Mediterranean diet latest research news versus the low-fat diet for heart health

Why does the breaking news today report that the "Mediterranean Diet Study Results Stun World?" Also recently, renowned cardiovascular disease prevention expert and author, Dr. Janet Brill, wrote the book on how to follow a Mediterranean diet. Now, results of a long-term study have been released touting the Mediterranean diet. But back in the Mediterranean, people are eating more foods that look like what everyone else eats in the USA, fast food and Western-style desserts.

If the diet is recommended for the general public, doctors trying to reverse artery diseases such as plaque-clogged arteries dismiss the findings as not actually preventing acute conditions or cleaning out clogged arteries. The classic Mediterranean diet is more like what that farmer in Crete ate 100 years ago, fresh grape leaves full of resveratrol naturally found in the leaf, lots of green vegetables such as spinach and kale, and fresh vegetables of every hue from tomatoes to eggplants, bean soup with vegetables, some olive oil, wine, if you drink wine or other sources of resveratrol such as grapes and strawberries, and olives. To lower blood pressure in Mediterranean folkloric medicine, people sipped olive leaf tea or in modern times may take olive leaf extract.

For years, there has been a contest between the health benefits of the Mediterranean Diet and the Paleo diet, which was the hunter-gather's diet of ice-age Europe, the Arctic, and much of Asia. And the farmer's diet or Neolithic diet of the people who grew vegetables, fruits, and grains, fished, and pressed olives for oil and ate legumes, the diet of the Mediterranean and Middle East, has been competing with the Paleo diet so to speak depending on which diet can be customized for your particular genetic expression and metabolic response to foods.

Diets will be recommended depending on what doctors think the majority of people will stay on for the long term

According to a February 25, 2013 New York Times news report released yesterday, "Mediterranean Diet Can Cut Heart Disease, Study Finds - NYTimes," reports that new and powerful research just published in the prestigious New England Journal of Medicine has shown that following the Mediterranean diet cuts rates of heart attack, strokes and death from heart disease by about 30%. The Mediterranean diet is different from the Pan-Asian diet or the vegan diet, vegetarian diet, Dr. Ornish's diet to reverse clogged arteries and heart disease plaque, or diets that emphasize cutting out foods high on the Glycemic Index, foods that turn to sugar quickly in the blood

The latest findings of research noted that about 30 percent of heart attacks, strokes and deaths from heart disease can be prevented in people at high risk if they switch to a Mediterranean diet rich in olive oil, nuts, beans, fish, fruits and vegetables, and even drink wine with meals, a large and rigorous new study has found. Also see the article "A Healthy Diet That Includes, Yes, Chocolate (February 26, 2013)."

First major clinical trial to measure the Mediterranean diet's effect on heart risks

The findings, published on The New England Journal of Medicine’s Web site on February 25, 2013, were based on the first major clinical trial to measure the diet’s effect on heart risks. The magnitude of the diet’s benefits startled experts. The study ended early, after almost five years, because the results were so clear it was considered unethical to continue, according to the NY Times article.

Research showed that the Mediterranean diet helped those following it even though they did not lose weight and most of them were already taking statins, or blood pressure or diabetes drugs to lower their heart disease risk. How would the diet affect those who were told they needed to take statins but refused prescription drugs and opted instead for dietary changes?

What about finding out whether the diet helps those who don't take statins, blood pressure, or diabetes drugs but have been told they need them?

If the diet can lower blood pressure and cholesterol or increase the life span of people who refuse to take drugs even though doctors want to prescribe them for those patients, then that diet would be what a lot of consumers would like, an alternative to taking expensive prescription drugs by choosing foods that can keep people alive longer and on their feet.

The researchers didn't look for risk factors

In the latest study's results, scientists didn't look at risk factors like cholesterol or hypertension or weight. They looked at heart attacks and strokes and death. The big picture is what foods extend life rather than looking solely at risk factors. What scientists have been telling consumers for decades is that evidence that the Mediterranean diet reduced the risk of heart disease was weak because the studies looked only what people ate, people living in Mediterranean countries.

It looked as if those living in those rural Mediterranean areas such as the mountains of Spain or Crete or Cyprus, seemed to have lower rates of heart disease — a pattern that could have been attributed to leading the laid-back life of sun and surf, eating from local gardens and eating fewer processed foods. For example, even the raw, home-made cheese in some Mediterranean areas usually came from sheep and goats rather than cows full of anti-biotics and hormones.

Dairy products not pushed in Mediterranean diets

People living in the Mediterranean region eat cheese, usually made at home or bought locally made from raw goat or sheep milk or cultured yogurt cheese. But the Mediterranean diet in the study discourages use of whole fat dairy products. People on the Mediterranean diet often are told to "hold the cheese" and other high-fat dairy products such as butter, ice cream, and milk and instead use ground nuts or olive oil instead of melted butter and whole milk when preparing foods.

That leaves out pasta with melted butter and cheese poured over it and encourages seafood and olive oil with salads. But those on a reversal diet for clogged arteries frequently are told to limit fat intake to only 10 percent daily, not 40 percent. How long will people stay on the low-fat diet? The vegan diet? It depends on how seriously they feel about their clogged arteries.

And it was eaten in small amounts rather than melted on fatty red meat burgers. In the Eastern Mediterranean, lamb is eaten only at certain times, not daily. More likely, fish and other seafood is eaten more frequently as are legumes and grape vine leaves. So now the evidence finally has come in.

Experts were skeptical in the past that dietary effects can be detected in people taking powerful drugs such as statins and blood-pressure pills

Doctors were reluctant to recommend a diet that was high in olive oil when people are trying to lose weight. Instead, many physicians recommended nuts and seeds as fats in the diet instead of olive oil. Walnuts, for example and sesame seeds are part of the Mediterranean diet, not peanuts But oils and nuts have a lot of calories and doctors asking people to cut out fats to unclog plaque-filled arteries recommended largely vegetarian foods so as not to irritate arteries with animal protein.

Heart disease experts reported to news sources that the study showed that a diet was powerful in reducing heart disease risk. The methodology of the study had been top of the line rigorous, according to news reports. In the study, scientists randomly assigned 7,447 people in Spain who were overweight, were smokers, or had diabetes or other risk factors for heart disease to follow the Mediterranean diet or a low-fat one.

The study looked at the diet of people in Spain which is different from the diet of people at the other end of the Mediterranean, in Greece or North Africa. The diet in Egypt is based on beans and kale with flat bread, different from the diet in Spain or Greece or even Italy, which is focused on wheat products and cheese along with red meat or pork.

Low-fat diets have not been shown to be helpful, the researchers reported to the media

How else can you reverse heart disease and clogged arteries except by cutting out most of the fat, and keeping the fat at only 10 percent of the daily diet, some doctors ask? But the study also noted that low-fat diets have not been shown in any rigorous way to be helpful, and they are also very hard for patients to maintain. The latest study focused on how difficult low-fat diets are for people when they can't eat any fried foods or more healthy fats such as cookies made from flax seeds, nuts, pumpkin seeds, walnuts, pistachio nuts, hazel nuts or other similar fat sources.

The huge study done in Spain tells people they can eat a balanced diet with fruits, vegetables, and olive oil (or seeds and nuts) and lower heart disease by 30 percent. The study, by Dr. Ramon Estruch, a professor of medicine at the University of Barcelona, and his colleagues, was long in the planning. The investigators traveled the world, seeking advice on how to find out whether a diet alone could make a big difference in heart disease risk. They visited the Harvard School of Public Health several times to consult Dr. Frank M. Sacks, a professor of cardiovascular disease prevention there, according to the NY Times article.

Three groups were divided into one low-fat diet cohort and two groups on the Mediterranean diet.

Those on the Mediterranean dieters met regularly with dietitians. But group participants on the low-fat diets received an initial visit to train them in how to adhere to the diet, followed by a leaflet each year on the diet. Then the researchers decided to add more intensive counseling for them, too. Scientists found that those on the low-fat foods had difficulty staying with that diet.

Did the Mediterranean diet eaters have more fun eating more fat from oil or nuts? One group assigned to a Mediterranean diet was given extra-virgin olive oil each week and was instructed to use at least 4 four tablespoons a day. That's a lot of oil to swallow, whether you dump it in soup or drizzle it over salads.

The other group got a better tasting thick and creamy combination of walnuts, almonds and hazelnuts. But they only could eat an ounce of the mix each day. An ounce of walnuts, for example, is about a quarter cup. Nuts can become a food people crave. Many can't eat just a handful any more than eating a handful of chips. But they had to avoid eating a can full of nuts or seeds. The mainstays of the diet consisted of at least three servings a day of fruits and at least two servings of vegetables.

When some people eat whole-fat processed dairy, it quickly clogs their arteries

Fish was allowed at least three times a week and legumes, which include beans, peas and lentils, eaten at least three times a week. They were to eat white meat instead of red, and, for those whose stomachs don't burn when drinking wine, they were instructed to have at least seven glasses of wine a week with meals. The only problem is some people can't tolerate alcohol in any form.

Even at one glass of wine daily seven days a week, that may be too much for small people or women who would be pulled over after a glass of wine, depending on how big the wine glass is, unless the glass of wine was taken before bedtime. But at that time of day when operating machinery or driving isn't required, also contributes to insomnia. You fall asleep and then wake up in the middle of the night, and sometimes the wine plays havoc with blood sugar spikes.

All groups were encouraged to avoid commercially made cookies, cakes and pastries, and to limit their consumption of dairy products and processed meats

Deli items were out. The mortadella of Sicilian cooking is out as it's a processed deli meat. What about home-made cookies that don't use sugar, but only fruit? That wasn't mentioned in the study's news reports. To assess compliance with the Mediterranean diet, researchers measured levels of a marker in urine of olive oil consumption — hydroxytyrosol — and a blood marker of nut consumption — alpha-linolenic acid.

Those on the low-fat diet didn't stay on that diet. Those on the Mediterranean diet stuck with the regimen

The study wound up comparing the usual modern diet, with its regular consumption of red meat, sodas and commercial baked goods, with a diet that shunned all that. But is that how people in Mediterranean countries eat in modern times or ate 50 years ago, and then plowed the land to work off the calories? The outcome is that the effect of the Mediterranean diet is due to the entire package, not just the olive oil or nuts. It's possible the diet worked in spite of the fats based on the amount of greens and other antioxidant vegetables and fruits in the diet. But scientists were surprised to see such a big effect so soon.

Researchers say more research is needed with people at low risk of heart disease

Researchers still had to end up with saying more research was needed to see whether the diet helped people at low risk for heart disease. But the diet did reduce heart disease for those at high risk of getting clogged-up arteries from foods. But if you want to use the Mediterranean diet for protection against heart disease risk, you need to really begin eating that way from early childhood. If you want to reverse clogged arteries with food changes, you might want to take a look at the Ornish diet (see, The Ornish Spectrum) that focused on people who already had clogged arteries and heart disease.

Some scientists focusing on reversal diets dismissed the study. For example, according to the NY Times news article, "Dr. Caldwell Blakeman Esselstyn Jr., the author of the best seller “Prevent and Reverse Heart Disease: The Revolutionary, Scientifically Proven, Nutrition-Based Cure,” who promotes a vegan diet and does not allow olive oil, dismissed the study." And Dr. Dean Ornish, president of the nonprofit Preventive Medicine Research Institute, have influenced many to try to become vegan and on low fat diets. Former President Bill Clinton, interviewed on CNN, said Dr. Esselstyn’s and Dr. Ornish’s writings helped convince him that he could reverse his heart disease in that way.

The Ornish diet: Low fat and touted in the news for reversing artery plaque and heart disease

Consuming fat and cholesterol

If you don't eat saturated fat from dairy or animals such as meat, cheese, or eggs and eat mostly vegetables, beans, legumes, some grains, and some fruit, even if you have few cholesterol receptors in your liver cells, it doesn't matter much if you're not eating much fat.

Even a 20% fat diet has too much saturated fat and cholesterol in it according to the reversal diet touted in the book, Dr. Dean Ornish's Program for Reversing Heart Disease, published in 1990 and 1996. The nineties decade focused on reversing clogged arteries and high cholesterol by eating a diet lower than 10 percent fats. See the sites, Does Ornish Diet Work? and A Diet That Restricts Daily Fat Intake to 10% Can Help Fight Against Heart Disease. Today, the typical American diet is a whopping 40% fat.

In 2012 we have diets such as the The Blood Sugar Solution | Reverse Diabesity in Just 6 Weeks that focuses on eating foods that don't quickly turn to sugar in the bloodstream and cause high insulin levels. These types of diets focus on controlling those high insulin spikes after eating, even if blood glucose levels test normal. The emphasis also is on looking at insulin levels to see whether they're high or normal after meals and not only relying on fasting glucose levels in the bloodstream.

The foundation of Dr. Ornish's studies report the following:

• Each gram of fat contains nine calories while protein and carbohydrates contain four calories per gram. A person can essentially eat more food on a very low-fat diet since fewer calories are consumed in each meal.
• "Eating fat makes you fat." and causes heart disease. Fat that is ingested by the body is easily converted into body fat. Complex carbohydrates, the staple of low-fat diets, are less easily converted to body fat. Complex carbohydrates are starches such as grains, beans, vegetables, and fruits.
• Saturated fat is converted by the liver to cholesterol and raises the blood cholesterol level. Saturated fat is found largely in animal products, but high amounts are also found in avocados, nuts, and seeds. Monounsaturated fat and polyunsaturated fat do not raise cholesterol levels.

Dr. Ornish's reversal diet for cleaning out clogged arteries:

The Reversal Diet is a vegetarian diet, consisting mostly of complex carbohydrates. Eating lower amounts of protein is healthy as long as you get some protein from the vegetables you eat. See,The Ornish Spectrum and Weight Loss & Diet Plans - Review: Eat More, Weigh Less. WebMD evaluates the Dr. Dean Ornish diet philosophy adapted from his regimen to reverse heart disease.

Frank Hu, MD, PhD, assistant professor of medicine at the Harvard School of Public Health, is critical of how severely fat is limited on Dr. Ornish's reversal diet, according to the WebMD site. "The data from numerous studies show that it is the type of fat, rather than the total amount, which is related to cardiovascular health," he says, according to the website.

"Polyunsaturated and monounsaturated oils actually protect against cardiovascular incidents." For example, Hu says, Ornish advocates limiting the consumption of fish and nuts, and Hu adds, "There is strong evidence that the fat in them is protective against coronary heart disease in both epidemiological studies and clinical trials."

Vegetarian food and health versus animal protein touted in the media for teeth and bones

Vegetarian foods do not contain cholesterol as do animal products, and they are low in saturated fat (except foods such as avocados, nuts, seeds, cocoa, olives, and coconut), according to a summary of Dr. Ornish's Reversal Diet is listed below. The diet has the following restrictions:

• "has less than 10% of calories from fat, and little of it is saturated
• excludes foods high in saturated fat (such as avocados, nuts, and seeds)
• is high in fiber
• allows but does not encourage moderate alcohol consumption (less than two ounces per day)
• excludes all oils and all animal products except nonfat milk [and nonfat dairy products] and nonfat yogurt [i.e. meats, poultry, seafood are all excluded]
• allows egg whites
• excludes caffeine, other stimulants, and MSG
• allows moderate use of salt and sugar
• is not restricted in calories"

The purpose of the reversal diet is to help unclog arteries stuffed up with plaque, cholesterol, and calcium as an alternative to getting bypass surgery. The majority of his participants on the reversal diet had some success in cleaning out some of their arteries to an extent where they got better blood flow.

For more information on the results of tests with patients on his studies, see the book, Dr. Dean Ornish's program for reversing heart disease. The program is based on landmark research published in the Journal of the American Medical Society. See the book, Dr. Dean Ornish's Program for Reversing Heart Disease.

Dr. Ornish's reversal diet says eat all the calories you want as long as they're vegetables such as broccoli and asparagus and not starchy fried potatoes or pasta

Most people on Dr. Ornish's reversal diet consume fewer calories than the average person residing in the United States. According to the book, Dr. Dean Ornish's Program for Reversing Heart Disease, the typical American diet consists of :

• 40% to 50% of fat, most of which is saturated
• 25% to 35% carbohydrates
• 25% protein
• 400 to 500 mg cholesterol daily

In contrast, his Reversal Diet consists of the following:

• 10% fat, most of which is polyunsaturated or monounsaturated
• 70% to 75% carbohydrates
• 15% to 20% protein
• 5 mg cholesterol daily

Too much protein can cause bone loss

Dr. Ornish dispels the myth that a diet lower in protein is harmful to the body and states that the amount of protein recommended in his Reversal Diet is sufficient for the body. Of the 22 amino acids that combine to form proteins in the body, nine, the "essential" amino acids, must be obtained through diet.

Three of the nine "essential" amino acids are critical: lysine, tryptophan, and methionine. The remaining six amino acids are found in most foods.

Plant based foods contain the three critical amino acids in varying amounts. So you simply eat a variety of foods to obtain the necessary amino acids.

To obtain enough protein on Dr. Ornish's reversal diet, you eat grains and legumes or you combine grains or legumes with small amounts of nonfat yogurt or skim milk to get a complete protein. Nonfat yogurt and skimmed milk is allowed, as the diet isn't totally vegan.

Dr. Ornish notes that plant-derived protein is identical to the protein found in animal products. That's why beans and brown or black rice or quinoa or similar grains that are not overly starchy such as white rice is lost by eating beans rather than chicken chunks, steak, burgers, or fish.

When it comes to your health, look as far back as possible in the causal chain of evens to find a solution to a problem instead of looking at putting a potent pill on the last symptom, assuming you're not a case for the emergency room yet. What goal you want is powerful healing rather than covering the latest symptom. All bets off if you're in a crisis where emergency action is needed within minutes if not seconds.

One example might be looking at cholesterol before you pop a statin pill. The more cholesterol receptors you were born with, the more efficiently your metabolic system removes cholesterol from your bloodstream.

How many cholesterol receptors did you inherit?

If you were born with only a tiny number of cholesterol receptions, which you inherited from family members, the more your blood cholesterol level will increase when you eat saturated fat and cholesterol. Here, we're talking about the 'bad' LDL cholesterol, not the 'good' HDL cholesterol, which you want to have at an increased number.

Who discovered all this? Two Nobel prize winners, Drs. Michael Brown and Joseph Goldstein won the Nobel prize in medicine in 1985 because they found out how LDL receptors work. Those LDL receptors are located in your liver cells. Their job is to remove LDL cholesterol from your blood.

You don't have to eat lots of fat to get your essential fatty acids

Dr. Ornish also dispels the myth that a person must consume a significant amount of fat to ensure that the body is ingesting the correct amount of essential fatty acids. In to get your daily essential fatty acids, the average person needs to consume less than 14 grams of fat daily. If you're deficient in fat, it could be because your body has a problem absorbing fat.

Even vegetables contain some fat. Also, many people take a spoon full of cod liver oil to get their omega 3 fatty acids with DHA for nourishing their brain and eyes. But in the 1990s when Dr. Dean Ornish's book, was first published, fish oil wasn't touted that much in the book. What the book noted then is that fish oil thinned the blood.

By 2012 fish oil was recommended in the book, Metabolic Cardiology | Dr. Stephen Sinatra's Heart MD Institute along with the four super supplements, magnesium, CoenzymeQ10, D-ribose, and L-carnitine for energizing the heart of those who have heart disease or are elderly and lacking enough ATP energy in their mitochondria and for those whose own mitochondria aren't making full use of oxygen in the lungs for exercise, walking, or general quality of life.

Vegetarian and vegan menus for reversing heart disease or unclogging soft-plaque-filled arteries are different from the Mediterranean diet and are low-fat

Dr. Esselstyn said, according to the N.Y. Times news article that, "those in the Mediterranean diet study still had heart attacks and strokes." The question remains whether the study created disease in people who otherwise did not have it? How would the general consumer know what to follow, perhaps based on family history, of tailoring foods to metabolic and genetic needs. The researchers are following a Mediterranean diet, the NY Times article noted.

Only about 30 percent of heart attacks, strokes and deaths from heart disease can be prevented in people at high risk if they switch to a Mediterranean diet rich in olive oil, nuts, beans, fish, fruits and vegetables, and even drink wine with meals, the large and rigorous new study has found. The question is, if you're in the remaining 70 percent, what do you eat?

What the diet study results revealed

The new study has shown that following the Mediterranean diet cuts rates of heart attack, strokes and death from heart disease by about 30%. The diet can also reduce the risk of a second heart attack by up to 70 percent. What if you want to avoid that type of illness in the first place?

The Mediterranean diet incorporates eight key food groups — like olive oil, oatmeal, leafy greens, and even red wine and dark chocolate — into your daily diet, and get moderate exercise each day. If the diet includes whole-grain pizza, what if you're sensitive to the wheat crust or even wheat bran and are not told to eat gluten-free? What if you don't want your pancakes fried in olive oil and would rather eat dehydrated and raw or steamed foods rather than baked or fried?

Olive leaf extract and resveratrol

There are other studies to consider if you are not taking prescription drugs and want to investigate how olive leaf lowers blood pressure. Check out the article, "How Resveratrol Combats Leading Causes of Death - Life Extension," by Brian Vogelman in the March 2012 issue of Life Extension magazine.

Resveratrol helps to combat high blood pressure (hypertension) by decreasing inflammatory cell infiltration into blood vessel walls and improves those vessels’ ability to respond to changes in blood pressure, according to the 2011 study, "Calorie restriction and resveratrol in cardiovascular health and disease." Biochim Biophys Acta. July 1,2011. Check out the Life Extension article, "How Resveratrol Combats Leading Causes of Death - Life Extension, March 2012, pages 83-90.

Recent studies confirm that a central mechanism of resveratrol’s activity is to mimic the biological effects of calorie restriction

Resveratrol has been shown to reduce the unfavorable remodeling and stiffening of blood vessels and heart muscle that results from sustained hypertension, according to the study on rats, "Resveratrol improves cardiovascular function in DOCA-salt hypertensive rats." Curr Pharm Biotechnol. 2011 March 1;12(3):429-36. Resveratrol also acts in the brainstem to reverse increases in blood pressure that are triggered by a variety of dietary and hormonal factors, according to the study, "Chronic estradiol-17β exposure increases superoxide production in the rostral ventrolateral medulla and causes hypertension: reversal by resveratrol." A lot of these studies, many with lab animals or livestock, were presented at the 2010 international conference on the uses and benefits of resveratrol.

What many senior consumers want to know is how resveratrol in some measured way will reverse the biological changes associated with chronic conditions and aging, since many of the studies were done with lab animals or livestock? People want to know how much power resveratrol has to prevent or change the gradual onset of various chronic diseases that are associated with older adults. Can it slow down chronic conditions from worsening?

Balancing cholesterol levels

Studies published in 2011 show that resveratrol helps lower or balance the cholesterol elevations that result from obesity and a high-fat diet by directly regulating expression of genes that control lipid metabolism, according to the study, "Effects of long-term consumption of low doses of resveratrol on diet-induced mild hypercholesterolemia in pigs: a transcriptomic approach to disease prevention. J Nutr Biochem. 2011 Aug 16. Note that a lot of these studies were done with animals.

The question remains can what results are seen in animals be applied to humans, since a lot of the DNA is similar, even though there are some differences in the way nutrients affect animals and humans? These studies were mentioned in the Life Extension article, "How Resveratrol Combats Leading Causes of Death - Life Extension," which has references to 65 different studies on the health benefits of resveratrol in specific amounts.

Resveratrol triggers the correction of abnormal fatty acid utilization, say some studies

In other studies, exposure to resveratrol triggers correction of abnormal fatty acid utilization, by inducing mitochondrial enzymes that help break down fat molecules. Even though the studies were done with pigs, those animals still have the equivalent of human metabolic syndrome, resveratrol supplementation lowered body mass indices, serum cholesterol, the inflammatory marker C-reactive protein, improved glucose tolerance and endothelial function. But can it also help humans?

What humans worry about that comes with age is the risk of arterial calcification. In the past it had been formerly thought to be caused by passive accumulation of calcium, similar to mineral deposits in pipes. Not really, what happens is that there's an active process whereby arterial cells “turn into” bone-forming cells as a result of age- and inflammation-induced genetic changes.

Do certain drugs or foods hurry the aging process when it comes to chronic conditions?

If you check out the Life Extension article, "How Resveratrol Combats Leading Causes of Death - Life Extension," you can see more details and further information of how certain drugs, can hasten this destructive process. New data demonstrate that resveratrol slows or reverses the process by which arterial cells become “bone-like,” reducing the amount and extent of calcium build-up in arterial walls.

Resveratrol limits the inflammation-inducing effects of calcium in cells lining blood vessels, according to the study, "Protective effects of resveratrol on calcium-induced oxidative stress in rat heart mitochondria." J Bioenerg Biomembr. 2011 Apr;43(2):101-7. People want to know whether the diet can be tailored to individual requirements that the body needs, which may be different for people depending upon their inherited predispositions, childhood diets, and the environment or lifestyle factors?