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Thursday, September 5, 2019

A soaring maternal mortality rate: What does it mean for you?

A new guideline from the World Health Organization (WHO) aims to help reduce steadily rising rates of caesarean sections around the globe. While crucial at times for medical reasons, caesarean births are associated with short-term and long-risks health risks for women and babies that may extend for years.

In June 2018, Serena Williams told Vanity Fair about her journey to motherhood, including the story of how she nearly died a few days after giving birth. In September, Beyoncé punctuated her Vogue cover with the story of how she developed a life-threatening pregnancy condition called preeclampsia, which can lead to seizures and stroke. Throughout the summer, headlines like “Dying to Deliver” and “Deadly Deliveries” and “Maternal Mortality: An American Crisis” popped up on newsfeeds and streamed on screens across America.

As a professor who studies safety in pregnancy, I was quoted in many articles and media features. I explained what the harrowing stories indicate about our health systems, our public policies, our society at large. But as an obstetrician, I’ve been puzzling over how to explain to my patients what this means for them individually. And my pregnant wife, who is due any day, has been noticing the headlines too.
What is maternal mortality?

Typically, deaths that occur due to complications of pregnancy or childbirth, or within six weeks after giving birth, are recorded as maternal mortality.
What do the statistics tell us?

In 1990, about 17 maternal deaths were recorded for every 100,000 pregnant women in the United States. While relatively rare, this number has risen steadily over the last 25 years, indicating a worsening safety problem. In 2015, more than 26 deaths were recorded per 100,000 pregnant women. This means that compared with their own mothers, American women today are 50% more likely to die in childbirth. And the risk is consistently three to four times higher for black women than white women, irrespective of income or education.

Additionally, for every death, pregnancy-related conditions, such as high blood pressure or blood clotting disorders, result in up to 100 severe injuries. For every severe injury, tens of thousands of women suffer from inadequately treated physical or mental illnesses, as well as the broader disempowerment mothers face in the absence of paid parental leave policies and other social support.
Are the statistics misleading?

The root cause of these startling statistics is often misunderstood. The public image of maternal death is a woman who has a medical emergency like a hemorrhage while in labor. However, very few deaths counted in maternal mortality statistics occur during childbirth. Rather, four out of five of these deaths happen in the weeks and months before or after birth. So, they occur not in the hospital, but in our communities. And they represent many failures — not just unsafe medical care, but also eroding social support necessary for women to recognize medical warning signs, like abnormal bleeding or hopelessness about the future, and to seek timely care.

A few days after having a baby, American women are sent home from the hospital, infant in hand. More often than not, mother and family are left on their own until a cursory 15-minute visit with a healthcare provider several weeks later. During long gaps between checkups, mothers experience deep worry for their infants. They struggle with rapidly accelerated responsibilities, extreme sleep deprivation, and relentless pressure to return to work. And all while recovering from pregnancy and adjusting to parenthood — a transition that marks one of life’s greatest physiological endurance tests. Too often, this experience is isolating, disempowering, and mortally dangerous.  And over time, these risks are getting increasingly severe.
What can we do to help?

Undoubtedly, clinicians and hospitals can do more to ensure the safety of women giving birth. For example, they can issue health guidelines and run simulations to better prepare to handle emergencies. Policymakers can do more, too, including tracking maternal mortality so that failures like delays in lifesaving care can be identified and fixed.

In some cases, moms can do more to take care of themselves, including by eating well and exercising to stay healthy. The challenge, of course, is that most new moms are exhausted because motherhood is exhausting. And in general, society expects moms to put themselves last in order to put their families first.

So, I would say a major responsibility to address the well-being of mothers actually lies with the rest of us. If rising maternal mortality is fundamentally a failure of social support, we all need to step up: birth partners, grandparents, friends, neighbors, professional colleagues — all of us. All people are vulnerable during the period surrounding the birth of their child. But in the United States, we forget to advocate for ourselves and for each other. We need to listen to moms. And we need to support them. After distilling all the data, and reading all the headlines, I believe saving their lives is as simple as that. While we know that breastfeeding has many health benefits for mothers and babies, the studies have been a bit fuzzy when it comes to the link between breastfeeding and preventing obesity in children. Some studies show a clear link, but in others that link is less clear. A new study published in the journal Pediatrics may help explain the fuzziness. It showed that what really helped prevent obesity was getting breast milk directly from the breast.

That’s not to say that drinking expressed breast milk from a bottle isn’t healthy. After all, it’s the food that was explicitly designed for infants — and in the study, babies that got breast milk from a bottle did have lower rates of obesity at 12 months. Some of that benefit is thought to be related to the microbiome that breast milk helps create. Babies who drink breast milk are more likely to have certain bacteria in their digestive tracts that help prevent obesity.

But the babies that had the lowest risk of obesity in the study were those that got only breast milk directly from the breast for the first three months of life. Why would that be?

To be able to breastfeed directly from the breast for three months, you have to be able to be with your baby constantly for three months. Mothers who can do that either have access to paid maternity leave or have enough resources to take an unpaid leave — or to stay at home with their babies and not work outside the home at all. Studies have shown that mothers who breastfeed longer are more likely to have higher incomes, more education, and private insurance.

These, then, are mothers who are also more likely to have access to and be able to afford healthy foods, to live in areas where there are safe places to exercise — and to be able to pay for sports and other forms of exercise as their children grow. It’s not just about how these babies are fed, but also about the context in which they are born and raised.

The way in which they are fed, though, is important. Babies who feed directly from the breast are less likely to be overfed. When they are full, they stop sucking, or switch to a “comfort” kind of sucking that doesn’t produce milk. When babies are fed from bottles, parents and caregivers are more likely to push them to finish the bottle; feeding becomes a bit less about appetite and more about volume and schedule.

Learning to eat only when you are hungry and stop when you are full is a really good skill when it comes to preventing obesity. That’s why the American Academy of Pediatrics has encouraged parents to learn and use “responsive feeding,” that is, responding to the cues of babies and children of both hunger and being full. The motto is, “You provide, your child decides.”

What this study helps us see is that the link between breastfeeding and obesity prevention is part of a bigger picture we need to pay attention to if we want to fight the obesity epidemic. It shows us that we need to:

    Do everything we can to help mothers stay at home with their babies for at least three months, which will require paid maternity leaves. The United States is way behind the rest of the world in this.
    Help all parents, regardless of how they feed their infants, learn about responsive feeding, and thus help their babies learn to eat when they are hungry and stop when they are full.
    Understand obesity risk as part of a bigger societal issue — truly, as a social justice issue. All children need — and deserve — access to healthy foods and exercise, and there is more we can do to make this happen.
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Home cooking: Healthy family meals

During the first year of life, naps are crucial for babies (who simply cannot stay awake for more than a couple of hours at a time), and crucial for parents and caregivers, who need breaks from the hard work of caring for an infant.

But as children become toddlers and preschoolers, naps aren’t always straightforward. Children often fight them (following the “you snooze you lose” philosophy), and they can conflict with daily tasks (such as school pick-up when there are older siblings) or lead to late bedtimes.

Here are some tips for making naps work for you and your child — and for knowing when they aren’t needed anymore.
Making naps work for your baby

Most infants will take at least two naps during the day, and early in toddlerhood most children will still take both a morning nap and an afternoon nap. Naps are important not just for physical rest and better moods, but also for learning: sleep allows us to consolidate new information. As children get older, they usually drop one of the naps, most commonly the morning nap.

Every child is different when it comes to napping. Some need long naps, some do fine with catnaps, some will give up naps earlier than others. Even within the same family, children can be different. A big part of making naps work is listening to and learning about your child’s temperament and needs. Otherwise, you can end up fighting losing battles.

The needs of a parent or caregiver are also important: everyone needs a break. Sometimes those breaks are particularly useful at specific times of the day (like meal prep time). While you can’t always make a child be sleepy at the most convenient time for you, it’s worth a try — which leads me to the first tip:

Schedule the naps. Instead of waiting for a child to literally drop and fall asleep, have a regular naptime. We all do better when our sleep routines are regular, even adults. If you can, put the child down awake (or partially awake). Learning to fall asleep without a bottle or a breast, or without being held, is a helpful skill for children to learn and can lead to better sleep habits as they grow.

A couple of scheduling notes:

    If you need a child to fall asleep earlier or later than they seem to do naturally, try to adjust the previous sleep time. For example, if you need an earlier morning nap, wake the child up earlier in the morning. It may not work, but it’s worth a try.
    Naps later in the afternoon often mean that a child won’t be sleepy until later in the evening. That may not be a problem, but for parents who get tired early or need to get up early, it can be. Try to move the nap earlier, or wake the child earlier. If the problematic afternoon nap is in daycare, talk to the daycare provider about moving or shortening it.

Create a space that’s conducive to sleep. Some children can sleep anywhere and through anything, but most do best with a space that is quiet and dark. A white noise machine (or even just a fan) can also be helpful.

Don’t use screens before naptime or bedtime. The blue light emitted by computers, tablets, and phones can wake up the brain and make it harder for children to fall asleep.
When is it time to give up naps?

Most children give up naps between the ages of 3 and 5. If a child can stay up and be pleasant and engaged throughout the afternoon, they are likely ready to stop. Some crankiness in the late afternoon and early evening is okay; you can always just get them to bed earlier.

One way to figure it out, and ease the transition, is to keep having “quiet time” in the afternoon. Have the child go to bed, but don’t insist on sleep; let them look at books or play quietly. If they stay awake, that’s a sign that they are ready to stop. If they fall asleep but then end up staying up very late, that’s another sign that the afternoon nap needs to go.

Whether or not your child naps, having some quiet time without screens every afternoon is a good habit to get into. It gives your child and everyone else a chance to relax and unwind, and sets a placeholder not just for homework but also for general downtime as children grow — and just like naps for babies, downtime for big kids is crucial.
There is no way to meet the need for substance abuse treatment through the current healthcare system. The number of people who need treatment for drug and alcohol abuse is far greater than the number of clinicians available to treat them. In more rural areas, patients might have to spend a lot of time traveling great distances to appointments, which can be difficult to do while working or taking care of a family. And, the cost and stigma of treatment can get in the way of getting help. Moreover, even if people do get to substance abuse treatment, they often do not receive the most effective ones. As illicit drug use increases in the United States, new ways to deliver treatment are urgently needed.

Computer-guided treatments are one way to overcome the hurdles of access to evidence-based treatments, including travel and scheduling, cost, and stigma. Additionally, using computers to treat one’s own substance abuse can be empowering, giving a sense of “I did it on my own.”
How well do computer-guided treatments work compared to live counseling?

Researchers from Yale University recently developed and studied the “Computer-based Training for Cognitive-behavioral Therapy” (or “CBT4CBT”) web-based substance abuse treatment as a fully standalone intervention. CBT4CBT provides cognitive behavioral therapy (CBT) — an evidence-based treatment for substance abuse. The treatment is completely computer-guided, and does not involve interacting with a counselor or other healthcare professional. It combines online games and video vignettes with actors to teach how to manage one’s own substance use. Specifically, CBT4CBT covers: how to understand and change patterns of substance use; dealing with cravings; refusing offers of alcohol and drugs; problem-solving; noticing thoughts about drugs and alcohol and how to change them; and strengthening decision-making abilities.

Earlier research has shown that CBT4CBT can be an excellent complement to make live treatment with a counselor more effective and efficient. Recently, the research team conducted the first comparison of any standalone web-based treatment for substance abuse to “treatment as usual” — and data suggest that it may be better.
The study on CBT4CBT

The Yale team recruited 137 people seeking substance use treatment from the Connecticut Mental Health Center in New Haven; 49% African American, 34% Caucasian, and 8% Latino or Latina. Substances used were marijuana, cocaine, alcohol, opioids, and PCP. It was a real-world sample in that most participants used more than one illicit drug and most also used alcohol.

One-third of the participants were randomized to use CBT4CBT, with 10-minute in-person weekly checkups to evaluate their overall functioning, their safety, and their use of the online program. One-third of participants were enrolled in “treatment as usual,” which was either group or individual therapy, and covered topics including motivational interviewing, life skills, relapse prevention, harm reduction, mindfulness, and others. The other third were assigned to in-person CBT with a therapist who delivered the same type of content as the CBT4CBT online program.

The researchers found that drug use (measured by urine tests — which corresponded closely with self-reported use) in the CBT4CBT group was significantly less than treatment as usual, and remained lower over six months of follow-up. Persons who received live CBT had the same level of drug use as the treatment as usual group after six months. They also found that participants in the online treatment learned the CBT concepts the best, and had the highest level of satisfaction and lowest dropout rate of any of the three study conditions. Overall, after treatment the percentage of days abstinent from any drug use was 75% for the CBT4CBT group, vs. 67% of days abstinent for the treatment as usual group and 61% for the live CBT group. The study did not enroll a large enough number of participants to conduct a head-to-head comparison of CBT4CBT and live CBT. That may come later, and the results could inform how to conduct live CBT more effectively.
Getting access to computer-guided CBT

Computer-guided CBT for substance abuse should be studied further should be studied further, with different populations and in different settings, the next real challenge is to disseminate it widely across the US and beyond. According to its website, the CBT4CBT program is not yet available to the public, outside of clinical trials.

Building computer-guided treatment programs is often easier than building companies to deliver them. Barriers include acceptance by institutions, payment by insurance companies, liability, FDA approval, and resistance from healthcare providers — as well as coming up with viable business models. But if these obstacles can be overcome, the world could benefit from a highly effective and accessible treatment for drug and alcohol abuse. Family meals are beneficial for so many reasons. People who prepare meals at home tend to consume significantly more fruits and vegetables, and less sugar and fat. People who enjoy meals at home with others, sitting together and conversing, also have reduced stress and higher life satisfaction. The more frequently families with children have meals together, the more likely the children are to eat a high-quality diet, and the less likely to be overweight or obese. There are also other benefits: these children tend to have higher self-esteem and better academic performance, as well as lower risk of engaging in risky behaviors (like drug use) or developing an eating disorder.
Family meals without distraction

All those benefits go out the window if dinner is eaten in front of the television or other devices. This makes sense if we think about why the family meal has such powerful positive effects: it’s about closeness and connection. Sitting down to eat together is often the only time families can reconnect and communicate. Given our busy, technology-driven lives, the family meal is a rare (and critical) opportunity to unplug and check in. What’s even better is getting the kids involved in making dinner, which is also significantly associated with their eating a higher-quality diet.
One of my favorite family meals: Make-your-own soft tacos

The kids can get involved in preparing this simple and healthy meal, which is incredibly rich in protein and fiber, as well as calcium, iron, and potassium. Beans provide plenty of heart-healthy fiber, protein, and are associated with a lower risk of diabetes. Corn and masa (the tortilla flour made from corn) are considered whole grains and are loaded with vitamins and minerals. Avocados and olives provide heart-healthy fats, and the veggies are risk in fiber, vitamins, and antioxidants. All these easy-to-find ingredients, plus healthy veggies, the option of dairy, and protein from the pumpkin seeds, make this nutritious and fun to prepare with the family — and everyone will love that they can build their own taco!
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steps toward a successful exercise resolution

Writing in the October 10, 2018 New England Journal of Medicine, Eve Rittenberg, MD, assistant professor at Harvard Medical School and practicing physician at Brigham and Women’s Fish Center for Women’s Health, reflects on the impact the Kavanaugh hearing and #MeToo movement have had on patients who have experienced sexual violence. Important principles of trauma-informed care—including ways to ask permission, offer control, and find support—described in her article and in Monique Tello’s post below can make a real difference to many women and health care professionals alike.

Many years ago, when I was a trainee, I helped take care of patients at a family medicine clinic.* One day, a school-aged brother and sister came in for their annual physicals. They were due for vaccines. Neither wanted any shots, and they were both quite upset. “You’ll do what the doctor tells you, is that clear?” ordered the mother. She and the nurse worked together to hold the sister’s arm down. But just as the nurse was about to deliver the injection, the young girl jerked her arm away and ran to the opposite corner of the room, crying. The brother then ran over and stood in front of her, his arm outstretched, guarding, and yelled “Get away! Leave her alone!” At first, the focus was on forcing them to have their shots, which were required for school. But it only made things worse. The young girl screamed, the boy fought, no one could calm them, and everyone was annoyed.

One of the senior doctors finally conceded: Let them go, we’ll have to work on this. But that family never returned.

Months later, we learned that the children had been removed from the home by the Department of Children and Families, for parental abuse. I could only imagine what had been happening.

*This vignette is based on a composite of several cases I have been involved with over the years. All potentially identifying details have been changed to protect patient privacy.
The prevalence of trauma

The CDC statistics on abuse and violence in the United States are sobering. They report that one in four children experiences some sort of maltreatment (physical, sexual, or emotional abuse). One in four women has experienced domestic violence. In addition, one in five women and one in 71 men have experienced rape at some point in their lives — 12% of these women and 30% of these men were younger than 10 years old when they were raped. This means a very large number of people have experienced serious trauma at some point in their lives.

Medical exams by definition can feel invasive. They often involve asking sensitive questions, examining intimate body parts, and sometimes delivering uncomfortable — even painful — treatments. So, it is important that healthcare providers are mindful of the fact that so many people come to that healthcare interaction with a history of trauma.
Could the case I described have been handled differently?

There have been some recent news articles about a relatively new (and improved) way for health professionals to approach patients. This is called trauma-informed care. Dr L. Elizabeth Lincoln is a primary care physician at MGH who has trained medical professionals and students about approaching patient care with an understanding of trauma. She explains: “Trauma-informed care is defined as practices that promote a culture of safety, empowerment, and healing. A medical office or hospital can be a terrifying experience for someone who has experienced trauma, particularly for childhood sexual abuse survivors. The perceived power differential, being asked to remove clothing, and having invasive testing can remind someone of prior episodes of abuse. This can lead to anxiety about medical visits, flashbacks during the visit, or avoidance of medical care.”
What does trauma-informed care look like?

The first step is to recognize how common trauma is, and to understand that every patient may have experienced serious trauma. We don’t necessarily need to question people about their experiences; rather, we should just assume that they may have this history, and act accordingly.

This can mean many things: We should explain why we’re asking sensitive questions. I might say, “I need to ask you about your sexual history, so I know what tests you may need.” We should explain why we need to perform a physical exam, especially if it involves the breasts or genitals. If someone is nervous, we can let them bring a trusted friend or family member into the room with them. I’ve had many female patients hold someone’s hand during a pelvic exam. We can tell them that if they need us to stop at any time, they can say the word. If someone refuses outright to have a certain exam or test, or if they’re upset about something (like having vaccinations), we can respond with compassion and work with them, rather than attempting to force them or becoming annoyed.

For someone who has experienced trauma, the hospital or doctor’s office can be a scary place. Dr. Lincoln explains: “Patients often do not volunteer such information about prior experiences, because of guilt or shame. Medical professionals often ask about safety in a patient’s present relationships, but few ask about past experiences. A simple question such as, “Is there anything in your history that makes seeing a practitioner or having a physical examination difficult?” or, for those with a known history of sexual abuse, “Is there anything I can do to make your visit and exam easier?” can lead to more sensitive practices geared to developing a trusting relationship. Patients can advocate for themselves by explaining to physicians their anxiety about medical visits, why this is so, and what they have found helpful or harmful in prior healthcare encounters.”
Trauma comes in many forms

It is also important to note that there are many types of trauma. A colleague of mine has a child who survived a life-threatening illness. Prior to his ICU stay, he never flinched at vaccines; since his hospitalization, any needle sticks make him extremely anxious. Another colleague describes how after years of invasive infertility treatments, and despite becoming a mother, she sobbed uncontrollably at her simple routine gynecologic exam, because it touched such a nerve of helplessness and failure. Trauma-informed care is the open-mindedness and compassion that all patients deserve, because anyone can have a history that impacts their encounter with the medical system.

We as providers need to recognize that many, many patients have a history of physical, sexual, and/or emotional abuse, as well as serious illnesses and negative experiences in the medical setting, and we need to learn to respond with empathy and understanding.All too many women recognize the signals of a urinary tract infection, or UTI: pain and burning when urinating, coupled with a frequent urge to do so. A simple change in behavior could help prevent a common UTI known as recurrent cystitis in women, according to a randomized controlled study published in JAMA Internal Medicine in October 2018. The study showed that drinking more water daily led to fewer episodes of recurrent cystitis and less need for antibiotics.
What is cystitis and what causes UTIs?

Cystitis refers to an infection in the bladder, which most women know as a urinary tract infection. Cystitis is extremely common among women, partly because female anatomy increases the risk of infection due to the proximity of the urethra to the anus. Additional risk factors for cystitis include sexual intercourse, diaphragm use, spermicides and spermicide-coated condoms, and a prior history of cystitis. Women with diabetes and those who have abnormalities of the urinary tract are also at increased risk for cystitis.

The vast majority of infections (up to 95%) are caused by one bacteria, E. coli. Signs and symptoms of an infection include pain with urination, increased frequency of urination, and an increased urge to urinate.
What is the treatment?

Cystitis is treated with antibiotics for three to five days, depending on the antibiotic used.
Can UTIs be prevented?

If you’ve ever had cystitis, you may have heard suggestions that are mostly based on anecdotal evidence. To decrease risk for cystitis, women are advised to urinate after intercourse, drink cranberry juice, drink more fluids in general, and keep the perineal area that lies between the urethra and the anus clean. Evidence is mixed on whether these steps may help prevent cystitis. This study sought to provide direct evidence of the benefits of drinking extra fluids.
What did the study tell us?

The study participants were 140 premenopausal women who experienced three or more episodes of cystitis in one year and reported that they drank less than 1.5 liters of fluids daily, which is about 6 1/3 cups. The average amount participants drank daily was a bit over a liter (1.1 liters, or about 4 1/2 cups).

The women were randomized to one of two groups. Every day, one group drank their usual amount of fluids plus an additional 1.5 liters of water. The control group drank just their usual amount of fluids. The women kept journals recording the type and amount of fluids they drank in a day. Their urine was periodically measured for volume and tested for hydration status. The study discovered that women who drank an additional 1.5 liters of water had 50% fewer episodes of recurrent cystitis, and required fewer antibiotics than women who did not drink additional fluid.
Is it safe to drink this much fluid?

While the amount of extra fluids tested in the study may seem like a lot, the Institute of Medicine recommends that women have 2.2 liters daily, which is about 9 cups. Not all of this needs to come just from water — or even fluids. Fruits and vegetables, which are part of a healthy diet, contain a lot of water.

This study used a rigorous scientific method to evaluate the benefits and risks of an inexpensive and safe anecdotal treatment. While it has been suggested that substances in cranberry juice can decrease the risk of urinary tract infection, no studies have conclusively demonstrated its benefits. Water may be the best means to increase hydration because it is inexpensive and has no calories. Although this study focused on women who had recurrent cystitis, its results could be extrapolated for a lower-risk population as well.

If you’re a woman with symptoms of cystitis, such as pain or burning with urination, increased urgency and frequency, try to drink more fluids, but also call your health care team for evaluation. A simple urine test in conjunction with the symptoms you describe may provide enough information for your health care provider to confirm an infection and start you on a brief course of antibiotics.

Better still, going forward, you may be able to decrease the chance that you will develop an infection by drinking more water daily. It’s a simple solution readily available for prevention — and now supported by evidence!6 steps toward a successful exercise resolution
Many people have decided to try the ketogenic diet for weight loss. The most recent evidence shows that reducing your carbohydrate intake to a minimum may help you shed a few pounds, at least in the first few weeks to months. However, we don’t really know whether, over the long term, achieving and maintaining ketosis is better for weight loss than other diets. Almost any intervention can cause undesirable consequences, and the ketogenic diet is no different. One of the most well-publicized complications of ketosis is something called “keto flu.”
What is keto flu?

The so-called keto flu is a group of symptoms that may appear two to seven days after starting a ketogenic diet. Headache, foggy brain, fatigue, irritability, nausea, difficulty sleeping, and constipation are just some of the symptoms of this condition, which is not recognized by medicine. A search for this term yields not a single result on PubMed, the library of indexed medical research journals. On the other hand, an internet search will yield thousands of blogs and articles about keto flu.

It is tricky to describe exactly what happens after the diet change, because we are left with only our own observations and experiences. These symptoms may not even be unique to the ketogenic diet; some of my patients describe similar symptoms after they cut back on processed foods, or decide to follow an elimination or an anti-inflammatory diet.
What causes keto flu?

Well, we don’t really know why some people feel so bad after this dietary change. Is it related to a detox factor? Is it due to a carb withdrawal? Is there an immunologic reaction? Or is this a result of a change in the gut microbiome? Whatever the reason is, it appears the symptoms attributed to the keto flu may happen, not to everyone but to some people, after “cleaning up” their diet.
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