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Hello Health Day (Part II)

Quick Update: So, we got Health Day’s attention and they produced, as promised, another article that was a little less bias and a little more inclusive this time around. Their re-write can be found here.

A Tale of Two Fish Stories

As you might know from this blog weve had a number of interactions with A & Es History and the Dr. Oz show in the past few weeks. The two case studies stand in stark contrast to each other and now some independent arbiters are weighing in.

Yesterday TheTVNews.TV compared the two as part of its daily video report, also available on YouTube. 2 minutes and 24 seconds into the report its time for The Big Picture segment and thats where host Jeff Grimshaw offers this analysis:

  • Todays installment of The Big Picture, analysis and commentary, is aptly entitled A Tale of Two Fish Stories. Fish story number one recently aired on the Dr. Oz show and it dealt with some alleged unseen health risks associated with certain seafoods. Fish story number two was to air on Historys Modern Marvels and it too contained some precautionary rhetoric about seafood. In stepped National Fisheries Institutes Director of Media Relations, Gavin Gibbons, supplying scientific proof what he called demonstrable evidence of errors in both stories. And with what he called public perception of a valuable source of protein on the line heres where the two stories divergeDr. Ozs group was said to have stone walled the inquire and then proceeded to bring in its legal staff. On the other hand History was extremely responsive and although they could not pull the East Coast airing of Modern Marvels they did preempt West Coast and all subsequent airings pending the validation of the NFI objections. Like all news gathering organizations on a shortened multi-platformed news cycle the TVNews-dot-Tv lauds the actions taken by History; bold, responsive and committed to getting the story right. By the same token we hope that media entities like the Dr. Oz show will emulate History and will strive to put accuracy in reporting as the paramount criterion above air schedules, reputation and everything else. Whats your opinion? Wed like to know.

Hello Health Day

You may come across a Health Day article about the UNLV study we told you about last week. You’ll remember it started with that Las Vegas Journal Review piece that we worked to put some perspective on. The problem with the Health Day article, as you can see in our letter below, is that it essentially reads like a press release. There’s no input from any voices that might add balance. Most important, the story doesn’t consider the report negatively impact public health by unnecessarily scaring people away from a healthy protein that is high in omega-3s.

In short, it doesn’t sound like a lot of healthy thought went into the reporting of this story.

In response to our letter, the Health Day editors let us know they would commission a new piece. I spent a good deal of time talking to an intrepid reporter who appeared to be doing the due diligence that the original report lacked. Keep in mind it’s not hard to find the lead author of the study saying that in reality, despite his own research into mercury, “problems” might present themselves only if a consumer was eating canned tuna for every single meal, every single day, continually.

Here’s the rub. When we pointed these problems out to Health Day they jumped at the chance to dig more into the subject, but they didn’t pull the old article from circulation or try to update the content as if they were a traditional wire service. So here we sit with a rudderless piece on mercury in canned tuna bouncing about the internet as unsuspecting Health Day subscribers like Business Week repurpose and publish the story unaware of the problems associated with it.

Read on:

February 5, 2009

Barry Hoffman, Editor-in-Chief

Health Day

VIA Email

Dear Mr. Hoffman,

I am writing to draw your attention to some serious issues found in your story “Tests show top tuna brands have high mercury levels.” The story lacks scientific perspective and journalistic balance. No one from the seafood community or any of the tuna canners that the National Fisheries Institute represents were contacted for this story. We ask that you remove it from your service while you thoroughly research the issue and make appropriate contacts with stake holders and scientists alike.

The fact is consumers should not be concerned by this report. Canned tuna continues to be a safe and healthy source of protein packed with heart-healthy omega-3’s. The report is very clear that in all of the brands tested the average methyl mercury level was well below the FDA limit.

The EPA level referenced in the report is not relevant. The EPA levels are applicable to sport-caught fish found in lakes, streams and other internal waterways where the EPA has jurisdiction. The FDA level is designed for commercial seafood like tuna. The EPA’s matrix for its level was developed using something called ambient water criteria. That standard measures the amount of dissolved mercury in water as an approximation for the amount of mercury fish might absorb. It would make sense that its level would focus on “environmental” standards as opposed to “food” standards. The EPA level is designed to work in conjunction with the agency’s mandate to regulate emissions, not food.

It is critical to point out that the methyl mercury found in seafood, like canned tuna, is predominantly the result-not of emissions-but of naturally occurring processes found in the ocean like underwater volcanic activity. For some reason, the authors of the study seem to have obscured this scientific fact, a common conflation used by environmental activists. In fact, the California Courts have ruled twice against the State Attorney General over a signage issue on the grounds that virtually all the trace amounts of methyl mercury found in canned tuna is “naturally occurring.”

In expressing concern that any of the cans supposedly exceeded the FDA’s level, a key fact is ignored. The FDA’s level of 1.0ppm has a built-in 1,000% safety factor also known as an uncertainty factor. The FDA says such a standard, “was established to limit consumers’ methyl mercury exposure to levels 10 times lower than the lowest levels associated with adverse effects.” This means a single can would have to exceed the FDA’s level by ten times to begin to even approach a level of concern for the average consumer. Even the highest levels reported in this study did not come remotely close to that point.

Another concern we have with our initial review of this study is that throughout the report the authors refer to levels of Hg. Hg is a measurement of total mercury while the focus for fish (via FDA and EPA work) is MeHg methyl mercury. Hg can be made up of elemental mercury and methyl mercury. The human body quickly excretes Hg. To combine the two has the potential to artificially inflate the levels.

What’s more, the report says “recent studies have established a link between heavy fish consumption and adverse health effects.” However, the studies they cite are far from “recent.” In fact the latest cited in this section is 1997 and the earliest is 1985. Published, independent, peer-reviewed reports that contradict those findings from 2002, 2004, 2007-among others-were not mentioned. The study even misreports the percentage of canned tuna consumed by Americans each year, over-reporting by as much as 18%, a fact that should shed considerable doubt on the author’s attention to detail and surmise that participants in the Women Infant and Children’s (WIC) program might be at greater risk from tuna consumption. Again, the vast body of scientific literature instead has concluded that Americans as a whole simply don’t get enough seafood in their diet in order to enjoy the full health benefit.

This single study in no way changes the conclusion of the FDA’s Report of Quantitative Risk and Benefit Assessment of Consumption of Commercial Fish released in January 2009 that showed, for instance, children eating fish provided a 99.9 percent modest benefit in brain and verbal development; 0.1 percent modest risk. It also does not change the fact that an independent Harvard University study published in the Journal of The American Medical Association found, “for major health outcomes among adults, based on the strength of the evidence and the potential magnitudes of effect, the benefits of fish intake exceed the potential risks. For women of childbearing age, benefits of modest fish intake, excepting a few selected species, also outweigh risks.”

The overwhelming majority of science finds the benefits of eating seafood and high omega-3 fish, like canned tuna, outweigh any concerns associated with the trace amount of methyl mercury found in fish.

A failure to highlight the fact that the average Hg level for all brands was well below the FDA’s level and that the study does not report on the fact that there is a 1,000% safety factor built in to that level would be an egregious failure in reporting this story. Likewise, we would expect your reporting to include another important fact left out of this study-there have been no cases of mercury toxicity from the normal consumption of commercial seafood in this country ever reported in peer reviewed scientific literature.

We are disappointed that your reporter failed to live up to the accepted journalism standard of balance and did little more than reprint UNLV talking points.

We look forward to reading a thorough revision of this report.

Sincerely,

Gavin Gibbons

National Fisheries Institute

The Revisionist History Channel

The History Channel is home to some world class programs but in last night’s episode of Modern Marvels the highly regarded outfit made some world class mistakes. In keeping with its highly regarded reputation we expect producers there to correct their mistakes and the record.

See our letter to History via A & E Television Networks below:

February 5, 2010

Dawn Porter

Vice President

A&E Television networks

VIA Email

Dear Ms. Porter,

We are extremely disappointed to be contacting you concerning several errors featured in the History Channel’s “Modern Marvels” episode on canned tuna. While we appreciated your prompt attention to our concerns on February 4th, it is imperative that the program be re-edited to prevent future distribution of factual inaccuracies. Additionally, clarifying at the very outset of the package that bluefin tuna is not and has never been part of the canned varieties of tuna that Americans eat is essential to providing an accurate story for your viewers.

As you have been made aware, despite the original “Modern Marvels” reporting, the FDA states in its recently released draft report on commercial fish that the very latest science shows that the vast majority of methylmercury found in ocean fish, of which tuna is one, comes from natural environmental sources-not the pollution that affects sport-caught fish found in internal waterways like lakes and streams. Despite the fluctuations associated with overt pollution, the FDA states that the trace levels of methylmercury in commercial fish have remained the same.

The FDA is not the only group that has weighed in on this issue. After a thorough review of the science, California courts ruled twice that virtually all the trace amounts of methylmercury found, in canned tuna specifically, is “naturally occurring.” An appellate court ruling explicitly states, “following a six-week bench trial, with a parade of expert witnesses, the trial court handed the Tuna Companies a complete victory” based on the fact that, “the amount of methylmercury in canned tuna does not rise to the threshold level that would trigger the warning requirement for this chemical; and virtually all methylmercury is naturally occurring.'” These rulings were well publicized and should have been part of the “Modern Marvels” research. To report otherwise is an egregious failure to follow basic journalism tenets.

Likewise, the show misstates the FDA/EPA advice on seafood consumption. Specificity and complete accuracy is essential when reporting nutrition advice from trusted public health sources. Modern Marvels erred in its attempt to do so. The FDA/EPA advice for seafood consumption is not directed at the general population and, as reported, “particularly pregnant women and young children.” It is directed only at pregnant women and young children. The FDA/EPA research and recommendations are tailored to only this very specific sensitive subpopulation and are absolutely not meant for the public at large. To state or suggest otherwise is erroneous.

Furthermore, canned tuna is characterized as a high mercury product, when the FDA’s own research reveals this is not the case. The inclusion of canned tuna in the FDA/EPA advice comes simply as a result of the volume that is consumed, not the levels found in individual fish. A simple review of FDA research would have found that, while the federal limit for mercury in seafood is 1.0 ppm, the average levels found in canned light tuna is 0.118 ppm and the average level found in canned albacore is 0.353 ppm. Both levels are well outside the FDA’s designation of “Fish and Shellfish with highest levels of mercury.” This perspective calls into question the entire relevance of featuring the mercury aspect in the production.

As a journalism professional with extensive media standards experience, I am confident you are well versed in the problems associated with “misleading” impressions. As recently as January of 2005 a report of the Independent Review Panel on CBS News found a paramount problem with the, now infamous, 60 Minutes segment titled “For The Record,” was that it created “misleading” impressions (p127). Whether outright falsehoods about the source of methylmercury in canned tuna or distorted production that leaves the illusion for a time that bluefin tuna is used in canning, the viewer is left with misleading impressions about a safe healthy source of protein that is packed with essential omega-3’s.

In an effort to uphold standards that include unflinching accuracy, we ask that the History Channel immediately cease further broadcast of this piece, reedit the inaccuracies we have highlighted for any future consideration and post a clarification on line for viewers who may have originally been misinformed.

Thank you.

Sincerely,

Gavin Gibbons

National Fisheries Institute

Dr. Oz — Way Off On Fish Facts (III)

Imagine this; you hear your doctor dispensing questionable advice that you know contradicts the latest science and demonstrably confuses two distinctly different topics. So, you call him on it.

What does he do?

He excuses himself from the exam room and sends in his lawyer to tell you everything is oaky and that his recommendations have been thoroughly researched by a phantom staff of “research professionals.”

That wouldn’t give you a great deal of confidence in your doctor, would it? Well, that’s essentially what physician turned Oprah-wannabe, talking-head doc Dr. Mehmet Oz has done.

Have a look at his lawyer’s response to our concerns and our letter back:

Gavin Gibbons

National Fisheries Institute February 2, 2010

Dear Mr. Gibbons:

Thank you for your interest in “The Dr. Oz Show.” We appreciate you sharing your concerns about the subject matter of our show and we always welcome comments from viewers. We are responding to your letter dated January 27, 2010.

Our January 26 th show addressed the issue of methylmercury levels in fish and the potential health hazards that could result from this contaminant. As with all episodes of “The Dr. Oz Show” our team of researchers consisting of health care professionals worked with producers to research all available scientific evidence around this subject. While we welcome the discussion and always want to hear opinions, it’s the position of our producers that we presented accurate facts based on the existing body of knowledge regarding safe mercury levels in fish. We also feel that we structured the show in such a way that was helpful and useful to our audience.

It is important to consider the January 26th show in the greater context of Dr. Oz’s overall position on fish consumption – which is that fish is a necessary part of a healthy diet and a vital source of Omega 3’s. Dr. Oz recommends eating fish in virtually every nutrition discussion on his show, in news interviews, on his radio show and in his books. Simply put, there is no greater advocate for including fish in your diet than Dr. Oz. But to make such a consistently strong recommendation without addressing a health risk factor such as methylmercury would be irresponsible to our audience.

Dr. Oz will continue recommending fish as part of an overall healthy diet and the show may address methylmercury at some point in future episodes. To answer the central question posed in your letter, we believe “The Dr. Oz Show” neither overstated the risk of methylmercury in fish nor engaged in any scaremongering. Rather, we always strive to present our audience with the latest, research-verified information and let them make their own decisions regarding their personal health. We can assure you that as our research team becomes aware of additional research or information we will take it into consideration for future episodes.

Thank you again for your letter.

Regards

C. Denise Beaudoin

Legal Counsel for “The Dr. Oz Show”

Our letter back:

February 5, 2010

C. Denise Beaudoin

Legal Counsel

ZoCo Productions, LLC

VIA Email

Dear Ms. Beaudoin,

Thank you for your February 2nd letter regarding scientific inaccuracies in a segment about mercury and fish on the January 26th edition of “The Dr. Oz Show.” While I was pleased to hear back from you, I was surprised the response came from a lawyer rather than a health professional or one of the “team of researchers” you reference in your response.

This is not a case of industry disagreeing with television celebrity. This is a case of the latest independent, peer-reviewed science not being reflected in a physician’s recommendations. We demand Dr. Oz address the scientific errors in the report and correct them on air and on the Web immediately.

Dr. Oz clearly contradicted the U.S. Food and Drug Administration’s (FDA) advice about eating seafood when he said mercury in seafood is a concern for not only pregnant women and children, but “all of us.” As we noted earlier, the FDA advice clearly states, “for most people, the risk from mercury by eating fish and shellfish is not a health concern.”

Dr. Oz also ignored the fact that the CDC study he cites actually says “finding a measureable amount of mercury in blood or urine does not mean that levels of mercury cause an adverse effect.” These types of omissions in and of themselves raise Dr. Oz’s presentation to the level of the very “scaremongering” you decry. Unfortunately those were not his only failures which, through your letter, the show has refused to directly address.

Dr. Oz’s explanation of why mercury is found in commercial seafood was incorrect. A recent FDA draft report on commercial fish and two California court rulings found virtually all the trace amounts of methylmercury present in ocean fish were “naturally occurring.” This is in stark contrast to freshwater fish that are regularly contaminated by man-made processes. Were Dr. Oz and his researchers unaware of this distinction?

  • Dr. Oz overtly confuses commercial fish and recreational fish. When discussing a report that shows almost all “freshwater” fish found in the U.S. have some mercury in them he fails to explain that the study he referenced did not test the seafood available in restaurants and grocery stores. While this is a common error made by the press, an individual giving nutrition advice ought to be more careful. To clear up confusion on this point, researchers at UC Davis released a statement called, “Mercury in Commercial and Sport-caught Fish: Apples and Oranges,” which concludes “The information presented in the study relates to fish that are typically recreationally caught. Commercially caught and sold fish (includes finfish, shellfish and mollusks) is safe and beneficial to consume.” Were Dr. Oz and his researchers unaware that the study they were discussing was unrelated to fish primarily consumed in the U.S.?

With just these examples alone it is clear that Dr. Oz’s team did not “present accurate facts based on the existing body of knowledge.”

The National Fisheries Institute does not simply disagree with what Dr. Oz said or how he presented it. Dr. Oz’s guidance is at odds with the latest, independent, peer-reviewed science on fish and nutrition. We respectfully request that ZoCo Productions work to produce another more balanced and scientifically accurate episode on what happens when people eat fish as a whole food.

I noticed in your letter you ignored our concerns about Dr. Jane Hightower and her clear ties to environmental activists. Dr. Hightower’s term “fish fog” is not an actual diagnosis and is simply unsupported by any shred of peer-reviewed science.

While we would be more than happy to offer our own in-house nutrition expert, Jennifer McGuire, MS, RD, as a guest for your show to accurately articulate current seafood recommendations and how people can eat more fish, might we suggest that you consider inviting one of the country’s preeminent independent scientists on this issue? Resources like Dr. Joshua Cohen, PhD from the Tufts New England Medical Center; Dr. Nicholas Ralston, PhDfrom University of North Dakota Energy and Environmental Research Center; Dr. Joseph Hibbeln, MD from the National Institute of Health; Dr. Dariush Mozaffarian, MD from Harvard School of Public Health; Dr. Eric Rimm, D.Sc. from
Harvard School of Public Health and Dr. Gary Myers, M.D. from University of Rochester Medical Center could all offer an unbiased review of the latest science. And with your medium in mind, these doctors are not only preeminent in their field, but are very comfortable turning lab-talk into common sense.

The National Fisheries Institute does not make unique claims about the health effects of eating fish; the science speaks for itself. But when obscured by agendas and misinformation, we must insist the record be corrected.

Thank you for your continued dialogue on this issue.

Sincerely,

Gavin Gibbons

National Fisheries Institute

cc Laurie Rich c/o Jackie Barth

Executive Producer

ZoCo Productions, LLC

Common Sense Questions And Answers

Just the other day a question appeared on Yahoo Answers that asked:

  • What is up with Mercury and Fish? If fish is so bad for people, why have Asian cultures eaten it for thousands of years with no negative impact? I love fish, it is great to lose weight and delicious. I am wondering why the government, and many others, are saying to limit our consumption of fish. If anybody knows the truth about what is going on please let me know.

NFI’s registered dietitian (who, by the way, is a great resource for you media folks), Jennifer McGuire (you might know her from BlogAboutSeafood.com), spotted the question and provided this answer:

  • Hi – Quite a few people are confused about this, and as a dietitian with the National Fisheries Institute, I’d love to clear the water. Here’s the official seafood advice from the Food and Drug Administration and Institute of Medicine:

    -For the general population: Eat a variety of fish twice a week, and there are no fish to limit or avoid because of mercury.

    -For women who are or may become pregnant, nursing moms, and young kids: The nutrients in fish are especially important for you, so eat a variety of fish twice a week. Half (6 ounces) of the fish you eat every week can be white albacore tuna. There are four fish to avoid that you probably aren’t eating anyway: shark, tilefish, king mackerel, and swordfish.

    The more we learn about the good things eating fish does for your body, the more doctors and dietitians are focusing on the health risks of not eating enough fish. One of the most important studies to date on this issue found “Avoidance of modest fish consumption due to confusion regarding risks and benefits could result in thousands of excess CHD [heart disease] deaths annually and suboptimal neurodevelopment in children.”

    For a look at what plenty of seafood looks like in the real-life diet of a registered dietitian (me!) visit my BlogAboutSeafood.

    Sincerely,
    Jennifer McGuire, MS, RD
    National Fisheries Institute

Source(s):

http://www.blogaboutseafood.com
http://tinyurl.com/2g2ohm
http://tinyurl.com/y8nj9e7
http://tinyurl.com/yjlyset
http://tinyurl.com/lgu882

I thought it was nice to see an actual health professional chime in on these things with the facts. All too often it’s – a friend once told me his sister etc… and that just fosters misinformation.

Common Sense Questions And Answers

Just the other day a question appeared on Yahoo Answers that asked:

  • What is up with Mercury and Fish? If fish is so bad for people, why have Asian cultures eaten it for thousands of years with no negative impact? I love fish, it is great to lose weight and delicious. I am wondering why the government, and many others, are saying to limit our consumption of fish. If anybody knows the truth about what is going on please let me know.

NFI’s registered dietitian (who, by the way, is a great resource for you media folks), Jennifer McGuire (you might know her from BlogAboutSeafood.com), spotted the question and provided this answer:

  • Hi – Quite a few people are confused about this, and as a dietitian with the National Fisheries Institute, I’d love to clear the water. Here’s the official seafood advice from the Food and Drug Administration and Institute of Medicine:

    -For the general population: Eat a variety of fish twice a week, and there are no fish to limit or avoid because of mercury.

    -For women who are or may become pregnant, nursing moms, and young kids: The nutrients in fish are especially important for you, so eat a variety of fish twice a week. Half (6 ounces) of the fish you eat every week can be white albacore tuna. There are four fish to avoid that you probably aren’t eating anyway: shark, tilefish, king mackerel, and swordfish.

    The more we learn about the good things eating fish does for your body, the more doctors and dietitians are focusing on the health risks of not eating enough fish. One of the most important studies to date on this issue found “Avoidance of modest fish consumption due to confusion regarding risks and benefits could result in thousands of excess CHD [heart disease] deaths annually and suboptimal neurodevelopment in children.”

    For a look at what plenty of seafood looks like in the real-life diet of a registered dietitian (me!) visit my BlogAboutSeafood.

    Sincerely,

    Jennifer McGuire, MS, RD

    National Fisheries Institute

Source(s):

http://www.blogaboutseafood.com

http://tinyurl.com/2g2ohm

http://tinyurl.com/y8nj9e7

http://tinyurl.com/yjlyset

http://tinyurl.com/lgu882

I thought it was nice to see an actual health professional chime in on these things with the facts. All too often it’s – a friend once told me his sister etc… and that just fosters misinformation.

Dr. Oz — Way Off On Fish Facts (II)

Paging Dr. Oz…

Paging Dr. Oz…

February 1, 2010

Laurie Rich

Executive Producer

ZoCo Productions, LLC

VIA Email c/o Jackie Barth

Dear Ms. Rich,

I am writing to confirm receipt of my January 27th letter expressing concerns about serious scientific inaccuracies in Dr. Oz’s January 26, 2010 segment on fish consumption and mercury.

As I noted in my initial letter we have already begun to correct the record with this YouTube video and will be chronicling Dr. Oz’s response to the issue with blog postings.

We eagerly await your response.

Thank you.

Sincerely,

Gavin Gibbons

National Fisheries Institute

CBS And BPA (Part IV)

Any dentist worth hissalt (or sugar) can tell you the age old joke that reads something like, “ignore your teeth and they’ll go away.” However, the same cannot be said for NFI:

February 1, 2010

Bill Felling

National News Editor

CBS News

VIA Email

Dear Mr. Felling,

I wanted to thank you for initiating contact with Linda Mason regarding our concerns about Kelly Wallace‘s report on the January 18th edition of the Early Show. However, she has not responded to our January 22nd letter.

We asked Ms. Mason to release the results of any and all lab tests that were performed during the production of the report in order to provide a clear, open and journalistically sound view of the alleged impact of eating a single tuna sandwich on Wallace’s BPA blood levels. Ms. Mason has not responded to our request.

Our concerns about this report and the clear impression it left are valid and will not simply disappear if they are ignored. I am sure you share our belief that CBS News has a responsibility to its viewers to not only produce the highest quality reporting but to ensure that when concerns are raised the issues are thoroughly investigated with CBS’s standards in mind.

Ms. Mason defends the report on a number of levels insisting that CBS never actually stated a single tuna sandwich was responsible for elevating Ms. Wallace’s BPA levels. Evidence that this misleading impression was conveyed to viewers can be found in internet posts like the following:

  • As Kelly Wallace from CBC News discovered, just eating one tuna sandwich caused BPA levels in her blood to soar to over five times the average BPA level found in the blood of American consumers (and that “average” level is dangerous to begin with). — NaturalNews

As I mentioned to Ms. Mason, CBS News has been specifically warned about the effects of creating “misleading” impressions in the past and we remain extremely concerned that such an impression is being allowed to stand as record in this case.

Thank you for your continued attention to this on going matter.

Sincerely,

Gavin Gibbons

National Fisheries Institute

cc Linda Mason

Senior Vice President

Standards and Special Projects

Andy Schotz

Society of Professional Journalists

Ethics Committee Chair

Perspective On Canned Tuna Tests

If you find yourself reporting on the UNVL canned tuna tests you might want to keep this quote in mind from the lead researcher on the project. And let’s not be coy about what he is saying here– despite his own research into mercury in canned tuna, he suggests “problems” might present themselves only if a consumer was eating canned tuna for every single meal, every single day.

  • “It’s like anything else when you do things in excess that’s when problems occur. Most of the exposure to mercury are chronic, meaning they’re small doses over long periods of time. If you eat mercury, or tuna more appropriately, on a regular basis it has a lot of good things. It has omega -3 fatty acids, it has protein… it’s… that’s good for you. If you ate it every day, for every meal, with everything… that’s when you can start to have problems occur.” — Professor Shawn Gerstenberger, PhD