The New Crunchy

It’s been quite some time since I’ve eaten granola, save the odd emergency bar during a long tennis match. But I miss it, the comfort food of my adolescence. In 1973 my Mom returned from a visit to her family in Eastern Canada bearing gifts – a bag of a new kind of cereal called “granola” and a Neil Diamond album called Hot August Night that included the song, Crunchy Granola – “Drop your shrink and stop your drinkin’, crunchy granola’s neat!” Mom immediately got on the case and created a recipe including 12 cups rolled outs, 2 cups sunflower seeds, 1 cup melted honey, 1 cup safflower oil and more, all baked together in a big pan. It was delicious and the granola jar was just wide enough to get your hand in for a favorite after school snack.

It wasn’t long after that granola caught on across North America, touted as the new health food. Soon “being crunchy” became synonymous with being a natural type of person, referring to “the crunch of granola, which (as goes the stereotype) hippie-esque people are likely to eat”. Since the 70’s granola has become mainstream. I know this because my son used to eat granola bars for breakfast and there is a whole aisle full of nothing but such bars in the grocery store. This once “health food” may now be filled with dangerous non-foods such as high fructose corn syrup and highly processed soy protein.

But was granola ever really a health food? On the pro side, my Mom’s was made from mostly whole ingredients, processed at home and infused with a mother’s love and care. But even good granola is primarily carbohydrate including a great deal of simple sugar. Look for example at the nutritional analysis of one of the better quality commercial granolas, Bear Naked. One serving provides 140 calories: 18 grams carbohydrate (6 grams sugar from honey, maple syrup and sugar-sweetened cranberries), 3 grams protein and 7 grams fat. Watch out though, one serving is only 1/4 cup. Aside from all that sugar, granola is largely made from its namesake – grain. Mainstream nutrition literature touts whole grains as a staple, but grains can irritate the digestive system and cause a host of health problems in some people. Since having cancer I’ve cut way back on sugar (which can feed many kinds of tumors) and also cut out grains almost entirely to avoid the inflammation they can cause. So even the best granola isn’t on my menu.

Imagine my delight when last year I discovered a raw grainless version made by Lydia’s Organics. Since then, following in my mother’s footsteps, I have worked out a new recipe that is too good to keep to myself. I call this Paleola, as I follow a Paleo. It fits the bill as a vegan, raw, gluten-free, grain-free, sugar-free and fat-free, thereby making it suitable for almost any eating regimen. It is delicious, healthy and yes crunchy too!

Paleola

• 3 pounds apples
• 2 cups sunflower seeds
• 6 dates
• 6 figs
• 6 apricots
• ½ cup goji berries
• 2 cups walnuts
• 1 1/2 cups pumpkin seeds (pepitas)
• 1 cup pecans
• 1 cup cashews
• 1 tbsp cinnamon
• 1/4 – 1/2 tsp cayenne (optional)
• 1/2 tsp salt (optional)

The nuts and seeds should be raw and refrigerated before and after purchase. Ideally everything should be organic.

Making Paleola requires some organization, a food processor, a sprout jar and a dehydrator.  It is fairly labor intensive, but well worth it. If you’re planning to make Paleola on Wednesday, for example, you will start on Sunday night. Remember, this is a labor of love!

Sunday overnight: Soak 2 cups sunflower seeds in a large sprouting jar (at least 4 cups) for 8 hours. Over the next couple of days you will keep these in a dark place and rinse twice a day. Drain well after each rinsing. They will grow a tail as long as the seed in this time. In warm weather be alert as they can turn sour if you miss a rinsing or grow them too long. If the sprouts are done but you’re not ready to make Paleola you can store them in the fridge for up to two days.

Tuesday morning: The rest of the nuts and seeds should be soaked and dried before using, as they contain anti-nutrients that soaking helps to deactivate. I do each nut or seed separately a pound of each at a time so my dehydrator is full. I keep the rest on hand for using as a condiment or for the next time I make Paleola. These soaking directions come from Sally Fallon’s Nourishing Traditions.

Soak the nuts/seeds in water, in a ratio of 4 cups of water to 1 tbsp salt. After 6 hours rinse the cashews and put them in the dehydrator on the hottest setting. Two hours later rinse the rest of the nuts and put them in the dehydrator. You will continue to dry the cashews as well. At this point you want to get the temperature as close as possible to 110 degrees without going over. Continue to dry the nuts in the dehydrator overnight.

Wednesday morning: Take the nuts and seeds out of the dryer and let them cool to room temperature. Take out what you need for the recipe and store the rest in glass jars. I’m not sure you need to keep them in the fridge at this point but that’s what I do.

Core and cut the apples, and grate them with the appropriate food processor attachment. After grating use the S blade attachment to gently process the apples a little more. If you miss this extra step your Paleola will be stringy. Next, use the S blade to process the sprouted sunflower seeds so they get chopped a little. It is better to process both the apples and seeds in small batches. Now, use kitchen scissors to cut the dried fruit into tiny pieces. Excessively dry fruit will need to be soaked first. Add the cinnamon, cayenne and salt and mix well. Divide evenly into your dehydrator trays and dry at the same temperature as you did the nuts, 110 degrees. Stir after about six hours. Depending upon your dryer it will be at least another six hours before this mixture is dry.

Next you mix in the dried nuts and seeds. The nuts are a feature of this recipe. You want them to be a little chunky and have a nice shape. You can chop them in the food processor, but I think it’s worth it to prepare them by hand. Pecans can be sliced into three slivers following the spine of the nut, the cashews can coaxed in half where they naturally divide. The pumpkin seeds and walnuts just need to be coarsely chopped or leave the pumpkin seeds whole if you prefer. Of course you could dry the chopped nuts with the apple and sunflower mixture and skip the separate drying step. My dryer isn’t big enough and I like to dry a lot of nuts at once for other uses. Suit yourself.

Depending how much you munch along the way, this makes about 16 cups. It is very concentrated, so use it sparingly – 1/4 cup is still the ideal serving size. Together with almond milk and currently mangoes, it makes a superb finishing touch to our Special Breakfast.

Paleola is a concentrated food and should be used as a condiment. It is also a great emergency food in my tennis bag or for travel. Eating well takes attention, time and commitment. Trust me though, once you have the knack of making Paleola it is a worthwhile way to spend a little of your precious time.

Re-imagining Imaging

As my regular readers know in recent blog posts I have been exploring breast imaging issues. I had my first thermography appointment this week and I have to admit, it was a bit anti-climatic after all this build-up. After changing into a lavender colored gown on my top, the appointment started with a health history review and time for questions, after which I sat on a swiveling stool in front of an infrared camera while my practitioner took six pictures from different angles. I was in and out within half and hour. The best part was seeing the colorful images of my breasts displayed on the laptop monitor looking kind of like a topographical map. Although the images are produced instantaneously, they need to be interpreted by a qualified doctor, so I had to wait for my results.

All my research indicates that thermography can indicate the earliest signs of breast cancer, is radiation-free, pain-free and poses no health risks whatsoever. It actually detects the activity of abnormal cells and has the ability to accurately assess younger women with dense breast tissue for whom mammography is notoriously unreliable. Oh by the way, it is also the least expensive screening technology available. So why isn’t it the dominant breast cancer screening modality? Why isn’t it even recommended by most physicians?

Thermography, also known as digital infrared imaging, is based upon the principle that chemical and blood vessel activity in both precancerous and the area surrounding a developing breast cancer is almost always higher than in normal tissues. This activity frequently results in an increase in regional surface temperature of the breast. Thermography uses ultra-sensitive infrared cameras and sophisticated computer software to detect, analyze, and produce high-resolution images of these temperature variations, which may be the earliest signs of breast cancer.

In the race for better imaging spearheaded in the 1970’s thermography showed promise, but was sidelined by the conventional medical establishment by the 1980s. I found several different explanations for this.

1. Early Mistakes – In Beyond Mammography, Len Saputo recalls that breast thermography became available in the 1960s, before clinical trials of its effectiveness were completed and before there was a clear understanding of how to interpret the images. A relatively high rate of unnecessary surgeries resulted, leading the technology to be “sidelined by mainstream medical practice for several decades”.
2. Technology improvements – When I asked the technician who performed my thermogram the reason that thermography was not used more often, she replied that the medical infrared imaging cameras and computer technology had improved greatly over the past decade making it much more suitable now for widespread use.
3. Inappropriate Comparison – According to the American College of Clinical Thermology, when thermography was first explored for breast imaging during the 1970s, it was tested and evaluated as a competitive strategy to mammography. In 1974 a major project on breast screening called the Carolina Breast Cancer Detection Project that included thermography concluded that mammography should become the primary imaging modality. In fact, the two tests are complementary and both have a place in the detection of breast cancer. Mammography is a structural test that looks at the anatomy of the breasts, density changes and lumps, masses and calcifications. Thermography, on the other hand, measures the activity of the tissue by how much heat is generated. Clinical studies show that in women under age 50, thermography alone is more sensitive (better at detecting suspicious tissue) than mammography, finding 90% of cancers vs. only 70% for mammography alone. However the two modalities combined offer 97% sensitive detection of breast cancer!
4. Insurance Coverage Revoked – Also according to the American College of Clinical Thermology, while thermography’s role in breast imaging was being explored, it was also being used in other diagnostic roles. It became popular to use in court as a visual proof of pain in accident and injury lawsuits. In response, the insurance industry lobby succeeded in removing insurance coverage for thermography in the United States.
5. Economic/Political Issues – Thermography is inexpensive and because it is inherently safe and doesn’t involve any radiation, requires no regulation or an expensive clinical environment to administer. Screening mammography and the associated follow-up tests (e.g. ultrasound, biopsies) represent an $8 billion industry which might be threatened if thermography was more prominent.
6. Too Early Detection – Thermograms can pick up changes that precede cancer. When it was first tested on younger women, abnormalities were detected that mammograms couldn’t find. At the time, these were considered “false positives” and led to a mistrust of thermography. It turned out that a large percentage of the women who had these so-called “false positives” developed breast cancer years later. “Thermography’s only ‘error’ was that it was too accurate too early and the results couldn’t be corroborated at the time.” Thermography can provide an early warning signal before tissue actually becomes cancerous. However, if a woman has an abnormal thermogram that no other test can corroborate, the conventional medical establishment still will likely discard it as a “false positive”. Currently there is no protocol (other than surgical removal) in the conventional standard of care for what to do about something that is not cancerous but might become cancer in the future.

What Next?

At the moment there is a resurgence of interest in thermography due to the accumulation of clinical research, improvements in infrared imaging technology and the growing realization that mammography is not an effective option for pre-menopausal women. Thermography could play an important role in the development of a real breast cancer prevention strategy, acting as an early warning system by detecting tissue changes that reflect the early cancerous process. Studies on thermography have demonstrated its ability to warn that this process is underway 8-10 years before any other test can detect it – even before the cells become cancerous. At this early stage, preventive measures such as nutritional supplements, increased exercise and a lifestyle that reduces cellular inflammation and acidification would have time to take effect before cancer ever formed. In addition, thermographic baseline studies are appropriate for women as young as age 20 or 25 whereas harm from the mammogram’s ionizing radiation is cumulative and much worse for younger women.

Robert Kane, a lecturer and thermal imaging interpreter, suggests that the popularization of thermography will have to occur at the grassroots level due to the current political, funding and insurance issues. For my part, I can whole heartedly endorse my first experience of thermography. Three days after my test I received a call from the owner of Advanced Thermal Imaging offering an overview of my results (they had also been mailed to me in a report that morning). I did not realize the undercurrent of stress I had been holding until I heard the words “nothing suspicious”. I was informed that there is “an irregular heat pattern on the left side of my left breast” that although not of concern at this time, should be monitored given my previous history. The fact that there is a way to assess and follow the health of my breast tissue and the lymphatic area on the side where my breast tissue was removed feels very reassuring.

You can find the articles I used to reference this post embedded in the text. I recommend you check them out if you are considering thermography for yourself. A list of approved thermography clinics can be found here. The photo is from the Advanced Thermal Imaging website.

The D-bate

Prior to my first thermography appointment (in less than a week) I have done a lot of research on imaging and early detection. While learning some fascinating facts on cancer screening and diagnosis, I have begun to question whether the emphasis on detection and diagnosis might completely miss the point. What about preventing cancer in the first place?

I despair at attempting a comprehensive answer which would include proper nutrition, suitable physical exercise, stress and inflammation reduction, avoidance of toxins (e.g. industrial chemicals, pollutants, pesticides, drugs, tobacco smoke, alcohol, and ionizing radiation), a healthy mental attitude, nourishing family and social relationships and beliefs (religious or spiritual) that connect us to something larger than ourselves. The prospect of trying to comprehend and apply all of this is almost enough to send me scampering back to the straightforward recommendations of my doctors and the seeming certainty of the Standard of Care.

This week I want to focus attention on the debate on vitamin D. There is promising evidence that it has a role in the prevention and treatment of breast cancer and other diseases, but the American Cancer Society and the National Cancer Institute do not currently recommend vitamin D supplements. Beyond a basic multivitamin, many people do not regularly take supplements. There is a common belief that “if we eat properly we will get everything we need” and the conventional medical system has downplayed the importance of supplements. So what is the evidence for and against taking vitamin D supplements?

The case for vitamin D supplementation

Vitamin D is a pro-hormone that influences many genes. Proper levels of vitamin D have been linked to improved muscle strength, proper immune function, reduced inflammation and absorption of calcium and phosphate required for bone health. Our skin produces Vitamin D when exposed to sunlight. Today about half the adults in developed countries have deficient levels of vitamin D probably due to lower exposure to unscreened sunlight. The role of Vitamin D in cancer prevention first became apparent in the 1990s through geographic correlation studies showing that individuals living in southern latitudes have lower incidence and death rates from cancer. In the laboratory Vitamin D slows the growth and increases the differentiation and death of cancer cells. In a four year randomized clinical trial of 1200 healthy post-menopausal women found that women taking calcium (1400-1500 mg) and Vitamin D (1100IU) together had a 60 percent lower incidence of cancer overall than the women taking a placebo. A 2009 article published in the Annals of Epidemiology concluded that if the population at large raised levels of Vitamin D to optimum levels, 58,000 new cases of breast cancer and 49,000 new cases of colorectal cancer could be prevented annually and ¾ of all deaths from these two diseases could be avoided. Grassroots Heath (a organization of scientists promoting public health) published a Vitamin D call to action statement and posted a video calling for increased research and stating that delays in encouraging daily supplementation of Vitamin D3 of 2000 IU per day is leading to a great deal of unnecessary loss of life.

The case against vitamin D supplementation

Much of the evidence sited above comes from observational studies (based on questionnaires) that are inherently inaccurate. The one randomized clinical trial sited above was focused on bone health, not cancer prevention, and did not test the effect of vitamin D without calcium. The National Cancer Institute’s summary of the direction of Vitamin D research in the last 20 years concludes that evidence for Vitamin D’s benefits is “limited and inconsistent”. Vitamin D for breast cancer prevention is not in the American Cancer Society summary of current and proposed research on breast cancer. The Vitamin D Council suggests that the lack of research may be because Vitamin D is simply too cheap. “Therefore, the idea that [vitamin D] could help breast cancer offered no financial incentive to drug companies or researchers hoping to discover a drug they could patent.”

So what do I think?

I have my doubts about any magic bullet for tricky diseases like cancer and the compelling figures given are undermined by the deficiencies of the current research. But given that there is no harm caused by testing vitamin D levels and supplementing at 2000 IU per day, it seems like a no-brainer to do it.

I have my vitamin D levels tested regularly via the 25 hydroxy vitamin D blood test and have taken vitamin D3 supplements since I was first diagnosed. My results have never been dangerously low, but they have regularly been below the recommended 40-80 ng/ml. When doubling my daily supplement didn’t significantly raise my blood serum levels of vitamin D, my nutritionist recommended that I use a form that includes isoflavones to help the absorption. She told me that some people are genetically predisposed to have lower vitamin D levels. It’s shocking to think that insufficient levels of vitamin D might be related to both my mother’s and my own breast cancer.

I believe that taking dietary supplements (vitamins, minerals, probiotics, enzymes, herbs and other compounds that detoxify and support the immune system and certain organs) is one of the easiest things we can do to improve our health and help prevent disease, yes, even cancer. I consult a nutritionist 3 to 4 times each year to help me refine my eating and modify my supplement and dosage schedule to suit my changing needs. Currently I take 16 different supplements every day. I think it’s very helpful to have professional help in deciding on what to take. Our local health food store Natur-tyme offers free mini-consultations that can help people start on a supplement program.

In the nearly six years I have regularly taken supplements I have rarely been sick, my moods have continued to stabilize and I have less muscular and joint pain in my body. My massage therapist noticed that over time my body tissue has become more pliable and hydrated. Granted, supplements are not the only healing modality I have used and thus I cannot say how much is one thing and how much another. As the D-bate goes on, I take the tiny pill each morning, test my blood levels each year, and gently expose my skin to the sun whenever our upstate New York weather allows.

Milk & Cookies

This week I decided to share something that brings me great joy, that’s right, milk and cookies. I venture to say that these recipes are about as healthy as you can get. Like many good things, they take a little time and organization to prepare.

Although I occasionally eat cheese and include a little yogurt with breakfast, I aim to keep the amount of dairy in my diet to a minimum. I also don’t drink soymilk, for reasons I outlined in Soytistics. Recently however, Special Breakfast has taken on a whole new look with the addition of home-made almond milk. My friend who grew up on a dairy farm marvels at how much it looks and feels like cow’s milk, so I figure that’s a pretty good endorsement. It has that slightly slippery, thick texture and tastes slightly sweet.

Almond Milk

• 1½ cups almonds, soaked 8 hours and rinsed
• 3½ cups water
• 2 cups coconut water
• 1 tsp non-alcoholic vanilla

Blend the soaked almonds and water; a high speed blender like a Vitamix works best. Strain the mixture through cheesecloth or a jelly bag. You will need to squeeze out much of the liquid by hand, as if milking the animal herself. Mix with coconut water and vanilla. This makes about five cups and will keep fresh in the refrigerator for up to five days. It will separate with an almond cream layer on top, so stir before drinking. You can make almond milk without the coconut water, however this addition makes it simply wonderful.

I have to admit, I have abandoned hacking open the fresh coconuts for this purpose (as I described in Cream of the Crop) when one of my milk batches went sour after two days. I blamed the coconut water. I just don’t how fresh it was, as the coconuts are shipped from Thailand and then sit in the store before sitting in my fridge, awaiting the right moment to put it all together. I discovered some 100% pure coconut water that comes in a convenient 2 cup Tetra Pak. The seven month old coconuts are from northern Brazil, hmm, still not local but closer than Thailand.

Now you might be wondering what you do with the soft almond pulp that is left-over, or perhaps you are just waiting to hear about the cookies. I couldn’t bear to throw away the pulp, so I created some “cookie” recipes. They are raw, gluten free and nearly vegan. I use honey rather than agave nectar since the supposed health benefits of agave were brought under scrutiny earlier this year.

Chocolate Cookies

• Pulp from 1 1/2 cups almonds
• 1/4 cup finely ground flaxseed
• 1/4 cup cocoa powder
• 1/3 cup coconut
• 1 tsp alcohol free vanilla
• 1/4 cup honey
• 16 drops liquid stevia
• 2 tbsp coconut oil
• 1/2 tsp cinnamon
• Pinch cayenne
• 1/4 tsp salt

Vanilla Cookies

• Pulp from 1 1/2 cups almonds
• 1/4 cup finely ground flaxseed
• 1/4 cup coconut flour
• 1/3 cup coconut
• 2 tsp alcohol free vanilla
• 1/4 cup honey
• 16 drops liquid stevia
• 2 tbsp coconut oil
• 2 tbsp very finely chopped dried apricots (optional)
• 1/4 tsp salt

Place ingredients in a small bowl, mix and then knead with your hand. Press and roll dough out on wax paper. Cut using 3 inch round cookie cutter or glass and transfer to dehydrator with thin spatula. Dehydrate for about 6 hours until dry, ensuring that the heat is no more than 108 degrees for a raw cookie. (If you don’t have a dehydrator or an oven that has this modern option, I think you could probably bake these at 350 degrees for 8 to 10 minutes.) Each recipe makes 24 lightly sweetened cookies.

One of the difficulties of transitioning to a healthier diet is the loss of treats. Using foods like almond milk and cookies in moderation can give us that sense of comfort we all enjoy at times.

What am I Missing?

Last week (To Beam or Not to Beam) I discussed the pros and cons as well as my thoughts and feelings about regular breast screenings using mammogram, MRI or thermogram. This week I had the opportunity to discuss this topic with two prominent doctors in the field of medical imaging at a social occasion. They understood my reluctance to continue to subject my breast to the ionizing radiation of mammograms and felt that an MRI was the alternative of choice for me, as it generates a comprehensive picture with radio waves which are not harmful. They were not supportive of thermography because in their opinion, the image produced is just not detailed enough and that “it would be a pity if you missed something.” This got me thinking, just what might be missed if I choose to monitor my remaining breast with thermography instead of mammograms and/or MRIs?”

Mammography is the standard breast cancer screening technique and is used to detect both invasive and non-invasive (known as in situ) breast cancers. It works by passing x-rays through the breast onto a sensor to create an image. The manner in which breast tissue passes or absorbs the x-rays determines what the radiologist sees on the mammogram.

When reading a mammogram a radiologist looks for shadows, distortions, tissue density, masses and tiny specks of calcium deposits called microcalcifications. Although microcalcifications are not cancerous or dangerous in themselves, they indicate the possible presence of cancer cells contained within the milk ducts, called ductal carcinoma in situ (DCIS). The incidence of DCIS increased rapidly through the 1980s and 1990s, primarily a result of the increased use of screening mammography. In 2001 DCIS accounted for about 19 percent of all cancers found compared to less than 4 percent prior to 1984. The diagram on the left, from an article by Dr. Susan Love, shows the breast duct and tubules and a cross-section of a duct demonstrating DCIS.

Magnetic Resonance Imaging (MRI) images are formed by passing high intensity radio waves through breast or other tissue in the presence of an extremely strong magnetic field. MRIs are more detailed and sensitive than mammograms and allow the radiologist to see indications of in situ cancer cells themselves. Recent studies suggest MRI may be better than mammography for finding the more dangerous DCIS lesions which might someday become invasive cancers. MRI is also better at imaging dense breast tissue, more common in younger, premenopausal woman like myself. Earlier this year, the American Cancer Society recommended that certain high risk women should add MRI to their screening regimen.

If a radiologist reading a mammogram or MRI finds something that looks suspicious in the image, he or she may recommend further tests or monitoring, or recommend a biopsy. In themselves imaging methods can only indicate the possible presence of disease; microscopic examination of the tissue by a pathologist is the only way a diagnosis is made. While it does make logical sense to find cancer at this early, easily curable stage, it comes with certain costs. Both imaging methods are subject to false positives leading to biopsies that determine that cancer is indeed not present.  If DCIS is found, there is pressure to undergo considerable treatments that may be harmful, even though DCIS might never progress to invasive cancer.

After biopsied DCIS cells are examined microscopically, they are categorized as either “high-grade” (likely to become invasive) or “non high-grade” (likely not to cause harm). I was surprised to learn this, as I had frequently read that there is no way to determine which abnormal cells will progress beyond the in situ condition to become invasive versus those which will remain harmless. The thing is, there is not 100 percent certainty that a non-high grade DCIS will not become invasive, so the recommended treatment for all DCIS is lumpectomy and radiation (or if it is widespread, mastectomy). Five years of hormonal treatment may also be recommended. Since DCIS is very curable, with 98 percent of women surviving, it is debatable whether the benefits from radiation and/or tamoxifen outweigh the associated risks, some of which are life threatening. In fact, there is considerable controversy surrounding the treatment of DCIS, in part because for so many women it would never cause any harm even without treatment.

I am not suggesting it is better to wait until breast cancer is in a later stage to find and/or treat it. But I do question the emphasis on finding the signs of cancer earlier and earlier and then applying treatments that cause harm (biopsies, surgery, radiation treatments, etc.) for conditions that may not ever develop into invasive cancer. And I do worry that perhaps the cumulative ionizing radiation from mammograms actually contributes to the development of cancer, especially in women like myself who are under 50.

Wouldn’t it be great if imaging could provide an indication of the health of breast and other tissue in addition to searching for signs of disease? All screening methods today are about finding disease rather than assessing tissue health, but thermography has potential. It measures the heat produced as a metabolic by-product. Perhaps one day we can detect generalized inflammation (not just tumors) which might be addressed by adjusting nutrition, supplements and/or lifestyle before disease occurs. While we wait for that kind of technology, I rely upon blood work to give me an indication of overall health. I use the absence of blood tumor factors, manual breast examination and imaging to establish that nothing abnormal is going on.

If I had to choose between mammography or MRI for breast screening, I guess I would go with the MRI. Having had invasive breast cancer and family history, I fall into a category of risk that would probably result in my insurance company covering the cost of the test. However, despite the recommendations of my doctor friends and my oncologist, I am still reluctant. This may sound strange, but having faced breast cancer already, I am not afraid to miss something small, like the presence of DCIS. When I take a step back from the current cultural obsession with early detection, I find the whole emphasis of searching for and eradicating disease antithetical to the way I view my health.

I realize that conventional medicine is not in support of thermography, but to me, as a health care consumer, it makes sense. First, it does no harm because it works by passively measuring the heat produced within tissues, rather than bombarding the body with radiation. If my thermogram, blood work or manual breast examinations show anything worrisome, I can follow up with further imaging through conventional means (i.e. MRI). I reason that:

1. My careful attention to nutrition, supplements, exercise and other alternative practices will keep my tissues healthy.
2. The combination of three screening techniques (thermography, blood work and manual self-exams) gives me a very good chance of catching anything deleterious early enough to treat it.
3. There is a high percentage chance that anything missed by such screening is benign or non-invasive (like DCIS).

For me it’s a trade-off. The small increased risk of missing something important is, in my humble opinion, worth it. I will avoid the potential worry and discomfort of false positives and unnecessary biopsies associated with more sensitive imaging. Last but not least, thermography is in sync with my health priorities and principles (set out in Baby Steps). Throughout my cancer treatment and healing I have chosen a path less traveled that supports the health of my entire being. I want to take this path for monitoring the health of my remaining breast. For this reason I have booked an appointment for my first breast thermogram on August 17. I’m excited to have taken this step as it is something I’ve been thinking about for over five years. I will let you know my thoughts as I actually have my thermogram and continue my research and look forward to hearing your feedback on the issues I am raising.

The amount of material easily accessible on these topics is incredible. At times this week I felt buried in on-line articles, unable to remember where I had read this or that.  I hope you take the time to click on today’s links. The articles I chose to reference are all scientific, trustworthy and accessible!

To Beam or not to Beam

My annual breast screening appointment date is coming up in September. In Between Two Worlds, I reported that I’d already decided not to have another mammogram. At that time I agreed with my oncologist’s urging to have an MRI instead. Almost immediately I felt uncomfortable with that decision and now I don’t know what to think or what I’ll do as this deadline approaches.

First, let me explain my dilemma with respect to having another mammogram. Having already had breast cancer, I have a higher than average risk of getting it again. An annual mammogram is the “gold standard” for detecting breast cancer at an early stage. Therefore, I should be happy to have one annually (and my oncologist certainly holds this position). However, mammogram machines deliver a powerful x-ray, according to one source perhaps 1000 times stronger than a chest x-ray, sending ionizing radiation, a known carcinogen, into the breast tissue. Since mammograms have difficulty detecting cancer in dense breast tissues, I am often subjected to additional radiation as the radiologist works conscientiously to take extra views of my breast in the hopes of not missing anything. Having already demonstrated the predisposition to develop cancer in the breast, I reason that it is unwise for me to continue to expose myself to known carcinogens. Experts think that in part, it is the cumulative exposure to radiation over a lifetime that increases the risk of cancer from that cause. Therefore, it seems to me that any time is the right time to stop such exposure.

Even though annual mammograms are considered the Standard of Care, as I recounted in The Ninth Life, mammograms are by no means fool proof. The false positive rate is significant, 95 percent of women who are called back for additional screening do not have cancer. Two out of every three women who end up being referred for biopsies do not have cancer. The false negative rate is also noteworthy, with about one in every five cancers missed by mammograms.

So what about the MRI? An MRI makes a clearer, more detailed image than a mammogram, so it should be a better screening tool, right? An MRI doesn’t use x-rays. Rather, the patient is given a contrasting agent (like gadolinium) by injection and then put into a powerful magnetic field and probed with radio frequencies. There is no scientific evidence that these frequencies of electromagnetic radiation cause cancer or are otherwise harmful. The contrasting agent can cause reactions in persons with kidney problems, but otherwise, this test seems less deleterious than the mammogram, although it is lengthier, more expensive and more uncomfortable in my opinion. Unfortunately it also increases the risk of false positives and could lead to unnecessary biopsies and the associated anxiety, cost, time and discomfort.

This is at the heart of my distress as I approach the crossroads in September. I don’t want to subject myself to additional carcinogenic radiation through a mammogram. Neither do I want to expose myself to the anxiety of an MRI which is a stressful test in itself and runs a greater risk of a false positive requiring a biopsy to disambiguate. I am especially sensitive to anxiety because of my propensity toward mood and sleep issues (as I reported in Good Night Sweet Princess). In fact, after having a colonoscopy a few years ago at the recommendation of my OB/GYN and GP, it took me about three months to reestablish my equilibrium. I treat the havoc in my life that results from anxiety as a very real side effect of such a test.

Which leaves me where? Do I want my remaining breast to go unmonitored? With my history, completely opting out of breast screening seems like a foolhardy idea. Thankfully there are three options which do not have any negative health effects. The first is the old standby – manual self examination. This is actually the way I discovered my cancer, so even though it is not a method of early detection, I believe it is still a worthwhile practice. If I find something manually, I can have a sonogram, although at that point a mammogram would also be recommended. A sonogram, also known as ultrasound is quick, not uncomfortable, requires no contrasting agent or ionizing radiation. It creates an image which can distinguish between a solid tumor and fluid filled cyst. The third harm-free alternative is a relatively new imaging method is thermography.

Thermography measures the amount of heat emitted by the body, in this case the breast tissue. Abnormal cells are usually hotter because they require a greater blood supply and therefore show up on the color image that is formed. The upsides are that it is a comfortable procedure with no negative side effects. It also seems that it can detect abnormalities in the breast tissue before a mammogram and has a lower false positive rate. The downsides are that although a thermogram is relatively inexpensive, it is not currently covered by medical insurance and is therefore an out of pocket expense for the patient. Second, thermography is unregulated so one has to be careful to use a reputable provider. Fortunately we have a provider who visits a nearby office monthly. Finally, the vast majority of radiologists and oncologists are not trained in this technology, and will not make recommendations based on its results. Therefore, the thermogram is sent to a center to be read by properly trained radiologists and will not be read by the radiologist who has followed my case since 2005.

As I said in Baby Steps, my first principle in making decisions about my health and healthcare is “First, do no harm.” For this reason, I’m reluctant to have another mammogram or an MRI for purely screening purposes. There is more research on this that I want to understand fully and I will report on what I discover in future blogs. In the meantime, I do intend to have a series of two thermograms to establish a baseline that any future changes in my breast tissue can be measured against. The thermogram satisfies my final principle: “if a treatment causes no harm whatsoever and I want to try it, then it is fine, even if there isn’t conclusive scientific evidence for its effect on cancer.”

I’m not 100% sure of any of this and I am certainly not making recommendations about what anyone else should do. For now, it’s what feels right for me and I’m being consistent with my principles and priorities in making my own health choices.

Six Months

This week marks the first 6 months of this blog. That’s 26 posts, 2,269 views and 78 comments. In this time I have learned to insert hyperlinks, pictures and do internet research at lightening speed (lol). I decided it was a good time for a review to provide a summary for my regular readers and introduce new readers to the discussion thus far. Hopefully the links will easily direct you to the posts you want to read or reread.

It was a lot of fun to review, as I clearly remember writing and the events preceding each post. It ended up taking quite awhile to read through all of the posts and make some kind of order out of the smorgasbord of my life. As such, I want to thank my #1 supporter, my husband Chuck. He initially set up the blog and is my editor and problem solver. He also patiently endures the times (like now) when I spend “our” Saturday night at the keyboard.

I began Five Years Plus in the dead of winter, on the eve of the five year anniversary of my breast cancer diagnosis. The act of starting the blog spun me into a period of over-excitement and sleep deprivation which I chronicled in Good Night Sweet Princess.  The response to this on and off-line was striking, with people sharing their own mood issues so openly and honestly. In my third post I introduced my struggles with over-eating and the constant vigilance it takes to feed myself properly.

The subject of eating is a big part of my life and has likewise been featured in a number of blog posts. In Special Breakfast I introduced the general idea of food as medicine and that eating well is an act of self-love. At times I included recipes which reflect the changing seasons, such as cabbage soup in winter (a reminder of the simple good things in life) and coconut ice cream in summer. I have written about foods that I use, like eggs or the sugar substitute stevia, and those that I’ve moved away from for health reasons, such as soy.

With the coming of spring I got fired up about eating locally, writing a series on this topic and coming up with four keys to get started:

1. shopping at local farmers’ markets
2. sourcing local pasture raised meat and eggs
3. subscribing to a CSA (community supported agriculture)
4. supporting local foods restaurants

As summer and berry season rolled around I think it’s appropriate to add a fifth key: pick local (organic) berries

Currently there are further options for both budding and experienced “locavores”. Tomorrow is the first day of Madison County’s “Buy Local Week” which includes an opportunity to discover some of the 33 local farms that are opening their gates to visitors on Saturday, July 24. There is also a new I-phone app that directs one to local foods in upstate New York.

In addition to being dedicated to eating locally whenever possible, I am committed to the Paleo diet that features meat, fish, eggs, plenty of vegetables, fruit and some nuts and seeds, thereby resembling what our Paleolithic ancestors may have eaten. Although I was a vegetarian for many years I now choose to include meat in my diet. I have to admit, I find it an ongoing challenge to eat in accordance with my intentions, especially when eating out or on vacation. Even so, I have managed to lose 10 pounds and am maintaining a comfortable healthy weight. One of my most enjoyable eating journeys and something I would like to explore further was a period of paying deep attention to the way I eat.

When we think about taking care of ourselves, diet and exercise come to mind first. Moving my body is fundamental to my own well-being and my work outside our home is dedicated to teaching others to be present in their bodies through yoga and tennis. I credit tennis with helping me “get back into life fully” after my breast cancer treatment and continue to better myself through competition. The desire to play tennis well helps fuel my motivation for working out two or three times each week. I am so happy every time I effortlessly move from a deep squat to standing, as this is an improvement that is a direct result of working out.

Although my experience with breast cancer has infiltrated every aspect of my life, I see that only a few posts relate specifically to cancer or medical issues. I outlined ideas for getting started on an alternative path when first being diagnosed and written some advice about do’s and don’ts when dealing with friends who have been diagnosed. I touched on iatrogenic (medically) caused illness and the uncertainty of imaging techniques through a story about my beloved cat. I am also well aware that I have not settled my inquiry into breast screening techniques and that my next oncologist appointment is approaching. I have already started researching the effects of ionizing radiation (i.e. mammograms) on breast tissue health, so you can expect to see this soon.

Writing this blog does take a tremendous amount of time and determination. In return, it helps me to live a more examined life and to believe that perhaps through my efforts I am making a difference. As I reflect over this past six months I recognize that I have made positive changes in my life. My diet has improved, my workouts are regular and my sleep and moods are in equilibrium. At the same time I see there are areas where I continue to struggle and need more awareness and self-love.

I really appreciate you reading Five Years Plus, commenting and passing the link along to others who might enjoy it. If you want to have each weekly post automagicallly delivered to your Email inbox, fill in your address and click on “Email Subscriptions” on the right side of this page. Beware though, you need to open a confirmation Email which may end up in your “junk” folder. I believe we all have a great deal to share with one another and I intend to continue to learn to harness the power of the internet to benefit all of us.

The Cream of the Crop

This week we have experienced extremely hot, humid days that remind me of living in the tropics. In 1991 I spent the summer in Mysore, India, studying yoga with Pattabhi Jois. On my bike ride home after each morning’s vigorous sweaty practice, I stopped at the coconut vendor’s stand to replenish my energy with the satisfying fluid and white succulent flesh of a young coconut. My coconut vendor knew I preferred plenty of water and a minimum amount of flesh. After tapping a number of the round, green coconuts to listen to each ones distinctive sound, he would choose one, hack it open with his cleaver and let me pick out a colorful straw. After I had savored the sweet, clear liquid I would hand it back, asking him to “open”. He would carve a scraper from the coconut husk itself and expertly split the coconut  into two for me to scoop out the thin layer of slippery innards. (This photo by Vikas Kamat shows a common method of coconut transport in India.)

Now, nearly twenty years later, my husband hacks open the young coconut I buy from our grocery store with the precision gained from a couple of months of practice. These coconuts appear to be an off-white color because the outer skin has been stripped away to give a flat-bottomed and pointy topped shape (see photo below from Melissa’s website). Inside this lies the seed of the coconut. The water inside is completely hygienic and under slight pressure. The amount of flesh clinging to the inside of the nut varies considerably; when scraped away it can yield between a couple of tablespoons to a cup or more of pulp. Coconuts with more pulp generally contain less water. These tender coconuts are picked before they are ripe when the liquid inside is sweet, almost clear, and the flesh is soft, thin and easily separated from the shell.  Mature coconuts from which the familiar dessicated coconut is made are different. They have thick white flesh and a cloudy, perhaps bitter liquid inside.

Since I committed to a Paleo diet, young coconuts have found their way into our diet. Coming from Thailand, I realize that they are a long way from local but I make an exception because they are such a wonderful healthy treat and remind me of my years living in India. I chose coconut as the base when I decided to create a raw, vegan, paleo, sugar-free ice cream recipe. I recommend using whole young coconuts if you can. They taste so pure and you can blend both the pulp and coconut water together, rather than only getting the blended meat that canned coconut milk is made from.

The coconut oil in this mix is not only good for the hair and skin, but also bestows a plethora of health benefits, contributing to stress relief, maintaining cholesterol levels, weight loss, increased immunity, proper digestion and metabolism, relief from kidney problems, bone strength and dental health. Coconut oil has also been associated with improvements in conditions such as heart disease, high blood pressure, diabetes, HIV, and cancer. The main active ingredients providing these benefits appear to be lauric acid, capric acid and caprylic acid which show antimicrobial, antioxidant, antifungal, antibacterial and anti-inflammatory properties. Specifically, digestion converts lauric acid into monolaurin which appears to be active against the viruses causing influenza, herpes, AIDS and others. It also appears to thwart disease caused by harmful bacteria such as listeria monocytogenes and heliobacter pylori, and harmful protozoa such as giardia lamblia.

Ginger Coco-Cream

• 2 young coconuts – use all the pulp and up to 1½ cups of the water (or 2 – 13.5 oz cans of coconut milk)
• 4 tsp ginger juice, grated ginger or ginger powder
• 4-6 soaked, pitted dates or 2 tbsp xylitol
• 8-12 drops liquid stevia

With cleaver, open the coconut and drain out liquid. Chop coconut in half. This takes some force, as if splitting wood. Use an upside down spoon to peel the flesh out of shell. Remove any hard bits and rinse if needed. Blend flesh from the 2 coconuts with 1.5 cups of coconut water. You will probably end up with extra water which you can drink straight or add to homemade almond milk. If you have a juicer, simply juice the whole ginger root – no need to peel. Add remaining ingredients and blend thoroughly. Freeze using an ice cream maker of your choice. Makes about 4 one cup servings.

Chocolate Coco-Cream

• 2 young coconuts – use all the pulp and up to 1½ cups of the water (or 2 cans coconut milk)
• 6 tbsp cocoa powder
• 1 tsp cinnamon
• 1 tsp vanilla
• Pinch cayenne
• 4-6 soaked, pitted dates or 2 tbsp xylitol
• 12-16 drops liquid stevia
• ½ cup lightly chopped raw macadamia nuts (optional)

Follow directions as above. I make this recipe with a raw cacao powder that is grown and produced in Bali, Indonesia. Its flavor has incredible depth that is makes this product well-worth the effort to find.

Coco-cream is meant to be enjoyed in small quantities. Although made from top quality ingredients, it is a concentrated high calorie, high fat food. I serve it in small ceramic bowls so we get the feeling of eating a full dish. It is best to eat it right away as the texture is best right out of the ice cream maker. Because it does not contain emulsifiers, it will freeze solid if you put it in the freezer. In this case, simply let it soften up at room temperature before eating.

Making your own ice cream takes a considerable amount of effort and equipment. However, it is very satisfying to create such a delicious treat and you know exactly what is in it.

The Ninth Life

July 1 is my dad’s birthday, Canada Day which commemorates the birth of Canada where I was born and the one year anniversary of the rebirth of Ivy, our cat. As I awaken to the “cat alarm” (her incessant meowing outside the bedroom) at 6 am, my annoyance is tempered with gratitude that she is still alive.

Most people have heard that pets are good for the health of their human companions. They can help to improve mood, reduce stress, lower blood pressure and provide unconditional love, which can lift depressed spirits and extend life. Ivy also seems to have special powers and her former cat-sitter identified her as a “natural healer”. For example, when I am experiencing insomnia, she will rest on my belly for as long as it takes for her tender purring to bring relief.

Ivy was born in a barn. Luke found her on an annual sojourn to Lucksinger’s tree farm. “Since its Christmas time, let’s call her Ivy”, the kids suggested. Chuck nicknamed her after Avalokitesvara, the Bodhisattva of great compassion. She certainly embodies the quality of steadfast commitment to her family, coming back time and time again to shower us with her love even when we, tangled in our busy lives, reject her approaches. Both Chuck and I are allergic to cat dander, so any physical contact must be followed by hand washing and sometimes clothes washing. Even so, Ivy is such a special cat that we feel blessed to have her in the family.

During the spring of 2009 Ivy was noticeably depressed, showed no interest in going outside, was overweight, and having some issues with her teeth. I thought she might have diabeties and took her to the vet for some tests. Her blood work showed anemia and we put her on vitamins and a course of antibiotics in preparation for surgery on her teeth. Within ten days she suddenly began to vomit severely. Hours later her breathing was labored and I feared she might not survive the night.

The next morning she was still alive, but breathing with difficulty. After more blood work and some x-rays, Chuck was shown a fuzzy slide that supposedly revealed “extensive cancer”, pronounced as certain to be terminal. The vet suggested we consider her “quality of life” and say our good-byes, but agreed to give her intravenous fluids over the next day. We had the kids and a few friends come by and I spent every available moment with her, appreciating the little time I had left. There were many tears. Each day thereafter we took her to the vet for intravenous fluids. When she arrived home she would take a few wobbly steps before collapsing into her makeshift nest in the laundry room. I could not entice her to eat or drink anything, but she did not seem to be in pain or worsening so we could not bring ourselves to put her down.

Nine days into the ordeal, a friend who is a vet warned us that when cats stop eating, especially overweight ones, they face the danger of developing hepatic lipidosis, a life threatening condition whereby fat being burned for fuel is not fully metabolized and ends up accumulating in the liver tissue. At this point we noticed she actually did better when not having the stress of the daily vet visit, so we kept her at home and began to force feed her, slipping small amounts of watered down wet cat food into her mouth. We thought it was a good sign that she fought us all the way. By the end of the second week she drank a little water on her own and licked some heavy cream off my finger. Every day, Chuck held her and fed her with a syringe until one morning she had had enough and started eating on her own again.

It’s been a year and I think we’ve finally figured out what works best for her food. Since her teeth are not strong, she primarily eats high protein canned food and no longer chows down the dried kibble that made her so fat in the first place. She also enjoys chicken, salmon, scallops and shrimp. I supplement her food with vitamin paste and cod liver oil. I know there is a theory that cats should eat raw food only, but she is doing so well that I hate to meddle. Marveling at Ivy sprinting across the garden and bounding through the stone path this afternoon, it’s hard to believe she ever had cancer. The truth is she didn’t.

Blurry x-rays images are difficult to read even for experts. Human x-rays are read by experienced radiologists and there is still a risk of false positives and negatives. For example, most suspicious mammograms do not result in a cancer diagnosis. It is estimated that of 1000 women receiving a mammogram, 70 are called back for further imaging. Ten of these 70 will have biopsies, and of these 10, 3.5 will be diagnosed with cancer. To put it another way, 95% of women called back for additional screening after a routine mammogram don’t have cancer. On the other hand, receiving a negative result on a mammogram doesn’t guarantee that the breasts are cancer-free. The National Cancer Institute estimates that about one in five cancers present at the time of screening are missed by mammograms.

So, if Ivy didn’t have cancer, what made her so sick? I have no way to prove this, but my suspicion is that she had an adverse reaction to the injectable antibiotic I had been giving her for 10 days prior. Although none of my Internet research reported a reaction as strong as this, nausea and vomiting are common side effects of Baytril. Negative reactions to drugs are very common in humans as well and is the number one cause of iatrogenic death (death brought about  by a “physician’s activity, manner, or therapy”). It’s rather shocking that 225,000 deaths per year may be iatrogenic, making this the third most fatal disease in the United States.

So perhaps our cat’s illness was iatrogenic and then misdiagnosed as cancer by a false positive reading of an x-ray. To this day it remains a mystery, as does the mechanism behind her recovery. I do feel quite certain that our love played a large part in her healing. We believed in her and were not willing to give up. Of course medical treatments are often an important component of healing. However, one must not underestimate the power of love.

Strawberry Fields

Strawberries are the most popular berry worldwide and are available all year round from Californian or imported sources. Here in upstate New York the local strawberry season is brief,  sandwiched between  summer solstice and the fourth of July. I have picked berries with my good friend Bodhi for three years now. Yesterday we finally found a day we were free and Cobblestone Farm’s organic strawberry patch was open. By chance Deb and her daughter Mel were able to join us.

Strawberries are one of the foods I aim to always eat organic, as conventionally grown ones are heavily sprayed. In fact, this year strawberries are number 3 on the Environmental Working Group’s “Dirty Dozen” list. This list rates the conventionally grown fruits and vegetables most likely to contain high pesticide residues, even after washing. Eating organic (where pesticide use is prohibited) or eliminating these most contaminated foods can reduce ones exposure to pesticides by 80 percent. It’s really worth following the link to check these foods out; for those of you who want to read it here, starting from the worst, here are this year’s “dirty dozen”: celery, peaches, strawberries, apples, blueberries, nectarines, bell peppers, spinach, kale, cherries, potatoes and grapes.

According to the Environmental Working Group, up to 59 pesticides were detected in residue on strawberries. The PAN Pesticides Database is a document that quantifies the amount of 50 common pesticides used on Californian (the primary strawberry growing state) fields. In 2008 a whopping 9,686,580 pounds of pesticides were applied, amounting to an average of 7 pounds of pesticides for every acre of strawberry fields treated (some acres are treated more than once).

"A dense canopy of leaves"

Methyl bromide, one of the pesticides used on conventionally grown strawberries, has received a great deal of attention worldwide. It is a colorless, odorless gas that is used as a soil fumigant to help control weeds, soil-borne diseases, nematodes and insects. Respiratory, kidney and neurological effects are noted health risks and farm workers are particularly susceptible. Methyl bromide is also a recognized ozone depleting chemical. In response to a 2002 amendment to the Montreal Protocol of 1987, its use is being phased out for all uses in all countries. While this was intended to be completed by 2005 in America, a “critical use” exemption has extended this deadline in some areas. The PAN report shows that 2.7 million pounds were still being applied to Californian strawberry fields in 2008. The irony is that organic growing methods are available, can be even more profitable than conventional methods and do not use chemicals that are toxic to the ozone, the earth, farm workers and consumers.

I picked about 30 pounds of chemical-free berries in just over two hours. Not only is picking strawberries physically demanding, it’s a bit of a hunt. The berries are hidden under a dense canopy of leaves and especially in the case of organic strawberries, weeds. I alternate between bending over with a straight back, squatting and later in the morning, picking from my hands and knees. This latter method only works when the berries are plentiful, which fortunately for us, was the case yesterday morning. Below are some picking tips I have developed over the years:

1. Arrive early.
2. Remember to bring containers to put picked berries in and a few extra just in case you strike a bumper day.
3. Resist the temptation to pick the berries where the pointy tip is still green or white. They aren’t ripe and strawberries won’t ripen further once picked.
4. Pay attention to your body mechanics and stop before you drop.
5. Remember it takes at least as long to prepare the berries when you get home as it did to pick them.

Deb & Mel: the "straight back" method

Of course, strawberry grazing on the field is one of the highlights of the pick your own experience. I find biting into a strawberry an adventure. Even when choosing that perfect berry to sample, I never know for sure whether it will be bursting with the essence of sweet, deep strawberry-ness or be mouth-puckeringly tart. Each berry is a little different and I pay attention to its unique flavor even as I continue to pick.

Bodhi: the "squatting" posture

What do I do with all those berries, you might ask? I like to eat strawberries year round, as according to Ann Louise Gittleman[1], they contain a cancer-protective agent called ellagic acid and a phyto-nutrient that helps the liver break down excess toxins. So besides a two week in-season feast, I mainly freeze them whole with stems removed to use in smoothies and with Special Breakfast.  I am taking the extra time to first freeze them flat on a cookie tray before bagging them, as last year they stuck together, retained a lot of moisture and became icy. I am also planning to make ice cream (more about this in a future blog) and some strawberry-rhubarb jam for my sister. In the meantime each time I open my fridge I am transported back to the strawberry field by sight and smell. Summer is definitely here.

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[1] Fat Flush Foods, New York: McGraw Hill, 2004