Sunday, 30 August 2009

Take the Sugar Warning of American Heart Association with a Pinch of Salt


New AHA statement adds upper limit to added sugar intake, cites links with CV risk factor

The scientific statement incorporated new evidence on the relationship between sugar intake and cardiovascular health gathered since the publication of the 2002 AHA Statement on Sugar Intake and CV Disease. In 2006, the AHA published an update to its recommendations for the intake of beverages and foods with added sugars. Citing results from several studies, the authors of the 2009 statement said that intake of excess sugars has been associated with risk factors for CVD such as elevated blood pressure and higher triglyceride levels.

“Although the mechanisms are unclear, relative to other carbohydrate sources, sugar intake appears to be associated with increased triglyceride levels, a known risk factor for coronary heart disease,” the researchers wrote in the statement. “However, relative to other sources of carbohydrate, the effects of sugar intake on HDL and LDL levels remain unclear.”

Hold on, it is not time yet to throw out your sugar containers and switch on mass to no calorie substitute, don’t feel happy that you can now drink Diet Coke instead of the Regular Coke!


Do you think Sugar is the Culprit?

When I say sugar, what comes to your mind?

Above, white sugar and brown sugar in the photo

(reminds me what Louis LaRose, a HoCank Indian, once asked me, are you a white sugar doctor or a brown sugar doctor? There is more irony in it than meets the eye, since I am brown skinned and I am a “sugar doctor”, someone specializing in treatment of Diabetes)

And whenever I ask an audience, do Americans Consume more Sugar now than ever before? The answer is always a resounding YES. Then I show them the above graph..

Most Americans are astounded to hear that we eat 45 pounds less sugar now than thirty years ago. What they mean by Sugar is Sugar Additives and Sugar substitutes. As you can see from the above graph, the consumption of their ever increasing High Fructose Corn Syrup now occupies the lions share of Sugar Consumption. It is produced from Corn chemically.

The other chemical products in this category which has entered into the imagination of American Public include: Maltodextrin, Corn syrup Solids, Dextrose, Crystalline Fructose etc.

Knowing that in 1970 High Fructose Corn Syrup did not exist and Obesity and Diabetes were not in the minds of Americans and in 2000 High Fructose Corn Syrup is in everything, with Americans consuming at least 65 pounds of that stuff each year for each and every adult American…now look at the statement of the American Heart Association..

So whatever reason, American Heart Association does not want to come out and say it is High Fructose Corn Syrup and other artificial additives that is raising Triglycerides (a fact known to the biochemical scientific fraternity for a long time, but not the medical community), they can lump everything together and say Sugar is the culprit.. and thus the innocent American Public can go on reducing the meager white sugar consumption (instead put the deadly Splenda in their coffees) and happily go on consuming High Fructose Corn Syrup, with the outcome that nothing beneficial happens to their triglycerides and Insulin Resistance and Diabetes..

Dr Sudah Yehuda Kovesh Shaheb, an Endocrinologist and an Anthropologist, works with UmonHon and HoCank Indians, among other things. His social blog is at

Wednesday, 26 August 2009

Native Americans, Diabetes and Happiness in their Clinic

Indian Faces one day at the Clinic. 26 August 2009

A colleague who lives in a nearby town, said, At the party last Friday, I met so and so, they would love to see you, they cant understand why you just stopped seeing them, ten years ago..

A party of petite bourgeoisie in this isolated part of the world, where they tell each other who wonderful their lives are, sequestered into their own insecurities, show and tell kind of existence.. what do I do with them?

I am sorry, when I come to the Indians, I have only just enough emotions to share with the Indians, and they give me a lot so I really don’t have anything left over to share..When I am with the Indians in the USA, I am very reluctant to mix with the Non Indians of this country, however nice they are, I don’t want to be dragged into their world of worries and concerns, so different from the people I have come to serve.

Look one day at the Clinic of the Indians: I have learned so much personal history of so many people.. let me try and recollect..

77 year old Lakota, met and married the Omaha tribal member, lived in LA where she had her three daughters, now all three daughters are nearby. She is on Dialysis, going on eight years, she was telling me about optimism and acceptance of life. When I told her my sister was undergoing chemotherapy for cancer, she said, tell her to be strong and be positive.

When I said good bye to her, she said, I have one request, could you please send me a post card from Paris?

I remembered, when I first started working with this tribe, I was living in Jamaica and when I returned home from my work here, I used to spend hours writing post cards to the people I had met on that trip. What a pity in this world of Face Book and emails.. No, I wont fall for that excuse, I will send her a post card of tour Eiffel to her..

Her two daughters came to see during different hours. So quickly they filled me up with their individual lives, because they knew that I had already placed myself in their world . I am the doctor who is a friend of their mother.. this trust can be utilized to achieve the results of treatments. Only a naïve person would believe that in most of the chronic diseases, just the pharmaceuticals will achieve the desired outcomes.

A 17 year old who had been prescribed medications, brought it in. Indians are brutally honest and tend not to lie. If you ask someone, are you taking the medications prescribed for you, they tend to answer: no, doctor, I have not been taking any of the medications you gave me two months ago. Perhaps that could explain the blood pressure of 180/120 mm Hg and a blood sugar close to 300 mg/dl.. and all of 17 years old.

I saw his 15 year old sister later on, and she is following the same road. Forget about family history, the physiology of diseases, this definitely a social phenomenon. In this tribe like many other tribes, the behavior is so influenced by the unspoken rules of the tribal ethics.

Their mother was with them, a lady not even 45 years of age but already in a wheel chair because of the right sided stroke she sufferd a few years ago. A very cute young child was with them and they were all laughing and making the consultation room ring with joy..

At 11 am went to the school in the nearby village where most of the students are Indian. The principal is a very pleasant woman and they had just hired a new school nurse. We talked to them about our projects of prevention of diseases among the school children especially Obesity. And made plans to come on my next visit to check all the students for their growth, height and weight and any unnatural body habitus!

Lunch had been prepared by the Filipina who met this Indian sailor in Subic Bay in 1988 I think, married him and here she is , almost an Indian herself. No one thinks of her other wise. She mentions that she would like to take her daughter aptly named after the Mexican national saint and her husband to a newly opened Chinese buffet in the nearby town. I made arrangements for that. She always takes care of me and once in a while visitors to the house where I stay here, the Blue House, are treated to Filipino delicacies.. chicken adobo, pancit etc..

Working in the clinic, there are so many interactions with various people working there. It is almost as if you are on a holiday in an exotique location. The helper at the kitchen, who wanted to know whether I have children at every port. The resident of the nursing home attached to the clinic wanting to know why I am covering my face with a mask, are we that smelly? She laughs..

Then there are my colleagues, the same two women I have worked all these years I have been with the indians. Incredible coincidence indeed.. and we have become good friends and when they have questions about medical care in the family or the news about their children or grandchildren to share, I am informed. Also when their family members meet me, in or outside the clinic, it is always a little intrigue about this foreign friend who speaks a little differently, who dresses a little differently and who is always travelling and sending post cards!

Those of us who work with poor people and try to provide medical care at the best of our ability. As Pablo Neruda had written: it is only the rich think that poverty breeds character. It is not as if the medical care you can get in these isolated parts of America, whether it is Bismarck North Dakota or Sioux city, iowa are anywhere comparable to decent clinics in the developed world, they are expensive and they are not compassionate and downright damaging to your health.. such are the examples we see, the dodgy health care given to our patients, the Indians, who once owned the entire land and now disposed and poor and unable to afford the system that has been hoisted upon them.

The afternoon is marching on, the hours are full of conversations and chatting, with various peoples, some of whom happen to be patients as well.

The video of the day was taken of a man, coming to be 70 years of age, who just a short five years ago, was a walking advertisement for American Health. He had embodied every single disease of the civilization. I got to know him around that time, and to use an American term, he was truly a medical basket case: diabetes, hypertension, heart disease, vascular disease, obesity and an array of over 16 different medications prescribed by a slew of practitioners who looked at his organs with their scotomatous medical gaze.

He sought to lead a spiritual life and read voraciously about various philosophies and his wife was a mental health counselor and they lived in a nearby village. I asked him, while I filmed him with the camera which had been lent to me by my best friend in Asia, how did you manage to control your blood sugar so well?

He began; about five years ago I was tired of being a poster boy for Obesity. I was 260 pounds and had been given three oral medications and two types of insulin for high blood sugar and four medications for blood pressure.

I was dieting and then not dieting, loosing a few pounds and gaining some back and putting some more on, the typical Yo Yo diet ! then I decided that if I ate Protein for breakfast: eggs; a salad for lunch and then some fish/chicken salad for dinner, may be I will loose weight. Since he was reading many self help books, Cinnamon and its effects on diabetes caught his eye. Soon his blood sugar began falling down, he began loosing weight and one by one he was able to abandon his medications for diabetes, in fact currently he is on no medications at all. He dutifully checks his blood sugar and they are incredibly within a narrow normal range and he continues with cinnamon and also a variety of herbs. His blood pressure is under good control and the number of the medications there also has decreased. He is going to celebrate his 70th birthday with a happiness he thought was not possible. We had given him as a gift a pair of trekking sticks that Robert Sweetgall used on his walks across America. When you use those sticks for walking an extra 20 per cent of effort is transferred to the upper body and a greater expenditure of energy. Our patient loves those sticks and goes for a walk, one mile or so a day to the swings of the trekking sticks.

He is on no medications for his diabetes (remember he was on three oral agents and two types of insulin, what was going through the minds of the doctors or nurses when they loaded him up with all these?). he feels good and enjoys his newly found freedom in health.

I suggested to him that he get together people he knows in his village, for weekly sessions on health where he would be the peer teacher. There has been much interest in my recovery he told me.. good luck, and thanks for the inspiration and when you have the group together, I will come over one evening when you are meeting, and talk to you about whatever you want to hear.. my philosophy of heath and disease and the immediate actions to take back control over your own bodies.. don’t surrender it doctors, nurses, pharamacists and worse still, the nutritionists!

Oh I didn’t mention about the Indian adolescent with Type 1 Diabetes ( somewhat rare), I visited him at the school. Time to rest a little bit…..

Tuesday, 25 August 2009

Eat Well.. and have a glass of wine.. and viola.. NO Diabetes


Over 23 000 German Citizens were followed for development of Type 2 DM, Myocardial Infarction, Stroke and Cancer.

They were between the ages of 35 to 65 years. They were followed up for closely 8 years.

The objective of the study was to determine the effects mainly reduction in the above chronic diseases just by FOUR common lifestyle factors

1. No Smoking

2. Body Mass Index less than 30 kg/m2

3. 3.5 hours per week or more of physical activity

4. A healthy diet as defined by high intake of fruits, vegetables, and whole grain bread and low meat consumption

The four factors ( healthy 1 point and Unhealthy 0 points)

The Risk ratio for developing a chronic disease decreased progressively as the number of healthy factors increased

Participants with all four factors had a 78 per cent reduction of developing a chronic disease, 81 per cent less chance of a Heart Attack, 50 per cent less chance of a stroke and 36 per cent less chance of developing a cancer.

These diseases are collectively called Diseases of Western Civilization.

Only 1 in 10 adhered to all four healthy habits. But only one in 25 did not practice any of the above.

So the Western Man can prevent the Western Diseases by going back to a lifestyle which is slightly less Western.

Let us take a group of people, to compare the Germans with. Say, Indians from India.

The percentage of people adhering to all 4 healthy habits would be more like 6/10 rather than the 1/10 among the Germans.

Has that protected the Indians from Diabetes epidemic? Not all? Why not?

First of all, 30 kg/m2 of BMI is extreme for Indians from India, where 22-23 is considered normal and 30 would be in the obese range.

The diet has been consistently good since the majority of them are Vegetarians. And very little meat consumption. It would be interesting to see the DM prevalence among vegetarians vs non vegetarians. I remember reading an article that one of the highest prevalence of DM in India was among a caste which practiced strict vegetarianism. So it is not protective for them. They are not sedentary people.

What explanations come to mind then?

First of all, what is good for the goose may not be good for the gander..

The aetiology of diabetes Type 2 may be more than just physiological. I have felt that Diabetes is a Social Disease and it is much more prevalent among people who are




Living in conflict ridden societies.

In India, the epidemic of Diabetes coincides with the Economic Liberalization of that country which brought in untold wealth to a few and a necessity to change work ethics and morality to the majority.

What have I seen in that population?

They respond well to a more disciplined lifestyle with less emotional stress along with continuing a strict nutional adherence in keeping with their cultural norms. I have seen many many vegetarians under the age of 30 with type 2 DM who walk or bicycle 5 to 6 km per day but are under heavy stress to produce and meet deadlines in their newly found IT prominence. That is something new for the Indian bodies. And they are being given the gift of the Western Diseases..

Those who aspire to western way of living will be rewarded with western disease as well…

Sunday, 23 August 2009

Fructose and Gout

Fructose and Gout

In 1970, Prof (now emeritus) Fiorenzo Stirpe of Univesity of Bologna in Italy wrote a letter to The Lancet, the medical journal published in London, England, informing them that the administration of Fructose ( the sugar of the fruit, also 50% of the white sugar) brings about an elevation of Uric Acid.

A low Fructose diet (no sugar, no sweets, limited fruit) benefitted the patients (who had Gout). All of us are taught in the medical school that it is the Purines ( such as barley in Beer, spirits) that raises the risk of gout.

A large survey of 50 000 men were followed up for 10 years. In this study men who had two or more sweet drinks had an incidence of gout almost double than the other men.

So, if you have Gout, perhaps you might want to consider abstention from Fructose- limit the fruit intake except Grapes which contain Glucose.

In 1970s we did not have High Fructose Corn Syrup. Now it is ubiquitous. If Fructose can cause Gout, so can HFCS..

In a huge study of 46,393 male health professionals in Canada, a survey was carried out and then they were followed every four years for 12 years. Over that time, 755 men developed Gout.

Compared with men who almost never drank sugar-sweetened soft drinks -- fewer than one per month -- frequent soft-drink drinkers were significantly more likely to suffer gout:

· Two or more soft drinks each day upped gout risk by 85%.

· One soft drink each day upped gout risk by 45%.

· Five or six soft drinks each week upped gout risk by 29%.

HFCS sweet drinks raise the Gout risk by 35 %, more than twice the risk run by 2-4 spirit drinkers per day!

Soft drinks can certainly increase the risk of Diabetes.. and Gout.. in fact one by one, all the Diseases of Western Civilization the so called Western Diseases would be shown to be caused by Artificial and Processed Material which is sold as Food.. so eat Food when you can, and not something that passes for food…

Monday, 10 August 2009

Soft Drinks and Diabetes. Regular or Diet?

If the Diet soft drinks which trumpet no calories and no carbohydrate is implicated in the incidence of type 2 DM, this opens up a new chapter in the Food and Nutrition Knowledge of common man.. the current damage done by food probably is not done by calories, carbohydrates or fats but by chemicals which pass themselves as food.. this could explain the high rates of Non alcoholic fatty liver in rich countries such as USA and poor countries such as Sri Lanka..

I am begining to think that Calorie Counting and Obsession about Carbohydrate, Fats etc are symptoms of an Eating Disorder: Orthorexia...

Sugary Soft Drinks and Type 2 Diabetes

Sugary Soft Contribute to Diabetes Risk

Strong evidence indicates that sugar-sweetened soft drinks contribute to the development of type 2 diabetes. The Nurses' Health Study explored this connection by following the health of more than 90,000 women for eight years. The nurses who said they had one or more servings a day of a sugar-sweetened soft drink or fruit punch were nearly twice as likely to have developed type 2 diabetes during the study than those who rarely had these beverages. (1)


1. Schulze MB, Manson JE, Ludwig DS, Colditz GA, Stampfer MJ, Willett WC, Hu FB. Sugar-sweetened beverages, weight gain, and incidence of type 2 diabetes in young and middle-aged women. Journal of the American Medical Association. 2004; 292:927-934.

What About Diet Soft Drinks?

Using artificial sweeteners in soft drinks instead of sugar or high-fructose corn syrup seems like it would sidestep any problems with weight or diabetes. Artificial sweeteners deliver zero carbohydrates, fat, and protein, so they can't directly influence calorie intake or blood sugar. Over the short term, switching from sugar-sweetened soft drinks to diet drinks cuts calories and leads to weight loss. Long-term use, though, may be a different story

To date, the FDA has approved the use of five artificial sweeteners. Gram for gram, each one is far sweeter than sugar. (12) They include:

  • aspartame (Equal®, NutraSweet®, others), 180 times sweeter than sugar
  • acesulfame-K (Sunett®, Sweet One®), 200 times sweeter than sugar
  • saccharin (Sweet'N Low®, Necta Sweet®, others), 300 times sweeter than sugar
  • sucralose (Splenda®), 600 times sweeter than sugar
  • neotame (no brand names), 7,000 to 13,000 times sweeter than sugar

Some long-term studies show that regular consumption of artificially sweetened beverages reduces the intake of calories and promotes weight loss or maintenance. Others show no effect, while some show weight gain. (12)

One worry about artificial sweeteners is that they uncouple sweetness and energy. Until recently, sweet taste meant sugar, and thus energy. The human brain responds to sweetness with signals to, at first, eat more and then with signals to slow down and stop eating. By providing a sweet taste without any calories, artificial sweeteners could confuse these intricate feedback loops that involve the brain, stomach, nerves, and hormones. If this happens, it could throw off the body's ability to accurately gauge how many calories are being taken in.

Studies in rats support this idea. Purdue University researchers have shown that rats eating food sweetened with saccharin took in more calories and gained more weight than rats fed sugar-sweetened food. (14) A long-term study of nearly 3,700 residents of San Antonio, Texas, showed that those who averaged three or more artificially sweetened beverages a day were more likely to have gained weight over an eight-year period than those who didn't drink artificially sweetened beverages. (15) Although this finding is suggestive, keep in mind that it doesn't prove that artificially sweetened soft drinks caused the weight gain.

Diet soft drinks linked with type 2 diabetes risk

6 February 2009

They may not contain any sugar or many kilojoules, but diet soft drinks may increase the risk of type 2 diabetes and the metabolic syndrome, according to the findings of a new American study.

Researchers from the University of Texas studied more than 5,000 white, black, Hispanic and Chinese adults, aged 45–84 years, who did not have cardiovascular disease or diabetes when the study began.

Five years later, the results show that drinking diet soft drinks at least daily was associated with a 36 per cent increased risk of developing the Metabolic Syndrome and a 67 per cent increased risk of type 2 diabetes, compared to those who didn’t consume the diet soft drinks.

The results published online in the 16 January ahead of print section of Diabetes Care, show that about 14 per cent of the participants consumed one or more diet soft drinks each day. 59 per cent reported never consuming the drinks.

It is the artificial sweeteners in the diet drinks that are implicated in obesity and the risk of diabetes or metabolic syndrome.

The latest findings support previous studies suggesting a link between diet soft drinks and type 2 diabetes but the American researchers stopped short of concluding that diet soft drink caused diabetes.

They say theirs was an observational study and the results could have been affected by other dietary, lifestyle and behavioural factors.

Diabetes Australia-NSW advises it is best to avoid regular soft drinks and limit diet soft drinks to the occasional treat.

Water is the best drink to quench your thirst but if you feel like something different, try natural mineral or soda water with a squeeze of fresh lemon or lime.

Sunday, 2 August 2009

Peer to Peer Nutritional Education is Better ..

Priests of the New Nutritionism: An American Tragedy

Since when do we need these self appointed guardians of packaged food to supervise our eating?
My Lunch today
chicken kebab. salad. hummus. Pita. Mango Juice. English Tea with milk and Sugar
Dinner: Stewed peas and dumplings Jamaican Style. Fried sweet plantains. Nan. One glass of Kim Crawford Sauvignon Blanc from NZ.

I am not concerned about the carbohydrate content, nor the fat content, I couldnt care less about Protein percentage.
Even though I grew up in Australia and have lived in Cuba, USA and now in Paris, the food I had today is what my ancestors have eaten for centuries. I dont need a historically naive new age maven with a degree in Nutrition or something similar to tell me about saturated fats or calories.
In fact, Calorie counting should be considered an Eating Disorder according to an article published in England..
There is a new word for these , obsessives quantitative people: orthorexics, like anorexics... these are the people with UNHEALTHY obsession with Healthy eating..
For those of you, who want some numbers, i monitored my blood sugar all through the day..

Tea with Milk and Sugar. Mango Juice
2 hrs later RBS 91 mg/dl (divide by 18 to get mmoles/l)
Who could resist a Cortadito made hot and strong by a Palestinian, now exiled to Miami from his native Venezuela? about one hour later the blood sugar was 110 mg/dl
Lunch as described aove . Began eating at 14 25 and finished eating at 14 50 with an English Tea with milk and sugar. finished lunch at 15 10.
soon after I felt the post prandial sleepiness, the RBS was 156 mg/dl. at 15 30. By 16 10, one hour after my lunch my blood sugar had returned to 91 mg/dl. at 16 25 it was 105 mg/dl and at 1920 just before eating dinner, it was 102 mg/dl. Dinner as described above and I enjoyed the Sauvignon Blanc from NZ very much.. One hour post dinner the blood sugar was 101 mg/dl.
The best nutritionist I have worked with in my years with the American Indians, is a self taught Indian from the Winnebago Tribe, who teaches them How to eat rather than What to eat, who does not talk about Carbohydrates/protein/fat ratios but tells them little tricks how to make their restricted monies last longer and give them a good feeling of satiety and feel that they have done something good to their bodies. May Others learn from her...
Dr Yehuda's Principles for Good Eating
1. Eat only when you are hungry
2. Eat Just Enough
3. Eat with Friends

Calorie Counting without paying much attention to the ingredients is foolish. Why are you eating Fabricated Food, some of which you cant even pronounce. If i were to give you a big white tablet, will you just swallow it without asking me to explain what it is? it is metformin 1000 mg and within one hour your sugar will hit rock bottom and you will have all sorts of symptoms, once you know that you are not going to take the tablet are you?
So eat only that which you can understand. If the new priests of this food religion, cannot explain to you what is Maltodextrin and its effects on the heart and the insulin; if they cannot explain to you where the substances that are in a twinkie comes from, really you are a fool to listen to their advice!
These Calorie counting Consultants do not tell you, perhaps out of their ignorance, that not all calories are created EQUAL...
you are not going to believe me, if I were to tell you that a 175 lb Burmese General has the same Moral Ethics as that of a 175 lb Buddhist Monk? After all they both weigh 175 lbs!

Eat Food whenever possible, not food substitute, not imitation food..The imitation label was removed when the manufacturers argued that since the NUTRIENTS in artificial food is the same as REAL food, then they are not imitation! It reminds me of the Chinese Pharmaceutical Industry which argued in front of the world regulatory agencies that since their fake medications contain the same amount of ingredients as the proprietary medications, then their medications cannot be fake, they are real... Dont tell that to the parents of children who died of Malaria in West Africa because the fake medications from China for Malarial treatment just turned out to be fake...
Despite the increasing number of Nutritionists, Endocrinologists, Diabetologists, Certified Diabetes Educators, the number of people becoming Obese continue to rise, the number of people becoming Diabetic continued to rise. Is there a connection ?
While having Lunch and laughing and having a conversation with my friends, one of them asked me to look at a Book called Eat this and Not that.. It listed 61 Fast Food or Chain Restaurants in America and some of which are in other countries as well. I have been, from the point of view of Food, extremely fortunate to have lived outside USA most of my life, eventhough did do post graduate studies at Washington University School of Medicine and University of Miami School of Medicine, in addition to my studies in London, Melbourne and Brisbane. Going through the list, i realize that reading that book would be a waste of time for me, of the 61 named entities, the only one i have walked into, would be the Starbucks at La Defense in Paris, but never for a muffin or a frappucino but for a simple Cafe Americano.. espresso with hot water and milk...
There is no role for fast food restaurants such as those mentioned in that book in a discussion about Nutrition with Real Food. There are absolute No Nos: Potato Chips, French Fries, Regular and Diet Soft Drinks...
Food is more than about Health, satiety and curbing includes these and more.. No real australian, however far removed from his homeland, would shun VEGEMITE.. it is a cultural icon.. dont talk bad about roti canai in Malaysia, I am not interested in the caloric components of Awadhi cuisine nor the nutrient composition of Mohinga Noodles of Myanmar or the Bun Bo Hue in Vietnam...
I have a bit of advice to my friends in the Far East who think that to understand western civilization they have to eat western food as well. Leave Western Diet behind without leaving western civilization.. Read Descartes and not People Magazine...if you wish to understand the western philosophy...East Indian migrants (India, Paquistan, Bangladesh, Sri Lanka) eating French Fries to simulate their newly found immigrant status, die the youngest with the heart disease rate unheard of among westerners.. in fact the highest rate of heart disease in the world are found among their immigrants to the USA... they are dying for the wrong reasons...
This fundamenally highlights a serious flaw in the health care delivery in the western model, placing importance on the Quantity rather than trying to understand Quality. The providers and counsellors are Quantitative whereas the patients are interested in Quality ...

What we can do against this tyranny of numbers and restrictions? EAT FOOD for a change..