Saturday, February 28, 2009

Food And Medicine: Fat Duck.

Latest: HPA,Colchester Oyster Fishery

The Guardian Headline:
Heston Blumenthal's Fat Duck shut over food poisoning scare
Friday 27 February 2009

"He is often described as a 'culinary alchemist' and tonight the owner of the Michelin starred Fat Duck restaurant was desperately seeking a panacea after a food poisoning scare closed his dining room.

Heston Blumenthal has shut the award-winning eatery - described in 2005 as the 'the best place to eat on earth' - after up to 40 diners called in to say they were feeling unwell."

The first idea that came to my head was that it must be the work of the Norovirus which normally hits luxury cruise ships such as the QE II in 2007.

Unlikely though as the environment was different.

The time lag of symptom emergence points to some clever bacteria, perhaps the ones equipped with
quorum sensing powers. Salmonella and E. Coli all carry such power. E. Coli would have been detected by now and the symptoms a good deal more serious.

Ducks in Teochiu, China © 2008 Am Ang Zhang

Duck is famous for harbouring

Salmonella typhimurium which of course is hitting the headlines in the USA for peanut butter contamination. I doubt if Heston Blumenthal would be using any contaminated peanut butter in his “alchemy”.

“In 2004 - the same year it was awarded a third Michelin star - food and safety officers found 'borderline' levels of listeria in the foie gras and expressed concern that 'no core temperatures of the meat are taken'. The problems were swiftly dealt with, however, and Blumenthal has since introduced stringent procedures.”
The Telegraph.

Listeria can be a problem and as so many customers were involved, they must all have had some foie gras! Chef’s compliments perhaps!

Or was it the cheese table? Many cheeses harbour listeria.

Blumenthal also suspected that as some of his staff had returned from Venezuela they might have picked up some bug and he is waiting for tests on them. Some of us can be symptomless carriers of germs or even protozoa such as Giardia lamblia. Good luck with the tests.

Then there is Ciguatera poisoning, from exotic tropical fish but as the symptoms did not seem to include rash it is unlikely.

Of course one cannot rule out sabotage. Being at the top, you are likely to upset someone some time.

The race is on to find the culprit.

Good luck Fat Duck.

Thursday, February 26, 2009

Cockroach News Catches: Paroxetine and Citalopram

For all the news that the Cockroach Catcher finds interesting!

Looks like GlaxoSmithKline PLC (GSK) is in the news again and this time it is not about

In today’s Wall Street Journal:

U.S. Probes Emory Doctor's Glaxo Ties

FEBRUARY 26, 2009, 12:02 A.M. ET

“Federal officials are investigating Emory University to determine if the school misled the National Institutes of Health about its star psychiatrist's lucrative consulting work for big drug makers, people familiar with the matter said.
The probe by the inspector general for the Health and Human Services agency, which investigates fraud in NIH programs, concerns the work of Charles Nemeroff. From 2003 until last year, Dr. Nemeroff served as primary investigator on an NIH-funded research effort to study five GlaxoSmithKline PLC drugs for use as antidepressants. During that time, Dr. Nemeroff also received hundreds of thousands of dollars from Glaxo.
The NIH requires universities to report potential conflicts of interest to the agency and to ensure research is carried out objectively.
Schools that violate those policies could face sanctions, ranging from fines to a freeze on funding. Emory received $251 million in NIH grants last year, more than half of all the Atlanta school's outside research funding.
An Emory investigation of the matter in December concluded that Dr. Nemeroff failed to report more than $800,000 he received from Glaxo from 2000 to 2006. Dr. Nemeroff stepped down as chairman of the psychiatry department and the school said it wouldn't submit any research requests to the NIH involving Dr. Nemeroff for at least two years.”
This bit in the WSJ is worrying:
“Records obtained by Mr. Grassley show that Dr. Nemeroff played a role in a Glaxo program that was established to aggressively promote the British company's top-selling antidepressant, Paxil (Paroxetine).
Glaxo described this "PsychNet" program in an internal 2000 document as "an ideal way for key opinion leaders to influence clinicians...on the benefits of Paxil versus competitors" and to train doctors to "help build Paxil advocacy."
Dr. Nemeroff was listed as one of two speakers at a March 2000 session in Naples, Fla., to train doctors "on the efficacy of Paxil and the PsychNet presentations." Doctors were paid $2,500 per talk and required to sign agreements barring them from saying how much they were paid or sharing materials Glaxo provided.”

Paroxetine has been in the
UK news before now.

But GSK may not be alone and this time it involves the company directly.

In the New York Times:

Drug Maker Is Accused of Fraud

Published: February 25, 2009

The Justice Department charged the drug maker Forest Laboratories on Wednesday with defrauding the government of millions of dollars by illegally marketing the popular antidepressants Celexa and Lexapro (versions of citalopram) for unapproved uses in children and teenagers.

In a civil complaint filed by the United States attorney’s office in Boston, federal prosecutors alleged that former top executives at Forest concealed for several years a clinical study that showed that the drugs were not effective in children and might even pose risks to them, including causing some to become suicidal.
From 2001 to 2004, Forest heavily promoted results from another clinical trial it had financed that showed that the drugs were effective, without disclosing the negative study to those researchers, its own medical advisers or its sales representatives, the complaint said.

Celexa and Lexapro are two versions of the same drug, citalopram. The drugs are currently approved by the
Food and Drug Administration only for adults.

Prosecutors said in the complaint:

“Forest told prescribing physicians a half-truth and thereby prevented them and the public from having all potentially available information when making decisions about how to treat a serious medical condition in pediatric patients.”

Wednesday, February 25, 2009

Picasso: Challenging the Past

National Gallery
25 February - 7 June 2009

'Seated Woman', 1920 Musée Picasso, Paris

(MP67)© RMN / Jean-Gilles Berizzi / Succession Picasso / DACS 2008

From the National Gallery Website:

The exhibition is organised thematically, showing how Picasso repeatedly returned to the great subjects of the European painting tradition, analysing them as his personal style developed in myriad directions. Sections include self portraits, the Spanish tradition of male portraiture, the female nude, still life, and the seated female figure.

‘Picasso: Challenging the Past’ culminates in a display of the artist’s Variations where, late in life, Picasso makes direct reference to masterpieces such as Velázquez’s ‘Las Meninas’ and Manet’s ‘Déjeuner sur l’Herbe’, turning them into “something else entirely”.

Le déjeuner sur l'herbe after Manet27 February 1960

Oil on canvas
London, Nahmad Gallery© Succession Picasso, 2008

Picasso's Prints: Challenging the Past

This display of 13 prints by Picasso coincides with the major exhibition 'Picasso: Challenging the Past'. It expands on many of the themes of the major exhibition, particularly his exciting ‘variations’ after the masters.

1971© British Museum Images/ Succession Picasso / DACS 2008
The Times is media partner of the Exhibition.

From an earlier Post:

Wednesday, March 12, 2008

Picasso and Tradition
This is how Ibsen was mentioned in The Cockroach Catcher

“The early seventies was a very exciting time in London as the first ever course in Family Therapy in the U.K. was just launched. Gregory Bateson just published Steps to an Ecology of Mind, which to this day still manages to be exciting for anyone interested in family systems – a term coined to describe the interaction within a family or extended family. Of course years before that, Ibsen neatly observed family interactions in Ghosts and Wild Duck. Both plays vividly captured family interaction that has hardly been bettered by any other modern writings.”
Duveen was introduced to me very early on in my career, by the same guru who suggested that I should read Ibsen.
“A startling number of masterpieces now in American museums are there because of the shrewdness of one man, Joseph Duveen, art dealer to John D. Rockefeller, Andrew Mellon, Henry Clay Frick, and William Randolph Hearst.”
I have been visiting museums in the U.S. since the early 1980s. Outside LondonNew York is an excellent place for one’s artistic ventures. Many other cities also have treasures and you may be surprised to hear that Las Vegas is the latest to join the list. It must be the money.

New York © 2008 Am Ang Zhang

When visiting a museum, I am not in the habit of joining guided tours, but prefer to explore on my own. However at one time at the New York’s Metropolitan Museum of Art there was just such a tour starting and I thought I should put away my prejudices and follow the guide.
We stopped in front of a painting, Picasso’s Harlequin (1901), that was to start me thinking about change. Change in every field is often met with criticism and sometimes hostility. Picasso was very talented and he could paint and draw in the classical sense, unlike some modern artists.

Harlequin, 1901 Pablo Picasso 
© 2003 Estate of Pablo Picasso/Artists Rights Society (ARS), New York

Our guide talked about the time when Picasso painted this:
“His friend had just committed suicide. Picasso has in this picture revealed the private sadness behind the public face of this character—an interpretation that has greater resonance when one considers that the artist often regarded his clowns as representations of his alter ego.”
I consider painting a superb way to deal with loss and bereavement and Picasso did it in his own way.
The Girl in a Chemise (1905, photo shown in my previous posting on Anorexia Nervosa) drew attention to Picasso’s astute observation power that made him one of the greatest artists of modern times. The Tate’s own display caption stated:
“…… She is fragile, perhaps sickly. Her delicate pink flesh evokes the skin-colour that Picasso’s friend Guillaume Apollinaire identified among street performers: ’that purplish pink one finds on the cheeks of certain fresh young girls close to death’.”
The next painting we looked at was Gertrude. There was something peculiar about this painting and without the guide, I probably would not have paid much attention.
Gertrude Stein, 1906 Pablo Picasso

© 1999 Estate of Pablo Picasso/Artists Rights Society (ARS), New York
She told us the story of Gertrude Stein, herself a writer and her contribution to modern art was well recognised. When she was in Paris she sat for Picasso – many many sittings indeed. Now look closely again. Gertrude is truly the transition from Harlequin to Cubism. To appreciate this, we were urged to go to MOMA to have a look at Les Demoiselles d'Avignon.

Les Demoiselles d'Avignon 1907 Pablo Picasso, MOMA Collection
©2008 Estate of Pablo Picasso / Artists Rights Society (ARS), New York

The impact of Picasso on the world of art and beyond is immeasurable. One should be encouraged to be innovative and creative in all fields, including psychiatry and medicine.
Review: Telegraph

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Tuesday, February 24, 2009

Anorexia Nervosa: Olanzapine (Zyprexa)-Veganism

Girl in a Chemise circa 1905 Pablo Picasso (1881-1973) Tate Collection

Mental Nurse Zarathustra recently had two important posts on Anorexia Nervosa: One on the use of Olanzapine (Zyprexa) and the other on Veganism.

Mental Nurse: Anorexia and Olanzapine

……..Here’s the thing though. As we know, Olanzapine has a fair few side effects. Two of these are:
1. It makes you sleep until doomsday.
2. It makes you so hungry you eat the contents of the fridge.
Could these side effects be the reason for the improvement in these anorexic patients, rather than any antipsychotic effect? God no, says our consultant. The Olanzapine is being used to reduce the levels of intrusive anorexic thoughts that are causing distress to the patient. It’s being used as an antipsychotic, not simply to make people drowsy and hungry.
Though the burning question is, if that’s the case, why isn’t he keen to try, say, Aripiprazole? You know, the antipsychotic that isn’t supposed to make you fat and sleepy. Admittedly Aripiprazole is also a bloody awful antipsychotic that rarely seems to reduce psychosis, but that hasn’t stopped him prescribing it en masse to his psychotic patients.

Read the full post

In the opening chapter of
The Cockroach Catcher:

“’It is our view that clinically it was wrong for Candy to be transferred at this stage. It was wrong for the NHS to accept her back and in our view Candy is in serious risk of – quite frankly – dying.’
“Those were more or less the words said at the transfer meeting by the nurse from the private hospital where Candy had been for the past eighteen months. She had been compulsorily detained twice and she had been put on Olanzapine. Olanzapine is one of a new group of drugs licensed for Schizophrenia and has been found to induce a voracious appetite especially the bingeing of carbohydrates. Some psychiatrists have started using it for this specific effect. In Candy’s case she managed to fight the biochemical effect of Olanzapine.”

You can read the complete chapter

At least in my days there was still honesty and most Child Psychiatrists who used to prescribe Olanzapine (Zyprexa) to Anorectics did not pretend to be using its main effect.

Now that there is EBM, it is well known that the major Pharmaceuticals
ghost write articles in pushing for off-label use by doctors. Because of medical confidentiality issues, it is difficult to find out if the so called patients were genuine.

I am amazed that given Olanzapine (Zyprexa) has been in so much trouble in the US, UK and Europe still have not done much to curb its off-label use.

Perhaps one should not forget Lena Zavaroni, former child singing prodigy who died aged 35, following a 22-year battle with anorexia. She had various drug treatments and ECT, and eventually a neuro-surgical procedure that was not a lobotomy according to the hospital but was meant as a “cure” for her depression. She died shortly after of unrelated pneumonia. That was in 1999. It was before Dr Crippen, Jobbing Doctor, Angus Dei and other blogs. Otherwise the neurosurgeon Brian Simpson might have a lot more explaining to do. Anyway, neurosurgery was not part of NICE Guideline on Treatment of Depression.

Have we really learned anything about the treatment of Anorexia in the ten years since her death? Why are we going the same way, only the drug is different!

Mental Nurse: Case Study Vignette - Anorexia and Veganism

“…….Kate has announced that she’s becoming a vegan. She now insists that she won’t eat any meat, fish, dairy or poultry products, and has taken out a membership to PETA. She states that this is because vegan diets are “healthier” and because she is ethically opposed to the use of animal products.

The multidisciplinary team, on the other hand, believe that she is doing this because she wants to restrict her intake of carbohydrates, fat and protein, and also because of anorexic thinking patterns that involve the demonisation of certain food groups.

The dietitian states that a vegan diet will make it much more difficult for the ward to refeed Kate and bring her BMI back up to a safer level. We could get around this by giving Kate nutritional supplements. However, while this would help her to gain weight, it wouldn’t do anything to treat the anorexic thinking patterns. Indeed, arguably we’d be running a risk of reinforcing them by colluding in the avoidance of these food groups.

So, is it ethical to compel Kate to eat animal products?”

Zarathustra talked about the role of the multidisciplinary team and of course its collective view. In my opinion, contrary to widely held views, a good Adolescent In-patient Unit dealing with Anorexia Nervosa patients needs to be able to accommodate and hold opposing views in its team, just like a well functioning family. These patients themselves more often than not come from families that try to avoid conflicts at all costs.

Conflict containment that is more or less non-existent in the families these patients come from.

As to the vegan diet, it is not impossible to have a vegan diet that has high calorific value. That, the dietician should know. I have seen many vegans in the Caribbean becoming quite obese from the high yam and sweet potato diet. (There you go: these are two food items that can be part of a vegan diet!)

The trick with Anorexia Nervosa is you need to be inventive and inventive every single day. Think Jay Haley, think Hobson’s choice. The patient can still be a vegan. She does not need any drugs. She does not need any ECT or neurosurgical procedure.

In the end, Anorexia Nervosa could be a rewarding condition to deal with:

“If our work is to be therapeutic then a sort of therapeutic alliance is important, even if tentative. Some people do not realise that you can fight with your patient and still have a sort of therapeutic alliance.” The Cockroach Catcher

Have a good fight!!!

Friday, February 20, 2009

A Brief History Of Time: Food and Medicine

In Chinese culture, food is important in the promotion of good health and much has been documented in Traditional Chinese Medicine textbooks. This knowledge, generated by several thousand years of experience by keen observers, does not sit nicely with modern science especially that of Western medical science. There are believers and non-believers especially. It would be foolish to fully endorse everything, and yet it would be even worse to reject all that it could bring.

On the other hand, in recent times, illegal mixing of
western medicine into so called natural products has given such natural remedies a very bad name. The FDA has yet to deal with the large number of slimming preparations that contain modern slimming drugs.

Not all things natural are safe either, and even the ever so popular glucosamine has its

There is so much that could be learned from experience, as shown by the
hands only CPR which can be traced to China over two thousand years ago.

Many Chinese today believe in traditional ways: we know it works, we just may not yet know how it works.

There may of course be a more sinister explanation to all the mystique. Early rulers of China and some later ones realised that in order to govern you must not educate your people. So rituals and superstition were introduced instead to keep people from harming themselves. After all, people were needed to serve their rulers. Even today certain
knowledge is not widely disseminated or shared, and worse still, the wrong knowledge is disseminated.

The Cockroach Catcher has a rule about any food product: if it claims to deal with all the most common illnesses, one should become suspicious. On my travels I often come across claims of natural substances that manage to deal with high cholesterol, high blood sugar, high blood pressure, and Alzheimer for good measure, all at the same time.


It was just a little over a year ago I started blogging after my book
The Cockroach Catcher was published. I would like to indulge in a bit of nostalgia and quote you some passages from the book and a few of my favourite postings on Food and Medicine.

From The Cockroach Catcher:

“The garden was filled with the fragrance of the white tropical jasmines. That fragrance is only second to that of the Osmanthus (Gui Hua), the flowers of which are tiny and appear more towards winter. We used to collect the Osmanthus flowers, dry them and use them to flavour our best teas. Jasmine is more a late spring and summer flower and we had a big bush. By nightfall the cooling hill breeze brought with it occasional whiffs that made you want summer to last forever. It was a peculiar time for those of us who had lived in or around the university for the past five years. We left home as school children and now we were back, and with any luck the majority of us would in a few weeks become fully fledged doctors ready to apply our skills. We had changed and the rest of the family probably not as much; and yet it was a time to savour – the last of the old before embarking on the new and brave. It was good to be reminded of the fine cooking back home, of an older and more sedate time when shopping was done twice a day for fresh ingredients. This practice of course still continues in some parts of the world.”

One of the earlier postings was indeed a tribute to what the Cockroach Catcher’s mother taught him:

Antioxidants and cooking 31st January, 2008:

”The Cockroach Catcher however goes by what his mother taught him from an early age. In Chinese cuisine, soup is often seen as an important part of a meal. The process of slowly cooking various ingredients is part and partial of that of producing something that is nutritious, delicious and revitalizing. To save energy, we invested in a highly efficient ‘shuttle chef’, which is basically a double pot, consisting of a smaller inner pot and a larger outer insulating chamber. You first of all heat up the food in the smaller pot, and then seal it in its insulating outer chamber to let the cooking process continue in a slow fashion for a few hours or over-night. Another doctor friend of ours discovered that she could achieve the same slow cooking by putting an ordinary pot into a cool box!

"Imagine the disappointment when we first tried to make consommé with good quality meat and found an ever so slight rancidness setting in over-night. Something was not quite right. To solve this problem, we had to go back to basics. We tried adding one more traditional ingredient: gouqizi (derived from Lycium). Eureka! The presence of the antioxidant meant no more rancidness whatsoever. The French always knew and used red wine in their famous Boeuf Bourguignon and Coq au Vin.”

Chinese New Year and the Goose 9th February, 2008: Then the posting on goose drew some attention from Foodie blogs and my wife was invited to post the recipe on: World Foodie Guide 21st February, 2008:

How To Make Chinese Teochiu Goose. Goose fat is the new ‘black’ and was sold out at Christmas time a couple of years back in England.

Loquat and Medicine: 16th May, 2008

Loquat (Eriobotrya japonica)

A good friend who read my book The Cockroach Catcher said she wished I had written a lot more about the village and I posted:

“As a result of modernization, in one generation we have seen the passing of something that provided us with a uniquely enchanting experience that no modern developments with their charming 'cool' shops can ever hope to match. Are we being over-romantic to ignore the hardship many of us put up with during that period, not to mention the struggles of many of our parents to provide for us? Have we forgotten the leaking roof, the rudimentary toilet facilities and our constant battle with cockroaches and other pests, not to mention poisonous snakes and the like? I have to say that on balance, it was still a sweet memory. Who can fail to remember the constant supply of fresh fruits and vegetables from our own land? The chickens we reared and their eggs poultry were just out of this world. I have conversed with a few friends and relatives about this, and they all seem to agree.”

You can read all about it here.

The Cockroach Catcher still marvels at some of the ancient remedies from a modern scientific standpoint as in: Ancient Remedy: Modern Outlook

Sometimes health claims rebound in a peculiar way and my posting on Ribena has turned out to be a great favourite with readers.

Finally, be wary of outrageous claims and take everything in moderation.

“Over time health benefits have been associated with red wine, olive oil, chocolate, almonds, pomegranate, blueberry, green tea and coffee. The Cockroach Catcher is skeptical of extreme claims, but for the record I do take all the items mentioned above, in moderation. It is indeed more important that you should enjoy what you eat and drink and not just what researchers tell you, and in moderation.”

Grand Rounds 5:23 The Blog That Ate Manhattan

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Friday, February 13, 2009

Coffee in Panama – Faking Is Not All Bad

In my earlier blog Anhinga in Costa Rica - Faking Is Not All Bad I reflected on how in my child psychiatric practice, I came across a number of children who seemed to have made good use of faking. Indeed I came to the conclusion that faking might not be all bad.

Panama has been associated with some fabricated plots. There were the John Le Carre book
The Tailor of Panama that was turned into a film, the location shoot of the Quantum of Solace (in Panama, doubling as a country in South America), and the Canoeist faking death, just to mention a few.

Panama ©2009 Am Ang Zhang
Then there was the coffee scandal.
In 1996 in California, a certain  Michel Norton, owner of Kona Kai Coffee was sentenced to 30 months in prison. Apparently for an extended period of time (some reckoned a decade may not be an over estimate), cheaper and “lower grade” Panamanian and Costa Rican coffee were used to pass off as “Pure Kona Coffee”.

Cheaper, certainly, as you would not otherwise be doing it. But, INFERIOR? I think many would certainly dispute that. I do not think you can really use an inferior product to pass off as something superior and fool people for long.

So the Ambassador of Panama in Washington D.C. wrote to the
New York Times:

To the Editor:
I read with amusement about the indictment of a coffee supplier on selling fraudulently marked beans to retailers (news article, Nov. 13).
Without making light of the charges, I am pleased that the coffee buyer for Peet's Coffee and Tea is uncertain that he can tell the difference between the ''cheaper'' Panamanian beans allegedly substituted for the more expensive Kona.
Panama's coffee is among the world's best. In fact, members of my staff have seen Panamanian beans for sale at high-end coffeehouses for little less than Kona. Perhaps we can arrange a taste test of Kona and Panamanian coffee for the sellers mentioned in the article. I am sure that no one will be more pleased with the results than my native coffee growers.

Ambassador of Panama, Washington

The Cockroach Catcher was fortunate enough to have visited both Costa Rica and Panama. Costa Rica coffee is quite well known but few people realise that Panama produces coffee. I was determined to find out more about coffee grown in Panama.

Plants need to struggle to produce the kind of ‘poison’ against diseases, and coffee apparently is no different. This is well known for wine: vines grown in abundant sunshine may produce wine with a high alcohol content but does not produce enough of the ‘poison’ that humans love — we call the ‘poison’----- anti-oxidants.

Now even for the wonder malaria drug, Artemisinin, the plant Artemisia annua if cultivated with good fertilisers will not produce the anti-malaria ingredient at all.

Yes, plants need to struggle. Shade, and a misty atmosphere all work together to help the coffee shrubs struggle and help certain varieties of to develop health conferring properties, although the yield is lower than if you apply fertilisers and cut away the shading trees.

Misty Boquete, Panama ©2009 Am Ang Zhang Berry picking ©2009 Am Ang Zhang
  My friend's coffee©2012 Am Ang Zhang
Happily the shading trees provide a sanctuary for birds. Panama is famous for the number of bird species both resident and migrating, and for a number of years, has achieved the highest Christmas bird count as audited by the Audubon Society. A traditional coffee plantation (known as Finca) can play host to nearly 280 varieties of birds.

Well, call it chance or luck, someone bought a Finca in Boquete in Panama. Unfortunately a fungal blight wiped out most of the coffee plants that were originally there. A quick research by the owner showed that one variety of coffee called by the unlikely name of Geisha is resistant to the fungal disease. Remember, it can probably produce the ‘poison’. This tree grows taller, yield is lower but the coffee it produces is just wonderful.

In the last few years, in international cupping competitions, this coffee came first. Yes: FIRST.

The name: La Esmeralda Especial, from the
Hacienda Plantation.

But wait for this, in 2007 the price fetched at auction was US$130 per pound. That is expensive. Or is it? With espresso extraction you can get 40 cups to the pound. Is that not under $4 per cup, and since you can extract a second cup – water based “decaf”, is that not under $2 per cup? Here is the latest
tasting note.

As I was preparing this blog, news came about:
Coffee Linked to Lower Dementia Risk
Over time health benefits have been associated with red wine, olive oil, chocolate, almonds, pomegranate, blueberry, green tea and coffee. The Cockroach Catcher is sceptical of extreme claims, but for the record I do take all the items mentioned above, in moderation. It is indeed more important that you should enjoy what you eat and drink and not just what researchers tell you, and in moderation.

Next time in Trivial Pursuit you will know the answers to: What is the best coffee in the world? What country has the highest count of birds at Christmas?

Birding in Boquete, Panama ©2009 Am Ang Zhang

Happy cupping.

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