Standard American Diet

Health and the Nutrition Connection: Focus on Fats and Cholesterol

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I am a migraine specialist, but recently, I have had more opportunities to work with non-migraineurs to improve their general health. Patient by patient, I have learned that most of the steps I use in my migraine-prevention protocol result in significant improvements for many health conditions. With the use of proper nutrition alone, patients reverse their pre-diabetes, insulin resistance, prostate issues (PSA number), cholesterol issues (high triglycerides, high LDL, and low HDL), arthritis, migraines, and even fibromyalgia flareups. Here, I would like to summarize what I found is wrong with our current nutrition paradigm and how to correct it.

The Cholesterol Problem: A Convoluted History

In the mid-20th Century, a charismatic and highly influential researcher (Ancel Keys), based on somewhat fraudulent data selection, “proved” that saturated fat causes cardiovascular disease (CVD). Keys came to this conclusion based on what has come to be known as the 7 countries study even though he originally studied the data from 22 countries. The data of 15 countries (including France) were not included because they didn’t line up with the original hypothesis that “saturated fat, particularly LDL cholesterol, causes CVD”.  This created later what was referred to as the French Paradox: how is it that the French have the fewest number of CVD and yet eat the most saturated fat?

Based on Keys’ “findings”, further research aimed at describing the connection of saturated fat and CVD. What they discovered was that for every person with a fatal heart attack, cholesterol (LDL in particular) filled the artery. Without further ado, they decided that cholesterol, particularly LDL (low density lipoprotein), must be the reason for CVD. Since cholesterol in the arteries seemed like it was made from fat, highly saturated fat is a solid lipid at room temperature, saturated fat was held responsible. This theory became the dogma and was subsequently taught to generations of medical professionals.

For many years, and to a great extent even today, it has been difficult to publish any result of studies in disagreement with the dogma. Information about unpublished data (by the NIH among others) has only recently surfaced. Read “The Big Fat Surprise: Why Butter, Meat and Cheese Belong in a Healthy Diet” by Nina Teicholz for a great explanation. The newly revealed data show that not only is saturated fat not responsible for CVD, but that it can, in fact, help reduce its occurrence.

Problems with Current Measures of Cholesterol

Although the original confusion about cholesterol and CVD stemmed from Ancel Keys, it was reinforced with laboratory testing methods that don’t quite measure what we think they measure (here). Briefly, although the original confusion about cholesterol and CVD stemmed from Ancel Keys, it was reinforced with problematic laboratory testing methods based upon incorrect assumptions.  Namely,

  • LDL is not cholesterol but a lipoprotein ball that contains cholesterol as well as fat soluble vitamins and minerals.
  • LDL is not measurable in the blood by conventional blood tests. It is calculated.
  • Triglycerides are not measurable in the blood by conventional blood tests. They are estimated.
  • VLDL is measured and an assumption is made that triglycerides/5 = VLDL, which is likely incorrect—see explanation later.
  • The equation used (with the listed assumptions) to calculate LDL: 

LDL = Total cholesterol – HDL – (triglycerides/5)

The equation above has two unknowns, and thus, it is impossible to solve mathematically. The two items we can measure with conventional blood tests are total cholesterol and HDL. An assumption is then made that everything else they measure is VLDL. It is unclear how they can separate VLDL from the remaining “cholesterol” since the blood test doesn’t measure what are called chylomicron or remnant pieces of lipoproteins. It simply assumes that chylomicrons don’t exist if fasting preceded the blood test. Below is a picture of lipoprotein formations, within which there are cholesterol and fat-soluble vitamins and minerals.

Cholesterol--Lipoprotein Balls
Cholesterol–Lipoprotein Ball

Image used from Medscape

Fasting is required for a cholesterol blood test and is assumed that after 12 hours of fasting chylomicrons don’t exist, thus the above equation is valid; see Friedewald et al 1972. If chylomicrons do exist during blood test, it invalidates the equation. Healthy individuals’ liver releases glycogen when fasting. Glycogen is stored energy in the liver that is converted to glucose and released in the blood; the lack of existence of chylomicrons may not be true.

Therefore, the above equation doesn’t really give us reliable quantitative information about LDL and definitely no information about the amount of cholesterol in LDL. Even if we could measure LDL, it is still just a lipoprotein ball, as is HDL. In effect, with the current tests, we are counting cars on the freeway to determine how many people travel on that freeway; a very rough estimate at best, but more likely, just a misleading guess.

There is one test, however, that can assess cholesterol inside lipoprotein, but it is infrequently used. It is called the nuclear magnetic resonance (NMR) imaging and is based on atomic weight and motion.

Even if the Cholesterol Tests Were Accurate, Do They Tell Us Anything About CVD?

Let us assume that despite everything we have detailed so far, we can measure cholesterol from the conventional blood test or any other test accurately and that we know the precise amount of cholesterol that is carried in LDL; we still have to ask:

  1. Does our cholesterol knowledge tell us anything about CVD?
  2. Does saturated fat (or any fat) have anything to do with cholesterol?

To understand these two questions, we need to look at what cholesterol and fat are, how they are made, and from what raw materials.

What is Cholesterol?

Cholesterol is so important for the body that, unlike other nutrients, such as glucose with a very short presence in the body, cholesterol is kept for days and is reused. Twenty five percent of all cholesterol is in the brain, forming the white matter necessary for the insulation of axons to protect against voltage leaks. Voltage leaks occur in many diseases, such as seizures, migraines, multiple sclerosis, Alzheimer’s, Parkinson’s, and alike. In the brain, a cholesterol molecule stays functional much longer than days, often for weeks, months, sometimes for years. So what exactly is cholesterol?

Good and Bad Cholesterol

There is no such thing as good or bad cholesterol; we only have one type of cholesterol with the chemical formula: C27H46O. We have some differentiation within cholesterol in terms of size and the size variation is a representation of oxidative damage1,2  but it is still the same exact cholesterol. It may have shrunk and folded on itself, became dense and sticky, caramelized. Indeed, the cholesterol inside LDL is found in 2 particle sizes: large fluffy (healthy) and small dense (damaged). The latter small, dense, damaged, caramelized ones are created by the pyruvate process by oxidation, and this cholesterol indeed participates in CVD. One should ask then why some cholesterol molecules become damaged and why some don’t. And also, is cholesterol and saturated fat connected? This is the heart of the matter, pun intended.

What is Fat?

Fat is made from fatty acids. All fatty acids are essential, meaning we must eat them. Our body cannot make them. There are two types of essential fatty acids: Omega 3 and Omega 6, within each of which there are three types: monounsaturated, polyunsaturated, and saturated fats.  Here is an example of a typical monounsaturated fat molecule: CH(CH2)7COOH (oleic acid, making up about 83% of olive oil, a mostly monounsaturated fat). Here are two types of typical saturated fatty acids: CH3(CH2)6COOH a short chain and CH3(CH2)24COOH a long chain fatty acid, and a typical polyunsaturated fatty acid is Linoleic acid C18H32O2.

As you can see, all fatty acids have hydrogen tying down (bonding to) at least some of the oxygen. Whether the fatty acid is unsaturated or saturated depends on the number of hydrogen bonds. Monounsaturated has a single hydrogen bond, polyunsaturated more than one, and saturated has all oxygen tied down by hydrogen. The more saturated a fat is, the more stable are its bonds. Saturated fats last longer without going rancid, can be used at higher temperatures, and are solid at room temperature.

An important point about omega 3 and omega 6 is that humans are not able to convert the vegetable form of omega 3 (ALA), found in fruits, vegetables, nuts, grains, and seeds, into the animal form that the human body can use (DHA/EPA) efficiently. Therefore, the consumption of animal products and seafood is essential for all humans to meet the necessary omega 3 requirement of our brain, which is mostly made from DHA.

How Cholesterol is Created

The chemical formula for cholesterol is not the same as for any of the fat types; in the cholesterol molecule there is no opening for saturation with hydrogen anywhere. No fat of any type has the same configuration in carbon, oxygen, or hydrogen as cholesterol. Fats are fatty acids, whereas cholesterol is a waxy substance. Cholesterol has not much to do with fat. It is not created from fat. The body can acquire cholesterol two ways:

  • Directly from cholesterol containing foods
  • Making it from carbohydrates.

If we eat enough cholesterol, the liver doesn’t make more. In other words, the liver only makes as much cholesterol from carbohydrates as the body needs. Cholesterol is essential in cell functioning and, as a result, is closely regulated by the liver. Cholesterol also serves as a precursor for the biosynthesis of steroid hormones, bile acid, and vitamin D. The cholesterol-making pathway is 37 steps long. The first step is Acetyl-CoA, a molecule generated by cellular respiration. It is produced in the second step of aerobic respiration after glycolysis and carries the carbon atoms of the acetyl group to the TCA cycle to be oxidized for energy production. Cholesterol is a byproduct of glycolysis. Glycolysis breaks down glucose and forms pyruvate with the production of two molecules of ATP. Cholesterol is not only integral to cellular respiration and the formation of ATP,  it is a product of that very function. Cholesterol is a result of glucose metabolism. This is crucially important knowledge. It goes against the dogma of “cholesterol is made from fat, therefore fat is bad”.

Cholesterol regulation is a key component of metabolic processes. When we don’t eat enough cholesterol from meats and eggs, more is made by the liver from carbohydrates. Glucose oversupply, starches, and fructose either convert to cholesterol—as noted earlier—or excess carbohydrates get packed away as future storage (visceral and ectopic fat) in and around our organs. This fat storage is initiated by insulin and is completed by our liver.

Triglycerides form visceral and ectopic fat, which are our energy reserves converted from the unused glucose and fructose. The liver’s capacity for this storage is limited and so it needs to expand in size to accept more. This is the cause of non-alcoholic fatty liver diseases, and then later, the need for more and more fat storage is what becomes insulin resistance,  that may lead to type 2 diabetes. So, by avoiding excess consumption of carbohydrates, the creation of dense, sticky, caramelized cholesterol particles can be prevented. From the cholesterol in LDL, these low-density, sticky, caramelized, damaged cholesterol particles are the only ones that contribute to CVD. However, when we reduce carbohydrates in our diet, we need to increase the consumption of fats.

There is no food that is pure saturated fat. All fats, no matter if it is in a leaf of lettuce or a pork belly, is a combination of saturated fat, monounsaturated fat, and polyunsaturated fat. They are not found separately in nature. What we can say is that some foods have less saturated fat than others. Some of the foods that have been excluded from recommended diets based on the fear of saturated fat are pork and beef:

Fat types
Table 1. Fat types

Note in the above table that pork lard has more monounsaturated fat than saturated fat, so can we say that pork lard is saturated fat? It is important to see which fat type is closest to human fat because that is what we need to eat. If we look at the human body’s fat composition (this is very hard to find, so I put this together from several research papers), it is very similar to that of pigs, meaning that to maintain our health, we should consume the type of fats our body is made from, and thus, needs.

Carbohydrates and the Insulin Connection

At this point, your head is probably spinning from too much chemistry, but bear with me. If we don’t understand the chemistry, all sorts of errant assumptions about health and disease can be made and have been made. Most importantly, for generations we have failed to recognize that cholesterol comes from carbohydrates, not fats, and as result, millions of us have developed type two diabetes by following the accepted medical advice. Just how bad is it?

When Carbohydrates Dominate the Diet

Carbohydrates were elevated to primary consumption status at the same time fats were demoted. Of the three macronutrients: fat, protein, and carbohydrates, carbohydrates are the only non-essential macronutrients. There is not a single essential element in carbohydrates. Carbohydrates provide glucose (the body can make glucose from protein and fat), fructose (44% of fructose converts to glucose and the rest to triglycerides), vitamins (all vitamins in plants are also available in animals—including vitamin C if certain parts are eaten raw—and many vitamin in animal products are not found in plants).

Another note on vitamins: we consume most vitamins in order to help our immune system fight free radicals. Free radicals are only created in the pyruvate (glycolysis) step, which is participant only in the glucose metabolic process. If we stop eating exogenous glucose (carbohydrates), our need for antioxidants is greatly reduced. Fat-burning bypasses the pyruvate process and doesn’t generate free radicals3. Over 50% of protein converts to glucose4. However, the amount of free radicals generated from protein-converting is so small that only minimal free radicals are generated.

When the USDA removed “saturated fats” and everything that contained them from our diets, it replaced all that with vegetable oils (Omega 6 oils), transfats (artificially hydrogenated vegetable oils), and carbohydrates. Diabesity (diabetic obesity), increase in CVD, Alzheimer’s disease, cancer, arthritis, incontinence, PCOS, prostate problem, neurophathy, fibromyalgia, etc., followed.

The Problem with Grains

According to the, 1% of the global population has celiac disease and 0.4% has been diagnosed to have wheat allergy—a large percent remain undiagnosed. The wheat allergy or sensitivity of those not yet diagnosed show up like arthritis, prostate concerns, PCOS, allergies, asthma, Crohn’s disease, IBS, etc. How can we tell? When they stop eating all grains (wheat, rice, corn, rye, oats, etc.,) for at least 2-6 months, their inflammatory markers improve and they reverse their health conditions. Grains are also responsible, in a large part, for CVD and potentially cancer, because grains are inflammatory, increase blood pressure, and narrow the arteries. It was a human genetic variant that allowed some of the damaging factors of grains to be mitigated: ACE and apolipoprotein B genes, because they relate to blood pressure and the cholesterol in LDL. Blood pressure and cholesterol are both factors that respond well to low-carbohydrate, and thus, low-grain diets, suggesting that the polymorphisms may be a protective adaptation against the cardiovascular effects of grains5.

In spite of all this knowledge, grains are considered to be the most vital nutrient on “My Plate” by the USDA. Furthermore, grains are indigestible and reduce nutrition absorption.  They also need to be fortified to get any nutrition while eating them. They are the most frequent carbohydrate items on our plate that have no nutrition, only glucose from starch.

Fruits, Vegetables, Nuts, and Seeds

Other carbohydrates are fruits, vegetables, seeds, and nuts. The ideal maximum blood glucose level is 99 mg/gL (equivalent to about 1 teaspoon, a little over 4 gr of glucose for an average person. By eating a medium size sour Granny Smith apple, we take in almost 23 gr carbohydrates, of which 10.225 gr is pure glucose. This is 2.5 times as much glucose as what the entire blood supply prefers to have, so eating a medium sized sour Granny Smith apple challenges the body to remove all that glucose from the blood very fast, a large amount of glucose staying in the blood is toxic. Mind you, this one apple, with all the trouble it caused, gives nearly no vitamins at all; no vitamin C noted in the USDA table, very few amino acids and no fatty acids, those would be the essential macronutrients. An apple offers nothing but glucose and fructose. Therefore, from what we now know about the connection of carbohydrates to cholesterol, part of that apple will become cholesterol, and since it is a carbohydrate and is converted to energy using the pyruvate process, it also creates more free radicals than if you, instead, ate a steak. And lastly, since this apple has much more glucose than what the body can use, and also a lot of fructose, whatever energy from this apple is not used, gets stored as body fat.

Diet and Insulin Resistance

Insulin resistance is not a disease. It is nature’s way of helping creatures pile up fat-reserves for times of scarce resources, like winter. The trick is the seasonality of insulin resistance; it is nature’s way of remaining alive in winter but returning to normal insulin levels during the lean times, normally hibernation or starvation, thereby, when spring appears with fresh food resources, the liver will have reversed all its fattiness and by then the visceral and ectopic fat would have shrunken by fueling the body all through the winter. This is an equivalent process to the ketogenic diet – see below.

Lack of seasonality in energy storage necessarily leads to chronic insulin resistance. Chronic insulin resistance is unhealthy, leads to type 2 diabetes, and/or obesity. While this would need a lot of explanation, in short: obesity and insulin resistance need not go hand in hand. Sumo Wrestlers are extremely obese but are completely healthy without any insulin resistance while very thin people may have insulin resistance (TOFI—thin outside fat inside). Thus, insulin resistance is strictly associated with extensive visceral and ectopic fat and not with “being fat.”

One can prevent chronic insulin resistance by either following in the footsteps of our evolutionary past with seasonality, or by permanently preventing fat accumulation when not observing any seasonality. This requires cutting back on carbohydrates. When we cut back carbohydrates, depending on the depth to which we reduce carbohydrates in our diet, the body may move to burn visceral/ectopic fat by entering the state of ketosis. Ketosis is not equivalent to keto acidosis. Ketosis merely means that the body switched from burning glucose to burning fat in the form of ketones—or to be more precise, burning β-Hydroxybutyrate (βHB)6. Just like any fire needs some kindle to be started, a proper fat-burning diet is started by eating fat—and plenty of saturated fat. The ketogenic diet doesn’t use glucose for fuel, but this doesn’t mean the body has no access to glucose. A large percent of protein converts to glucose, so those organs that need glucose, still receive it, but the body’s main fuel is fat.

As noted earlier, cholesterol is made from carbohydrates, and deformed cholesterol is a consequence of the pyruvate/glycolysis process (a carbohydrate metabolic process). Since fat doesn’t convert to cholesterol and doesn’t use the pyruvate process, the ketogenic diet reduces the chance for the creation of any damaged cholesterol within LDL.

The Ketogenic Diet

The ketogenic diet is really not a diet but a metabolic process, in which the main fuel of the body is fat. While glucose is also used, it is only used for those organs that must have glucose, such as red blood cells and the brain. The ketogenic diet burns ketone bodies—fat converted to body fuel. The ketogenic diet induces nutritional ketosis—not to be confused by diabetic keto acidosis, which is the outcome of type 2 diabetes. During nutritional ketosis, the body burns stored energy for fuel (visceral and ectopic fat). As a result, it is often used for weight loss. It is an ideal nutritional method to reverse insulin resistance, since it reverses non-alcoholic fatty liver disease by reducing fat storage.

The ketogenic diet is a strict version of the low carbs high fat diet with moderate protein consumption. A typical ketogenic diet is 80% calories from fat, 16% calories from protein, and 4% from carbs. The type of carbs that are permitted are mostly green leafy salads, spinach, broccoli and cauliflower, fruits like avocado, zucchini, etc., and some minimal raspberries and blackberries. The fats contain olive oil and animal fats. Some people in ketogenic diet also consume coconut oil. Coconut oil can only burn as ketones and so eating coconut oil prevents the burning of stored fat for fuel. Thus, coconut oil should not be consumed by those wishing to lose weight.

The strictest form of the ketogenic diet is used therapeutically for seizure cures. It appears that the ketogenic diet rebuilds the myelin (mechanism not yet understood), the layer made from fat and cholesterol (white matter in the brain) that coats neurons to insulate them from possible voltage leak. This more extreme form is also used to help other diseases where the white matter is damaged, such as Alzheimer’s disease, Parkinson’s disease, and Multiple Sclerosis, among others.

Since cancer cells feed on glucose—called the Warburg Effect, the ketogenic diet is also being tested for cancer treatment, so far with great success. For an example, see Andrew Scarborough and his recovery from Anaplastic Astrocytoma that was diagnosed in 2013.


There are nutritional concepts, other than the ketogenesis, that can help reverse some metabolic damage, such as the LCHF (low carbs high fat) diet. It is a comfortable alternative to the ketogenic diet for those who don’t wish to become fat burners, only want to reduce their chances for insulin resistance, obesity, and metabolic diseases that include non-alcoholic fatty liver disease as well as CVD.

The LCHF diet is still a carbohydrate burning diet, and as such, antioxidants are necessary, and fat is not burned. However, it removes most of those foods from the diet that appear to cause problems for many people, such as refined carbohydrates (all sweeteners, prepared, canned, and processed foods, juices, shakes, and smoothies. Some LCHF diets permit the use of some sugar substitutes), all grains (even gluten free grains are grains, so they are not part of the LCHF diet), all starchy vegetables (potatoes, yams, carrots), and the majority of fruits, with the exception of raspberries, strawberries, and blackberries.

LCHF diet encourages olive oil, coconut oil, and animal fats, lots of fish, all meat types, and dairy. The focus is on reduced carbohydrates, typically to around 100 net carb grams a day.

Individualized Nutrition

No single diet works for everyone. Genetic (heritable) and epigenetic (environmental) factors mostly determine what is healthy for a person and what is not. People whose ancestry is from Nordic environments will likely have trouble metabolizing foods that were not readily available in their location prior to commercialization, such as tropical fruits. Others, whose ancestry is more tropical, may end up with metabolic health issues from eating too much fat.

It is important to understand that the goal is not to just follow a nutritional regimen but to recognize the reaction of an individual to the food consumed.

What we see in the US, and increasingly around the world, is an epidemic created by the Standard American Diet (SAD) that assumes that all humans have identical metabolic processes. That this is not true should have been realized when Native Americans were changed to the SAD (sugar, soft drinks, grains) diet and they all became unhealthy. While the experts at that time perhaps didn’t understand what was happening, we understand it now. We need to maintain flexibility! Those suffering from metabolic disorders such as obesity, insulin resistance, type 2 diabetes, CVD, etc., should consider it a sign, a warning, and change their eating habits, change to a different nutritional base for health. Those who do well on SAD can carry on. The important point is to pay attention and be willing to change.


  1. Gesquière L, Loreau N, Minnich A, Davignon J, Blache D. Oxidative stress leads to cholesterol accumulation in vascular smooth muscle cells. Free Radical Biology and Medicine 1999; 27(1): 134-45.
  2. Al-Benna S, Hamilton CA, McClure JD, et al. Low-Density Lipoprotein Cholesterol Determines Oxidative Stress and Endothelial Dysfunction in Saphenous Veins From Patients With Coronary Artery Disease. Arteriosclerosis, Thrombosis, and Vascular Biology 2006; 26(1): 218-23.
  3. Pigozzi F, Giombini A, Fagnani F, Parisi A. CHAPTER 3 – The Role of Diet and Nutritional Supplements A2 – Frontera, Walter R. In: Herring SA, Micheli LJ, Silver JK, Cd AEft, Young TP, eds. Clinical Sports Medicine. Edinburgh: W.B. Saunders; 2007: 23-36.
  4. Coulston AM, Liu GC, Reaven GM. Plasma glucose, insulin and lipid responses to high-carbohydrate low-fat diets in normal humans. Metabolism 1983; 32(1): 52-6.
  5. Salomón T, Sibbersen C, Hansen J, et al. Ketone Body Acetoacetate Buffers Methylglyoxal via a Non-enzymatic Conversion during Diabetic and Dietary Ketosis. Cell Chemical Biology; 24(8): 935-43.e7.
  6. Reger MA, Henderson ST, Hale C, et al. Effects of Beta-hydroxybutyrate on cognition in memory-impaired adults. Neurobiology of Aging; 25(3): 311-4.

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Angela A Stanton, PhD, is a Neuroeconomist who evaluates changes in behavior, chronic pain, decision-making, as a result of hormonal variations in the brain. She lives in Southern California. Her current research is focused on migraine cause, prevention and treatment without the use of medicines.

As a migraineur, her discovery was helped by experimenting on herself.

She found the cause of migraine to be at the ionic level, associated with disruption of the electrolyte homeostasis, resulting from genetic mutations of insulin and glucose transporters, and voltage gated sodium and calcium channel mutations. Such mutations cause major shifts in a migraine brain, unlike that of a non-migraine brain. A non-migraineur can handle electrolyte changes on autopilot. A migraineur must always be on manual guard for such changes to maintain electrolyte homeostasis.

The book Fighting The Migraine Epidemic: How To Treat and Prevent Migraines Without Medicines - An Insider's View explains why we have migraines, how to prevent them and how to stay migraine (and medicine) free for life.

Because of the success of the first edition and new research and findings, she is now finishing the 2nd edition. The 2nd edition is the “holy grail” of migraines, incorporating all there is to know at the moment and also some hypotheses. It includes an academic research section with suggestions for further research. The book is full of citations to authenticate the statements she makes to be followed up by those interested and to spark further research interest.

While working on the 2nd edition of the book she also published academic articles:

"Migraine Cause and Treatment" Mental Health in family Medicine, November 23, 2015, open access
"Functional Prodrome in Migraines" Journal of Neurological Disorders, January 22, 2016, open access
"Are Statistics Misleading Sodium Reduction Benefits?", Journal of Medical Diagnostic Method, February 3, 2016, open access
“A Comment on Severe Headache or Migraine History Is Inversely Correlated With Dietary Sodium Intake: NHANES 1999-2004” Angela A Stanton PhD, 19 July 2016 DOI: 10.1111/head.12861 not open access, membership required to read it.

Dr. Stanton received her BSc at UCLA in Mathematics, MBA at UCR, MS in Management Science and Engineering at Stanford University, PhD in NeuroEconomics at Claremont Graduate University, and fMRI certification at Harvard University Medical School at the Martinos Center for Neuroimaging for experimenting with neurotransmitters on human volunteers.

For relaxation Dr. Stanton paints and photographs. Follow her on Twitter at: @MigraineBook


  1. Excellent article, Angela. You put many controversial nutrition issues into reader-friendly perspective. Seems to me that too many – and not surprisingly, these are mostly vegans and vegetarians – conflate ethical and health issues as if they are one and the same. I can well understand not wanting to eat animal foods for love of animals. However, there’s simply no getting away from the fact that animal foods are the most nutrient-dense on the planet. Always have been, always will be. And many people simply do not and cannot thrive on a vegetarian or vegan diet. Indeed, such diets may be actively harmful for some people. In most cases, and likely depending on the individual microbiome, it isn’t possible for vegetarians and vegans to get all the nutrients they need for good health without fairly extensive and regular supplementation from other sources. I simply don’t believe that people have to choose between health or ethical eating. There is middle ground. Just requires the will and open mind to find it. As a journalist, I don’t find those traits very well-developed in prosletysing vegans. Thanks again.

    • Thanks Marika,

      You are very correct. I think part of the problem is that overall outcomes of the vegan diets (longitudinal studies) don’t exist–or if they do, they are as misleading as all of the past 60 years worth of academic research has been. People believe that veganism is healthy–that is what they read and what they are told. They simply don’t know any better.

      I am very fortunate to have been able to work with many vegan migraineurs. Veganism and migraines don’t get along too well, since migraineurs are not able to metabolize exogenous glucose without major problems. So most vegan migraineurs–if they wish to get rid of their migraines–need to convert to LCHF or in best case scenario ketogenic. Interestingly, I have yet to find a vegan without insulin resistance! This is the biggest secret apparently, since there are no papers on it. 100% of those I so far worked with and have tested by a 5-hour at home (simplified, glucose-drink-free) glucose test with measuring blood glucose every 30 minutes revealed the very interesting pattern of advanced insulin resistance in all cases–some with amazing reactive hypoglycemia.

      Some of these vegans are now on the zero carbs diet–yep, all meat and fat, and loving it. They only stay on that while they recover from insulin resistance.

      Some refuse and walk away–that is going to be their problem. They are the ones you are talking about: they confuse their health with their ethical stands. They also ignore that plants are just as sentient, only they don’t hear them cry. I believe this to be selective ethical bias toward those things whose cry they can see but which allows them to ignore those live things that they cannot hear cry or see run away. There is really nothing ethical about it; it is a belief system. Nothing we can do about it.

      Have a nice evening,

  2. Thank you for the excellent article and rebuttal of the anti-meat comment.

    I’m intrigued by your comment on coconut oil as it is touted for weight loss.

    Do the same principles apply to MCT oil?

    With regard to minimising visceral fat how does olive oil stack up? Monounsaturated fats are promoted for reduction of weight and trimming the waistline.

    • Hi Talia,

      Coconut oil is touted for weight-loss–misleadingly. Please don’t misunderstand, coconut oil has great benefits. For example, those who don’t wish to reduce their carbohydrate consumption but would like the benefits of an alternate energy source–particularly useful for the brain for Alzheimer’s it seems–it is a great product. Coconut oil burns only as ketones and so the body will burn it as such no matter when and how much of it is taken.

      The problem comes when one is already in ketosis and successfully burning her own fat; why on earth would she need to add coconut oil then to burn? That is extra energy to burn…

      The body has a certain metabolic rate, and unlike a camp fire, it will not burn with a larger flame if more fuel is poured on it. It cannot burn with a larger flame, unless you increase the rate at which it burns. You can change that rate by using up more energy with heavy exercises or fasting, both of which create more mitochondria and more efficient cells! So you can increase your metabolic rate and reduce weight but you don’t need coconut oil for that.

      I have many migraineurs on the ketogenic diet and coconut oil is only allowed for those who need not lose weight. It can always be used for flavoring if one cares for it, but not taken as a supplement. It can also put you into false ketosis. I had a migraineur once joining my keto group who started the day with a bowl of white rice and 6 tablespoons of coconut oil… did he show ketones? You bet! Was he in the ketogenic metabolic process burning mode (ketogenesis)? Nope. So you need to be careful about coconut oil because your test results maybe fake results.

      In terms of MCT versus coconut oil: coconut oil is MCT only as an MCT product, they usually mix palm kernel oil into the oil. I found that palm kernel oil can cause GI distress for many people so I would recommend you stick with cold pressed coconut oil. MCT stands for Medium Chain Triglycerides and both coconut oil and palm kernel oil are MCTs.

      Hope this helps,

      • Thanks so much for the fast reply. I really appreciate it. This is the best article that I have read on saturated fats. The others seem to either unfairly malign fats or use pseudoscience to justify using coconut oil on and in everything – the famous bulletproof coffee with butter or coconut oil being one example.

        I fell for some of the hype! I had been adding coconut oil to try and increase my saturated fat intake. My reasons for doing that may not stack up now that I have read your article. There is a lot of literature suggesting saturated fat increases blood pressure and I have low blood pressure and was hoping to increase it. My logic is that cholesterol helps make hormones and may help my body make aldosterone and other hormones that will optimise my blood pressure. I think I’ll need to do more research 🙂

        • You are very welcome Talia; any time. I totally agree with you. In all fairness, few people really understand fat because in the past 60+ years they were not permitted to research saturated fat. Even today, I read scientific articles that consider high fat low carbs (HFLC) diet to contain less than 40% of the calories from fat and calling the experiment LCHF–the LCHF diet is minimum 60% of the calories from fat.

          Researchers just simply cannot get any funding when they would like to study a true high fat diet and they are particularly prevented from researching anything with higher percentage of saturated fat in it. Even coconut oil was the subject of a major criticism by the American Heart Association (AHA), because coconut oil is high in saturated fat and they still have not left the 1960’s room with Ancel Keys. It is impossible to get any research published even when it is done, since no reputable journal dares publishing anything that is against dogma–this is just now starting to change a tad but not by USA journals!! Only UK journals dare.

          This is why the most informative new research is in books. Books are not considered to be scientific, they are not peer reviewed (as if that mattered), and so most of the recent research is up to the consumer to decipher. That is where some people, like me, come in. We try to translate new findings that could not be published, because many scientists “of the same clan” bunch together and discuss. We learn from each other, stepping over the boundaries set for discussion by academic politics and dogma.

          So yes, you will get a bunch of junk science out there. The trick is to discover friend and be able to tell it from faux. Not an easy job! <3

          In terms of increasing your blood pressure, fat has absolutely nothing to do with blood pressure so it is impossible to increase blood pressure by piling on fat. That is also the highlight of my article: fat has nothing to do with anything you were told about. The thing that increases blood pressure is inflammation–in other words, in order to increase your blood pressure by conventional means, you would need to cause an inflammation and thereby narrowing your arteries, but that will cause long-term illness. So why do you want to increase your blood pressure?

          As noted in the article–and I think you know from our past conversations–that I work with migraineurs. Migraineurs have amazingly low blood pressure, some sport 80/40 but the typical is 90/50 to 110/70. As a result they often feel dizzy when they get up or start walking–I do too. This is a sign that you are doing 2 things wrong:

          1) Not eating enough salt.
          2) Not drinking enough water.

          To calculate how much water a woman needs, take your weight in lbs and take 55% of it; for example, if you weigh 150 lbs, then 150*0.55=82.5 oz water, divide by 8 to get in glasses: 10.31 glasses of water minimum. For a man, replace the 55% by 70%. There are many water calculators on the internet but this is a good start. Only water you drink, unflavored, pure flat or sparkling, counts toward water. Teas and coffee are diuretic, juices are pure sugar even if unsweetened, so nothing but water counts. Also, water from the food has a slightly different metabolic process and as a result, I don’t count that as water. If you drink way less water than you should, increase very slowly to prevent edema and to prevent urination excess.

          As for how much salt? The USDA recommends so low salt amount (in sodium, which is 40% of salt) that if you increase your water without also increasing salt, you will surely end up with water toxicity and urinate your heart out. So you need to increase salt together with water.

          Latest research shows that the ideal sodium amount (this is not an open article so you just have to trust me or purchase a copy here) is between 4,000 and 5,000 mg sodium a day for both hypertensive and also healthy. That is more than twice what the USDA recommends. There is a caveat the USDA should pay attention to: eating too little salt leads to cardiovascular disease! The very thing they want to prevent by reducing dietary sodium actually causes it. So as you increase water, increase salt such that you don’t urinate more than 4-6 times a day and that your urine color is always slightly yellow–like a light lemonade–and never ever clear water colored.

          Once you increase water and salt, your blood will be volumized. The proper blood volume is essential to have healthy blood pressure–this may increase your blood pressure a little bit though after four years of doing this, neither my blood pressure not any of my migraineurs’ blood pressure noticed a significant change, but the dizziness is gone.

          Best of luck!

          • Thank you! Yes, I am below the 90/60 and constantly dizzy and lightheaded. I also get postural hypotension. I am definitely doing the fluids and salt, for some reason it’s no longer working. I have a litre of water in the first hour I get up with a teaspoon or Himalayan salt. I eat so much salt I rarely taste it!

            So more fat won’t help my blood pressure but I’ve got to enjoy eating more butter and cheese and your comments on glucose and antioxidants have inspired me so I am moving towards LCHF. I was already grain free.

            Professor Grant Schofield and Caryn Zinn here in New Zealand of What the Fat? fame are doing good work on LCHF. Thanks for helping me learn more

            • Hi Talia,

              A couple of things: you are hydrating all wrong. Never drink more than 1 glass (140 ml) of water at once, so drinking a liter is a bit over the top. That then removes your electrolytes and increases your POTS and dizziness. For POTS in the US the recommended sodium is 10k – 13k per day and definitely not in Himalayan salt–it has lead and mercury, also arsenic, and a ton of radioactive materials. You really don;t want that. All salt are sea salt no matter what kind but Jimalayan is so ancient and with the mountains pressing with major heat, the color is actually metals and radioactivity.

              You also need to eat much more iodine than what is in unpurified salt like this–you need 150 mcg iodine a day and unpurified salts only have trace amounts. So switch to iodized salt that is not radioactive and drink one glass of water at the time, taking salt with each one.

              Enjoy your fat!! And also try to fast a but here and there to improve your body’s health in general–like today I am fasting all day–I had nothing since last night. 🙂 This can keep you healthy!


          • There seems to be some evidence that coffee is not diuretic, when consumed in moderation. I was wondering if you looked at any research? My feeling this is another topic where we were always told this is so, so it became the accepted truth – much like the point of your article about cholesterol.

            • Thanks for your comment Jack,

              Coffee is always diuretic–it is a vasoconstricting agent. Vasoconstriction can only be achieved by removing water–but the amount of coffee, epigenetic factors matter, and circumstances matter. The terms “moderation” always disturbs me. This is for several reasons: one of them is that everyone is different and so what may be too much for me may be perfectly fine with you–genetics has a lot to say about this. If one is a “fast metabolizer,” a “medium metabolizer,” or a “slow metabolizer” in terms of CYP2C9, CYP1A2, NAT2, or similar genes, for example, it makes a huge difference if a sip of coffee causes trouble or if one can drink 2 cups in one sitting and have no issues. One’s general health is another factor–as is age, of course. A person with hypertension that is not well controlled by medicine should not even taste coffee but a person with full health, pending genetic variances, may be able to drink several cups without trouble.

              In terms of its diuretic effect, since it causes vasoconstriction, it is used in medicines. If so, then we can consider caffeine to be a medicine of sort! I suppose you have not given it a thought along these lines. Caffeine is included in both prescription and OTC medicines for some health conditions. So then we need to also evaluate it from the perspective of a drug, or a toxin. Is a drug or toxin OK to take for everyone in moderation?

              To demonstrate caffeine-effects in coffee, here are a few clinical questions for you to see the problem:

              1) A man spent a day outdoors in the heat working and had little access to salt and water all day. He is complaining of a headache: iced coffee is right in front of him; should he take a sip?
              2) A woman, hiking up a 2-mile long steep black-lava hill, had water in hand and drank water all through the hike. It was hot, no shade (the Kona side of Hawaii–I have been there and did this hike, hence the question). She is sick to her stomach, feels chilled but sweats at the same time: should she have a sip of iced coffee to cool off?
              3) It is miserably cold outside; people can barely move against the wind. A man, coming indoors, reaches for something hot to drink. Should he drink a cup of hot coffee?
              4) A family is going on a vacation to Death Valley–282 feet below sea level. It is not hot but had been a long drive and they are tired. There is a little shop in the deepest part of Death Valley, so they stop to get some refreshments. Should they drink a cup of coffee to “wake up”?
              5) The same family is on vacation again and this time they are driving up to Mammoth (or any other tall mountain). They reach the top very tired. Should they grab a cup of coffee on top of the hill before doing any sport?

              To help you, of the 5 above, only one case merits drinking coffee but in the other four cases, coffee can cause trouble–even in moderation. Can you explain which 1 is OK and why in the case of the other 4 it is not OK to have coffee?

              Hope you have a nice day,

  3. Thanks Dr. Stanton, for this piece.

    Here comes a long response mainly because I write about food and the environment, and the fossil fuel inputs, embedded energy loads and the amazingly destructiveness of industrialized flesh-dairy-egg operations, as well as the destructiveness of corn, soy, wheat, and anything on an industrial level, including coffee, palm oil, etc.

    My apologies up front for going sideways here!

    Comments —

    Interesting, really, and in need of more discussion. What the meat, poultry, swine, dairy and beef industrial producers have unleashed on the world, both in the USA and other countries is massive Armageddon. For the other millions of species on planet earth, as well as those cultures who have figured out how to live and prosper for millennia.

    That’s not to say industrial wheat and palm oil and coffee and tea and other fruit and vegetable and nut operations are doing any better with the land, with all the metals and toxic inputs like fumigants, pesticides, fertilizers, and calories of fossil fuel energy to get that slab of meat to the table. And, the amount of forest, jungle, plains, and other elegant and natural ecosystems destroyed to plow over land for grains and GMO corn and soy for both human direct consumption but more largely for human secondary consumption by feeding these products to livestock.

    Not one apex marine fish in the ocean is free of dioxins and mercury, thanks to our coal burning and cement making and other factory processes. Really, and then, the over-harvesting of fish and meal fish to feed a bigger and bigger market for farmed toxic salmon and just a hungry world, and the pollution run off from both industrial livestock and agriculture destroying rivers, ponds, lakes, deltas and entire reef systems.

    So, unless the world is making enough bucks to end up at a Amazon dot com/Whole Foods (whole check) to get that supposed organic, grass-fed, natural flesh product (and, yes, Whole Foods has been exposed for those marketing lies), well, we will have to figure out how to be more vegetarian the right way (like most of the world), and with global warming, new studies show the soil is now degraded, and the actual nutrients/vitamins/minerals of plants are degraded.

    Water, exercise, days and weeks away from computers, jobs that matter, community connections, and a vigorous diet of the omnivores type, yes, that will help with a healthier Homo sapiens. No dairy and that deadly casein, that too.

    Okinawans live the longest as a small sub-group of folk, and what was their diet for centuries before the toxic sea was born?

    Check it out –

    Dr Craig Willcox, who has spent many years investigating Okinawan longevity and co-wrote a book, The Okinawa Program, outlining his findings (recommending that we “Eat as low down the food chain as possible” long before Michael Pollan’s similarly veg-centric entreaty).

    Willcox summarised the benefits of the local diet: “The Okinawans have a low risk of arteriosclerosis and stomach cancer, a very low risk of hormone-dependent cancers, such as breast and prostate cancer. They eat three servings of fish a week, on average … plenty of whole grains, vegetables and soy products too, more tofu and more konbu seaweed than anyone else in the world, as well as squid and octopus, which are rich in taurine – that could lower cholesterol and blood pressure.”

    Okinawa’s indigenous vegetables were particularly interesting: their purple sweet potatoes are rich in flavonoids, carotenoids, vitamin E and lycopene, and the local bitter cucumbers, or “goya”, have been shown to lower blood sugar in diabetics. Like most of us, I am familiar with mainstream dietary advice – eat less sugar, salt and saturated fat, cut down on the cronuts and so on – but I much prefer the idea of discovering little-known shortcuts to longevity; I’m more of a “silver bullet” kind of guy. With this in mind, over a lunch of traditional goya chanpuru – bitter cucumber, stir-fried with tofu, egg and pork – in a restaurant that was little more than a tumbledown hut close to his campus, I asked Willcox which elements of the Okinawan diet he had introduced to his life. Turmeric and jasmine tea, he said; both potentially ward off cancer. Needless to say, both now feature in my morning ritual.


    And, we are what we eat, drink, say, read, do, think, dream, learn, practice, and believe. Imagine a true happiness index for Americans that takes this country up over the lowly #35 in happiness factors compared to the other industrialized nations.

    But back to pollution, environmental racism (as in all those hog farms, poultry plants, egg ranches, CAFOs, rendering plants, feed-lots, factories making the toxic-poisonous inputs for industrial flesh-dairy-egg operations).

    Back to the millions of gallons of antibiotics and other medicinal toxins thrown into the flesh-dairy-egg operations because the diets of Americans are going more the way of eggs-cheese-beef-chicken-pork.

    Two books, with “Against the Grain,” in their opening two-part titles talk about how wheat (as does the great Daniel Quinn’s book Ismael and other titles) and how we as tribal people had it together for several hundred thousand years, and then agriculture locked up the food and put the majority of Homo sapiens under spiritual, economic, and religious lock and key:

    Against the Grain: A Deep History of the Earliest States by James C. Scott

    An account of all the new and surprising evidence now available for the beginnings of the earliest civilizations that contradict the standard narrative

    Why did humans abandon hunting and gathering for sedentary communities dependent on livestock and cereal grains, and governed by precursors of today’s states? Most people believe that plant and animal domestication allowed humans, finally, to settle down and form agricultural villages, towns, and states, which made possible civilization, law, public order, and a presumably secure way of living. But archaeological and historical evidence challenges this narrative. The first agrarian states, says James C. Scott, were born of accumulations of domestications: first fire, then plants, livestock, subjects of the state, captives, and finally women in the patriarchal family—all of which can be viewed as a way of gaining control over reproduction.

    Scott explores why we avoided sedentism and plow agriculture, the advantages of mobile subsistence, the unforeseeable disease epidemics arising from crowding plants, animals, and grain, and why all early states are based on millets and cereal grains and unfree labor. He also discusses the “barbarians” who long evaded state control, as a way of understanding continuing tension between states and nonsubject peoples.


    Against the Grain: How Agriculture Has Hijacked Civilization by Richard Manning

    For 290,000 years, we managed to meet that need as hunter-gatherers, a state in which Manning believes we were at our most human: at our smartest, strongest, most sensually alive. But our reliance on food made a secure supply deeply attractive, and eventually we embarked upon the agricultural experiment that has been the history of our past 10,000 years.

    The evolutionary road is littered with failed experiments, however, and Manning suggests that agriculture as we have practiced it runs against both our grain and nature’s. Drawing on the work of anthropologists, biologists, archaeologists, and philosophers, along with his own travels, he argues that not only our ecological ills-overpopulation, erosion, pollution-but our social and emotional malaise are rooted in the devil’s bargain we made in our not-so-distant past. And he offers personal, achievable ways we might re-contour the path we have taken to resurrect what is most sustainable and sustaining in our own nature and the planet’s.


    Daniel Quinn, Ishmael: An Adventure of the Mind and Spirit

    “This is considered almost holy work by farmers and ranchers. Kill off everything you can’t eat. Kill off anything that eats what you eat. Kill off anything that doesn’t feed what you eat.”

    “It IS holy work, in Taker culture. The more competitors you destroy, the more humans you can bring into the world, and that makes it just about the holiest work there is. Once you exempt yourself from the law of limited competition, everything in the world except your food and the food of your food becomes an enemy to be exterminated.”


    I would love to write about the devastation of a flesh-dairy-egg centric diet to not only humanity but to the other more important species. It’s easily pursued in looking at the ecological footprints of what we call food in an industrial age. How fossil fuel is embedded in each grain we eat, each chicken breast baked. These are existential times, and, well, I wonder just how screwed up our American Physiology is tied to a society that is living on planned and perceived obsolescence, that in my terminology is a species more aptly categorized as, Retailipithecus Sapiens or Consumipithecus Sapiens.

    You have to get under the veneer of our flesh-dairy-egg centric society and look at the grotesque nature of hog farms with ponds of blood and byproducts, seeping into water systems. The methane and nitrous oxide, hydrogen sulfide and ammonia and volatile organic compounds off-gassing like a death chamber from these CAFO’s – concentrated animal feeding operations.

    Food and war – the by-products of World War I and II weapons, used now in the insecticide-fertilizer business. Banned antibiotics and medicines in the US — banned for human consumption — now used liberally in the flesh-dairy-egg industries.

    Very complicated looked at just why Americans are gluten intolerant, obese, chronically ill, fatigues, with leaky gut syndrome, bloating, immune issues, hyper-sanitized, and stuck in a western diet of western media, medicine, milk, mush, myth. That’s what I like about thinkers and appreciate this piece for that as well, using chemistry as the foundation for her thesis.

    Note here the diet of flesh-dairy-eggs:

    Ammonia contributes to soil and stream acidification and particulate air pollution. Nitrous oxide and methane are potent greenhouse gases that hasten climate change—in fact, farms account for 9 percent of greenhouse gas emissions and farm and ranch runoff is the leading cause of impaired water quality in the U.S.

    Both hydrogen sulfide and ammonia can irritate the nose, eyes, respiratory tract, and throat. People who live near CAFOs have increased exposure and inflated health risks compared to people outside the impact radius. They are more likely to experience acute or chronic asthma, respiratory irritation, immune suppression, and mood disorders. Children who attend school close to industrial hog farms, for instance, have higher than average rates of asthma.

    One research study analyzed the distribution patterns of 2,500 hog CAFOs in North Carolina and discovered that there were 7.2 times more CAFOs in areas with the highest poverty levels and there were five times more hog CAFOs in areas with the greatest percentage of nonwhite residents. The study conclusively found that schools close to hog CAFOs had more children of color and low-income children.
    A similar study in Mississippi found the same pattern, as did a study of industrial poultry farms in Maryland.


    • Dear Paul,

      Thank you for your comment, which is, indeed, a very long one. Let me start by saying that this statement is incorrect “we will have to figure out how to be more vegetarian the right way (like most of the world),” and not sure where and how you came to this conclusion—most of the world population is not vegetarian, see here. Chinese, the biggest population on earth, is not vegetarian—never were and never will be; Japan that you refer to is famous for eating a lot of fish and the region that you specifically mention with longevity in Okinawa, the people there eat very little rice and fills most plates with seafood. Indeed, they do have low rates of cancers—they also eat most fish, most food fermented, and very little whole grains. In fact, all East Asian countries eat “whole grain” mostly in their variety of rice—and, by the way, this is no longer true today, they are now fighting an obesity crisis, with a greater percent of the population diabetic than the US; see here and here. Before the Japanese and the Chinese dinner tables were also filled with sugar and bread—something they never ate before our civilization arrived there—they indeed were the healthiest population—except China had (and still has) a big problem of strokes as a result of the high carbohydrate diet—they still sport the highest rate of strokes in the world; see here. Notably they also didn’t eat much starchy stuff like potatoes, just to name a few.

      So when you are talking about how long vegetarians live, we need to look at what is happening in places where there really are lots of vegans and vegetarians: India. India is the diabetes (type 2) capital of the world as we speak; see here and here.

      While you are making a valid point about our ecosystem’s collapse, and indeed we can blame that on global warming and overpopulation and thus the weakening of our soils, you must also connect to that thought what happens to vegetables, plants, and fruits,

      Not only are they more damaged than animals and fish, they cannot run away from it so they put on the best fight they can! Plant have natural toxins (some of which are toxic to humans in our everyday foods, see here and here) to protect themselves from insects and other predators—and human are their predators. Thus the next time you bite into that lettuce leaf, consider what that means! That lettuce has grown up in the same exact impoverished soil from which the grass grows that feeds the cows. So if the cows are sick, so are the plants!!

      In addition, plants have always had a purpose to live—just like any other living creatures—plants are alive, communicate with each other, feel pain, see also here and here, and prefer to have their seeds dispersed. Plants created fruits to disperse the seeds but they themselves wish to remain alive. I see no difference between a lettuce and a cow: they are alive, they are sentient beings, and both require equal respect!

      In terms of grains: if you only go back in “evolution” to our recorded human time, that is a drop in an ocean in terms of evolutionary time in human. Like in my article, why not go back to the bacteria we all came from? They didn’t eat grain. I don’t accept the argument that once people settled down and stopped their hunting and gathering habits and as a result were forced to grow and herd what they ate represents our ancestry. They also had ancestry themselves, not to mention, that historically, there is much literature about how health turned for the worst when grains entered human diet, see here and here.
      I am summarizing my response to your comment short and to the point: every point you made is incorrect. It is clear that you are a vegan/vegetarian camps supporter—and there is nothing wrong with that. However, this website is for the education of the people who have been misled for over 60 years by now by researchers, doctors, and growers like you must be. I appreciate your comments. Thank you. I disagree with all.

      Best wishes,

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