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Your disease, your fault

Earlier this week, my colleague Dr. Gorski explored a common theme in alternative medicine: the idea that all disease is preventable.  This implies that all disease has a discrete cause and that individual behavior can mitigate this cause.

If biology worked this way, my job as an internist would be very different.   Many people would love to believe that life is this predictable, and that they have that much control over their health, but they don’t.  Most disease represents the interaction of environment and genetics, and you can’t change your genes (with a few exceptions, of course).

It’s natural to want to be able to exert an impossible level of control over your health, but when unscrupulous charlatans (redundant redundancy alert!) play on these beliefs and fears, they can cause, rather than prevent problems.

Which brings us yet again to the Huffington Post.  Yet another Promiser of Big Promises is telling us why we’re sick and what to do about it, without the benefit of actual truth or science.  Dr. Joel Fuhrman starts by frightening us, but the reassures us:

The American diet causes disease.

[…]

You cannot escape from the biological law of cause and effect — food choices are the most significant cause of disease and premature death. We cannot win the war on these diseases by putting more money into medical interventions or drugs. We must unleash the disease-fighting artillery in our own kitchens.

Well, there is no “biological law of cause and effect”.  There is biology, there is medical science, but no “law”.  The best lies are built on truth, and contain both fear and hope.  It’s true that Americans are suffering from obesity and diseases associated with obesity.  It’s obvious that diet has something to do with this.  And as every primary care physician knows, lifestyle change are an important part of preventing and treating these diseases.

But real doctors also know that we will never “win the war on these diseases.”  Biology is indifferent to our desires.  We all get sick, we all die.  We have learned to moderate this in some cases, but we will never “win”.  Anyone who tells you otherwise is trying to sell you something.

And Joel is trying to sell you something.  Like most so-called medical writers at HuffPo, he links directly to his website, where he sells all sorts of miracles.  In the usual whirlwind of internal contradiction that is alternative medicine, he at once denigrates the progress possible with science-based medicine, while at the same time inventing his own “science”.  This is what I found particularly interesting about this particular brand of fake medicine.  Rather than appealing to unseen forces such as qi or “water memory”, Joel goes straight for what Michael Pollan calls “nutritionism”.   He invents what he calls his “health equation”: Health = Nutrients / Calories (H = N / C).

In real equations, it’s important to define ones terms, and in this case the big undefinable is “health”.  Since this can’t be quantified in any real way, this is nothing more than a parlor trick.

But like all medicine shows, this one needs more than just some fancy equations.  Joel explains that he is sharing with you a secret that “they” don’t want you to know:

Doesn’t every American have the right to know they don’t have to suffer a heart attack or a stroke? They can protect themselves. They could choose otherwise, but shouldn’t they be informed of the most effective lifestyle to protect against cancer? Should they just be given drugs for diabetes, cholesterol, blood pressure and more or should they know they have the opportunity for a complete non-drug recovery?

Or maybe people have the right to know that they cannot control every aspect of their health, and that if they cannot make necessary lifestyle changes, they should not be “punished” by being denied access to life-saving medications.  Not everyone has “the opportunity for a non-drug recovery”.  As physicians, our job is to use the best available evidence to help all of our patients.  It is not to dispense false promises, fake science, and a heaping portion of blame to those who don’t do everything we tell them to.

Posted in: Science and Medicine

Leave a Comment (62) ↓

62 thoughts on “Your disease, your fault

  1. LovleAnjel says:

    Apparently he doesn’t believe in germ theory. Or accidents. Or exposure to toxic chemicals in an industrial setting. Nice.

  2. Mr Ed says:

    Health = Nutrients / Calories

    So I can drink battery acid as long as the calories are zero because this would give me infinite health.

  3. latenac says:

    I’ve encountered so many people who believe in this kind of thing along with the idea of manifesting what you want and it will come. It’s always sad to see them unable to cope when they do end up getting sick with something. And it pisses me off when they tell people, “Oh well you must have manifested hard enough or gotten enough of vitamin X, that’s why you have cancer.”

  4. evilrobotxoxo says:

    There is a whole interesting psychological literature on the illusion of control over one’s environment. Here is an interesting link I found by googling – I didn’t read the whole thing through rigorously, but it looks like a pretty good summary.

    The underlying point is that being powerless over your environment is very stressful, and there is massive psychological benefit to believing that you have control, even when you do not. I suspect that this is a major component of alternative medicine, as well as mainstream religion.

  5. CarolM says:

    I confess to believing in some cause-and-effect beyond the obvious ones of smoking and obesity. That doesn’t mean that the promoters’ prescriptions will prevent disease. I don’t subscribe to any of that marketing bs.

    But when I was diagnosed with abnormal cell growth that showed me at high risk for cancer, I couldn’t help but think back over my lifestyle for the last 40 years. As much as the doctors seemed to want to pooh-pooh any connection at all, I had seen some of the data.

    The more my doctors want to “reassure” me that nothing is my “fault,” the more suspicious I get. Maybe doctors should get out of the reassurance business and stick to science.

  6. Joe says:

    My diet consists of free-range vegetables, high-fiber water, fish that contains no high fructose corn syrup and gluten-free decaf. And you say this discipline won’t protect me from disease; what’s a fella to do?

  7. qetzal says:

    @Joe,

    What’s a fella to do? Buy stuff from “Dr.” Fuhrman, of course!

  8. gaiainc says:

    Sometimes, you just can’t fight your genes. You can eat as healthy as you want, exercise as much as you want, but if your genes are bound and determined for you to have Huntington’s, sickle cell disease, cystic fibrosis, Tay-Sachs disease, familial hypercholesterolemia (is that the term these days?), etc, then you’re probably going to get it. Yes, eating better, not smoking, and exercising more can lower your risk and can mitigate a lot. However, that risk never approaches zero. Sometimes your coronary arteries just spasm. Sometimes a little clot or plaque just flakes off. Sometimes someone decides to thump you in the chest at just the right moment. Sometimes the DNA dance is not in your favor. Life happens. The universe is random.

    CarolM, I’m sorry to hear that your doctors’ reassurances made you more suspicious. I will say that it is challenging to go back over a life and say, yep, that was where you did the wrong thing that caused what’s going on. Seriously. It’s not that cut and dry most of the time. Sometimes it is, but most of the time, it just isn’t.

  9. Enkidu says:

    I wonder if Dr. Fuhrman thinks the same way about something like miscarriage? I’d love to see him tell a woman who just lost her baby that if she had only done X, Y, and Z that she’d still be pregnant.

  10. mikerattlesnake says:

    “The more my doctors want to “reassure” me that nothing is my “fault,” the more suspicious I get.”

    That sounds like your problem, not theirs. Doctors really can’t win. If they rigidly stick to the evidence and statistics, they’re accused of being cold and clinical (not like those alt med practitioners who REALLY listen), if they try to reassure a patient to relieve some feelings of guilt (based on good science, mind you, unless you were a lifelong smoker who got lung cancer), their speculations make you suspicious. You seem to assume you KNOW how you became high risk, but these doctors (who maybe have studied cancer at some point) have no idea and are just trying to make you feel better and lying in the process. Chances are they know the statistics and they know that lifestyle, genetics, and random chance contribute to cancer risk. Looking at your case and the risk factors for your particular diagnosis, maybe they realized it was most likely the latter two. Or maybe they WERE trying to make you feel better, but given that you can’t change your diagnosis, is that such a bad thing?

  11. Chris says:

    CarolM:

    The more my doctors want to “reassure” me that nothing is my “fault,” the more suspicious I get. Maybe doctors should get out of the reassurance business and stick to science.

    For doctors then it is “Damned if they do, and damned if they don’t.”

    I agree with mikerattlesnake, it is more about your attitude than what they are saying. For instance, how can it be your fault if you got exposed to radon in someone’s basement? (second highest known reason for lung cancer) Another “for instance”, how can it be your fault if you got exposed to a virus? (don’t laugh, it is known that viruses can cause cancer, perhaps there are some that have not quite known about)

  12. Presumably there is a way to discuss risk factors with people realistically. “We have looked at 17 different possible risk factors for your condition and 5 of them seem to be important. 30% of people with your condition don’t have any risk factors at all. You have 2 of the 5 we have identified. Maybe if you didn’t have the risk factors you wouldn’t have developed your condition, but maybe you would. We don’t know and you don’t know.”

    Alternatively, “We have looked at 17 different possible risk factors for your condition and 2 of them seem to be important. Only 2% of people with your condition don’t have the risk factors we identified. You have both. If you didn’t have the risk factors you almost certainly wouldn’t have developed your condition, but maybe you would have. We don’t know for sure and you don’t know for sure.”

    Confirming that 1) yes we have looked and 2) yes we have some idea of what’s significant and 3) we really do have some idea of how significant is better than a plain “we don’t know” even if that’s the conclusion.

    If a heavy smoker miscarries, why wouldn’t you advise her that quitting smoking would probably increase her chances of carrying a healthy pregnancy to term? She might not want to hear it, but it’s true. It doesn’t have to be, “You killed your baby!” It could be, “Quitting smoking now could increase your chances of carrying a healthy pregnancy to term. Would you like to do that? Would you like me to help you?”

  13. Enkidu says:

    Alison: I totally agree with your last paragraph. There are certainly some obvious risk factors when it comes to miscarriage, but a good percentage of the time, doctors have no clue why it happens. These women are doing “all the right things” in terms of what we know: prenatal vitamins, not smoking, not drinking, etc.

    It’s the attitude like those quacks quoted above, ie “Doesn’t every American have the right to know they don’t have to suffer a heart attack or a stroke? They can protect themselves.” I was wondering if they believed this not only for cancer and strokes, but other aspects of human biology as well.

  14. Alexie says:

    Well, this strikes a chord. When I was diagnosed with cancer, someone wrote to me and told me it was because of all the anger I was carrying around (!!!). How are you supposed to react to that?

    Something else I get a lot is people recommending this or that to ‘boost the immune system’. Maybe the oncologists here can correct me about this, but I thought the immune system leaves cancer alone, because it recognises that it’s home grown.

  15. Scott says:

    Something else I get a lot is people recommending this or that to ‘boost the immune system’.

    It gets even better. I particularly like recommendations to “boost the immune system” to cure lupus. Not only is “boost the immune system” a claim so general as to be meaningless, most of the real things that would fall under that heading would be actively bad for an autoimmune condition.

  16. Sean says:

    Health = Nutrients / Calories (H = N / C).

    Celery has negative calories (after digestion), so by his formula, Celery would be the greatest poison in all of creation because it would put you into NEGATIVE Health.

    Whatever that means… but it doesn’t sound good. Probably it means you’re dead. Or dying.

    Remember people: Waldorf Salad kills.

    -S

  17. vicki says:

    It also makes sense to focus on risk factors that the person can still do something about. That includes both risks for problems someone doesn’t have yet, and things that may affect prognosis. But “this thing in the past may have caused your cancer” is less useful, whether it’s a sunburn at age 12, an unlucky gene, or parents who smoked, but quit during the Reagan administration.

    There is no point in yelling at someone for being an ex-smoker or ex-junkie, or having ridden a motorcycle without a helmet ten years ago. They’ve already stopped doing whatever it is; they know it would be a bad idea to resume; criticizing them would just produce resentment and get in the way of any useful message you might have to offer.

  18. Maz says:

    Alexie,

    The immune system can recognize and destroy some types of abnormal growths. Once one pops up that can hide itself, you’ve got problems (of the cancerous variety).

    It’s true that, occasionally, someone’s immune system starts to recognize a cancer and destroy it. There are currently researchers hoping to make this a more likely thing to occur (“alerting” the immune system)

    You are correct, however, that “boosting” the immune system is just a bunch of BS that doesn’t mean anything.

  19. Ken Hamer says:

    @Alexie

    “Well, this strikes a chord. When I was diagnosed with cancer, someone wrote to me and told me it was because of all the anger I was carrying around (!!!). How are you supposed to react to that?”

    Punch them really, really hard. Then explain to them that their broken nose is because of all the stupidity they are carrying around.

  20. Prometheus says:

    Much of this follows the usual “alternative medicine” mantra of “If you follow a ‘healthy’ lifestyle, you will live forever in perfect health.”

    It sounds so simple but – as usual – the devil is in the details. What “following a healthy lifestyle” usually means is “buying my products” and adhering to a complex and – in most cases – difficult and expensive set of dietary (and “supplement”) rules.

    Then, if the “client” remains healthy, the “alternative” practitioner can claim that their “healthy living” regimen was the reason. On the other hand, if the client falls ill or dies, well, it was because they didn’t follow all of the rules all of the time.

    Heads I win, tails you lose.

    Besides, if the client gets a serious illness or dies, they can always fall back on the “Quack Miranda”:

    “This is not intended to diagnose or treat any illness. Consult your physician before using this product.”

    Prometheus

  21. nybgrus says:

    @ Ken Hamer – Good on ya!
    @Alexie – Indeed the issue of cancer has to do with an immune system failure to pick up the cells. Almost every single person will develop a cancer cell or two before we die. It is usually picked off by our immune system. When it doesn’t, then you have a benign or malignant growth. Current research in cancer treatment also involves finding ways to specifically target the immune system against a specific cancer. My best thoughts are with you.

    I am currently a medical student, and I will tell you all (and I am sure most know anyways) that the FIRST thing we are taught to address with a patient is lifestyle and diet. When a middle aged man comes and high a high blood pressure, we don’t bury our noses in a chart, look at a number, and write a script for some pills and walk out! We talk to him and try and ascertain what his diet is like, stress, exercise levels, home situation, etc and then recommend that he change these to a healthier lifestyle in the hopes that this will correct the issue (and I use hypertension as an example but it is not the only one!!). There are no “lifestyle secrets” we are keeping from people so they have strokes and heart attacks! If every patient ACTUALLY listened to their doctor’s advice on healthy eating, exercise, and weight loss we would be friggin ecstatic! But they don’t. And sometimes, when they do, it just doesn’t work for them. So then it is imperative for us to step in with a pill or two to help them along the way for a better health outcome – but never stop offering support and encouragement for that lifestyle change.

    At least, that has been my experience (as a patient with chronic, severe, essential hypertension that started in my late teens/early twenties and that remained even after I lost 75 lbs, became a competitive cyclist, and ate healthy foods) and it is what is being hammered into me as part of my medical school curriculum in both didactic teaching AND clinical coaching. But what do I know. I’m sure Dr. Fuhrman is right and the “medical establishment” that teaches me to keep all these health secrets away from my patients kicks in during residency, after I’ve taken the time to learn all this stuff in the first place. It would make me more effective at lying and a good member of the giant worldwide conspiracy of the New World Order.

    Good grief, Charlie Brown.

    Strong work with the SBM site. My buddy at Chicago Med started me on it, and I love it! Thank you all!

  22. CarolM says:

    “but given that you can’t change your diagnosis, is that such a bad thing?”

    Mike, not to go into detail, but I think it might not have been too late to make changes and stop doing what I was doing, but there were no lifestyle questions and no advice either way by the oncologist. It’s as if I had heart problems yet no one asked about smoking history. One thing I do know is that I had excellent genes, no cancer history on either side and long-lived parents.

    What I do notice is that my thinking that seems to make others angry, because they assume I judge them or their loved ones for their diseases, when I don’t. Like the person who blamed Alexie’s cancer on anger – I remember when that one was going around. I think it was a corollary of “the good die young.”

  23. “Doesn’t every American have the right to know they don’t have to suffer a heart attack or a stroke? They can protect themselves. They could choose otherwise, but shouldn’t they be informed of the most effective lifestyle to protect against cancer?”

    Maybe it’s just contrary me, but when I read things like that it makes me want to live on a diet entirely of french fries, lattes, martinis (or scotch, which is less healthy?) and ice cream and sit on the couch watching Doc Martin and Lie to Me reruns full-time. Okay, I admit it. It doesn’t take Dr F’s articles, I always want to do that, BUT I don’t. Seems somehow I got the idea from “mainstream medicine” that that isn’t a healthy lifestyle.

    Now probably Dr F has a much more in-depth, ornate, elaborate, expensive lifestyle in mind. I suspect that following his plan, I still would not live forever. It would just feel like eternity.

    Regarding Immune Boosting – I remember a well intentioned good friend once brought me some immune system boosting tea and juice when I was not feeling well. Thing was, I had just been diagnosed with auto-immune thyroid disease and I was also having a rather bad bout of asthma and taking mild steroids. I remember thinking (melodramatically) “jeesh, my body’s already trying to do me in, don’t help it! :)

  24. maus says:

    @Chris: “For doctors then it is “Damned if they do, and damned if they don’t.””

    Absolutely. If the doctor is right, they need to take how a person “feels” about being wrong into account. If the doctor takes the person’s feelings into account, the doctor is being nosy and must be wrong.

  25. bundle.of.glee says:

    I really don’t understand the idea that you are responsible for the sick that happens to you, and gee, if you just 1) eat the right thing; 2) be spiritual the right way; 3) avoid modern medicine; and 4) buy these supplements all will be well and you’ll live to a ripe old age of 106. I can only assume that it’s the same mindset that the devoutly religious get into – that there’s some sort of control that can be had over this out-of-control life. Either way, if something goes wrong, you’re going to be saddled with a helluva lot of guilt.

    Incidentally, this post couldn’t come at a more sanity-seeking time. I am currently at work – I work at a company connecting medical staff with foreign language interpreters – and a lady two seats down is talking about just about every form of CAM imaginable, and how medicine knows nothing. Were it not work, I’d refute everything she says; in the interest of peace, my trap is staying shut.

    So, a general THANK YOU THANK YOU THANK YOU for the great SBM post. :) Breath of fresh air.

  26. rokujolady says:

    Mr Ed, actually, n/0 calories would give you undefined health.
    You are welcome ;)

  27. rokujolady says:

    Oooh. Ooh!
    So, if I eat battery acid with zero calories, that gives me undefined health which means I would be dead! Maybe I would even cease to exist at all temporally. Is it true,I dont know anyone who has eaten battery acid but how do I know that they didn’t die and get erased from memory? We will say it’s true.
    Buuuut, if I ate something with zero nutritional value and any number of calories, my health would be zero and I’d just be dead. I drink pepsi zero and that stuff will surely be found to cause cancer in the near future, so, true again!
    However, I could totally game this system if I ate something with minimal nutritional value and 1 >n>0 calories, the more minuscule the amount of calories I had, the closer I would get to living forever! So, apparently Crystal Lite is the fountain of youth, especially if drinking it while doing some very minimal exercise like typing to drive the net calorie count towards zero.
    Of course, I would be racking up the health points faster if I ate something nutritious that happened to only be a fraction of a calorie, so popping ab bunch of supplements and chasing it with some fish oil would work, too.
    However you must be very careful not to eat something with negative nutritional value and minimal positive calories, or something with negative calories where -1<n<0 calories. For example, you and your crewmen are stranded in the arctic and dying of scurvy while starving, and you kill and eat one of your companions. He is only minimally nutritious since he himself is malnourished and he probably takes slightly more energy to kill and butcher than he will ultimately give you. Therefore, your net health approaches negative infinity meaning that not only are you going to die but so is everyone around you and nobody will ever know exactly why or where.
    This is uncannily true.
    So, as you see, the edge cases work. I'm not sure what the big problem with this equation is.

  28. marcus welby says:

    A good example to ponder is that of former U.S. tennis great Arthur Ashe. Perfectly fit, he competed at the elite tennis competitition level, weight perfect, probably about 165 lbs. and nearly 6 ft. tall, never smoked. Ate correctly. Developed coronary artery disease anyway due to genetics and bad luck.

  29. cloudskimmer says:

    I went to Dr. Fuhrman’s website and sent him an email, directing him here and asking him to reply. I also asked why there were little numbers after some of his assertions with no links to any supporting evidence, what he thinks of his ethical position in selling supplements, and if he has any evidence that they work. He has time to write for the HuffPo, but I doubt if he’ll find the time to come over here and educate us poor misfits.

    rokujolady wrote, “I’m not sure what the big problem with the equation is.”
    The equation is meaningless. He doesn’t define the terms or quantify them. Let’s see… how can I maximize “Health”? By increasing the numerator (nutrients) and minimizing the denominator (calories). How can I do that? By not eating food (more calories = BAD), but increasing nutrients (whatever that is… I guess vitamins and minerals.) The answer must be: take supplements! How convenient that Dr. Fuhrman sells them! Why eat nasty food and get all those calories when you can just live off of water and pills? As calories approach zero, health becomes infinite!

  30. yellowbug says:

    I’ve grown tired of reading articles in health magazines about prevention prevention prevention. They are all the same.

    Meanwhile, I find very few articles focusing on, well, how to live if you actually have an incurable disease.

    I’m 32 and was recently diagnosed with Ankylosing Spondylitis. Nothing I could have done would have prevented this disease, as it is genetic. While I can find helpful information in medical journals, it would be nice if mainstream sources would stop ignoring people like me.

  31. rokujolady says:

    Uhm…cloud skimmer…my whole nonsensical diatribe was satirical…and making the same point you just made.

  32. JMB says:

    Calories are nutrition. The equation should reflect that balancing caloric intake with energy demands yields the maximum health.

    Fat soluble vitamins have well documented toxicities when taken in excess (excess water soluble vitamins are simply eliminated by the kidneys). Even water is potentially toxic if intake exceeds the capacity of the kidneys to eliminate.

    Moderation is an important component of healthy lifestyle that is not reflected in the simplistic mathematical model of nutrition / calories. Solutions of simultaneous differential equations for specific maxima and minima at a given time would be a closer approximation of nutritional needs at any given time (and will vary with time). There is some truth to the “grandmother’s old fashion remedy” of, “feed a fever”.

    H = (N / C) is worthy of a fifth grader, but grandmothers know better.

  33. cloudskimmer says:

    my apologies, rokujolady; I should have read more carefully. No offense intended.

  34. Wolfy says:

    @MrEd

    “So I can drink battery acid as long as the calories are zero because this would give me infinite health.”

    Yes, and you’d keep going, and going, and going. . .:)

  35. woo-fu says:

    Thanks for posting this. This subject hits very close to home for me.

    I spent years working with an internal medicine doc who promoted alternative medicine. I was simply trying to get a handle on anything I could to improve my lifestyle which, ideally, would improve my health.

    We worked on fine-tuning my diet, she prescribed lots of supplements (which she also happened to sell), and when I still wasn’t improving, she recommended I obtain unpasteurized milk and eat more raw foods. I was skeptical but felt like, hey, she’s a doctor, she ought to know. So I tried the raw milk and ended up with a bad case of gastroenteritis. Her response? My immune system needed more boosting, more vitamins, etc., but nothing she recommended really worked.

    When I asked about other possibilities, she acted like I needed to have more faith in her expertise. With the exception of the raw milk, I was diligent in the lifestyle changes she recommended but saw little improvement. I also miscarried more than once during this time.

    I finally saw an immunologist who discovered I had a genetic immune system quirk, making me susceptible to infection. None of the supplements my former doc prescribed would help correct that problem. Furthermore, I had developed vitamin A toxicity from the high-potency supplements.

    In this case the Health=Nutrients/Calories is proven completely false. The nutrient level was high, too high in fact. I can’t even believe someone would try to use that as an equation for health. There are so many nutrients that can become quite toxic with high doses.

  36. JMB says:

    @woo-fu

    Write a letter to your state board of health documenting how much money was spent purchasing supplements from the doctor, and detail of dietary intake to calculate average daily intake of vitamin A (you may need a registered dietician to calculate), as well as documentation of the diagnosis of vitamin A toxicity. While the doctor may escape reprimand for selling supplements that they prescribe, prescribing a toxic dose of vitamin A intake may be grounds for a reprimand. Toxicity of fat soluble vitamins was taught in the first year of my medical school. Here’s a link to textbook type material,

    http://emedicine.medscape.com/article/126104-overview

    You may not be the only patient with Vitamin A toxicity due to your doctor’s practice. Repeated reprimands may result in restriction of practice, or termination of license.

    Integrative medicine may skirt ethics issues thanks to politicians. When a patient is injured, the issue goes beyond ethics, and becomes incompetence of the physician. The issue is no longer the ethical issue of whether the profit motive was a factor in the physician prescribing the treatment. The issue after documented patient injury is whether the physician was prescribing toxic levels of vitamin A.

  37. Phil Weinstein says:

    Does there exist ONE disease for which there would be no benefit to having had a commitment to excellent nutrition?

    Dr. Joel Fuhrman isn’t writing for doctor-lawyers, who haven’t themselves done a great job conveying to the rest of us the most important conclusions from good current health and nutrition science. “H=N/C” (micronutrient, mostly phytochemical density with respect to calories) is an abstraction to characterize just ONE OF SEVERAL important risk factors which Dr. Fuhrman identifies.

    Sure, most doctors are firemen. But does every medical doctor need to focus on treating mainly the final stages of disease? I’m an adult, and I very much appreciate being reminded that the medical emergency has already started — for each and every one of us.

    Dr. Fuhrman comes across as a scientist rather than as a lawyer. Fundamental to “nutritarianism” is accommodation of emerging health and nutrition science. But the basic ideas of “nutritarianism” (by the way, not trademarked by Fuhrman) are well supported by large scale evidence, and have been characterized in great detail.

    And how many physicians are standing in front of a camera to teach us how to buy and prepare vegetables and fruits? That’s real Surgeon General material, in my book.

  38. Chris says:

    The difference is that not every disease is because of diet. Not every case of diabetes, high cholesterol or blood pressure is because of diet.

    And how many physicians are standing in front of a camera to teach us how to buy and prepare vegetables and fruits? That’s real Surgeon General material, in my book.

    Does the CDC count? They want us to eat more fruit and veg!

  39. Chris says:

    Aaag! HTML fail, and no preview nor edit available. See:
    http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5935a1.htm?s_cid=mm5935a1_e

  40. # Phil Weinsteinon 14 Sep 2010 at 2:46 pm

    “And how many physicians are standing in front of a camera to teach us how to buy and prepare vegetables and fruits? That’s real Surgeon General material, in my book.”

    To each his own. My opinion would be that buying and preparing vegetables and fruits is more of an art than a science. Aside from the basics of eating a certain number of servings a day, I’ll take my instruction from someone with some culinary talent.

  41. Scott says:

    How to buy and prepare vegetables and fruits is something we should be listening to chefs about.

    That we should be buying and eating fruits and vegetables is something in the purview of doctors, but they DO that. Ad nauseum.

  42. Prometheus says:

    Phil Weinstein asks:

    Does there exist ONE disease for which there would be no benefit to having had a commitment to excellent nutrition? [emphasis added]

    While there aren’t any diseases that can’t be made worse by malnutrition (even recovery from trauma is slowed by malnutrition), the “devil in the details” is how Mr. Weinstein (and Dr. Fuhrman) define “excellent nutrition”. In fact, stuffing oneself with excess vitamins and “minerals” can have a negative impact on health and one’s ability to recover from disease.

    Mr. Weinstein continues:

    And how many physicians are standing in front of a camera to teach us how to buy and prepare vegetables and fruits?

    And the reason we need physicians to do this is…….?

    For the preparing part, I would suggest a cook book. As for buying…try the market. I doubt that many people are looking for fruits or vegetables in the library or the hardware store, but that may be Mr. Weinstein’s issue.

    Prometheus

  43. Chris says:

    I also grow many of my fruits, and some veggies. I have a whole pile of Orcas pears that need to be chilled for a couple of weeks to perfect sweet buttery ripeness (pears get picked when they just can be pulled from the tree, then kept in a cool place for a little bit to finish, some take longer — I get to eat my Bosc on New Year’s Eve).

    I am about to process many of my apples into applesauce (no sugar or cinnamon), which I use in muffins to replace some egg and oil. I need to get to my grapes before the squirrels!

    Mr. Weinstein, have you ever cooked? Or gardened?

  44. “I need to get to my grapes before the squirrels!”

    huh! My grapes are too sour*, even for the squirrels.

    Phil Weinstein – If you are having trouble selecting fruits or vegetables, I suggest visiting the grocery store on a week-day and following the one of elderly ladies around.** She will be happy to tell you how to select the best melons, apples, beans, zucchini, etc. You’ll probably also get a lesson in finding good prices.

    *literally, not figuratively.

    **Not in a creepy way. In fact don’t follow her. Just stand there looking confused and helpless. She’ll come to you.

  45. Chris says:

    While it is a very expensive kitchen store, Williams Sonoma does have some nice free classes on how to cook. You should look into that, Mr. Weinstein.

  46. Joe says:

    @Phil Weinstein on 14 Sep 2010 at 2:46 pm wrote “Dr. Fuhrman comes across as a scientist rather than as a lawyer. ”

    Many of these charlatans appear to have the trappings of science; but they don’t pass muster to knowledgeable scientists.

  47. JMB says:

    Does there exist ONE disease for which there would be no benefit to having had a commitment to excellent nutrition?

    This is not my area of specialty, so feel free to correct me. The rest of grandma’s saying was “feed a fever, starve a cold.” Since viruses (colds) tend to use the metabolic machinery of the body to reproduce and spread, reducing the dietary nutrients may actually slow reproduction of the viruses, allowing faster recovery from self limited viral infections. Of course, I don’t mean to imply the old saying is completely true, but that there is some truth to it. Some types of cancer cells may benefit more from dietary intake of nutrients than the remainder of the body, resulting in a quicker death of the patient, or reduced response of cancer cells to chemotherapy (which is poison).

    Dr. Joel Fuhrman isn’t writing for doctor-lawyers, who haven’t themselves done a great job conveying to the rest of us the most important conclusions from good current health and nutrition science.

    Part of the reason I didn’t go for internal medicine was that it was so frustrating to preach about the benefits of good diet, exercise, and moderation, only to see so few patients follow the advice. Most doctors in training quickly learn the futility of such endeavors. It is of course easier to sell them a supplement, than to convince the patient to increase the fresh fruits and vegetables in their diet. Perhaps the registered dieticians who follow this blog would comment on whether a good diet would eliminate the need for dietary supplements in an otherwise healthy individual. In fact, replacing fresh fruits and vegetables in the diet with dietary supplements may even have a negative effect on health. Patient noncompliance is the biggest reason for failure of physician’s attempts to advocate healthy lifestyles. Ask a patient what the doctor told them after getting a lecture on healthy lifestyle and diet, and you will often get the answer, “Just the usual b#%s.”

    Dr. Fuhrman comes across as a scientist rather than as a lawyer.

    Dr. Fuhrman may come across as a scientist to a nonscientist because of his use of the mathematical formula. A real scientist would immediately evaluate the formula for counterintuitive results. Science has a hardcore of mathematical calculation, because mathematical formula can be readily tested. The hardest science allows us to make calculations of what the results will be in a given scenario, such that someone careful to reproduce the scenario and make measurements will be able to test the formula’s predictions. A physician or nutritional scientist would also compare the results of the formula calculations with documented clinical observations. In the formula, H = N/C, health decreases as calories increase from the value of 1 to positive infinity. Health increases as calories decrease from 1, to fractions of a calorie, approaching infinity as calories approach zero. That is counterintuitive because people can starve. Health becomes a negative value as calories become negative. Any physician or nutritional scientist has received education on the disease processes associated with vitamin deficiencies, as well as hypervitaminosis. Therefore H = N/C fails as both a mathematical model, and as a scientific concept because it fails to include one of the most important clinical scientific concepts, that of moderation. But moderation would not be good for the bottom line of somebody selling supplements. H = N/C is a good business model for somebody selling dietary supplements, not a good scientific model.

    Doctors giving up on telling patients about the value of a good diet ultimately has nothing to do with whether Fuhrman’s article represents science or pseudoscience. The inaccuracy of results of calculation in well documented scenarios marks it as pseudoscience.

  48. Phil Weinstein says:

    It is so easy and satisfying to tear down something that takes a huge amount of time and effort to put together. If this is all just about playing “gatcha” over a rhetorical device used to convey an abstraction to the general public, then fine. H=N/C is pseudoscience.

    It’s very difficult to convey these ideas in a very short, generally accessible article. The authors of a recent book based on the same broad body of science, and coming to similar conclusions, “Building Bone Vitality” [2009, Amy Joy Lanou and Michael Castleman] spent much of the book explaining to lay people the nature of scientific health and nutrition research, and how contradictory conclusions can be understood. It’s tough. Of course a small number of studies can always be construed to support just about any claim. And it’s always possible to pick on a small piece of any presentation and shout “pseudoscience!”. Big deal.

    Of course the boundary values of the H=N/C illustration is silly — this isn’t an actual governing equation. (And “C” more aptly refers to EXCESS calories — beyond those needed to maintain a health-promoting weight — but of course, not exactly, literally).

    I will respond to the frat boys on this blog that “N” doesn’t refer to isolated supplements. It refers almost entirely to the myriad phytochemicals found especially in green leafy vegetables — and practically non-existent in refined carbohydrates (flour and sweeteners) and fats (oil) and animal-source foods. Fuhrman promotes whole foods, primarily unrefined plant foods, and VERY CONSERVATIVE use of isolated supplements. For example, for people following his advice to center their diet on high-nutrient plant foods, he strongly recommends avoidance of isolated vitamin A / beta-carotene and Folic Acid. For people testing low in vitamin D (with 25-OH-D), he generally recommends a slow ramp up (e.g. 4000 IU each day) and retesting, so that people can determine their optimal supplement level, rather than blasting with 50000 IU and having no idea of their appropriate supplement level. Many many people know of HUNDREDS of Fuhrman’s research-and-practice based nuanced and evolving recommendations. (No thanks to anyone on this blog).

    A very condensed but relatively comprehensive book of Dr. Joel Fuhrman’s analysis and recommendations is “Cholesterol Protection for Life” (2nd ed, 2006). I’m looking forward to Fuhrman’s revised edition of his heavily cited book, “Eat to Live”, to be released in January 2011.

  49. Thanks for the infomercial, Phil.

  50. JMB says:

    @Phil Weinstein

    I will concede my limitations as a communicator, but I have never been a member of a fraternity.

    I will try to express my thoughts more clearly.

    Without any specific health education, the equation can be seen to fail in the boundary conditions. That failure can be proved to anyone who has been taught fractions, or negative numbers, or division by zero, and understands that we cannot live forever. So that argument against the scientific validity of the equation should be accessible to anyone with an elementary school education.

    Beyond the boundary conditions argument, within the central ranges of the mathematical model, the equation fails to embody certain important concepts in health. One is the concept of moderation. For example. a moderate alcohol drinker will have a longer life expectancy than a heavy drinker, or a person who doesn’t drink (all other health factors being equal). The second health concept is that it is better to eat a balanced diet, including fresh fruits and vegetables, than to make up for dietary deficiencies with supplements. That simply reflects our limitations of knowledge. The third health concept is that there are many causes of disease. Nutritional deficiencies are just one cause of disease. Many diseases are multifactorial, addressing just one factor will not eliminate disease. Therefore, with some medical knowledge, the equation can be seen to fail in all numerical ranges, not just boundary conditions.

    Dr Lipson communicated the main arguments (covering the central conditions) about how the article represents pseudoscience. I just added a comment because of my experience with mathematical models. It is not my first comment on SBM about what represents a medical scientifically valid mathematical model (that which will optimize health outcome, as opposed to that which optimize a measure of economic efficiency). The simplification to H=N/C optimizes the business outcome of someone selling N, more than the outcome of someone seeking H. That’s my two cents worth, compared to Dr Lipson’s $1 worth.

  51. DrFuhrman says:

    Dr. Lipson, we have never met or corresponded, we are not friends; please do not refer to me by my first name. I am trying to sell something, I am trying to sell the concept that people do have marked control over their health destiny (that they cannot achieve with just medications) and that nutritional excellence can have profound effects on lessening disease risks and human suffering and that conventional medical care with it over-reliance on drugs is inadequate.

    The leading cause of death for adults in the United States are related to lifestyle—predominantly poor diet, not lack of medical care. This is evidence-based and should not be controversial.(1) Your post just reinforces and demonstrates your ignorance and incompetency, typical of physicians lacking the knowledge and skill to motivate patients and encourage a major change in people, compared to what modern nutritional science makes potentially possible.

    For example, heart disease is almost totally avoidable as many cultures around the world consuming primitive diets have no heart disease (2) and even in the USA heart attack deaths were under 4 percent of total deaths 100 years ago. (See graph at –> http://www.americanheart.org/downloadable/heart/12626426574432010%20Stat%20charts%20FINAL.ppt
    Slide #6

    With regard to heart disease and even most cancers, I would argue the environmental causes (especially diet) has more profound effects than genetics. This is particularly apparent when you look at heart disease statistics and cancer statistics worldwide and throughout the last 100 years in America and in other countries and cultures. Did I say winning the war on cancer, heart disease and stroke means we will live forever or nobody will still get cancer? I found your post anything but scientific and rather than delineate our disagreement your attempt was to distort my message so you could ridicule something. However, I do think nutritional science has advanced to the point where people can add 10 – 20 years to the average lifespan. I do think it possible to achieve heart attack and cancer statistics that are as good or even better than populations around the world that have eaten a healthier diet than we have. Why should we accept mediocrity? Do you deny that breast cancer rates vary significantly around the world, yet when those cancer- protected society migrate to America they and their offspring develop breast cancer at American rates?

    Not only are their significant body of scientific evidence to suggest that more intensive nutritional modifications can prevent the vast majority of heart attacks occurring today, but also that most heart disease is reversible with aggressive nutritional interventions. (3)

    The thousands of patients that have reversed their heart disease via my nutritional recommendations speak loudly for the value of my nutritional message. For example, look at Ronnie Valentine’s story posted on my blog –>

    http://www.diseaseproof.com/archives/interviews-features-interview-with-a-nutritarian-ronnie.html

    I you would like to debate me on scientific issues, please refrain from the name-calling, and this contemptuous and superior attitude. Maybe you will find you have something to learn and you don’t know everything. Also let’s stick to the issues and not twist the argument into discussing asbestosis, gene defects, supplements and miscarriages, those are a different subjects. However, this arguement is about the potential disease-protective effects of nutritional excellence, not about the value of nutritional supplements, which I also argue are in many cases worthless or harmful, such as folic acid, Vitamin A, beta carotene, selenium, copper and Vitamin E, which all have been linked to increased morbidity or mortality.

    Maybe before you attack H = N/C, you should understand what it means. If you want to know more what It means, ask me. By the way H = Healthy Life Expectancy and it can be quantified and measured, and the World Health Association does so. By worldwide standards here in America our “H” or Healthy Life Expectancy is relatively poor and access to more and “better” medical care is does not increase it, it usually decreases it.

    I have no problem with you disagreeing, or offering a critique, but you should at least disagree with my real opinion and not something you falsely created about me. Maybe the fact that you consider yourself a “real doctor” and I am a “charlatan” and a “fake” makes you feel important, but such name calling are usually used by those with no substance behind their arguments and have no interest in looking at the facts. Your article does show you have a distinct preconceived bias and incompetency in lifestyle medicine. By the way, did you review my references and read all the studies? (see below) Was there an interest to see what they showed? For a person interested in science don’t you think you should learn more before you critique? As a physician our job is also to continue to learn continually. Do you feel you have anything to learn from me?

    So if you or anyone else here has an interest in continuing any form of dialogue let’s look at some of this evidence and let’s see how you disagree with the science and my interpretation of it, because I am saying that in a population motivated to achieve nutritional excellence heart attacks should be a relatively rare occurrence. My opinion is that if you want to eat, drink or smoke any self-destructive way you want, but don’t take away the opportunity for others who choose otherwise or deny the value of proper nutrition. That is not only wrong; it is ill-will for others. Maybe one day it will be considered malpractice.

    1. Lianov L, et al. Physician Competencies for Prescribing Lifestyle Medicine. JAMA. 2010;304(2):202-203.
    2. Esselstyn CB Jr. Changing the Treatment Paradigm for Coronary Artery Disease. Am J of Cardiology 1998;82(10B):1T-4T.
    3. Koertge J, et al. Improvement in medical risk factors and quality of life in women and men with coronary artery disease in the Multicenter Lifestyle Demonstration Project. Am J Cardiol. 2003 Jun 1;91(11):1316-22. Ornish D, et al. Can lifestyle changes reverse coronary heart disease? The Lifestyle Heart Trial. Lancet 1990 Jul 21;336(8708):129-33. Jenkins DJ, et. al. Effects of a dietary portfolio of cholesterol-lowering foods vs Lovastatin on serum lipids and C-reactive protein. JAMA 2003 Jul 23/30;290(4):502-10. Appel LJ, et. al. Effects of comprehensive lifestyle modification on blood pressure control: main results of the PREMIER clinical trial. JAMA 2003 Apr 23/30;289(16):2083-93.

    Original References Posted on Huffington Post

    1. USDA Economics Research Service, 2005. ; http://www.ers.usda.gov/publications/EIB33;www.ers.usda.gov/Data/FoodConsumption/FoodGuideIndex.htm#calories

    2. Johnson PM, Kenny PJ. Dopamine D2 receptors in addiction-like reward dysfunction and compulsive eating in obese rats. Nat Neurosci. 2010 Mar 28. [Epub ahead of print]. Scripps Research Institute (2010, March 29). Compulsive eating shares addictive biochemical mechanism with cocaine, heroin abuse, study shows. ScienceDaily. Retrieved April 16, 2010, fromhttp://www.sciencedaily.com/releases/2010/03/100328170243.htm

    3. Higdon JV et al. Cruciferous Vegetables and Human Cancer Risk: Epidemiologic Evidence and Mechanistic Basis. Pharmacol Res. 2007 March ; 55(3): 224-236

    4. Powolny AA, Singh SV. Multitargeted prevention and therapy of cancer by diallyl trisulfide and related Allium vegetable-derived organosulfur compounds.
    Cancer Lett. 2008 Oct 8;269(2):305-14.

    5. Zhang M, et al. Dietary intakes of mushrooms and green tea combine to reduce the risk of breast cancer in Chinese women. Int J Cancer. 2009;124:1404-1408

    6. Bazzano LA, Li TY, Joshipura KJ, Hu FB. Intake of fruit, vegetables, and fruit juices and risk of diabetes in women. Diabetes Care. 2008 Jul;31(7):1311-7. Hannum SM. Potential impact of strawberries on human health: a review of the science. Crit Rev Food Sci Nutr. 2004;44(1):1-17. Joseph JA, Shukitt-Hale B, Willis LM. Grape juice, berries, and walnuts affect brain aging and behavior. J Nutr. 2009 Sep;139(9):1813S-7S. Stoner GD, Wang LS, Casto BC. Laboratory and clinical studies of cancer chemoprevention by antioxidants in berries. Carcinogenesis. 2008 Sep;29(9):1665-74.

    7. Aviram M, Rosenblat M, Gaitini D, et al. Pomegranate juice consumption for 3 years by patients with carotid artery stenosis reduces common carotid intima-media thickness, blood pressure and LDL oxidation. Clin Nutr 2004;23(3):423-33.

    8. Bazzano LA, Thompson AM, Tees MT, et al. Non-soy legume consumption lowers cholesterol levels: A meta-analysis of randomized controlled trials. Nutr Metab Cardiovasc Dis. 2009 Nov 23. [Epub ahead of print]. Aune D, De Stefani E, Ronco A, et al. Legume intake and the risk of cancer: a multisite case-control study in Uruguay. Cancer Causes Control. 2009 Nov;20(9):1605-15.

    9. Sabaté J, Ang Y. Nuts and health outcomes: new epidemiologic evidence. Am J Clin Nutr. 2009 May;89(5):1643S-1648S. Epub 2009 Mar 25. Mattes RD et al. Impact of peanuts and tree nuts on body weight and healthy weight loss in adults. J Nutr. 2008 Sep;138(9):1741S-1745S.

  52. David Gorski says:

    Dr. Fuhrman,

    Your self-righteous complaint might sway me a bit more than it does (which is close to not at all) if you hadn’t finished your post with the following sentence:

    We don’t need to find the cure, it has already been found and it is sitting there on the shelves of our grocery stores.

    I’m sorry, but that last sentence, more than anything else, persuades me that Peter’s criticisms of your overhyping of food as a “cure-all” are valid.

  53. Chris says:

    Dr. Fuhrman:

    So if you or anyone else here has an interest in continuing any form of dialogue let’s look at some of this evidence and let’s see how you disagree with the science and my interpretation of it, because I am saying that in a population motivated to achieve nutritional excellence heart attacks should be a relatively rare occurrence.

    Seriously, do you really think that food choices will cure or prevent genetic heart anomalies like my son’s hypertrophic cardiomyopathy?

  54. Peter Lipson says:

    First, I’m happy you found your way over here, Joel. SBM has a terrific repository of science-based medical knowledge. You’ll love it. And, I’m fairly certain you’re not the Pope, the Queen of England, or Dr. Ann de Wees Allen, so a first name seemed pretty appropriate, given that’s what most of us doctors use when we talk to each other.

    Complaining about a mode of address or a tone of a piece is a pretty lame rhetorical distraction from making substantial arguments, so I’m glad you moved on from that quickly.

    But despite the numerous citations and the offended tone, you didn’t actually say much to dispute my argument. My argument was (although I may not have made myself clear) that while it may be easy and comforting to believe that lifestyle modification, including intensive nutritional interventions, have all of the benefits you cite, the evidence simply doesn’t support it.

    But more important than that, you view failure to achieve your desired lifestyle modifications as a failure on the part of the physician (and implicitly, on the patient and society as well). I certainly cannot argue against the “culpability” of doctors, patients, and society in fostering unhealthy lifestyles, but I can and do argue forcefully that our job as physicians is to treat real people and give them realistic advice.

    There are no data that successfully argue that for secondary prevention of coronary heart disease, diet is as effective as aspirin, beta blockers, statins, and ace-inhibitors. There is no moral argument to support withholding metformin from a diabetic who “fails” to meet a doctor’s nutritional expectations.

    Joel, you are promoting a fantasy at best, a punitive pipe-dream at worst.

  55. daedalus2u says:

    The idea that it is only the diet of individuals in the undeveloped world that protects them against the heart disease, cancer, allergies, and the myriad other disorders that are leading causes of death and dysfunction in the developed world is, I think, mistaken. There is the hygiene hypothesis.

    http://books.google.com/books?id=a3mwmXzpsjkC&lpg=PP1&pg=PA103#v=onepage&q&f=false

    There are a number of hygiene related treatments that are quite effective at some disorders of the developed world. Gut worms are very effective at treating inflammatory bowel disease and very effective at treating Crohn’s disease. Not a little bit effective, so effective that if the trial had been blinded it would have been stopped because the treatment leg was obviously better.

  56. JMB says:

    I see nothing in Dr Lipson’s post that denies the importance of diet and lifestyle in reducing the incidence of heart attack and stroke. From Dr Lipson’s post,

    And as every primary care physician knows, lifestyle change are an important part of preventing and treating these diseases.

    The main issue is whether it is more correct to say that a person can minimize their risk of diet and stroke by diet and lifestyle changes, or,

    Doesn’t every American have the right to know they don’t have to suffer a heart attack or a stroke?

    If the equation isolated nutrient density as a factor in healthy diet, I wouldn’t have criticized it. If the H in the equation means Healthy Life Expectancy, and the person using the equation as a rhetorical device sells health supplements, then all of the criticisms of the direction of oversimplification apply (especially in analysis of HLE as in WHO reports).

  57. Joel said – “My opinion is that if you want to eat, drink or smoke any self-destructive way you want, but don’t take away the opportunity for others who choose otherwise or deny the value of proper nutrition.”

    At what point did anyone take away the opportunity for others to choose a healthy diet? As I see it, you wrote an article, Peter Lipson posted an article disagreeing with your approach.

  58. Dr Benway says:

    Eating right may help fight heart disease. But it won’t cure being a douche.

    Anecdotal data suggest that mega-vitamins cause hypochondria, egocentrism, and teh crazy.

  59. daedalus2u – just wanted to say I find your comment fascinating. I seem to be having a hygiene hypothesis weeks, since I also heard a doctor talking about intestinal flora and fecal transplants on Fresh Air yesterday (or Wednesday, maybe)

    I wonder if someday these ideas will help me with the intense sinusitis and eye inflammation that’s been bothering me all summer.

    A really interesting area to watch in medicine.

  60. Dawn says:

    @DrFuhman: You don’t REALLY use primitive tribes and the lifespan of 100 years ago to prove less heart disease, do you? Please! How many of those people DIED at young ages before heart disease could occur? How many people died “suddenly”, “in their sleep”, of “apoplexy”? Few people knew they even had heart disease. And they certainly couldn’t treat it effectively.

    I believe in healthy diets, my doctors have preached at me for years about diet and exercise. My mother’s family has a history of members in the 1900-1950′s dying at young/relatively young ages. When my grandfather, who was a GP, married my grandmother, he discovered that several of her family members were severely hypertensive. One died in her early 40′s. Several others died in their 60′s. Others died from symptoms that were probably cardiac but at this time we’ll never know. These were farming people who grew, canned, raised almost 100% of their own food. Eating in a healthy way didn’t help THEM. My mom, her brothers, her parents, lived or are are living well beyond those ages, even with the hypertension, thanks to modern medicine.

    Sure, I try to eat a very healthy diet, exercise, don’t smoke, drink very moderately. My weight is controlled. But I still have to keep an eye on my blood pressure and other cardiac measures because genetics beats all.

  61. Dr Benway says:

    First, I’m happy you found your way over here, Joel.

    I love you, Dr. Lipson.

  62. Xplodyncow says:

    I <3 you, SBM. It's posts like these that help me evaluate claims on sites like this:

    http://www.gorillaprotein.com/

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