Nutritional Treatments for Hypertension: your guide to lowering blood pressure with diet and nutritional supplements

 

 

Download our new Hypertension guide--this is a work in progress derived from Dr Vasquez's new book on hypertension.  This free information will be updated weekly, so re-visit this page to get the newest edition.

 

 

 

 

CoQ-10 (Co-Enzyme Q-10) 100 mg, 60 caps

 

Summary: CoEnzyme Q-10 is a vital nutrient necessary in every cell of the body.  Generally, the body makes enough to support normal function.  However, some people—especially patients with asthma, allergies, migraines, high blood pressure, and a type of heart failure called idiopathic dilated cardiomyopathy—do not make enough in their bodies to support optimal health. These patients often benefit from CoQ10 supplementation.  Patients with high blood pressure and patients taking “statin” drugs generally also benefit.

Use: 1-5 capsules per day to provide 60-300 mg per day.  60 mg per day is the minimal dose.  Most research studies and doctors working with patients use 180-200 mg per day.  CoQ-10 is best taken with a small amount of fatty food, since timing the consumption of fat with taking the CoQ-10 supplement will enhance absorption of this fat-soluble nutrient.

Benefits:

• Antioxidant--protects cells from free radicals and the aging process,

• Neuroprotective--protects brain cells,

• Immunosupportive--supports healthy immune function; appears to provide benefits for patients with allergies and chronic viral infections,

• Cardioprotective--provides numerous cardiovascular benefits.

Cautions: CoQ-10 may interfere with the absorption of Coumadin/warfarin.

See more details below

 

Everything you need to know about CoQ-10: an excerpt from Dr Vasquez's book "Patient's Guide to Hypertension (High Blood Pressure): An Evidence-Based Review of Diet, Nutrition, Exercise and Integrative Therapeutics"

Introduction and Summary: Co-enzyme Q-10 is also called “ubiquinone” (you’-bick-win’-öne), CoQ-10, and Co-Q. Here, we will refer to it as CoQ-10; it is found in every cell of the body, where it is produced from cholesterol. While it is also available in limited amounts from food (average dietary intake of CoQ-10 is 2-5 mg/d), most CoQ-10 in the body is made endogenously. Some patients—particularly those with migraines, asthma, hypertension, allergies, heart failure and a heart disease called idiopathic dilated cardiomyopathy—may have an inborn or acquired error of metabolism that prevents them from making sufficient amounts of this vitally important substance. These patients tend to benefit from supplementation with CoQ-10. The standard dose for supplementation is 180-240 mg per day according to most studies; however doses ranging from 60 – 1,000 mg can also be used.

 

Safety: Because it is present in every cell of the body and is required for life, CoQ-10 is very safe when taken as a dietary supplement. Hardly any risks are present for the vast majority of people. People taking the drug Coumadin (also known as warfarin) should take CoQ-10 a few hours away from their warfarin/Coumadin because CoQ-10 may interfere with the absorption of the drug; these patients should continue to have their regularly scheduled laboratory tests (ie, INR) in order to ensure that their medication continues to work properly. With very high doses of CoQ-10 in the ranges of 1,000 – 3,000 mg, some patients might show signs of mild liver involvement which is reversible when the dose is reduced; most patients don’t need to take such high doses and therefore CoQ-10 is very safe for the vast majority of people.

 

Laboratory testing: Laboratory testing is not required before the use of CoQ-10 supplementation, and certainly the vast majority of people who have benefited from and who have use CoQ-10 supplementation have done so without the use of laboratory testing. As mentioned previously certain diseases are associated with low blood levels of CoQ-10. Whether this deficiency causes the disease or results from the disease is sometimes not clear; but what is clear is that these patient groups tend to benefit from CoQ-10 supplementation. The conditions with the best research support for showing benefit from CoQ-10 supplementation are migraine headaches, asthma (particularly in children), high blood pressure (chronic hypertension), allergies, heart failure and a heart disease called idiopathic dilated cardiomyopathy. New research has also shown benefit for patients with chronic renal failure, including patients requiring dialysis. Typical blood levels of CoQ-10 range from 0.7-1 mcg/ml; however clinical benefit in the treatment of cardiovascular disease may require serum levels of 2-3 and up to 4 mcg/ml to attain maximal clinical benefit. While testing of serum CoQ-10 levels is not necessary before starting treatment; patients who do not benefit as expected should have their CoQ-10 levels measured and supplementation increased to attain optimal serum levels before deciding that treatment is ineffective. While clinical benefit may occur within the first week of supplementation, maximal improvement generally takes 4-8 weeks in order to obtain tissue saturation and beneficial changes in cell physiology.

 

Forms available: CoQ-10 has generally been produced and studied in its form as “ubiquinone” however some newer research suggest that the reduced form “ubiquinol” is better absorbed and is a more effective antioxidant; the clinical benefit of this newer form of CoQ-10 is not clear, and it’s increased cost may not be justifiable, particularly as CoQ-10 is already one of the more expensive nutritional supplements. Furthermore, CoQ-10 is available as a powder in capsules, as liquid gels, and in emulsified forms; generally, the dry powder provides the best cost-effectiveness. The other forms may provide slightly better absorption when taken on an empty stomach, but if CoQ-10 is taken with a small amount of fatty food, the absorption is about the same while the cost is certainly lower with dry CoQ-10 powder in capsules.

 

Clinical applications—CoQ-10 for High Blood Pressure (Hypertension): High blood pressure (increased pressure of the blood inside the arteries) causes damage to the artery walls and promotes occlusion of arteries; when the blood can no longer flow to the organ being serviced, the organ itself can be damaged (partially or completely) due to lack of oxygen and nutrient delivery. Occlusion of an artery servicing the heart can result in heart attack, while occlusion of an artery servicing the brain can lead to a stroke; occlusion of an artery to a limb or the intestine can cause that part of the body to be damaged or die. In addition to heart attack and stroke and other forms of peripheral vascular disease, chronic HBP can also cause heart failure and kidney damage. Effective lowering of blood pressure in patients with HBP is generally considered the single most important preventive measure in helping people avoid cardiovascular disease (any one of the triad of heart attack, stroke, or heart failure), hypertensive kidney damage, and peripheral vascular disease.

In hypertensive patients, CoQ-10 doses of 60-120 mg/d can typically lower BP by about -15/-9 mm Hg. CoQ-10 can be safely used with antihypertensive medications and is generally safer than antihypertensive medications. This is not necessarily to say that CoQ-10 is superior in all clinical situations when managing HTN; fast-acting drugs are needed in urgent and emergency situations. However, CoQ-10’s numerous collateral benefits and its superior safety make CoQ-10 a very reasonable treatment option for many people with HBP. In the paragraphs that follow here, various representative examples of published research will be reviewed to present CoQ-10’s beneficial effects on cardiovascular health.

Review: Role of coenzyme Q10 (CoQ10) in cardiac disease, hypertension and hearing disorders: In this excellent review that covers the role of CoQ-10 in the treatment of various cardiovascular diseases (heart failure, HTN, heart attack, arrhythmia, Kumar et al[1] review the research literature to conclude that CoQ-10 provides major clinical benefit in all of these conditions and without adverse effects. Cardioprotective properties of CoQ-10 include its role as an antioxidant, vasodilator, and membrane stabilizer in addition to its ability to decrease blood viscosity (ie, CoQ-10 makes blood flow more easily), proinflammatory chemicals called cytokines, insulin resistance (ie, CoQ-10 makes insulin work better; this is very important for diabetics), and to help the heart function as a more efficient pump. According to this review article, blood pressure reduction with use of CoQ10 can be as high as -18/-11, depending on dose, attained blood levels. To improve effectiveness, other common nutritional deficiencies such as magnesium, potassium, and vitamin D can also be addressed to improve effectiveness and to promote further normalization of blood pressure. Maximal improvement might take 4-8 weeks; however, some patients will respond more quickly—within the first week. Patients with HBP who are taking medications need to monitor their blood pressure on a regular basis so that once CoQ-10 begins to take effect (perhaps as soon as the first week), their drug doses can be reduced so that blood pressure does not become too low. By itself, CoQ-10 never causes blood pressure to get too low; however, if someone has high blood pressure due to CoQ-10 deficiency and then that deficiency is corrected, blood pressure lowering drugs—if still being used—could cause the blood pressure to get too low. Low blood pressure can contribute to a feeling of fatigue, but it can also cause dizziness and faintness.

[1] Kumar A, Kaur H, Devi P, Mohan V. Role of coenzyme Q10 (CoQ10) in cardiac disease, hypertension and Meniere-like syndrome. Pharmacol Ther. 2009 Dec;124(3):259-68

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Randomized, double-blind, placebo-controlled trial of coenzyme Q10 in isolated systolic hypertension: Twice daily administration of 60 mg of oral CoQ-10 (total dose per day = 120 mg) was given to 46 men and 37 women with isolated systolic hypertension in a 12-week randomized, double-blind, placebo-controlled trial. “RESULTS: The mean reduction in systolic blood pressure of the CoQ-treated group was -17.8 mm Hg. None of the patients exhibited orthostatic blood pressure changes [This means that the patients did not get dizzy or faint]. CONCLUSIONS: Our results suggest CoQ may be safely offered to hypertensive patients as an alternative treatment option.”[1]

[1] Burke BE, Neuenschwander R, Olson RD. Randomized, double-blind, placebo-controlled trial of coenzyme Q10 in isolated systolic hypertension. South Med J. 2001 Nov;94(11):1112-7

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Clinical trial with water-soluble CoQ-10: Effect of hydrosoluble coenzyme Q10 on blood pressures and insulin resistance in hypertensive patients with coronary artery disease: In this randomized double-blind placebo-controlled trial among 59 patients receiving antihypertensive medication and with coronary artery disease, patients received oral coenzyme Q10 (60 mg twice daily = 120 mg per day) for 8 weeks. In the coenzyme Q10 group, beneficial reductions were noted in systolic and diastolic blood pressures. The average blood pressure of 168/106 was reduced by CoQ-10 to 152/97 for a drop of -16/-9. Other benefits included a reduction in heart rate (ie, heart rate was reduced because the heart was working more efficiently), reduction in waist–hip ratio (ie, better body fat distribution), insulin and glucose levels (ie, better diabetic control), reduction in triglyceride levels (ie, reductions in the amount of fat in the blood) and reductions in angina (ie, less chest pain). An additional benefit is that CoQ-10 supplementation raised the “good cholesterol” known as HDL-cholesterol. The authors of this research, published in Journal of Human Hypertension, concluded, “These findings indicate that treatment with coenzyme Q10 decreases blood pressure possibly by decreasing oxidative stress and insulin response in patients with known hypertension receiving conventional antihypertensive drugs.”[1]

[1] Singh RB, Niaz MA, Rastogi SS, Shukla PK, Thakur AS. Effect of hydrosoluble coenzyme Q10 on blood pressures and insulin resistance in hypertensive patients with coronary artery disease. J Hum Hypertens. 1999 Mar;13(3):203-8

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Open trial using average dose of CoQ-10 225 mg/d for the treatment of essential hypertension with coenzyme Q10: This is an important study because it is one of the few studies that actually tailored the dose of the CoQ-10 to the patient’s response by monitoring CoQ-10 levels in the blood. Researchers customized the dose to attain blood CoQ10 levels of at least 2 mcg/ml. The authors of this study, published in a medical journal named Molecular Aspects of Medicine, describe the design and findings of their study as follows: “A total of 109 patients with symptomatic essential hypertension presenting to a private cardiology practice were observed after the addition of CoQ10 (average dose, 225 mg/day by mouth) to their existing antihypertensive drug regimen. … A definite and gradual improvement in functional status was observed with the concomitant need to gradually decrease antihypertensive drug therapy within the first one to six months. Thereafter, clinical status and cardiovascular drug requirements stabilized with a significantly improved systolic and diastolic blood pressure. Overall New York Heart Association (NYHA) functional class improved from a mean of 2.40 to 1.36 (P < 0.001) and 51% of patients came completely off of between one and three antihypertensive drugs at an average of 4.4 months after starting CoQ10. … In the 9.4% of patients with echocardiograms both before and during treatment, we observed a highly significant improvement in left ventricular wall thickness and diastolic function.”[1]

[1] Langsjoen P, Langsjoen P, Willis R, Folkers K. Treatment of essential hypertension with coenzyme Q10. Mol Aspects Med. 1994;15 Suppl:S265-72


 

 

 

 

 

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Much of the above information is adapted from Dr Vasquez's recent book on hypertension, described in the section below.

Chiropractic Management of Chronic Hypertension: An Evidence-based Patient-Centered Monograph for Integrative Clinicians (ISBN 9780975285848)

 Available early February 2010!

 

 

Introduction to the Hypertension Monograph: This monograph explores and substantiates the following positions in the ensuing discussion of hypertension in particular and true health and wellness promotion in general.
 

1. The chiropractic profession should play a major if not dominant role in the clinical management of chronic hypertension. At present, chiropractic care of the hypertensive patient is marginalized to an “alternative and complementary” role. The medical profession has taken a leadership position on the management of hypertension based on a wealth of drug research and the establishment of evidence-based clinical protocols and professional standards of care. In contrast, the chiropractic profession, although it has within its scope of practice the most effective treatments for hypertension, has not until now had a cohesive evidence-based guide for the clinical management of the hypertensive patient. This monograph serves to fill that void by providing clinicians an overview of the disease, its differential diagnoses and assessment and then by providing clear evidence-based treatment options.

 

Sections: Preamble, Introduction, and Foreword Hypertension: Introduction, epidemiology, pathophysiology Differential diagnosis Clinical presentation Physical examination Laboratory and imaging assessments Management strategies and clinical pearls Integrative treatments with nutritional, botanical, and pharmacologic drug treatments Dr Vasquez previously published essays related to hypertension Appendix 1: Clinical Assessments and Concepts Appendix 2: Wellness Promotion: Re-Establishing the Foundation for Health Appendix 3: Competencies and Self-Assessment Index

 

 

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CME/CEU credits are being applied for.

Introduction to the Hypertension Monograph: continued

2. Drug management of hypertension is by no means a panacea, leaving significant numbers of patients untreated, undertreated, or mistreated. The expenses and adverse effects of drug management leave many patients untreated. Furthermore, according to recent peer-reviewed research, shortcomings in the medical management of hypertension place patients at risk of adverse effects, inefficacy, and unnecessary expense. Lastly, by failing to address the underlying causes of high blood pressure, and by failing to treat the constellation of comorbid conditions (e.g., insulin resistance, overweight, hyperuricemia, and nutritional deficiencies), medical suppression of elevated blood pressure cannot be viewed as optimal therapy.

Evidence sample from New England Journal of Medicine: The data from this study show that the medical profession leaves many hypertensive patients untreated and undertreated. Specifically, profession-wide deficiencies were noted in the following areas:

1. Lifestyle modification for patients with mild hypertension: underused
2. Change in treatment when blood pressure is persistently uncontrolled: underused
3. Pharmacotherapy for uncontrolled mild hypertension: underused

The authors wrote, "METHODS: We telephoned a random sample of adults living in 12 metropolitan areas in the United States and asked them about selected health care experiences. We also received written consent to copy their medical records for the most recent two-year period and used this information to evaluate performance on 439 indicators of quality of care for 30 acute and chronic conditions as well as preventive care. We then constructed aggregate scores. RESULTS: Participants received 54.9 percent (95 percent confidence interval, 54.3 to 55.5) of recommended care. … CONCLUSIONS: The deficits we have identified in adherence to recommended processes for basic care pose serious threats to the health of the American public. Strategies to reduce these deficits in care are warranted."

McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr EA. The quality of health care delivered to adults in the United States. N Engl J Med. 2003 Jun 26;348(26):2635-45
 

Evidence sample from Milbank Quarterly—A Multidisciplinary Journal of Population Health and Health Policy in 1998: The authors review pertinent literature on healthcare quality and note that among Americans only “41%–54% of patients had their hypertension controlled (mean blood pressure (150/90).” By weak criteria of HTN control, 55% of people with hypertension had blood pressure “under control” with pressures of 160/95 treated with at least one antihypertensive medication; when using strict criteria (medicated blood pressure of 140/90) only 21% of Americans were properly treated.  "Studies over the past decade show that some people are receiving more care than they need, and some are receiving less. Simple averages from a number of studies indicate that 50 percent of people received recommended preventive care; 70 percent, recommended acute care; 30 percent, contraindicated acute care; 60 percent, recommended chronic care; and 20 percent, contraindicated chronic care. These studies strongly suggest that the care delivered in the United States often does not meet professional standards."

Schuster MA, McGlynn EA, Brook RH. How good is the quality of health care in the United States? Milbank Q. 1998;76(4):517-63

 

3. Because hypertension is a major patient-centered and public health concern, the chiropractic profession must have an evidence-based protocol for its management. Chronic hypertension is “disease” of epidemic and indeed pandemic proportions in America and increasingly in other nations. The lifetime incidence of high blood pressure among Americans is 90%, while on any given day, approximately one in four Americans has high blood pressure. These patients and potential patients would benefit more from integrative chiropractic care and the nutrition-based protocols in this document than they can hope to benefit from drug-only treatment. The evidence supporting the dietary and nutritional prevention and treatment of hypertension and cardiovascular disease is irrefutable. Adding to this the recent evidence that chiropractic spinal manipulation is as effective as two-drug treatment for hypertension makes the case for the chiropractic profession’s assumption of a leadership role timely and of paramount importance. This document not only serves to provide individual clinicians with practical protocols, by perhaps more importantly this document is a call to action for the chiropractic profession. The chiropractic profession must stand and deliver the quality healthcare that our patient population needs and deserves.

 

Double-blind, placebo-controlled pilot study of chiropractic manipulation for treatment of hypertension: Atlas vertebra realignment and achievement of arterial pressure goal in hypertensive patients (n=50): The authors introduce this study by writing, “Anatomical abnormalities of the cervical spine at the level of the Atlas vertebra are associated with relative ischemia of the brainstem circulation and increased blood pressure (BP). Manual correction of this mal-alignment has been associated with reduced arterial pressure.” The authors used a double-blind, placebo-controlled design at a single center among 50 drug naïve (n=26) or washed out (n=24) patients with Stage 1 hypertension; patients were randomized to receive a National Upper Cervical Chiropractic (NUCCA) procedure or a sham procedure. Significant findings included the following, “At week 8, there were differences in systolic BP (-17 mm Hg, NUCCA versus -3 mm Hg, placebo) and diastolic BP (-10 mm Hg, NUCCA versus -2 mm Hg). … No adverse effects were recorded. We conclude that restoration of Atlas alignment is associated with marked and sustained reductions in BP similar to the use of two-drug combination therapy..” Link to full-text

 

Excerpt from “The Council on Chiropractic Education's New Wellness Standard: A call to action for the chiropractic profession” by Marion W Evans Jr and Ronald Rupert (Parker College of Chiropractic Research Institute) published in open-access format in Chiropractic & Osteopathy 2006: Excerpt provided here in accordance with open access terms and conditions  http://www.chiroandosteo.com/content/14/1/23 

Health Status of Spine Patients

“A review of some of the co-morbidity issues that accompany musculoskeletal conditions like low back pain, will demonstrate why chiropractors need to become aggressively active in addressing patient lifestyle and other health promotion and wellness issues. The impact of spine problems on health status has been examined through co-morbidity analysis. In 2000, Fanuele and colleagues [5] reported an observational study of 17,774 patients from the 25 National Spine Network agencies or academic centers. Their goals were to quantify the impact of spinal problems on physical function and to better understand the effects of co-morbid conditions on physical function. In their study population, 46.6% of spine patients had at least one other non-spinal condition or illness. When smoking was considered a co-morbid condition it was number one with hypertension 2nd, obesity 3rd and diabetes 4th. Fifty-two percent of patients had a primary diagnosis of lumbosacral symptoms and 82% had experienced three or more months of pain. They concluded that society bears a heavy economic burden from patients with spinal conditions and physicians need to recognize that spine patients have significantly more physical morbidity than the US population in aggregate. Fanuele and colleagues stated, "It is likely that the spinal diagnosis, in itself, is mostly responsible for the significant functional disability, expressed by low physical component scores."

A study published in Pain by Von Korff and others [6] concluded that after controlling for demographic variables and for co-morbidities, chronic spinal pain was significantly associated with role disability, other pain conditions, chronic diseases and mental disorders. Their information was derived from the household face-to-face National Co-morbidity Survey Replication which was a nationally representative sample (n = 9,282) of respondents age 18 or older. Almost 20% of the US population was estimated to have chronic spinal pain in the prior 12 months with about 30% reporting lifetime prevalence of chronic spinal pain. This chronic spinal pain was more than three times higher in patients who reported other chronic pain as those without these conditions and it was twice as high in patients with a mental disorder. Chronic physical disease associated with chronic spine pain included stroke, hypertension, asthma, COPD, irritable bowel syndrome, ulcers, HIV/AIDS, epilepsy and vision problems. After adjusting for demographic variables the increased risk of a co-morbid chronic physical disease associated with chronic spine pain was 2.0. Among the 40 million Americans who suffer chronic spine pain, 22 million had a co-morbid physical ailment (87% with chronic spine conditions had at least one co-morbid condition). Therefore, spine patients are in need of health education messages at a rate that may exceed that of non-spine patients.

The association of spinal disease with smoking and obesity is also fairly well established [7,8]. Obesity is associated with more severe pain syndromes among spine patients and they suffer greater impairment in functional status [7]. As previously stated, smoking is often the most frequently found condition associated with spine disease [5,8]. These factors should be important to chiropractors as they primarily see back pain and neck pain patients [9]. The average case mix of DCs tends to include a significant amount of chronic spine patients although there is an indication that DCs utilize certain health promotion measures with them such as; exercise recommendations, ergonomic advice and advice on dietary changes [9]. DCs need to place a greater emphasis on the use of common prevention and health promotion methodologies in their practices. It is our opinion that an emphasis on wellness and health promotion is compatible with either the primary care or the "spine care model" of chiropractic and is congruent with national health initiatives and the chiropractic tradition of holism and self-reported prevention practices [9]. This will be described in more detail but should include cancer prevention dietary recommendations, proper exercise recommendations, appropriate screening procedures that are within scope of practice including, but not limited to cardiovascular disease, hypertension, diabetes, breast, prostate and skin cancer screening.”
 

 

 

 

 

 

Promoting Unhealthy Eating: Atherosclerotic Recipes Endorsed by the US National Heart, Lung, and Blood Institute (NHLBI):

 

The following is a partial list of atherosclerosis-promoting recipes listed under the title “Stay Young at Heart: Cooking the Heart-Healthy Way” advocated on the website of the NHLBI in December 2009. Notice the lack of nutrient density, the emphasis on simple carbohydrates, the frequent use of baking with oil to create the effect of frying, the lack of raw foods, and the scarcity of phytonutrients:

• “Stir-fried beef” with boiled potatoes and white rice

• “Beef stroganoff” with 6 cups of cooked macaroni pasta

• “Crispy oven-fried chicken” cooked in cornflakes and buttermilk

• “Classic macaroni and cheese”

• “Candied yams” with brown sugar, margarine, white flour, and orange juice

• “Oven French fries” (white potatoes oven-fried in vegetable oil)

• “Potato salad”

• “Wonderful stuffed potatoes”

• “White rice” cooked with vegetable oil and salt

• “Sunshine (white) rice” cooked with vegetable oil, orange juice, and lemon juice

• “Homestyle biscuits” made from white flour, salt, and sugar

• “Banana-nut bread” made from mashed ripe bananas, low-fat buttermilk, packed brown sugar, margarine, all-purpose white flour, egg and salt.

• “Apricot-orange bread” made from dried apricots, margarine, white sugar, egg, white flour, dry milk powder, salt and orange juice

• “Apple coffee cake” made with peeled apples (please note that >90% of the antioxidants contained in apples are in the peel—thus when the peel is removed, virtually all that remains is antioxidant-poor carbohydrate), one cup of sugar, one cup of dark raisins, one-quarter cup vegetable oil, 1 egg, and two-and-a-half cups of sifted all-purpose white flour

• “Frosted cake” with 2 1/4 cups cake flour, 4 tablespoons margarine, 1 1/4 cups sugar, 4 eggs, low fat cream cheese, and 2 cups sifted confectioners sugar!!

• “Topical fruit compote” with sugar

• “Peach cobbler” with sugar, white flour, margarine, canned peaches “packed in juice”, peach nectar, and cornstarch

• “Rice pudding” with white rice, 3 cups of skim milk, and 2/3 cup sugar
   

The list goes onto include many other proatherosclerotic and prodiabetic meals. Now ask yourself why and how the US government by way of the National Heart, Lung, and Blood Institute is promoting a diet plan that is ensured to contribute to the pandemics of hypertension (affecting 25% of American adults), obesity, and diabetes mellitus. 

 

“It's not a matter of whether the war is not real, or if it is, Victory is not possible. The war is not meant to be won, it is meant to be continuous. … The war is waged by the ruling group against its own subjects and its object is not the victory over [the purported enemy], but to keep the very structure of society intact.” George Orwell, 1984