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Gluten-free foods: the healthiest for everyone?

A sign that says Gluten Free
Above: a sign that says “Gluten Free.”

Gluten-free foods are becoming increasingly popular around the college campus that I currently call home, reflecting, I believe, a similar trend at the national level. In fact, it is so popular that I begin to view it as the next fad food for very health conscious college students. We not only need to eat healthier desserts in the form of frozen treats called Tasti-D-Lites (it has become a phenomenon since it moved onto campus a few weeks ago; so many students can be spotted eating these frozen treats), but we now also need to eat the “healthiest” grains. However wheat, like frozen yogurts, no longer makes the top of the list anymore. In the search for the healthiest of everything, gluten-free foods and Tasti-D-Lites come out on top.

But do we really understand what a gluten-free diet means for health when we designated the newly installed gluten-free food section in our Great Hall cafeteria as our favorite place to find healthy food? Did we misunderstand the purpose of eating a gluten-free diet? These questions are addressed in a Health.com article titled “Will a gluten-free diet improve your health?”

The simple answer to the title question in Carina Storrs’ article mentioned above is: not really if you do not have celiac disease and you are not gluten-intolerant. In fact, eliminating gluten-containing foods might require you to supplement your diet with other foods and/or vitamin pills to complete a balanced and healthy diet. This is because gluten-free foods often lack iron and some important vitamins such as vitamin B and D, and because fortification of gluten-free foods is also not as common, people with a gluten-free diet need to find other sources of these essential nutrients. Furthermore, many currently available gluten-free foods are manufactured with excessive sugar and fat so they could mimic the taste and texture of food containing gluten, and therefore they could be very unhealthy.

Gluten is a protein found in some grains such as wheat, barley and rye. These grains are often made into bread, pasta, and numerous other grain-derived products. When consumed by people affected by celiac disease, gluten erodes their intestinal walls, leading to mal-absorption. So for these people, a gluten-free diet would definitely improve their health. Those who do not have celiac disease could also feel gastrointestinal discomfort upon gluten consumption if they are gluten intolerant or sensitive. Some symptoms include bloating, gas, diarrhea, and stomachache. For people who suffer from either celiac disease or gluten intolerance, completely forgoing every product made with gluten is the only treatment for their symptoms, therefore eating gluten-free food could benefit their health and well being.

Gluten-free food originated to provide more food options and to treat celiac disease and gluten-intolerance. However, today many health conscious people also eat gluten-free foods because they believe that a gluten-free diet is healthier. Unfortunately, for those not afflicted with either celiac disease or gluten-intolerance, gluten-free foods are not at all healthier than gluten-containing foods. Storrs put this fact clearly when she wrote:

“Even though celebrities like Oprah Winfrey and Gwyneth Paltrow have reportedly cut out gluten to ‘detox,’ there’s nothing inherently healthier about a gluten-free diet.” – Carina Storrs

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Posted by on April 21, 2011 in Uncategorized

 

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Banning Fructose (aka refined sugar and HFCS)


Above: Presentation “Sugar: A Bitter Truth” by Dr. Robert Lustig.

HFCS = high-fructose corn syrup

Several weeks ago, I wrote a post incriminating aspartame as a substance that could possibly cause cancer or other unforeseen health problems in the future. Although it is my personal belief that sometime down the road, problems associated with long term aspartame consumption would surface, my concern over aspartame’s effect on human health is not unfounded. Despite the fact that results from preliminary aspartame research in rodents are still inconclusive , I still firmly believe that aspartame usage could cause damage to health slowly but surely. However, even if aspartame consumption does not demonstrate any health problems in the future, avoiding this substance will at least give me the peace of mind. And perhaps this is why I will also soon begin to regulate my sugar intake. No, I am not referring to reducing sugar intake to the recommended daily level, but actually reducing the consumption of a specific type of carbohydrate: fructose. (Although reducing total sugar intake is also a good idea, it is not the focus of this post).

“Natural sweeteners” include the common refined sugar and the more ubiquitous high fructose corn syrup. If a processed food is not sweetened by an artificial sweetener like aspartame, it is usually sweetened by one of these “natural sweeteners.” However, how “natural” are these sweeteners? And more importantly, does the “naturalness” of these sweeteners guarantee their safety to health? This last question is answered by Gary Taubes on the Health News section of the New York Times via an article titled “Is Sugar Toxic?”.

In “Is Sugar Toxic?”, Taubes, writer and independent investigator in health policy, summarizes a presentation (see video above) given by Dr. Robert Lustig, a pediatrician at the University of California San Francisco Medical School. In his presentation, Lustig introduces his hypothesis that sugar, more specifically the fructose that makes up approximately 50 % of refined sugar and high fructose corn syrup, is actually a toxic substance when consume at high qualities and/or chronically. Furthermore, increased and prolonged consumption of fructose could lead to obesity, type 2 diabetes, and even cancer.

(And this is not about the number of calories in the sugar:
“It’s not about the calories,” he says. “It has nothing to do with the calories. It’s [fructose] a poison by itself.” – Dr. Robert Lustig
It needs to be emphasized that Fructose within the sugar is the real culprit.)

Lustig’s hypothesis, at first glance, might seem ludicrous and unbelievable because yes, we all know that overconsumption of sugar contributes to fat accumulation and obesity, but to claim that sugar is toxic might be blowing the sugar consumption problem out of proportion. However, Lustig’s hypothesis is formulated based on decades’ work of many independent scientists whose research were not financially supported by beverage companies, processed food companies, or any other commercial venture that sought to use science to prove the safety of their in fact dangerous products.

While Lustig provides many convincing evidence on the dangers of fructose consumption, one piece of scientific evidence especially helped to convince me of the validity of Lustig’s hypothesis. This simple fact is that fructose is only metabolized by the liver and thus increased consumption of fructose places increased metabolic burden on the liver, which turns fructose into fat when the metabolic machinery of the liver can no longer handle the large influx of fructose. From understanding this piece of information, I am able to understand the deductions that Lustig make on the effect of fructose consumption on health. For example, Lustig shows via data collected from rigorously conducted experiments that consumption of high fructose corn syrup leads to development of fatty liver that impair the metabolic system, namely the insulin and blood sugar control system, of the consumers, thus leading to metabolic syndrome,(a disease of insulin resistance, the precursor to type 2 diabetes), obesity, and finally type 2 diabetes.

In his presentation “Sugar: The Bitter Truth” (see above video), which was summarized by Taubes in his detailed article “Is Sugar Toxic?”, Lustig make many claims. Some of his claims include: 1) fructose consumption, not fat, is the main cause of metabolic diseases, obesity, and diabetes, 2) some cancers are caused by over production of insulin on an insulin resistant body and 3) fructose consumption can even produce fatty livers and metabolic diseases in lean people because “calorie in” no longer equals “calorie burned” in the world of biochemical processes of metabolism. Lustig make many other claims in his presentation, all of which are well supported by scientific evidence. I’m confident that you will be convinced by his eloquent presentation. Just now, he has convinced me of the evils of fructose.

[Fructose] is “the most demonized additive known to man.” –Dr. Robert Lustig
Perhaps I’m not this extreme, but removing as much fructose from my diet as possible might just give me the peace of mind that eliminating aspartame has.

 
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Posted by on April 16, 2011 in In our food...

 

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Chocolate, healthy or unhealthy?

A box of chocolate.
Above: A box of chocolate.

As a big chocolate fan, I can’t help but wonder whether chocolate is actually good for health or not. However amidst various claims on the health benefits or the harmfulness of chocolates, I choose to believe that at least dark chocolate is healthy for regular consumption. This possibly biased decision is actually based on my love for chocolate and recently this decision was challenged by my exercise partner for the semester.

Because she had eaten chocolate today, she must go to the gym to exercise in order to shed the cholesterol that she believed she had gained from the chocolate consumption. This is a rule that my friend strictly enforces upon herself. Since, like me, my friend also can’t resist chocolate, she decided to live by her rule in order to eliminate the cholesterol. However, is this exercising really necessary? How much cholesterol is actually in chocolate and is this amount detrimental to health? What about the fat in chocolate? The most important question (for me at least) is whether dark chocolate is included in this category of “bad-for-health chocolates”? What about the studies that suggest dark chocolate is good for the heart? To find accurate answers for these questions, I visited two credible websites: the Mayo Clinic website and the Cleveland Clinic website.

Cleveland Clinic, a premiere medical research, primary care, and education institution devotes an article to the explanation of the health effects of chocolate. According to this article, whether chocolate consumption is beneficial or detrimental to health depends on several factors: the flavonoid content of the chocolate, other components of the chocolate, and how much is consumed.

First, flavonoids are antioxidants found in plant-derived foods like tea, apple, and cranberries, etc. These antioxidants could prevent LDL (bad)-cholesterol oxidation, which hurts the arteries and promotes plaque formation on the arterial wall. Furthermore, these antioxidants could lower both the systolic and diastolic blood pressure, promote blood flow, and prevent clot formation. With all these benefits to health, it is not surprising that consumption of foods with high flavonoid contents, such as berries and tea, is vigorously promoted by health professionals and by the media (the number of times we see commercials boast the antioxidant content of their products. For instance, Snapple claims that they have “The Green Tea with the most EGCG on Earth.” EGCG is a flavonoid antioxidant.).

Snapple poster claiming that they have ‘The Green Tea with the most EGCG on Earth.’
Above: Snapple poster claiming that they have “The Green Tea with the most EGCG on Earth. EGCG is an antioxidant.

Fortunately I can also get some of this flavonoid from chocolate, not just from berries and tea. However, before rushing to purchase enough chocolate to replace berries and tea, it’s important to realize that not all chocolate contain the same amount of flavonoid. According to Cleveland Clinic, chocolate are processed differently and some production methods remove flavonoids. Therefore, it is important to find and consume those chocolate that retained the most flavonoids after processing. This is, however, easier said than done. A simpler way to choose chocolate that contain high levels of flavonoid is to choose dark chocolate over milk and white chocolate. Dark chocolate usually contains 50-80% cocoa (the component of chocolate that actually contains the flavonoids), milk chocolate 15-25%, and white chocolate has almost no flavonoids (Mayo Clinic, 2008). So choosing dark chocolate would mostly likely give you the flavonoids you want.

Despite its benefits, chocolate could have harmful effects on health. This is because 1) chocolate does contain fat and 2) unhealthy substances such as caramel and sugar could be added in large quantities to chocolate, depending on the type of chocolate you purchase. First, chocolate contains three types of fat that come from the cocoa butter used for chocolate production. Two of these fats, stearic and palmitic acids, are saturated fats that could increase LDL(bad)-cholesterol. When consumed in large quantities, these fats do have an unfavorable effect on the cardiovascular system. However, when consumed in lower quantities, these fats do not post a big health hazard. Thus, moderation is the key to gaining the benefits and avoiding the harmful effects of chocolate consumption. Second, chocolate that are not pure chocolate but chocolate “mixtures” with unhealthy components such as caramel and marshmallow definitely elevate the harmful effects of chocolate in comparison to the benefits of chocolate. Therefore it is necessary to avoid these chocolate mixtures. According to the article on the Mayo Clinic website, consuming 6 grams or about a square of pure dark chocolate is the best.

After reading about chocolate from both Mayo Clinic and Cleveland Clinic websites, I am now much more confident in my consumption of dark chocolate. Maybe I consume 3 squares a day, but I’m content that this amount, which does not equal over-consumption , can help to keep my cardiovascular system healthy while not requiring me to burn off the fat and cholesterol every time I eat chocolate. To my friend, and all chocolate enthusiasts out there, this might also be very good news!

 
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Posted by on April 11, 2011 in Uncategorized

 

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Food Coloring

Food for thought…
Easter bunny reading newspaper article on FDA restricting food dye use on Easter eggs.
Above: A fun cartoon of an Easter bunny reading a newspaper article about FDA restricting food dye use on Easter eggs, suggesting that food dyes might not be entirely safe.

Food coloring is a very common additive to our food. Many processed food we consume contain this substance in order to provide consumers with the “expected color” for a particular food. For instance, consumers expect banana or lemon puddings to be yellow while they expect their oranges to have brilliantly orange skin (yes, orange food coloring is sometimes injected into the skin of oranges to give off-season and not-so-great-looking oranges the bright orange color that we usually see in very well grown oranges).

Studies have shown that when a food does not have the expected color, it is perceived to taste different from the same food that does have the expected color. A study on the effect of food coloring on the perceived taste of Cheetos with the normal cheesy-looking orange color and Cheetos without the fo¬¬¬od coloring (which leaves it in a grayish color) discovered that consumers found the regular Cheetos to taste cheesier and that they derived a lot of pleasure from eating these Cheetos. In contrast, consumers who ate the gray Cheetos didn’t like them very much and reported that these Cheetos didn’t have the same amount of cheese as the regular colored Cheetos although both Cheetos were exactly the same except for the color. Because food coloring or food dyes are tasteless, it can be concluded from this study that the perceived difference in the taste of the Cheetos is entirely psychological; the difference in taste is generated by expectations. Based on results like this, it is no wonder that the food industry depends so heavily on the usage of food coloring in the production of its food. And this industry is reluctant to add a warning label on its food to inform consumers that ingesting food coloring could possibly cause undesirable side effects such as increasing hyperactivity in ADHD patients and causing ADHD-like symptoms in non-ADHD populations.

Using food coloring has the benefits of allowing consumers to have a better experience with the food they eat and allowing food companies to sell more of their products. However, is food coloring safe to consume? As mentioned above, food coloring could cause undesirable health problems in some consumers, and recent research supporting the link between hyperactivity and food dye use renewed the concern that the regulation on the use of this potentially harmful substance is not strict enough. Despite the findings of new research, a committee at the U.S. Food and Drug Administration voted, on March 31, 2011, to continue to allow the use of food dyes without warning labels. This decision is based on the committee’s belief that data generated from recent research do not produce enough evidence that food dyes could cause hyperactivity in most children, especially those that do not have ADHD. Therefore food companies should not be required to add warning labels that could unnecessarily damage sales.

Like research for many other food additives such as aspartame and MSG, research into the safety of food coloring has not yet provided strong data proving the safety or the harmfulness of food dyes. Therefore, it is hard to decide whether we should continue to consume these artificial substances or not. For now, this decision is based on personal preference rather than government regulations. However, it is important to be informed of these issues and to evaluate new research data objectively in order to make the best decision on whether to consume or not consume these food additives. Maybe we will be surprised * in what we will find out in the future!

* I just want to share this interesting fact: The coloring agent Brilliant Blue G (BBG), a relative of the approved food dye Brilliant Blue FCF (FD&C Blue No. 1), had been found to protect motor neurons in the spinal cord of rats that had experienced spine injury and thus allowing them to recover part of their mobility. This finding led to the hope that BBG could be used to treat humans who have experienced similar spinal injures. Currently, more research is being done on BBG. Who knows, perhaps in the not distant future, BBG’s relative Brilliant Blue FCF, the one we consume, turns out to be neuro-protective also, and those who consume more blue M&Ms’ have a better chance at recovering from spinal injury if it does happen.

 
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Posted by on April 4, 2011 in Uncategorized

 

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MSG vs. Aspartame: Different, Individualized Perceptions

MSG_pic3
Above: MSG use is more prevalent than many people believe or know. Many processed foods such as chips contain MSG.

I have a habit of crunching on snack foods periodically while working on a very long homework assignment for a very long time; eating snacks seems to give me comfort and relieve my stress. So while working with a friend on such an assignment “requiring” the periodic consumption of, on that day, Pringles, I came to register the fact that I was actually ingesting monosodium glutamate or more commonly known as MSG when I informed my friend of the “unhealthiness” of my choice of junk food snacks. This fact bothered me a little, not because I didn’t know most chips contained MSG but because I realized for the first time that I was ingesting this potentially harmful substance willingly and without caution. I was surprised at myself, who is strictly opposed to any consumption of aspartame, to not be also banning MSG from my diet. I became intrigued by the question of why I eat MSG-containing foods so often while abstaining from aspartame. What makes these substances so different to trigger such different responses? Could my reaction to MSG explain why so many others continue to consume aspartame? These are the questions that I will attempt to answer through this post entry.

Although MSG and aspartame have very different chemical structures and pharmacological actions in the body, MSG and aspartame resemble each other in several ways. For example, both MSG and aspartame are food additives that enhance the flavor of food, both are approved by the FDA as safe for consumption (MSG categorized as a Generally Recognized as Safe (GRAS) substance by FDA and a comprehensive review of aspartame research by Magnuson et al in 2007 shows that aspartame consumption at current level is safe), and the safety of both have been supported and challenged over the years. While both the proponents and opponents for the use of either substances come from all over the world, it seems to me that aspartame is more accepted in the United States while MSG is more accepted in Asian cultures.

Growing up in a Chinese household, I’ve consumed meals cooked with MSG ever since I was able to eat solid food. Although my parents only used MSG occasionally in soup, my grandparents cooked almost every dish with MSG. To my grandparents, adding MSG is as normal as adding salt. After eating this chemical almost every day for their entire lives, my grandparents remain healthy to this day. Myself of course continue to each this substance, albeit much rarer after moving to the United States. So far, I have not had any side effects from previous MSG use or current consumption of MSG containing food.

Although my grandparents and I did not experience immediate side effects or long term health consequences from consuming MSG, I understand that, like every chemical substance, a portion of the population do react unfavorably to this substance. Thus, knowing this, why do I still feel comfortable consuming MSG and not aspartame? Similarly, why is it more acceptable to consume aspartame than MSG in the United States? The answer, I believe, is the “got used to” factor. Every since I was young, I have consumed MSG with my family and relatives, and therefore MSG doesn’t seem dangerous at all. However, with all my relatives around me opposing the consumption of aspartame, citing its toxic effects and the danger it poses to health, I have grown up viewing aspartame as a very dangerous substance that I should never consume. In contrast, many of my peers growing up in more Americanized home environments (this include all ethnicity and nationalities, even Asian Americans, etc) are much more comfortable consuming aspartame, but they are as against consuming MSG as I am against aspartame consumption!

It is very interesting to me how despite the similarities between MSG and aspartame mentioned above, people developed opposite perceptions on their relative safety. This make me wonder whether many other such food additives and food by themselves (processed food most likely) are consider healthy or not healthy only because we have been exposed to them for such long periods of time that they’ve become an integrated part of our lives so we no longer question their safety? (i.e. food coloring).

MSG_pic2
Above: Some claims about the dangerous effects of MSG on health.

For fun…food for thought:
Cartoon of MSG usage in Chinese food
Above: Cartoon about MSG from an original artist on www.cartoonstock.com..

 
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Posted by on March 14, 2011 in In our food...

 

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Is Caffeine Safe?

caffeinated_drinks_shorter
Above: top left – coffee, top middle – energy drinks, top right – soda, bottom – caffeinated drinks.

While volunteering in the hospital this week, I came across an interesting situation that I feel could really affect anyone. I was instructed to not provide caffeinated drinks to patients who have tachycardia or rapid heart rate. Thinking about how caffeine stimulates the body and the mind, it is reasonable that patients with this type of arrhythmia are not allowed caffeinated drinks. It is important to control their heart rate, not to speed it up any further with caffeinated drinks.

Although the doctor only prohibited caffeine use by the tachycardia patients, the reason behind her restriction prompted me, a college student who consumes too much coffee, to reevaluate the effects of caffeine on the body of a healthy person. Is caffeine really safe for everyone to consume? Is it harmful to increase one’s heart rate often by consuming caffeinated drinks such as soda, coffee, and energy drinks? These questions led me to search for some answers.

Dr. David Katz, a physician at Yale University, provided the answer to the question of what are the health dangers of caffeinated drinks like Red Bull and whether these beverages are safe to consume. According to Dr. Katz, the amount of caffeine in an 8 oz can of Red Bull could be dangerous to people with heart arrhythmias, high blood pressure, and sensitivity to caffeine because of caffeine’s stimulating effect on the body. However, it is reassuring to know that a can of Red Bull or a strong cup of coffee, both of which contain about 80mg of caffeine, should be safe for a healthy person to consume. In fact, an individual may consume up to approximately 350mg of caffeine everyday without any danger to health.

Even though 350mg of caffeine can be consumed safely, it is not safe to indulge in too much coffee, soda, or energy drinks. The amount of caffeine in these beverages vary widely and it is easy to consume too much of these products, leading to a caffeine overload and damaging side effects. For example, five cups of coffee with a total of 400mg of caffeine can produce nervousness, irritation, tremulousness, and insomnia. Despite the fact that caffeine is safe to consume for healthy people, Dr. Katz still advises consumption of this stimulant in moderation.

In the same article on MSN Health, Dr. Katz expresses his concern with combining caffeinated drinks with alcoholic drinks. Dr. Katz explains that more and more young people are drinking caffeinated drinks to stay awake in order to consume more alcohol. Preventing the body from turning on the protective mechanism of falling asleep to prevent further ingestion of alcohol could lead to excessive consumption of this sedative substance. Overdosing in alcohol can be extremely dangerous and potentially lethal. Dr. Katz’s concern reminded me an article a few months ago about the banning of several caffeinated alcoholic drinks by the FDA. This ban reflects Dr. Katz and many other scientists’ concern on the safety of mixing caffeinated drinks with alcohol. Research into the harmful side effects of these two substances resulting from their pharmacological interactions, facilitated overdosing in alcohol, and the physical injuries resulting from their ingestion all point to the need to regulate these drinks.

According to CNN’s article “Companies stop shipping 7 caffeine-alcohol drinks” published a few months ago, seven caffeinated alcoholic beverages were taken off the market by their respective manufactures amid warnings from U.S. Food and Drug Administration claiming that these drinks were unsafe and pose a public health concern. Caffeinated alcoholic beverages, such as Four Loko, Joose, and Moonshot, had become increasingly popular among teenagers and young adults, replacing the pure alcoholic drink and pure caffeinated energy drinks. Despite their rapid rise to popularity, until recently few research studies had been down on whether this combination of a stimulant and sedative could pose a danger to health. With the FDA claiming that the labeling of these caffeinated alcoholic drinks as dangerous to health was based on expert studies showing that caffeine can mask certain subjective experiences of alcohol consumption, thus preventing the drinker from realizing the extent of his intoxication, it gives rise to question of whether caffeine and alcohol really interact with each other to impair the drinker’s judgment of his intoxication level.

In their 2006 research study titled “Effects of Energy Drink Ingestion on Alcohol Intoxication”, Ferreira et al. found that when taken together, caffeine can reduce the perception of certain symptoms such as headaches, dry mouth, and impaired motor movements caused by alcohol consumption. Ferreira et al.’s well-desired randomized study tested the effect of vodka alcohol alone, caffeinated energy drink Red Bull alone, and combined vodka and Red Bull ingestion in 26 research participants. Subjective tests such as participants’ perception of their degree of intoxication and objective tests on breath alcohol concentration, visual reaction time, and motor coordination were then given to each test subject.

Ferreira et al. observed that although the subjects sensed reduced symptoms of alcohol intoxication, their objective tests indicate that they are just as impaired as when they were taking alcohol alone in both motor coordination and reaction time. Similarly, the blood alcohol concentration did not change whether caffeine is added to the alcoholic drink of not. Therefore, it can be concluded with a scientific basis that caffeine does interact with alcohol and the resulting impairments could pose a health risk. Furthermore previous studies by the authors suggest that this impairment might be due to caffeine’s ability to decrease the depressant effects of alcohol.

For fun…food for thought.
Cartoon: insomnia caused by caffeine
Above: Cartoon by Jason Love. This cartoon illustrates one of the side effects of caffeine use, insomnia.

 
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Posted by on March 7, 2011 in In our food...

 

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Recall!

Screen shot of the Food Safety page of msnbc.com
Above: A screen shot of the Food Safety page of msnbc.com.

One click on the “Food Safety” link on msnbc.com produced a surprise that I had never expected. At the left center of the page was a brief paragraph with the title “Products recalled over concerns about broccoli,” and below the paragraph followed about 50 linked titles that all announced recalls to various food products. From broccoli to beef patties to cheese, so many different products are recalled that spinach no longer takes the center stage as a contaminated food product. This surge in the number of contaminated food products surprised me immensely, and it raised the interesting question of whether this surge is due to tighter government regulations and more thorough inspections on food safety or due to worsening food production procedures in recent years. More importantly, are more consumers sickened by contaminated food and the reason these incidents don’t attract national headlines is because food poisoning is much more common nowadays than several years ago? Are we moving into a period where some food, especially fresh produce, can no longer be produced in a clean environment? All these questions beg for answers as they are important to the health of consumers.

Although the bacterium E. coli, especially the serotype O157:H7, used to be the most prominent bacterium causing food poisoning in humans, other bacterium such as salmonella and listeria are also finding their way into the food supply. Apart from bacteria, larger and more visible objects such as glass shards and even “extra protein,” to put it in the words of one consumer, in the form of a dead frog inside a bag of mixed veggie, had become food contaminants that endanger the health of consumers.

 
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Posted by on February 28, 2011 in Uncategorized

 

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