Heart Disease Prevention: What You Really Need to Know About Diet, Exercise, and Heart Health



good morning and welcome to the second session of health matters my name is Margaret Rothen I'm a long time member of this community and serve on the Stanford healthcare board and chair this Stanford medicine community council it's my great pleasure to welcome you today and so wonderful to see so many people turn out to learn more about what happens here at Stanford medicine not only in patient care delivery but also some of the leading-edge advances in research and technology so thank you all for being here today it is my great pleasure to introduce our speaker today dr. David Marin who is the clinical professor of medicine cardiovascular medicine and director of the preventive cardiology department dr. Marin received his undergraduate degree from Stanford University his medical degree from the University of Southern California and trained at UCLA he was a Robert Wood Johnson clinical scholar a preventive cardiology fellow and subsequently a cardiology fellow at Stanford University he served as a faculty member at Vanderbilt as director of preventive cardiology and had the great wisdom and our good fortune to return to Stanford in 19 2014 where he serves now as clinical professor of medicine and director of preventive cardiology dr. marrows research interests include primary and secondary prevention of coronary artery disease so please join me in welcoming dr. David Marin good morning and thank you how's the sound is it good turnout oh thumbs up okay great thanks for coming I know that this is an unseasonable cold day for May in California I am NOT going to give a lecture I know that's what you came for I'm I really want this to be a give-and-take and make sure that I answered the questions that you have and I'm going to ask the first several questions just to warm us all up but anytime raise your hand we have mics and so everyone can hear your question and I'll try to answer your questions so I created a top ten list and this is the first question low fat it's a statement low fat diets are better than high fat diets for your heart true or false okay so this is a very educated community and it's going to it's gonna be tough and I may be asking you questions and well I am going to ask you questions that you may be the ones with the answers it depends on the type of that it's a false it's false now we in the last several decades have heard a mantra that low fat diet is the way it's the way you should go for your heart and for pretty much everything it's it's healthier to have a low fat diet so what the message is unless you're Time magazine what the message is is that we should feed a low saturated fat diet the total amount of fat not not so important where we get saturated fats they're shown on the slide what's the number one source of saturated fat in our diet someone said pizza someone else said cheese yes the end that's correct it's cheese and it's primarily from pizza we eat a lot of pizza and then cookies and cakes and ice cream and other whole fed dairy products red meat is actually you know that's what I think of is number one saturated fat but it's not even the number one in the American diet as the source of saturated fat that we eat but you know this this shows it now there's also a coconut shown on this slide and there's a lot of controversy about coconut sir coconut oil good for you it's a saturated fat if you have so-called virgin coconut oil it may not be so bad in general saturated fat bad coconut oil that's not virgin bad eggs you like to eat eggs okay what I never understood from the egg industry is why they didn't just encourage everybody to throw away the yolk and and they would eat more eggs and just egg whites because egg whites are such a healthy food great source of protein no fat but the very latest dietary guidelines say that eggs are don't don't worry about eggs now why would people worry about eggs at all because the cholesterol is maybe 250 milligrams or so of cholesterol in an egg yolk and the point is that dietary cholesterol is not a huge contributor to serum or blood cholesterol and so we you know naturally associate our blood cholesterol with cholesterol in our diet and we want to avoid it but in fact it's not a big deal there was a big study published from the epidemiologists at Harvard looking at egg intake and the long term risk of heart disease one egg a day no increased risk unless you have diabetes that was a result of that study that led to a Time magazine cover that I did I didn't make a slide of today showing a smile with the two big egg yolks you might remember that one from a couple decades ago now Time magazine last year really confused the issue with this cover if you read the article it it does elucidate that saturated fat not good it says it in the article not on the cover the cover says eat butter which is I think is really irresponsible because there is no controversy that a human being who eats saturated fat their cholesterol goes up their LDL the low-density lipoprotein the bad cholesterol goes up it's not controversial what happened was instead of getting the message either low saturated fat diet we got as I said earlier the message we eat a low-fat diet and we replaced saturated fat with carbohydrates and predominantly simple carbohydrates so you know there's a lot of excitement that ding-dongs and other high sugar foods are okay and they were marketed as low fat things that are really high in sugar and that did not improve our health if you replace saturated fat with polyunsaturated fats like corn oil or soybean oil or with monounsaturated fats like olive oil canola oil fats that are in nuts avocados if you make that kind of substitution that's healthy it's good and you can have a high-fat diet like a traditional Greek diet 40 percent of calories from fat and have a very low risk of heart disease but that's because the saturated fat intake in a traditional the Greek diet is low or you could have a traditional Japanese diet that's very low in fat and also low in saturated fat and have a very low risk of heart disease there are different types of diets that are healthy this is one type of fat that you should avoid it's hydrogenated or trans fats and they are disappearing from our food supply because of the very well be in part because of food labels and public awareness you don't get them in french fries anymore or in cupcakes or whatever kind of your popcorn they're really disappearing but that's a bad fat now the message that the American public got was in the late 50s early 60s around the time that I Chi hisin Haller had the age I think of 64 had an MI and it was very publicized and he was in a wheelchair recovering for weeks from his heart attack and there were twice a day news you know press conferences about is how he was doing and there was a lot of attention paid to his diet the public really got focused on this and we the American Heart Association said eat a low-fat diet and our saturate our total fat decreased this is where we are today our saturated fat decreased but our carbohydrate increased and during several decades what what happened was we went from being well the darker the states that are white just I have any data in them but the light blue tent less than 10% of the population was obese and the darker blue was 10 to 14 percent and then fast forward to 2010 we've become a fat nation now I'm looking in the audience and it looks a lot different than the audience that I saw in Nashville Tennessee we're which is sort of the buckle of the stroke belt and the heart attack belt a lot of obesity in our nation you guys are not representative and yet we went from being less than ten percent to now 20 to 24 percent in California that's where Nashville is in the darkest you know but more than a third of the population obese and that was related or associated I think caused by this inter misinterpretation of avoiding saturated fat we avoided fat entirely substituted it with simple carbohydrate and had a bad public health problem as a result you could superimpose a map of diabetes on top of the map of obesity the genetic predisposition meaning a parent with diabetes and becoming overweight leads to type 2 diabetes it's much much higher chance okay next statement cholesterol deposits can be reversed by diet true good it is true I wish I had well I'll explain what the next slide here on the top are coronary arteries from from monkeys that were fed a high-fat high cholesterol diet for a year and a half the monkeys were then sacrificed and their coronary arteries were examined and they were really clogged up there's very little room for the blood to flow through and there were blood clots it was that a group of monkeys that got that same diet were then fed a low cholesterol low fat diet without a lot of sugar for three and a half years and then they were sacrificed and their coronary arteries examples of their coronary arteries are shown and the bottom two panels much much less atherosclerosis so the inference is that they had really clogged up arteries these monkeys had arteries that looked like this and then they had regression yeah it was it wasn't all-around low-fat diet it was replaced with monkey chow and the monkey chow isn't like eating not you know cookies and cake it was more whole grain type of monkey food so in fact I I have to go back and look but this was a paper by Armstrong and I think they used coconut oil I'm not sure in the atherogenic diet so we have the evidence in on human primates I haven't shown you but I'll tell you in this area of the country in particular you've probably heard of a Dean Ornish and dr. Ornish fed people with coronary artery disease he did an angiogram at baseline and people who participated in the study a lifestyle heart trial and he had them changed their diets to very low low total fat and high complex carbohydrate in addition aside from a dietary intervention there was also exercise and meditation and food was provided it he made it relatively easy to adopt the the healthy food pattern that he was was encouraging and then repeated the angiogram after a certain period of time and found that there was less and he had a control group that didn't get that treatment and he found in the follow-up angiograms that the arteries of the people who got the low-fat diet who had a reduction in their cholesterol had a less progression and in some cases regression of the atherosclerosis so you were right it's true that with diet alone you said although there were other things going on in the lifestyle heart project in the monkey study it was purely a dietary intervention that diet can stop the progression and in fact induced regression of atherosclerosis alright fish oil yes the question is why has coconut oil been getting a good rep and there have been a couple of small studies looking at virgin coconut oil and the effect on cholesterol and it has shown that the virgin coconut oil raises HDL and lowers LDL cholesterol which is what we would think is a good thing there are no long-term studies looking at the impact of coconut oil on coronary arteries or long-term clinical outcomes like survival very hard to do a dietary study like that there are no there's no evidence except for short-term studies on lipids which appear to be good you you peggeleh coconut oil you meant I think yeah I I have to go back and look at the diet but typically coconut oil has been used in diets to try to create a Fross grossest yeah okay fish oil supplements prevent heart attacks true or false yes you're right it's false I see so many patients taking fish oil and I asked them why and usually they shrug their shoulders and they're not really sure it's very popular sales have gone up continuously over the last 15-20 years I Hey exactly the comment is people think that omega-3s are good for you and if they're not eating fish they're taking the fish oil and I think that a lot of people make that rationalization there is strong evidence that eating fish reduces the risk of dying from heart disease very consistent observational data it's really pretty very persuasive and there's a dose-response relationship the more fish you eat the lower your risk of dying from heart disease doesn't matter what kind of fish that's a good question and it probably doesn't it probably doesn't but there is a lot more attention on fatty fish which reduces the coagula ability the cloudiness how much has stickiness of blood there may be antioxidant effects and in high doses and you can only get this from fish oil supplements in really high doses fish oil will lower triglycerides and I'm talking about at least 2,000 milligrams a day of epa plus DHA you may know that there are some prescription fish oil medications that the FDA has approved they have high doses of EPA and/or DHA those are the fish oil the active ingredients if you will when you see a bottle of fish oil it may say a thousand milligrams in bold on the front and then you look at the ingredients on the back and there may be 350 milligrams of EPA and DHA on the back if you're taking it for triglyceride lowering then you would need for example and at least six of those to get to the 2,000 milligrams of EPA and DHA now fish oil may have some benefits it if there are anti-inflammatory effects it may help with arthritis but if you're taking it to prevent a heart attack you're wasting your money there have been so many studies now showing no benefit that there's no benefit even though it the evidence it's really disappointing when you believe something and the evidence doesn't support it that this is one of those things to eat fish yes sir lowers fish oil lowers your triglycerides then why would it have no effect on heart attacks ah good question um so first of all it's a little controversial whether or not triglyceride lowering reduces the risk of heart disease there is growing evidence that high triglycerides are a risk factor it's been sort of ignored relative to LDL cholesterol and to there there has not been a study yet of people with high triglycerides who were treated with high doses of fish oil followed for enough years to see if it reduces the risk of heart disease in the people who have been studied for generally primary there that I was gonna say primary prevention healthy people with no symptoms taking one fish oil capsule a day no benefit so it's it's still possible that a high dose of fish oil might reduce the risk of heart disease that study hasn't been done there was another commenter question yes you fish oil supplement a good question what's the benefit of eating fish versus the fish oil supplements I don't know it's hard to fool mother nature you know eating fruits and vegetables reduces the risk of heart disease and so you would think especially if you're Linus Pauling you would think that taking vitamins that are in those fruits and vegetables would reduce your risk because if it must be the vitamins well relax and lots of studies have been done now in thousands and thousands of people with vitamin supplements showing no reduction in heart disease risk and unfortunately among smokers you take vitamin A and the risk of heart disease goes up actually it's the risk of lung cancer goes up so I don't know the answer but there's something in fish that's good for you eating more fish versus how do you pity kind of me all right sorry okay right versus right like society that maybe rely a lot on legumes versa for their protein versus fish it is there some way to compare that so we understand whether fish is net beneficial or not yeah that's a really good question it's one that that I've asked I've been curious about that again we don't know that you do that study you would need to take you know vegetarians and then add fish to half the group and follow them for a long period of time observational data suggests that fish is is always beneficial but it's never really been studied in in a vegetarian population so I I don't know there was another thing she answered the question but maybe I asked a little bit differently it could be as simple as by eating fish or eating fruits and vegetables you're not eating beef or other foods that contribute to heart disease yeah that's a really good point and I think that there's probably add a an additional benefit from eating fruits and vegetables but it's so hard to do dietary studies because you you're always substituting you're not just taking something away you have to replace it with something and so is it the subtraction or is it the addition and it's very hard to answer so I don't know I'm saying that a lot all right so we've kind of covered this whole grains prevent dying from heart disease true no false okay so at least there's there's something here that you're not all definitely right on the answer is true and this is based on an observational observational type of data it comes from people at Harvard again who have done these long term studies of physicians and nurses and have them provide dietary information and follow them for a long period of time and if you eat whole grains and what you can't see is what these different graphs are this is the amount of whole grain intake here and this is the risk of dying and the more you eat the whole grains those over the risk now yeah ultimately unfortunately we all die but this is over a certain period of time and so you can delay your death by eating more whole grains now this is for all causes of mortality this is for cardiovascular disease mortality and there's a greater reduction it's a it's 15 to 20 percent reduction depending on how much whole grains you eat and they had a bottom line that with every serving of almost 30 grams of whole grains there's a per day every additional serving per day the full grains there's a 9% reduction of cardiovascular death with every serving pretty big you have whole grains three times a day compared with somebody who doesn't you have nearly a 30% lower chance of having cardiovascular death so whole grains as opposed to simple carbohydrate eating cake 30 grams three times a day he does not translate into benefit so what are the 3 s's that should be avoided in a heart-healthy diet sugar salt saturated fat I can't teach you guys anything okay all right the Mediterranean diet reduces the risk of heart attacks true ok so what are the having a little technical difficulty there what are the components of a Mediterranean diet red wine olive oil vegetables fish pasta now and say it's vegetables I think oh well with beans yeah you mentioned everything except cheese no you mentioned everything except low-fat dairy unless your cheese was a little fat sponsor Ella so yeah these were the clues which you didn't need V for vegetables fruit whole-grain pasta seafood legumes nuts and low and nonfat dairy products so that's what's in heart healthy and a Mediterranean diet this is what heart-healthy diet should look like yes oh okay so there's a little chick in there but fish and there's not red meat in this photograph the bread is whole-grain the pastas whole-grain you get the idea the chicken should be skinned yeah and that fried which is fried chicken is the fifth most prominent source of saturated fat in our diet okay cholesterol deposits can be reversed by exercise true no this is a case where when we do something that we think should be good for us is good for us it is true the the data are we don't have a lot of data on this and I'm going to show you a little now this is the first piece of data comes again from an on the monkey study monkeys were fed an atherogenic diet let's see what if they say here in the abstract no they just say atherogenic diet meaning something that would really raise their cholesterol and and then half were put on treadmill and half were kept sedentary and after a certain period of time and I can't remember how it was at least a year I think it was more like two years they again sacrificed the animals and examined their coronary arteries and on top is the coronary artery of a monkey who was in the control group who didn't exercise and in the bottom is an exercising monkey the monkeys that I got the atherogenic diet and didn't exercise had heart attacks they had they had you know complete closure and blood clots and they had much more thickening of their arteries with plaque the monkeys that exercised had some atherosclerosis but their look at the difference in the size it's the this is the same part of the coronary artery in a different animal and it's like 2 to 3 as wide I mean it's it's a much bigger artery and there's less atherosclerosis and the only difference between the monkeys was whether or not they exercised so pretty strong evidence again in non-human primate that exercise reduces atherosclerosis and another finding that it increases the size well this would translate to cardiovascular exercise so the question is what kind of exercise would this translate into these these monkeys were put on treadmills and exercise I don't think this but basically they were they were walking and running the slow heart rate is a training effect people who exercise a lot have slower heart rates so it would translate into walking for example do you have to work up a sweat no and they're really you know I was I was advised not to show you a lot of data so that you didn't get too bored but there are graphs that I could show you about physical activity and dying from heart disease they basically show that the greatest benefit from exercise is going from being a couch potato to doing a little exercise there is incremental benefit if you go to high intensity exercise and you do it all the time there's a little benefit pausing because I'll come back to my pause the so the big the big thing is doing something getting more active or running instead of walking going for an hour instead of 30 minutes getting your heart rate higher generally translates into better outcomes I say generally because in the last half year there have been two or three studies looking at sedentary people these are large population studies versus people who do a moderate amount of exercise versus the outliers who do a lot of high-intensity exercise and the high intensity exercises did not fare well they actually had death rates similar to the sedentary now it's hard to believe that it kind of goes against most of the evidence but at least to large population studies showing that and it might give some of you some comfort with what your what you're doing cardiovascular death heart attack our death and and then total cause all cause but in cardiovascular mortality yeah surprising no no after genic meaning like hi letter high high saturated fat yeah so a thorough genic meaning it creates or generates atherosclerosis so human beings these are monkeys here our corner is part of the coronary artery autopsy of mr. marathon Clarence DeMarre mr. d'amour ran a hundred marathons in his lifetime he won the Boston Marathon seven times and when he died at a ripe old age he had his body donated and one of the author's here you may recognize as Paul Dudley white who was I believe the cardiologist of President Eisenhower very famous cardiologist in the mid middle of last century and what this coronary artery shows is and this is taken from this article is that the coronary artery coronary arteries were unusually large two to three times normal size and there was very little atherosclerosis now this doesn't really prove anything he may have been born with big coronary arteries but it's remarkably similar to the photo I showed you in the previous slide of the monkeys who did a lot of exercise and there's another study that I haven't created a slide of that I'll tell you about it's looking at human beings with coronary artery disease proven by an angiogram a cardiac catheterization who were randomly assigned to an exercise intervention or control group that didn't you know they didn't do as much exercise and they were followed overtime and the group that exercised had significantly fewer deaths heart attacks angioplasties bypass surgeries so exercise does affect atherosclerosis we know from the animal studies that you can inhibit the amount of atherosclerosis and that you actually enlarge the coronary arteries does the same thing hold for people who have had a heart attack the study that I just told you about were people who had heart disease yes so raising HDL prevents heart attacks true or false gotcha finally yeah so far no soap so far not true and you we have observational data mmm by that I mean you study a bunch of people but you don't experiment you just collect information and see what happens to them over time a prospective observational study a population study consistently they show that people with high HDL have a lower risk of heart disease that that's different than showing that if you raise HDL you reduce the risk of heart disease and it's sort of confusing well you know you would think if if a equals B and B equals C then a must equal C but it's not the case we've had several studies so far with niacin which is a B vitamin in high doses it lowers triglycerides and raises HDL that when added to a statin does not reduce the risk of heart attacks we have several studies with fibrates these are drugs like tricor and lope in that especially the studies with tricor no benefit no reduction in heart attacks except in what's called post hoc analysis looking at a subset of people not the entire population the subsets that had high triglycerides and low HDL to begin with seem to benefit from these drugs fibrates but so far oh and we have studies infusing HDL intravenously that don't reduce the risk of heart disease so far so it's it's interesting we have recently seen data from people who did netiq we have lower triglycerides and they tend to they are protected from heart disease and we know that high triglycerides are associated with low HDL you lower the triglycerides you raise the HDL usually we've been so focused on HDL for the last few decades and have paid so little attention to triglycerides when it turns out maybe all the action is with the triglycerides and what's happening with the HDL is not really causal it's just sort of associated with where the action really is the ratio yeah you hear about the total cholesterol to HDL ratio it's a very powerful predictor of events what hasn't been shown that raising HDL which of course would lower the ratio the lower the ratio the better raising HDL has not been shown to reduce the risk of heart disease that the ratio is a good predictor and in fact HDL is a good predictor if you have low HDL your increased risk but that doesn't mean that the low HDL is the cause yes is it possible to have high triglycerides in high HDL yes and there are a couple of examples alcohol tends to raise triglycerides and HDL estrogen same thing will raise the triglyceride level especially if you take the estrogen orally by skin not so much so those are a couple of examples usually there's an inverse relationship high triglycerides low HDL dense are a good treatment for angina true or false okay so not so sure stents are definitely a good treatment for angina I am being very diplomatic though by choosing this question and the reason I say that is that this is what patients should be informed of before they have an elective angioplasty or stent procedure what I mean is that well I'll show you if you ask a bunch of people who have received informed consent to undergo a stent these are stable patients these are not people who are having a heart attack stable patient they've signed they understand they're going to have the procedure and you ask them well do you believe that this procedure will reduce your risk of a heart attack 88% say yes do you believe it will reduce your risk of a fatal heart attack 82% say yes now I participated in a notorious study notorious if you're one of my brethren in the interventional cardiology community they hate this study this is called the courage trial in the courage trial we took people who were stable they had they were not in the middle of a heart attack but they most of them had angina and we randomly assign them to get a stent and good medical therapy versus no stent and good medical therapy and we compared the two groups over four and a half years to see with the heart attack and death rate work and they were the same as you can see this is the medical therapy group in white and the stench group in green there was just no difference and so all these procedures are being done to put in stents when people believe that it's to prevent a heart attack but so far no proof but if you have a lot of angina getting a stent is a good treatment it improves quality of life now medical therapy also is a good treatment for angina but it's not as good as a stent or a period of up to three years after three years there's no difference between medical therapy and a stent how many patients you know this before they sign on the line to undergo a procedure usually not not very many statins prevent heart attacks boss yeah the answer is absolutely true statins it's weird this drug class has been studied more than any other drug class probably more than aspirin has been studied and there's so much misunderstanding I have so many patients I had them in Nashville and I have them in California that I see who are very apprehensive or absolutely have decided they do not want to be treated with a statin they are worried about the effect on their memory they are worried about the effect on their muscles they're worried about liver damage and there's no conclusive evidence that statins hurt cognitive function there's no there's virtually no evidence that statins will injure the liver there are very rare cases in fact the FDA used to recommend monitoring of liver functions the liver function tests on statins they removed removed that recommendation because it just never happens and muscle side effects definitely occur and they might occur in maybe 5% of people who take statins and I hate it that somebody who should be honest and is refusing when they might have a lot of potential benefit now in terms of benefit that here's one of the types of slides that I was told not to show on the x-axis is the LDL cholesterol level and on the y-axis is the rate of heart disease it says CHD it's for coronary heart disease events heart attacks and and fatal and non-fatal heart and this is a line showing that the lower the cholesterol this is these are a number of studies the lower the cholesterol achieved the lower the event rate and some of these have it like a P for the placebo group and then we here's for this the simba standard the the active drug group so there's very consistent evidence across many different types studies that have been done and here's another slide showing now on the x-axis again the LDL cholesterol on the y-axis is the change in atheroma volume that means with an intravascular ultrasound a little wire that goes inside the coronary arteries they're measuring the amount of plaque and the plaque this has to get go back to progression and regression the lower the cholesterol you can actually if you lower it in in this case it's below 70 you can achieve regression this is check doing an intravascular ultrasound at one point in time and then repeating it some time later after aggressive therapy you can shrink the plaque with statins so prevent they prevent heart attack they shrink plaque they're really one of the best things that the pharmaceutical industry has developed should you take it sprin everyday I know that we're we still have a few minutes so this is beyond them beyond ten questions yeah so the answer is it depends and and it depends on your risk no I outside there is a somewhere a place where you can get your risk and I what's the name of the station there's a biometric station and in that place you can get your cholesterol tested finger stick your blood pressure and then you'll know your your age sex and whether or not you have diabetes or smoke and you answer those questions look I'll go back to the other slide you put in the data and you get a risk estimate of what is your risk of having a heart attack or a stroke over the next ten years and if you are at high risk then it makes sense to be on aspirin so if you've had a heart attack if you've had a stroke if your risk is at least ten percent over the next ten years different people would draw the line at a different place but if your risk is elevated then low-dose aspirin makes sense defined in this country is 81 milligrams and used to be called a baby aspirin I put in this bullet colon cancer because there appears to be a cancer prevention benefit from aspirin specifically colon cancer so for example if colon cancer runs in your family that might be another reason to take aspirin on the other hand if you are as well if you have an intolerance of aspirin or for some reason a high risk of bleeding aspirins not a good idea for you well in general the risk of a serious bleed is three and ten thousand each year who anti-inflammatories work away aspirin does no aspirin good for the heart non-steroidal other non-steroidal anti-inflammatory drugs and unfortunately even Naprosyn motrin so I'm I've got a one more minute should you take a statin that sort of yes or no and again it depends on your wrist but here are the guidelines if you have coronary artery disease yes if you have really high LDL yes if you have diabetes yes if your risk with this at this biometric station is over seven and a half percent risk of stroke or heart attack in the next ten years yes and if you say I don't care what you say statins are bad and you're in my office then I'm going to order a coronary calcium scan if I think you should be on a statin and we're gonna get a picture and if you have calcium in your coronary arteries you might change your mind because that's a sign that you have a thorough sleep us is I'm gonna stop there and let's see what let you know the observation is called know your numbers in the back of your program you can record your results okay I'm gonna stick around for questions thank you very much for your attention the preceding program is copyrighted by the Board of Trustees of the Leland Stanford junior University please visit us at med.stanford.edu

3 Comments

  1. This cardiologist obviously doesn't realize hi carb diets lead to diabetes which leads to heart disease. The cholesterol doesn't cause heart disease. Half of heart attack victims have low cholesterol. … I'm shocked

  2. Hey, The best success that I have ever had was with Marks magic method (just google it) Without a doubt the most incredible diet that I have ever tried.

  3. Great to see that… Try woopep diet website diet to be more healthy 🙂

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