by Stuart M. Caplen, MD The concept of the medical apology pits the ethical issue of informing patients about medical errors, some of which they might never have realized occurred, against the deny and defend strategy traditionally used in malpractice litigation. A study of 30,121 hospitalized patients in New York State found that 0.93% (280) of them had adverse events due to negligence. Only 2.9% (8) of those patients filed malpractice suits.[1] Given the low percentage of litigation where an error occurred causing an adverse event, there is the concern that the medical apology might appreciably increase the litigation rate. The first documented US institutional use of medical apology was in 1987 at the Veterans Affairs Medical Center in Lexington, Kentucky. The medical center created a policy requiring improved reporting, review of all errors, and notification of patients/families about any error that caused harm, whether they were aware of it or not. If the risk management committee believed that the hospital was at fault, an apology that included admitting fault verbally, and if requested subsequently in writing, was made to the patient/family. An attorney could be present at this meeting if the patient or family desired. There was also discussion with the patient/family of corrective measures taken to prevent the error happening to other patients. The risk management committee then discussed further steps the hospital could take to aid the patient medically, as well as offering to assist in obtaining any entitled disability benefits and making a fair compensation offer for any injury. After initiating this process, the Lexington VA reduced its malpractice claims payments from one of the highest in the VA system to one of the lowest.[2] This process has been used at the University of Michigan[3], the Erlanger Health System[4] and the University of Illinois Hospital System[5] among other institutions[6]. The University of Michigan reduced its average monthly rate of new claims from 7.03 to 4.52 claims per 100,000 patient encounters and decreased the average monthly rate of lawsuits from 2.13 to 0.75 per 100,000 patient encounters.[3] While results varied by institution, in general an error communication and resolution process with investigation of the incident, apology if an error was made, error correction and offer of fair remuneration resulted in a decrease in claims, decreased legal defense costs, decreased settlement and liability costs and decreased median time to resolve a claim. It is felt that compensating patients for injuries caused by medical errors is an important component of the model. It may help to avoid litigation, provide closure, and establish organizational credibility. At the Erlanger Health System, the care was felt to be acceptable in 65% of the incidents investigated in their collaborative communication resolution program. If no medical error occurred, an explanation to the patient/family was made for the adverse outcome and why the hospital believed the standard of care was not breached. In the other 35% of incidents where a medical error was found, 85% of those errors caused physical injury to the patient. Almost half (43%) of the instances of errors resulting in patient injury were resolved completely by an apology, with lawyers present at 60% of those meetings.[4] This may indicate that many patients/families only want an apology, explanation of the reason for the adverse outcome, and change in the hospital system to prevent the error from occurring to others. The way the apology is made is also important, as a poorly planned or an insincere apology may make matters worse. One concept of the makeup of an authentic medical apology is the four R’s by Dr. Michael Woods. There must be Recognition that an apology is needed. There should be an expression of Regret . Expressing empathy such as “I am so sorry; I know this outcome is not what you expected, it is not what I expected either,” does not admit guilt but may help to reinstitute a therapeutic relationship. The third R is Responsibility , an explanation of what happened and why it happened, and what is being done to protect others in the future. Finally, what is going to be done to Remedy the situation for the patient, including who will pay the needed costs for that remediation.[7] In order to increase the use of medical apology and provide some legal protection for the practice, 39 states have enacted apology laws which exclude the use of the apology in any malpractice litigation. There are major differences in the statutes depending on the state. Vermont for example, covers oral but not written apologies. Some states only protect an apology, while others protect both the apology and an admittance of fault. A few states have mandated error reporting to the patient/family when there is an adverse outcome.[8] A study of malpractice claims comparing states with and without apology laws, found apology laws had no effect on surgeon claims. For non-surgical practitioners there was actually an increase in malpractice litigation in apology law states. Thus, apology laws by themselves do not appear to reduce the malpractice liability risk. It should be noted that this study did not determine whether more apologies were actually being made in apology law states, and just compared malpractice claims data.[9] Conclusions It appears that a formalized error communication and resolution process can reduce the litigation and the settlement costs of medical errors. The process is ethically sound and may be beneficial for patients and families. It consists of an investigation of the incident, an apology if an error was made, an offer of fair remuneration for the error, and having a process in place to try to prevent future similar errors. A heartfelt apology to the patient for delays or other care issues that don’t cause significant harm is generally recommended. However, an individual practitioner apologizing for medical errors that result in injury without a formalized error communication and resolution process set up, may possibly increase the chance of litigation. An important part of an error communication and resolution process is compensation for the error, or the remedy part of a medical apology, which an individual practitioner cannot offer. A practitioner may wish to speak to an attorney, malpractice carrier or be in situation where a formal process has been previously instituted before proceeding. Apology laws, while well intentioned, may not actually provide much protection from litigation for practitioners. References: [1] Localio R et al., Relation between Malpractice Claims and Adverse Events Due to Negligence — Results of the Harvard Medical Practice Study III, N Engl J Med 1991; 325:245-251. Retrieved from: https://www.nejm.org/doi/full/10.1056/nejm199107253250405 [2] Cohen J. Apology and Organizations: Exploring an Example from Medical Practice. Vol. 27 Fordham Urban Law Journal, 447-82, (2000). Retrieved from: https://ir.lawnet.fordham.edu/ulj/vol27/iss5/8 . [3] Boothman R et al, Nurturing a Culture of Patient Safety and Achieving Lower Malpractice Risk Through Disclosure: Lessons Learned and Future Directions, Frontiers of Health Services Management, 2012 Spring;28(3):13-28. Retrieved from: http://www.med.umich.edu/news/newsroom/Boothman-ACHE-Frontiers.pdf [4] Lecraw F et al., Changes in liability claims, costs, and resolution times following the introduction of a communication-and-resolution program in Tennessee, Journal of Patient Safety and Risk Management, February 14, 2018. Retrieved from: https://doi.org/10.1177%2F1356262217751808 . [5] Lambert B. The “Seven Pillars” Response to Patient Safety Incidents: Effects on Medical Liability Processes and Outcomes, Health Services Research, December 2016. Volume 51, IssueS3, Pages 2491-2515. [6] Kachalia A et al., Effects of A Communication-And Resolution Program On Hospitals’ Malpractice Claims And Costs, Health Affairs 37, No.. 11 (2018): 1836–1844. [7] Baum N, Apology: The Power of “I’m Sorry” in Patient Satisfaction (and Avoiding Litigation), Patient experience.com, September 10, 2012. Retrieved from: http://patientexperience.com/apology-power-im-sorry-patient-satisfaction/ . [8] McDonnell WM, Guenther E, Narrative Review: Do State Laws Make It Easier to Say “I'm Sorry?”, Annals of Internal Medicine, 2 December 2008 Vol: 149, Issue 11, 811-815. [9] Benjamin J et al., “Sorry” Is Never Enough: How State Apology Laws Fail to Reduce Medical Malpractice Liability Risk, Stanford Law Review, Feb 2019, Vol.71 p 341-409. Retrieved from: https://review.law.stanford.edu/wp-content/uploads/sites/3/2019/02/McMichael-71-Stan.-L.-Rev.-341-2019.pdf .

Will trading your beef burger for a plant-based burger, like Beyond or Impossible, really improve your health and the health of the planet? Culinary Medicine by Lori A Smolin, PhD and Mary B Grosvenor, MS, RD A new generation of plant-based meat alternatives is garnering attention from vegetarians as well as from those interested in cutting down on their meat intake for health or environmental reasons. Will trading your beef burger for a plant-based burger, like Beyond or Impossible, really improve your health and the health of the planet? These next gen fake meats have come a long way from the original “veggie” burgers made from ingredients such as black beans and quinoa. While the newer versions are also based on simple plant proteins, these proteins are altered, and numerous ingredients are added to simulate the appearance, texture, and taste of the burgers, sausages, or nuggets they replace. Fat, often coconut oil, is added to provide the mouthfeel of animal fats. Yeast extract and other flavorings, are added to provide a meaty taste. Impossible Foods uses soy-derived leghemoglobin to mimic the color and flavor that myoglobin provides in beef. How does all of this affect the healthfulness of these products? Nutrition experts tell us to choose a dietary pattern high in fiber and limited in red meat, saturated fat, sugar, sodium, and highly processed foods.[1,2] Replacing a beef burger with a plant-based alternative obviously helps reduce red meat intake and also provides more fiber than beef. But these alternatives can contain a significant amount of saturated fat and are often higher in sodium content than beef (see Table). In addition, they are extensively processed to make them look, cook, and taste like meat. Do the benefits of reducing red meat and increasing fiber intake outweigh the concerns with nutrient content and degree of processing? Unraveling this dichotomy requires a deeper look into these products. The recommendation to reduce meat intake is based on epidemiologic evidence that shows an association between a dietary pattern high in animal products and an increase in cardiovascular disease (CVD) risk.[3] Much of this increase in risk is thought to be related to the high saturated fat content of red meat, which is linked to an increase in blood levels of LDL cholesterol.[4] Data continue to support an increase in CVD risk with higher red meat and saturated fat intakes, while newer hypotheses suggest that metabolites of red meat digestion may also play a role.[5] High blood levels of TMAO (trimethylamine N-oxide), and other metabolites produced by the gut microbiome after eating red meat, have been linked to a higher risk of CVD.[5] A randomized 8-week crossover trial that replaced 2 or more servings a day of red meat with Beyond products found reduced levels of several CVD risk factors, including blood levels of both LDL cholesterol and TMAO.[6] From this, we can assume that replacing some meat with plant-based options is a healthier choice. What about the processing aspect of these new plant-based alternatives? The admonition to limit highly processed foods is based on the fact that processing can cause nutrient losses and highly processed foods often contain added fat, sugar, and sodium.[7,8] Diets high in these foods are associated with an increased risk of obesity and other chronic diseases.[9] Plant-based meat alternatives are highly processed. For example, the soy protein in Impossible burgers is isolated and concentrated from soybeans that have been cleaned, crushed, dehulled, and flaked.[10] The label on Impossible beef (see figure) lists over 20 ingredients, including coconut oil, which is high in saturated fat, and added salt. However, this burger also contains high-quality soy protein and has added iron, zinc, vitamin B12, and other micronutrients to match the amounts of these in beef. Therefore, even though these products are highly processed, they have nutritional benefits that put them in a different category than many other highly processed foods, such as cheese puffs or fruit punch. While the full impact of plant-based meat alternatives on our health is not completely understood, they may be healthier for the planet. Raising livestock is environmentally costly; it generates nearly 15% of total global greenhouse gas emissions contributing to climate change, and uses 50 to 75% of agricultural land, contributing to deforestation and water pollution.[11] Producing these meat alternatives has been reported to have less of an effect. A study conducted by the University of Michigan Center for Sustainable Systems, commissioned by Beyond Meat, found that producing a Beyond burger generated 90% fewer greenhouse gas emissions, had 99% less impact on water scarcity, and 93% less impact on land use than a traditional beef burger.[12] Skeptics of the data suggest they do not consider the total amount of greenhouse gas emissions across all of the company’s operations and supply chains or from consumer waste. It is well known that livestock production has a significant impact on the environment, but the impact of plant-based meats is still not fully established. So, as to the original question: “Will choosing a plant-based burger be healthier for you or the planet?”. While no single food can make or break a diet, choosing a pattern that limits red meat is probably better for you and the planet. Simply replacing a beef patty served with fries and a sugar-sweetened beverage with a Beyond burger patty does not result in a healthier overall dietary pattern. But reducing the amount of red meat in your diet by choosing smaller portions or eating it less frequently, while increasing less processed plant food choices, like whole grains, vegetables, fruits, and legumes, will be good for your health and the environment. Replacing meat with plant-based burgers, sausages, crumbles, and nuggets can be a first step in reducing the amount of meat in your diet. These products are readily available in restaurants and grocery stores and are easy to substitute into meat-containing recipes. Plant-based meat alternatives can help vegans and meat eaters alike eat more sustainably while enjoying the taste of beef. References [1] U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2020-2025. 9th Edition. December 2020. https://www.dietaryguidelines.gov/resources/2020-2025-dietary-guidelines-online-materials. Accessed April 7, 2023. [2] Grosso G, La Vignera S, Condorelli RA, et al. Total, red and processed meat consumption and human health: An umbrella review of observational studies. Int J Food Sci Nutr. 2022;73(6):726-737. doi: 10.1080/09637486.2022.2050996. [3] Yngve A. A historical perspective of the understanding of the link between diet and coronary heart disease. Am J Lifestyle Med. 2009;3(1 Suppl.):35S-38S. doi: 10.1177/1559827609334887. [4] Bergeron N, Chiu S, Williams PT, M King S, Krauss RM. Effects of red meat, white meat, and nonmeat protein sources on atherogenic lipoprotein measures in the context of low compared with high saturated fat intake: A randomized controlled trial. Am J Clin Nutr. 2019;110(1):24-33. doi: 10.1093/ajcn/nqz035. Erratum in: Am J Clin Nutr. 2019;110(3):783. [5] Wang M, Wang Z, Lee Y, et al. Dietary meat, trimethylamine N-oxide-related metabolites, and incident cardiovascular disease among older adults: The Cardiovascular Health Study. Arterioscler Thromb Vasc Biol. 2022;42(9): e273-e288. doi: 10.1161/ATVBAHA.121.316533. [6] Crimarco A, Springfield S, Petlura C, et al. A randomized crossover trial on the effect of plant-based compared with animal-based meat on trimethylamine-N-oxide and cardiovascular disease risk factors in generally healthy adults: Study with Appetizing Plantfood-Meat Eating Alternative Trial (SWAP-MEAT). Am J Clin Nutr. 2020;112(5):1188-1199. doi: 10.1093/ajcn/nqaa203. [7] McManus, KD. What are ultra-processed foods and are they bad for our health? Harvard Health Blog. January 9, 2020. https://www.health.harvard.edu/blog/what-are-ultra-processed-foods-and-are-they-bad-for-our-health-2020010918605. Accessed April 5, 2023. [8] TH Chan Harvard School of Public Health. Nutrition Source. Processed food and health. https://www.hsph.harvard.edu/nutritionsource/processed-foods/. Accessed April 5, 2023. [9] Elizabeth L, Machado P, Zinöcker M, Baker P, Lawrence M. Ultra-processed foods and health outcomes: A narrative review. Nutrients. 2020;12(7):1955. doi: 10.3390/nu12071955. [10] Van den Berg LA, Mes JJ, Mensink M, and Wanders, AJ. Protein quality of soy and the effect of processing: A quantitative review. Front Nutr. 2022; 9:1004754. doi: 10.3389/fnut.2022.1004754. [11] Santo RE, Kim BF, Goldman SE, et al. Considering plant-based meat substitutes and cell-based meats: A public health and food systems perspective. Front Sustain Food Syst. 2020; 4:134. doi: 10.3389/fsufs.2020.00134. [12] Heller MC, Keoleian GA. Beyond Meat’s Beyond Burger life cycle assessment: A detailed comparison between a plant-based and an animal-based protein source. CSS Report, University of Michigan, Ann Arbor. 2018, 1-38. http://css.umich.edu/publication/beyond-meats-beyond-burger-life-cycle-assessment-detailed-comparison-between-plant-based. Accessed April 3, 2021.

In an effort to further simplify your life we've created an easy way to access your www.FibonacciMD.app membership account via the APP Store. This feature is only available to people who have an iPhone, iPad, or Apple Watch. We call it the FibonacciMD BOOKMARK because it provides a shortcut on your phone to click to either view recent articles to go straight into the membership www.FibonacciMD.app. If you are with a patient or in the hospital just use your phone to access FibonacciMD. We will be coming out with an Android bookmark soon. NOTE: The bookmark is not necessary to access FibonacciMD, our app works on all devices. This bookmark just provides a visual reminder or shortcut.

Nivolumab + Yervoy (ipilimumab) combination therapy has shown superior efficacy to nivolumab monotherapy in several types of cancers, but combination therapy is also often associated with a higher incidence and increased severity of adverse effects. Oncology Term FibonacciMD Compendium In Short By Dan Reef, MD and Nancy Mills, MD Definition of Nivolumab Nivolumab is an immune checkpoint inhibitor used in treatment of an ever-expanding set of cancers. More specifically, nivolumab is a fully-human monoclonal IgG4 anti-programmed death-1 receptor (PD-1) antibody. Activated T cells express PD-1. When PD-1 interacts with its ligands, PD-L1 and PD-L2, on tumor cells and/or stromal cells surrounding a tumor, PD-1 signalling suppresses T cell function. Nivolumab blocks the interaction between PD-1 and its ligands, thereby disinhibiting T cell function and and allowing T cells to attack tumor cells. Basically, it impedes the brakes on the immune system allowing increased functioning of the immune system to attack the cancer. Directions Nivolumab is administered by intravenous infusion over 30 minutes. Contraindications would include severe autoimmune disease as it can cause a range of autoimmune toxicities. Indications Nivolumab is indicated for the treatment of: Melanoma BRAF V600 wild-type, Unresectable or metastatic BRAF V600 mutation-positive, Unresectable or metastatic Unresectable or metastatic, In combination with Yervoy (ipilimumab) With lymph node involvement or metastatic disease, After complete resection, In the adjuvant setting Squamous cell carcinoma of the head and neck With recurrence or metastatic disease With disease progression on or after platinum-based chemotherapy Non-small cell lung cancer With disease progression on or after platinum-based chemotherapy Note : In patients with EGFR or ALK tumor mutations, disease progression should occur on indicated targeted therapy before treatment with nivolumab. Renal cell carcinoma With advanced disease, With previous anti-angiogenic therapy With intermediate or poor risk, Without previous treatment, In combination with Yervoy (ipilimumab) Urothelial carcinoma With locally advanced or metastatic disease With disease progression on or after platinum-based chemotherapy With disease progression within 12 months of neoadjuvant or adjuvant treatment with platinum-based chemotherapy Colorectal cancer In patients 12 years and older Microsatellite instability-high (MSI-H) or mismatch repair deficient (dMMR) With progression following treatment with a fluoropyrimidine + oxaliplatin + irinotecan Hepatocellular carcinoma With previous sorafenib therapy Classical Hodgkin lymphoma In adult patients With relapse or progression after either (1) autologous hematopoietic stem cell transplantation (HSCT) + brentuximab vedotin, or (2) three or more lines of systemic therapy that includes autologous HSCT more about Nivolumab adverse effects and Pearls-to-Know in our FibonacciMD Compendium #Oncology Nivolumab in FibonaccimdCOMPENDIUM Sources: Brahmer JR, Lacchetti C, Schneider BJ, Atkins MB, Brassil KJ, Caterino JM, et al. Management of Immune-Related Adverse Events in Patients Treated With Immune Checkpoint Inhibitor Therapy: American Society of Clinical Oncology Clinical Practice Guideline. Journal of Clinical Oncology.0(0):JCO.2017.77.6385. doi: 10.1200/jco.2017.77.6385. PubMed PMID: 29442540. Motzer RJ, Tannir NM, McDermott DF, Arén Frontera O, Melichar B, Choueiri TK, et al. Nivolumab plus Ipilimumab versus Sunitinib in Advanced Renal-Cell Carcinoma. N Engl J Med. 2018;378(14):1277-90. Epub 2018/03/21. doi: 10.1056/NEJMoa1712126. PubMed PMID: 29562145. Opdivo (nivolumab) [package insert]. New York, NY: Bristol-Myers Squibb Company; April 2018. Topalian SL, Hodi FS, Brahmer JR, Gettinger SN, Smith DC, McDermott DF, et al. Safety, activity, and immune correlates of anti-PD-1 antibody in cancer. N Engl J Med. 2012;366(26):2443-54. Epub 2012/06/02. doi: 10.1056/NEJMoa1200690. PubMed PMID: 22658127; PubMed Central PMCID: PMCPMC3544539. IMIT takes pride in its work, and the information published on the IMIT Platform is believed to be accurate and reliable. The IMIT Platform is provided strictly for informational purposes, and IMIT recommends that any medical, diagnostic, or other advice be obtained from a medical professional. Read full disclaimer.

RECOMMENDED VIDEOS Support your kid's early childhood development with these music-making activities and lap songs for babies, toddlers and preschoolers. DoReMe&You - Beach Day VIDEO More videos for children on the Strongwater Studios YouTube Channel DoReMe&You is an original developmental music therapy program developed by Strongwater Studios for babies, toddlers, preschoolers and their families or caregiver. Participants will sing, dance, move and play while working towards developmental goals and exploring how to integrate musical experiences into their child's growth and wellness. Visit www.strongwaterstudios.co m  . #RecommendedVideos

RECOMMENDED VIDEOS It is well known that prolonged stress can be damaging to both our physical health and mental health. Research indicates that chronic stress can cause pain, headaches, sleep issues and weight problems and can be damaging to our mood, productivity and our quality of life. During stressful times, we can use listening to music as a skill to help us cope with and manage stress and anxiety. Evening Song (linked here) combines listening to music with guided reflection through a virtual nature walk to provide stress relief. Actively listening to this song, or your preferred relaxing music may slow the pulse and heart rate, lower blood pressure and decrease the level of stress hormones. Allow the guided imagery of this song to take your mind to a soothing venue. Evening Song VIDEO by Sam Seicol and Peri Strongwater Listening to music on your own or having music playing in the environment somewhere can certainly be relaxing, thought-provoking or rejuvenating, but in order for it to be Music Therapy it must be within a therapeutic relationship with a qualified professional. Music Therapy is an allied healthcare profession that incorporates the use of evidence-based music interventions to address individual patient treatment goals. Board certified music therapists systematically affect non-musical outcomes in cognitive, behavioral, social-emotional, psychological and physical domains . Music therapists use interventions such as songwriting, composition, active music-making, improvisation, singing, instrumental play, music listening and lyric analysis to reach a wide range of physical and mental health needs. Spiritual Care and Music Therapy at Mass Eye and Ear have collaborated on creating musical content to support and nurture patients, families and staff. Chaplain Sam Seicol wrote original lyrics and Music Therapist Peri Strongwater, MT-BC composed and recorded the music. Questions welcomed at music_therapy@meei.harvard.edu #RecommendedVideos

Entamoeba histolytica, an anaerobic protozoan parasite, affects 50 million people worldwide. A potential cause of amoebic dysentery, liver abscess, and other extraintestinal disease, amoebiasis is caused by fecal contamination of drinking water and food. The majority of people infected with entamoeba histolytica develop asymptomatic infections including colonization of their large bowel. About 10% of infections cause symptomatic disease. Topics like Amoebiasis are in the FibonacciCOMPENDIUM, a medical term encyclopedia.

Culinary Medicine Flaxseed is gluten free and high in alpha-linolenic acid, omega-3 fatty acids, lignins, and fiber (both soluble and insoluble). One tablespoon of flaxseed contains 1,560 mg of omega-3 fatty acids. Flaxseed may show promise in helping to prevent heart disease, stroke, hypertension, diabetes, and, possibly, breast, colon, and prostate cancer. Flaxseed lowers total and low-density lipoprotein cholesterol by its fiber content, which binds to bile salts and then is excreted from the body. Benefits on glucose metabolism may also be due to its high fiber content. Soluble fiber delays postprandial glucose absorption in the intestine. Warnings Do not eat raw or unripe flaxseed, which may contain potentially toxic compounds. Avoid use during pregnancy and nursing because of its phytoestrogen content (lignans). Flaxseed used as a high-fiber supplement may cause diarrhea or paradoxically worsen constipation and flatus; drinking more water may prevent the latter.

The Health Benefits of Dark Chocolate Culinary Medicine by Stefanie Schwartz, MS, RD, CDN and Rich Strongwater, M.D. Can chocolate really be good for you? Are there really health benefits? The answer is YES, but it must be the right kind of chocolate and the right amounts. The Kuna Indians of the San Blas islands of Panama experience less diabetes, hypertension, heart attacks, stroke and cancer than the mainland Panamanians. And when the Kuna migrate to the mainland their incidence of hypertension increases significantly. Their secret? The Kuma islanders eat more fruit, more fish and 10 times more cocoa! How Dark Chocolate Can Be Good For You Dark chocolate is made from the seed of the cacao tree and the higher the percentage of cacao solids in your chocolate, the greater the amount of antioxidants it contains. Antioxidants may protect your cells against free radicals, which play a role in heart disease, cancer, and other diseases. Cacao includes polyphenolic and methylxanthine compounds, these compounds can reduce your risk of cardiovascular disease by reducing your blood pressure, cholesterol levels, and possibly by reducing insulin resistance. Dark chocolate may also improve blood flow to the heart and brain while improving cognitive function and mood. The polyphenolic flavinols (catechin, epicatechin, and procyanidins) in dark chocolate exert their positive health effects in several ways including increasing the production of nitric oxide which in turn reduces endothelial dysfunction, lipoprotein oxidation, platelet aggregation and endothelial inflammation. In this case, the endothelium is referring to the inner lining of arteries. So dark chocolate has a greater polyphenol and flavonol content than does tea. By inhibiting low-density lipoprotein oxidation this appears to inhibit cholesterol deposition in the arteries. And dark chocolate not only inhibits LDL oxidation (which may improve endothelial function) it also lowers LDL levels slightly and raises HDL levels slightly. Remember, LDL cholesterol is the “bad” cholesterol, HDL cholesterol is the “good” cholesterol and oxidized LDL is the really bad stuff that lays down atherosclerotic plaque. Dark chocolate also contains fiber and minerals beneficial for vascular function. 100-kcal dark chocolate (70-85% cacao) contains 1.7 g of fiber 100-kcal dark chocolate contains 1.9 mg iron (25% of RDA in adult men and postmenopausal women) other minerals present- magnesium, copper, potassium and calcium Caffeine and theobromine, the methylxanthines found in cacao have well known robust physiological effects. See the article “Health Benefits of Methylxanthines in Cacao and Chocolate” by Rafael Franco, Ainhoa Oñatibia-Astibia, and Eva Martínez-Pinilla to learn more about the specific health benefits of these compounds. The Right Kind of Chocolate The key to getting the benefits from chocolate without the weight gain is to choose a high-quality dark chocolate that contains 60%-90% cacao and to limit portion size to 1 ounce per day. The greatest health benefits of dark chocolate are seen above a concentration of 60% cocoa solids. One ounce of dark chocolate containing 60%-69% cacao solids has 165 calories, 11 g of fat, and 15 g of total carbohydrate. As the percent of dark chocolate reaches 70%, the calories increase to 170 per ounce, but with only 7 g of sugar. This percent of cacao solids contains about 40 mg of caffeine. Warnings Chocolate can be contaminated with the heavy metal cadmium, which is a kidney toxin. ConsumerLab.com independently tested 42 chocolate products for purity and found that many common chocolate brands have dangerous levels of cadmium. Dark chocolate bars having the highest flavonol content and lowest levels of cadmium are: Endangered Species 88% cacao, Ghiardelli Intense Dark 86% cacao, and Lindt Excellence 90% cacao Supreme Dark. White chocolate offers few benefits, and milk chocolate contains too much sugar. Sources Schewe T, Steffan Y, Sies H. How do flavonols improve vascular function? A position paper. Arch Biochem Biophys. 2008;476:102-106. Baba S, Natsume M, Yasuda A, et al. Plasma LDL and HDL cholesterol and oxidized LDL concentrations are altered in normo- and hypercholesterolemic humans after intake of different levels of cocoa powder. J Nutr. 2007;137:1436-1441. Djoussé L, Hopkins PN, North KE, Pankow JS, Arnett DK, Ellison RC. Chocolate consumption is inversely associated with prevalent coronary heart disease: the National Heart, Lung, and Blood Institute Family Heart Study. Clin Nutr. 2011;30:182-187. Katz D, Doughty K, Ali A. Cocoa and Chocolate in Human Health and Disease. Antioxid Redox Signal. 2011 Nov 15; 15(10): 2779–2811. Michael J. Dark Chocolate: Does It Have Benefits? Nutrition Advance. May 27,2020. https://www.nutritionadvance.com/dark-chocolate-health-benefits/ Franco R, Onatibia-Astibia, Martinez-Pinilla E. Health Benefits of Methylxanthines in Cacao and Chocolate. Nutrients. 2013 Oct; 5(10): 4159–4173. Published online 2013 Oct 18. doi: 10.3390/nu5104159

FibonacciMD launched a new feature in the www.FibonacciMD.app, a Library listing of all articles in PDF form. They are available to all FibonacciMD member subscribers. Non-members can purchase a single PDF for $1.00 without subscribing to the APP. This feature is particularly useful for the medical community that is not visiting the public website www.FibonacciMD.com nor the social media notifications. Some of the articles were written with patients in mind - what we call Patient Handouts. The medical community are invited to download PDFs that they feel are useful for their patients and share them. The APP Library You can get to the APP Library by going to www.FibonacciMD.app and clicking on FibonacciLIBRARY. The COM Library The public website hosts a catalog of article topics and quick links to either the blog article or the APP PDF. You can get to the COM Library by going to www.FibonacciMD.com/library .

April 1, 2019 marked the launch of the new FibonacciMD app. The app was designed and created by the doctors of the Ironwood Medical Information Technologies group. This initial launch included two features the Search Compendium and the Annotate. The Search Compendium is a valuable time-saving tool for doctors during patient management and treatment. The APP quickly defines a broad spectrum of medical terminology and aids diagnosis. New terms are being added weekly through a rigorous, multi-level editing process. Annotate is another time-saving feature that assists practicing healthcare physicians by adding notes to medical documents to provide explanations. The medical community simply uploads a medical document in a PDF or Word (doc) format and receives comments and explanations within minutes. The APP is available on desktop and smartphones. Anyone can sign-up for FREE!

FibonacciMD Plugin For more flexibility and functionality, load our patented secure plug-in application, which will allow you to annotate any PDF or Word document in your Chrome browser. Then hover or click and find your information. Follow these simple directions to download our FibonacciMD Chrome Plug-in: Click on this link to access the plug-in in the Chrome store - FibonacciMD PLUGIN Once the link opens, click "Add to Chrome" A box will open, then click "Add extension" At this point FibonacciMD will be added to your Chrome browser and you will see the FibonacciMD icon on the upper right hand corner of the screen. In the future you can click on the icon to access FibonacciMD