 10lbs underweight, people were still telling me I looked great, because I was thin. Being thin is not the same as being healthy, but you'll never hear the above tell you that. This false equation comes out every time they talk about how eating their special food will make your exterior look good - shiny hair, glowing skin, etc. We all want to be attractive, so thousands fall for it.
More recently, after a month and a half of nursing my husband back to health after emergency surgery, I'm still trying to feed him high-calorie foods so he can get more energy and heal properly. Not only would the "super" foods the alties recommend put him so far into a calorie deficit, I don't think he'd be able to get out of bed, but all their magical thinking wouldn't have been able to fix what was wrong. I'll put my faith in doctors, and science, thanks.
I see so much of the same veggie porn wherever I alight whilst reading woo. Yes, the rainbow-hued cornucopia of phytochemicals that will supplant chemotherapy, CVD drugs and arthritis meds.
Exactly why I chose that picture after doing some Google searches. :-)
IF Hippocrates did write anything roughly translatable as "Let food be thy medicine and medicine be thy food," it's pretty clear that his concepts of the two nouns were not equivalent to what we take them to mean today, nor was 'medicine' so scientistic in Classical Greece that we can take the phrase literally – the far more telling second clause 'let medicine be thy food' clearly being poetic, the first is undoubtedly figurative as well. To make sense of a c. 400BC directive to 'let food be thy medicine', we have to ask: compared to what else that might have been considered 'medicine' at the time. Could ol' Hippo' just have been observing that your physical health will be more profoundly affected by what you ingest than by participation in any ritual mysticism? Sayeth Wikipedia: "He separated the discipline of medicine from religion, believing and arguing that disease was not a punishment inflicted by the gods but rather the product of environmental factors, diet, and living habits."
The ancient Greeks did cook a lot of their food, btw, so taking that possibly apocryphal quote as some sort of ancient endorsement of raw food diets as magical cure-all alternatives to the Big Pharma Pill Box isn't just a science fail, but a ludicrous fail in history and semiotics as well.
Yet another sterile blog post by Orac the Sterile.
You're not the only one consuming what's placed in your mouth.
I'm just going to leave this here.
"It comes with a bag of PureLife Enema Coffee, which, believe it or not, is the second brand of coffee specially blended for enemas that I’ve reviewed here. "
I've been served coffee that was best used in an enema (as an enema?), but I've never set out to make, and would never buy on purpose, enema coffee.
Unfortunately, the TMs seem to think that controlling what their children eat will change how they behave- including 'recovering' them from autism. The Recovery Panel @ Autism One involved their explanations of their extreme dietary regimes- GF, GFCF, GFCFSF etc.
Gluten be the very devil and what's worse, it feeds those mysterious GI 'bugs'. Supposedly it acts like heroin and kills brain cells as well.
AND I thought that only alcohol did that.
"I thought that only alcohol did that."
Reading TMR does as well, I'm sure.
The Ibsen cure uses "Enema of the People" coffee.
My dad pointed out that, when he started his general practice in 1958, he didn't really need to tell people to eat healthful foods, for at least a couple decades, because everyone already did. There weren't that many processed or fast foods (and, how many were there in 1928?): everyone ate home-cooked meals, mostly their ethnic group's traditional cuisine, which of course included vegetables and the like.
And who was it who started exploring the relationship of diet to things like heart disease, and made recommendations? I seem to recall that it was science-based medicine, in the 1960s or 70s, that first drew people's attention to the benefit of healthful diets, and that what they ate could make a difference to their chances of developing illness.
An aside: is caffiene absorbed through the colon? Because, if so, I can well understand that those multiple daily enemas might make one feel pretty energetic, and are addictive. The Maya used alcohol to induce visions from the gods, but found that they couldn't absorb enough orally because they kept throwing it up. So they used alcohol enemas, which got them mighty high and in touch with lots of gods. I'll bet methamphetamine enemas would make one feel pretty peppy, too, that'll probably be the next variation.
I'm sure that caffeine would be absorbed through the colonrectum(and other vascular mucous membranes). Here's some more info on "back door drugging":
When I was in the trenches of fertility treatment, I experimented with CAM. I was acutely turned off by the "eat better" brigade. Seriously, food was not going to make my 40 year old eggs turn 25. But the illusion of having some type of control, it's very seductive.
I have been a lurker for several years, the comments here are insightful enough that it has been a bit intimidating to try to add anything. But - in this case I CAN access a JAMA journal from 1992. Reading through the article, I had to glance back up at the author because it could have been Orac slapping the Gerson therapy down. Here are a few quotes:
"The explanations justifying the use of.....published first by Gerson, and now by his proponents, are not supported by the established tenets of cancer immunology, biochemistry, or nutrition. Their claims take no note of the demonstrated mechanisms by which cancers arise."
"Those who currently use coffee enemas to treat cancer are in effect endorsing the concept of purging."
"A critical review of the relationship between this science that is cited [work 'supporting' Gerson] and the mechanisms by which the treatment is supposed to work shows numerous instances of misinformation, misconception, and misinterpretation."
The article finishes with -
"These facts make the rationales offered for coffee enemas and diets by proponents of the Gerson therapy impossible to accept."
A critique of the rationale for cancer treatment with coffee enemas and diet
JAMA 268(22); 3224-3227, 1992
And slightly side-topic, I thank Orac for giving me ideas of how to approach my brother, who has not vaccinated his almost 5 year old son, and probably won't vaccinate his new daughter. A difficult subject to broach.
Maybe I should be Mrs Alice Woo...
Reading Mr Woo Vani Hari's blog post about yogurt. Then read him the back of my store brand (Aldi) Greek yogurt...
... and he immediately jumps on the corn starch (as far as I can tell, part of the ingredients of the fruit on the bottom jelly) - "corn starch! Terrible!"
"Everyone knows all US corn is GMO. This means corn starch is GMO!"
He is so well indoctrinated by his alternative sites. He was listening to a let your food be your medicine YouTube video that railed at one point against the heavy-handed tactics of the oversight of the supplement industry and how it limited the poor vitamin companies' in their quest to heal the world from the afflictions created by modern industry and corporate farming.
He has been quit yet another diabetic medication - as soon as he feels a side effect, it's over, even though I attempt to explain (regularly!) that often side effects are transitory in nature.
He insists that the $90/month supplements he takes that they assure him are as good as prescription medicine that don't touch his blood sugar numbers are proof positive that no oral medication would work, anyhow. :-(
Any way the get preview back some day?
Eric Lund: the name of the fallacy you described is "affirming the consequent".
Garnetstar: Rectal administration of methamphetamine is practiced; it's called a "booty bump".
"Curing Cancer with Carrots" is the self-published e-book that Anne Cameron, a writer of children's books, is hawking on Amazon. The cover has a picture of a carrot dressed as a doctor. If she's going to try refuting medical practices, why not dress the carrot up as something else? Perhaps a carrot dressed as a shaman?
I haven't read the book, but the website is a scream. On the page about the author, it's said that she is an "honors graduate from Harvard", as if that were relevant; an author of a number of children's books; and that she "never expected" to write a book about curing cancer. The self-awareness of a carrot. Dunning, meet Kruger.
Does her lack of knowledge on the subject phase her? Of course not. Not only does a blurb from a reviewer on the front page of the site say that Cameron is "the chosen one" for getting this information out. No, she's also been to Google University, reading the abstracts of a number of medical papers about epigenetics. Others report that some of the compounds in cancer might have beneficial effects for certain conditions. So, voila, epigenetics plus gross generalization of the type that the studies's authors would not support, combined with disdain for the chestnut that "the plural of anecdote is not data" and you have the Chosen One...who also has "cancer-busting" recipes on her website. She also advises cancer patients. I found an online forum in which Cameron advised a mother to forego cancer treatment and give carrot juice a try.
Sure, she's small fry compared to Adams, Hari, and Oz. But she still has the capacity to be causing much harm.
Looks like we're on a roll. (Cinnamon rolls, anyone?)
Re. Keith @ 27: And it's a darn good thing that Orac is sterile when he walks into the operating room. Or are you in favor of surgeons and other doctors not washing their hands?
Roadstergal @ 29: special blends of "enema coffee." Eww.
Denise @ 30, alcohol: yep, and when I was a kid, I read that getting drunk costs 30,000 brain cells. Decided as of that moment to never mess around with that, and have never been drunk in my life. Psychedelics & entactogens on the other hand, but carefully & meditatively rather than "party mode." Long story short, meditation itself is more reliable for purposes of understanding the big picture, though of course "understanding" != knowledge.
I'm inclined to believe that one of the bad influences on kids, is when they're told to not eat anything before dinner because it'll spoil their appetites, but Mom & Dad get to have cocktails before dinner. OK, so then what to serve the kids? Give 'em a can of soda. Alcohol for the grownups, caffeine for the kiddies, the family that drugs together hugs together?
So let's suggest setting a better example: save the drink for after dinner, like desert. And while we're on the subject:
Extreme Ice Cream Diet #1: Eat all the ice cream you want. But first, a nice big leafy salad before dinner, with plenty of carrots and tasty fresh spinach. Then, some fresh veggies with dinner, maybe broccoli with a bit of rice. OK, now another 15 minutes after dinner for conversation, and then you can have all the ice cream you want. Which won't be much, on a full stomach.
Extreme Ice Cream Diet #2: You get to eat as much ice cream, in weight, as you eat salad & veggies. Get a kitchen scale. Weigh those salads. Then weigh that ice cream. Guaranteed way to get the kids to eat more salad & veggies.
and would never buy on purpose, enema coffee
It turns out that an idle search for 'Enemanian' + 'coffee' primarily* yields Japanese-language references to this product.
* There is also a DVD by the same title.
^ The link is SFW, by the way.
I read that getting drunk costs 30,000 brain cells
I've mentioned this a number of times before, but I've yet to come across a decent reference for direct neurotoxicity. Withdrawal excitotoxicity is a separate story, as are the indirect possibilities from chronic abuse, such as thiamine deficiency.
I don't know how strong the case is for MDMA neurotoxicity these days; I mean, when "Reply to [Rick] Doblin et al." is on the first page of these results, I get the sense that there's an awful lot of agenda-driven noise even in the review papers.
I wonder if the enema bandits know about the civet poop coffee? I mean, it must be, like, sooper dooper extra special for enemas, right? I bet it would be almost as good for you as eating raw meat and feces.
I was thinking about that as well. It's pretty expensive, so that should make it even more attractive.
I will never forget the juicer my parents bought to cure my mother's lymphoma (at least they were doing both and vs either or), or being kind of okay with plain carrot juice and totally unable to choke down plain celery juice. It took me forever to be able to eat celery again. OR my sister and me arguing over the toy squeaky carrot on Mother's Day that someone brought to my mother as a present in the hospital.
Oy... Mr Woo asked what I was doing and I mentioned carrot juice cure... and he immediately announced it works and told me a story about a surgeon who "read all the research" knew "regular treatment always kills the patient" decided on nutrition, drank enough carrot juice to turn orange but cured her cancer.
And announced that any doctor who does cancer research can't be trusted because their livelihood depends on selling chemo...
I love him. I really do. I wish he was going to live as long as his science-believing father.
It surely seems you love a challenge.
# 12 Gray Falcon
OT but an interesting take on Stephanie Saneff whom Orac has also mentioned. It is an interesting thread by people who don't seem to know anything about the anti-vax campaigns.
Nobody tell these food = medicine people that the best way of aggravating gout is to eat lots and lots of broccoli, bok choi, pak choi, tun choi, cabbage, brussels sprouts, and so on, not to mention tannin-rich foods like tea, pomegranates, persimmons, and legumes...
@ Gray Squirrel:
Actually, according to Gary Null ( and who would EVER dispute his information?) each drink kills one million brain cells ( sometimes he adds a million liver cells as well).: he claims that he has NEVER has a drink in his entire life. Mike Adams says he doesn't drink or do drugs.
HOWEVER I've heard quite a few of Orac's minions admit indulging in this dangerous pastime, killing brain cells like mad and sometimes experimenting with illicit drugs. So I would invite all scoffers to merely read examples of what the aforementioned woo-meisters and people like us write and compare the results, remembering that the alties carefully prepare their screeds for their woo-selling websites and most of us just write informally and expressively.
Now there's a research project worthy of Stephanie Seneff- who sounds like they have less brains- sober alties or (occasionally) drunk/ drugged SBM folk?
@ Mrs Woo:
My heart goes out to you: I've always enjoyed your comments, seeing you as being excellent in many ways.
Some of us love people who live in different ( intellectual) worlds than we do- this is a testament to your tolerance and willingness to learn about others' ways . Mr Woo doesn't seem to share that ability and can't accommodate you but perhaps he values you for other reasons that we @ RI don't directly witness- your care and love for children and your devotion to him.
In short, you can try to affect his beliefs about health but in reality, you can't get him to 'see' what he isn't able to assimilate on an intellectual. Unfortunately, he has already suffered by following altie hype
So you have a lonely road there. However, you can develop your own strengths and branch out a little towards like-minded people - that isn't a rejection of him but an expansion of your own capacities. It's a big world out there.
on an intellectual LEVEL
HOWEVER I’ve heard quite a few of Orac’s minions admit indulging in this dangerous pastime, killing brain cells like mad and sometimes experimenting with illicit drugs.
Not only does my brain seem more-or-less intact, but I was just informed by a Hare Krisha that I have a "very positive aura."
@MikeMa - I guess I do. Since his most recent stroke, arguing with him has become impossible. He is no longer civilized about it, breaking rules he used to have in place and no longer having memory of them being hard and fast. He also no longer remembers nearly a year of much more moderated positions. He admits to memory loss, but can't be encouraged to come back to moderate positions any longer.
@Denice - Mr Woo has some very amazing good qualities. I have been astonished by how honorable he is. I knew that he liked alternative medicine (a beloved great aunt is the same way, but like others in my family, she does more of a both-and; I didn't realize that he would follow it to exclusion at first), but believed in the really scary things he would probably follow science.
And he is pro-vaccine. He teetered on the edge (one of our grandchildren is on the spectrum), but when the following grandchildren were still stubbornly vaccinated on schedule by their parents with no ill effects, he abandoned any worries about vaccines being the cause. After being assured that vaccination was supposed to be covered under the Affordable Care Act, we have both been disappointed to find that the shingles vaccine has a copay of just over $70. I just realized I should check the county health department and see if it might be easier to acquire there.
I am sure, from his perspective, it must be frustrating to deal with someone so blinded by "big pharma" to the "truth." The sicker he gets, though, the more angry I get at supplement sellers. I try to believe they honestly do not realize the harm they are capable of doing, but short of true believerism themselves, how can they?
Just asked him if he would do a science-based cure: "It depends on what the science is behind what they call science..." If he hadn't heard so much of the wild stories of alt-med providers, he might be more rational/reasonable. The old "99% of doctors would never prescribe chemo for themselves or their families; a small percentage might do radiation..."
You know, I was told that I had an outstanding aura as well!
I took classes at a yoga 'institute' whose head teacher gave a presentation accompanied by an aura expert/ sensitive/ trance channel who was devoted to a Christian saint- the latter read my aura saying that it was blue, lavender and white IIRC.
I have learned via the internet that means that I am an especially spiritual, aethereal creature.
Mrs. Woo @55 - My thoughts with you and your husband. I wish you much luck in persuading him back to science. My MIL and husband shared the same tendency with drugs. If they know of a side effect from the drug then they will manifest it through sheer hypochondria. I never looked up side effects for MIL because of course she would have some symptoms (or immediately develop them). My husband I have stern talking to about it because as soon as he is given a medicine if the doctor tells him what to watch out for he will immediately start having 'symptoms'. Its all in his head.
Mr Woo has known he has diabetes for several years, but insisted on treating it with various supplements (that haven't worked). Now he is attempting oral medication, but everyone develops side effects and he quits quickly. It took two strokes, one which kept him in hospital, then rehab for a month, before he considered talking to his doctor about oral medication.
My frustration and anger with 'alternative medicine' runs rather deep.
Dear Mrs Woo,
I am afraid that in the case of your husband, with type 2 diabetes, diet and physical activity are better than drugs.
"Not surprised if there's a Flat-Earth Society channel on YouTube." Just go to YouTube and type " flat earth" in the search space. Plenty of stuff. Lots of fun .
The freaking out about the profit motive is common. You might even consider it its own fallacy "Appeal to Profit Motive Fallacy". Socialist countries did develop drugs, proving that drug R&D is not exclusively a capitalist thing. Of course healthcare is going to be profit driven in capitalism. But most of these people, having grown up indoctrinated into Western liberal democracy will defend capitalism. There is a selective hatred of profit motive here. I think the US healthcare system does a lot to create this kind of fear of healthcare as they often pay out of profit they probably have more intense fears of profit motive driven medicine than someone who is in a country not paying out of pocket would.
Why does SEID have so much woo surrounding it? There is an insistence by some suffers to use the M.E. (Myalgic encephalomyelitis) thing which does not have evidence. My personal feelings is that people feel so hopeless with lack of approved drug treatments that they turn to supplements and other woo. The recommendations for CBT and GET can be harmful. The belief that its psychological is very triggering to me and many others. But I do tend to agree it would be good to find a light form of exercise like yin yoga or swimming that a SEID sufferer can tolerate without going over their threshold and burning out and therapy can be helpful as its a very isolating and hopeless experience but if the therapist treats it as a lack of motivation aka laziness it can be very upsetting and unhelpful.
Why does Lyrica make people gain weight?
While most all doctors and scientists agree on the importance of diet and exercise I'm not who he is listening to and if the supplement pushers would encourage him to follow a scientifically-based diet shown to make a difference. Would they tell him to do whatever the diabetes educator says or will they have some unproven super food or other not-so-evidence based dietary approach? Or say their supplements alone are magical enough he doesn't need to do all that other stuff? Selling supplements doesn't always go with promoting the appropriate lifestyle.
It also sounds like from what has been said here he may be at the stage where you are starting to see complications and while I would usually say try diet and exercise first, once you start having other health issues from it being uncontrolled for too long I feel it may be more important to get tight control quickly and hope to eventually reduce medication over time with lifestyle changes than delay using medications in the hope you can do it with diet and exercise alone.
Why does Lyrica make people gain weight?
Most likely for all the same exact reasons most any other drug is considered to increase weight gain.
1. Fluid retention
2. Increased appetite
3. Fatigue leading to less activity.
One other thought that I sometimes wonder about is how many calories are your normally burning up from dealing with the pain or disease. If you are constantly squirming because you can't get comfortable that does burn up a falr number of calories every day. OR if you are someone that just won't eat when you are miserable you may not realize how much the eating habits change when you aren't so miserable anymore.
I don't know if many of them have really been ever shown to effect metabolism in ways that are completely and totally independent of behavioral changes or food intake changes.
I was referring to Orac's title "food as medicine", not to the silly supplements, and I agree with you.
I was responding to you talking about Mr and Mrs Woo situation and his used of supplements rather than medicine.
Or didn't you intend the comment that appeared to be directed to Mrs Woo to be a general comment about the titel of the article.
"Actually, according to Gary Null ( and who would EVER dispute his information?) each drink kills one million brain cells"
How many Null brain cells did his massively vitamin D-overloaded Power Meal kill off?
Anyway, we're better off without certain brain cells. Stephen King remarked on this in "The Shining", when one of his characters would go into a bar and do the Bad Thing until his nagging brain shut up.
I wonder how many alties who happily quote Hippocrates about letting thy food be thy medicine, also subscribe to his treatment plan for mental disorders in women - "for hysterical maidens I prescribe marriage, for they are cured by pregnancy."
"And it’s a darn good thing that Orac is sterile when he walks into the operating room."
Why? Surely the nurses have nothing to fear from him.
Actually, i was referring to the title of the article, and what I was saying is that, if there is a condition where one can say that food is medicine, it is type 2 diabetes.
Yeah! Right. 7 servings of vegetables + seven glasses of wine by my calculations. Remember you need both green and red veggies so be sure to have both read and white wines. To increase you vegetable/fruit varieties take plenty of chocolate. Potato crisps will do too.
Jenny H, who are you addressing your comment to, the Drinking Moms' Revolution?
It just struck me as odd if your main (or only) point was that you didn't like the title of the article that you would have @ed the particular person you did given that particular situation. Could just be me. Your mileage may vary.
I don't think anyone here is denying that diet can be an important part of the treatment (more so for some diseases than others). Just that some people exaggerate the role of diet in health, including those who profit off of selling the lifestyle. Although I find the ones that just use the purity of their diet for ego gratification can be obnoxious as well.