“Men are from Mars and women are from Venus”
—John Gray PhD
Women and men are very different. The concept seems fairly easy to grasp. Most get it. It seems obvious. Even the science supports it. However, this point seems to escape most in Medicine today.
The perfect example of this biochemical difference is found in Testosterone. The effects and risks of Testosterone in women stand in stark contrast to men. Low Testosterone is associated with an increased cardiovascular disease risk in men. Yet, elevated Testosterone is associated with an increased cardiovascular disease risk in women. A recent publication highlights the different Testosterone picture in women with obesity and Metabolic Syndrome (elevated Testosterone) and men with obesity and Metabolic Syndrome (low Testosterone).
Join Nan Sprouse as she discusses the quagmire of Testosterone in women in her latest video blog. No opinion here, just science.
It is hard!
Health is to hard. Many don’t achieve it because it is to hard. These were the words of a recent conversation I had with a friend and client.
Is Health hard? Is Wellness really unobtainable? I may surprise you with my answer—for many the answer is unfortunately yes. The answer is not due to access to the ability to be Healthy and Well, but because they just don’t want to be. They like being unhealthy. In fact, the name of the disease that they carry is their identity. You take away their disease, you take away their identity. These individuals simply don’t want to make any changes necessary to achieve Health and Wellness.
But is Health that hard? The answer is no.
What is a Heart Healthy Diet?
As I mentioned last month, I want to devote this blog to a healthy diet with an emphasis on heart health and disease prevention. My hope is that I will encourage you to be your own best health advocate on what you should eat. One word I want you to consider while reading this article is indoctrination. As I research and study the many recommendations… low carb, paleo, low fat, vegan, Mediterranean and Myplate.gov. etc., I recognize that we have to be careful to sort out any bias and indoctrination of any possible profit motive information that would distort accurate research and information to benefit our health. Keep in mind that there is not one perfect diet. Many diets claim to be the one best way to eat. A one-size-fits-all approach never works—nutrition is no different. We must realize that we are in different stages of life and some of us are very healthy while others are struggling with compromised health. From last month’s blog, I pointed out that the American Dietary Guidelines indoctrinated us into believing that an unhealthy low fat, high carb (also refined) diet was healthy even heart healthy. Instead of improving health, statistics point to a declining health in Americans. This can be found in the rising rates of heart disease, hypertension, Type 2 diabetes and other chronic disease states. Let us take a closer look at the heart disease statistics.
As we have visited the Farmer’s Market or vegetable stand, we are reminded how colorful and fresh the produce has been during the summer season. However, even with the wonderful variety we have had, I find that few appreciate and understand how vital this food group is to our health. Unfortunately, even the USDA food plate recommendations fall short in providing a truly nutrient dense diet that can potentially prevent many of the chronic disease states we are battling in the United States. According to the CDC (Centers for Disease Control and Prevention), as a nation, 75% of health care dollars goes to treatment of chronic disease such as heart disease, diabetes, autoimmune disorders and cancer. Some of these persistent conditions could have been prevented including lifelong disability, compromised quality of life which then strains our burgeoning health care.
Unfortunately, the medical system is usually set up for patient’s visits to be in a forced quick paced conveyor belt method due to insurance constraints and the pressure to bring in as many patients as possible to offset costs and produce profits. This lends to little interaction with the patient’s concerns and no time for a much needed diet intake review. I am, though, grateful for these doctors because there is a place for their intervention. However, they are caught up in a system that is set up to not provide personal assessments and true preventative help. Here at Seasons, however, there is more care for the patients, with time and personal health evaluations given, thereby providing a more comprehensive plan that includes a nutrient dense diet that emphasizes fruits and vegetables.
Fruits and vegetables are an essential and integral part of your diet. There is no other food group that can provide what these super foods can. They provide antioxidants and phytochemicals that maximize preventative protection against the chronic disease states that we are struggling with. In fact, fruits and vegetables are the two foods with the best correlation with longer life in humans. Not whole wheat bread or bran, nor even a typical vegetarian diet shows as powerful a correlation as a high level of fresh fruit and raw green salad consumption. The National Cancer Institute has reported on at least 337 different studies that showed this information to be validated. ( Nelson, NJ. Is chemoprevention research overrated or underfunded? Primary Care and Cancer 168:29-30)
What are the best nutrient dense fruit and vegetables (though not all inclusive) that provide these protective compounds that do phenomenal changes in your health and immune system?
- Dark green leafy vegetables ( highest) – kale, spinach, Swiss chard, mustard, collard, turnip greens, arugula, watercress.
- Other green vegetables – romaine, red/green leaf lettuce, green peas, green beans, Brussels sprouts, broccoli, asparagus, bok choy, snow peas, celery, green peppers.
- Non-green nutrient-rich vegetables- beets, eggplant, mushrooms, onions, radishes, bean sprouts, red, orange and yellow bell peppers, raw carrots, tomatoes, artichokes, radicchio, cauliflower, garlic.
- Fruits – berries, apples, pears, oranges, grapefruit, lemons, limes, kiwi, melons, etc.
These foods should be added to your diet at each meal, and eating a variety of these essential foods will definitely improve your health decreasing your risk of chronic health conditions. You want to eat at least 9 servings of fruits and vegetables per day. Always include green salads with a variety of greens–optimally lunch and dinner. Organic, non-GMO, raw as well as lightly steamed or sautéed in a small amount of a healthy fat (olive or coconut oil) are your best ways in eating your fruits and vegetables!
Here is a fresh fruit and veggie salad to enjoy!
- 2 teaspoons extra virgin olive oil, organic
- 1 tablespoon cider vinegar, organic
- 1-2 tablespoons of filtered water
- 1 tablespoon raw honey
- 1/4 teaspoon whole mineral salt
- 2-3 cups torn fresh spinach, organic
- 1/3 cup chopped apple, organic
- 1/2 cup broccoli florets
- 2 tablespoons raisins, organic
- 2 dried apricots, organic, chopped (optional)
- 1 tablespoon sunflower seeds
- 2 teaspoons sesame seeds, toasted (optional)
- 1 teaspoon lemon juice
- In a jar with a tight-fitting lid, combine the oil, vinegar, water, honey and salt; shake well. In a small bowl, combine the remaining ingredients. Drizzle with dressing and toss to coat. Yield: 1 serving. Note: all organic is preferred and you can add your favorite herbs and spices in the salad dressing as well.
Will eating healthier make it easier to achieve superior skin health? If you’ve had a nutritional consultation at Seasons, then you already know the answer. Yes! The food you put into your body has a direct effect on how you feel and look.
Being diligent about applying SPF and regularly visiting your skin care specialist for rejuvenation treatments are two great ways to keep your appearance in tip-top shape, but consuming the right foods is also important to the health of your skin. After all, you are what you eat!
The following fruits are packed with antioxidants, vitamins, and nutrients that can help you live longer, look better, and even prevent disease. Here are our picks to keep your skin looking beautiful, healthy, and hydrated this summer!
- Cantaloupe. Consider cantaloupe your secret weapon for smooth, younger-looking skin. You can thank the Vitamin A and its derivatives for boosting cell reproduction. Cantaloupe also increases antioxidants in your body which increases your ability to absorb free radicals and decreases your risk of skin problems.
- Oranges. Like Cantaloupes, oranges are chock-full of antioxidants. Oranges and other citrus fruits are said to be among the best foods for your skin’s health because they are rich in Vitamin C. Vitamin C can help protect your skin against sun damage which reduces your risk of skin cancer.
- Peaches. Not only are peaches great for reviving your skin, but they have benefits that include aiding weight loss, preventing heart disease and high blood pressure, and they contain an abundance of antioxidants.
- Blueberries. Ranked number one in antioxidant activity by the U.S. Department of Agriculture, blueberries can protect your skin from premature signs of aging.
- Apples. An apple a day may keep more than just the doctor away. Apples are rich in pectin – the starch essential in driving away acne! And don’t throw the skin in the trash! Apple skin contains phenols which provide important UV-B protection.
Fighting acne? Food choices are a huge factor contributing to this dreaded skin problem. Like the rest of your body, what you eat directly and indirectly affects your acne. This is one factor that we can easily control by being mindful of what goes into our bodies. So, here are five things to remember:
- Take your vitamins. Whole food multi-vitamins taken daily are a good choice to fight acne. Acidophilus B and garlic are also great acne fighters.
- An apple a day. Eat red or golden delicious apples daily.
- Drink water, water, water.
- Clear is better. You shouldn’t drink sodas for a whole slew of other reasons; but if you must drink a soda, remember that clear is better. The ingredients that make sodas dark can make acne worse.
- Go natural with your sweets. Too much refined sugar can aggravate acne. This means stay away from candy, sodas, cakes and pies! Try to use natural sweeteners, like honey or stevia!
It’s a fact: Americans love eating out. We blog, Tweet, and post about it. It’s very gratifying to share a meal with friends or family while taking a break from cooking at home. Even while on a diet, you may give yourself a pass to “treat yourself” or overindulge while dining at your favorite restaurant. But have you ever thought about what you are eating and where the restaurant purchased their food? Well, it is quite eye-opening!
Dining out will make you fat and very unhealthy! Unless you are dining at a health food type restaurant (which are few in number), the average restaurant meal is usually between 1,000-1,500 calories. Studies show that we eat about 40 percent more when we are in groups as opposed to eating alone. However, the main reason we eat more is due to the portion size at restaurants, usually much larger than we would consume at home.
The goal of most restaurants is to make a profit, not to provide healthy foods that will reduce your risk for heart disease, obesity, and cancer. Because they want you to come back, most restaurants will provide foods that simply taste good but are high in fat in forms of processed oils, trans fat, butter and lard. Even the healthier options can still be loaded with calories. And don’t forget the high amounts of sugar including high fructose corn syrup, a cheap form of sweetener.
Since profit is the main goal, most restaurants are not serving high quality food. Unless they advertise themselves as providing truly healthier options like grass-fed/organic meats, USA or Canadian wild-caught fish or organic grains, fruits and vegetables, they are likely serving you genetically modified foods (GMOs). Since 60-75 percent of grocery foods are genetically modified, the likelihood is pretty great that these cheaper sources of food will be found in restaurants.
In addition to harmful GMOs, you may also end up eating industrially bred and raised food loaded with hormones, antibiotics, and pesticides. There are alarming and unhealthy practices that go on at a CAFO facilities (Concentrated Animal Feeding Operation). The problem begins at the massive CAFOs where cows, chickens, and pigs are fed genetically modified corn, soybeans, and excessive grains in general (not their natural diet, i.e. grass), along with many other unbelievable feed ingredients such as:
- Plastics: this is used for many animals whose digestive systems need more roughage to pass through them, thus CAFOs are now feeding them plastic pellets.
- Manure and animal feces: this can include cattle manure, swine and poultry waste. It also can include wood, sand, sawdust and other non-food substances.
- Roxarsone: more commonly named arsenic, which until recently was put into chicken and pig feed to control parasites, though Nitarsone (another arsenic-based poultry drug) is still approved. Chicken litter (containing the arsenic that passes through the birds) is also collected from chicken CAFOs and is fed surprisingly to feedlot cattle.
- Animal byproducts: categorized as “animal protein products,” this includes hair, skin, hooves, blood, internal organs, intestines, beaks and bones, dead horses, euthanized cats and dogs, and road kill.
Fast foods do not fare any better, and are usually chemically laden for shelf life and profit. Two examples of synthetic chemicals in popular fast food chicken nuggets are:
- Dimethyl polysiloxane: a type of silicone with anti-foaming properties used in cosmetics and variety of other goods like Silly Putty
- Tertiary butylhydroquinone (TBHQ): a petroleum-based product that has antioixidant properties.
Due to all of the processing (added sugars and other ingredients), studies have shown that eating fast food just twice a week, can cause you to gain excess weight, but even more alarming is that it doubles your risk of developing insulin resistance, the driving force behind many chronic diseases, including diabetes, heart disease and cancer.
Try these strategies for making healthier decisions while dining out.
- Reserve dining out for special occasions, not a bi-weekly habit.
- Seek out healthier-minded restaurants using seasonal, sustainable, non-GMO, organic, free range, or wild-caught ingredients and dedicated to preparing meals with healthy fats in mind.
- Ask questions about where they buy their foods.
- Avoid fast food as much as possible unless they advertise a truly healthier option as mentioned earlier.
Asian Lettuce Cups
- 1 1/4 lb. 93% lean, free-range/organic ground turkey
- 1 Tbsp cold pressed/organic oil
- 1 clove garlic, minced
- 1/8 tsp. ground ginger (can use fresh equivalent if desired)
- 2/3 cup thinly sliced organic green onions (about 4)
- 1 (8 oz) can sliced water chestnuts, drained and coarsely chopped
- 12 Boston lettuce leaves (or organic iceberg)
- 3 Tbsp hoisin sauce (recipe below)
- 2 Tbsp lower-sodium organic gluten free soy sauce
- 1 Tbsp organic rice vinegar
- 2 tsp. roasted red chili paste, organic if possible
- 1/8 tsp. whole mineral salt
- 1/8 tsp. ground organic black pepper
Homemade Hoisin Sauce
- 4 Tbsp. lower-sodium organic gluten free soy sauce
- 2 tsp. organic white vinegar (or lemon/lime juice)
- 1 tsp. organic sesame seed oil
- 2 Tbsp. unsalted organic unsweetened peanut butter
- 1 Tbsp. organic/raw honey, molasses or brown sugar
- 1/8 tsp. garlic powder
- 1/8 – 1/4 tsp. hot sauce/chili sauce (this will vary depending on your preference)
Mix together until blended. (Note: may need to slightly heat the sauce to disperse the peanut butter more uniformly)
Heat 1 tablespoon of oil in a large nonstick skillet over medium-high heat. Add turkey, garlic and ginger to the pan and cook for about 6 minutes or until turkey is browned. Stir to crumble. Combine turkey mixture, onions and chopped water chestnuts in a large bowl, stirring well, and set aside.
Meanwhile in a small bowl, whisk together hoisin, soy sauce, rice vinegar and roasted red chili paste, salt, pepper and drizzle over the turkey mixture. Toss to coat completely. Add about 1/4 cup turkey mixture to each lettuce leaf, serve, and enjoy!
Recently on his daily television show, Dr. Oz discussed IV nutrition therapy. I was very disappointed when Dr. Oz questioned the validity, benefit, and safety of this invaluable therapy. He had a guest physician on his show to defend IV therapies, but his guest talked in generalizations with no specifics and no scientific data. Dr. Oz’s conclusion at the end of the show, and I will paraphrase, was: “I guess if the Hollywood celebrity types are doing it, there must be some benefit.”
Wow! Now that’s scientific (insert sarcasm). We live in day where we have instant access to data and scientific research, and that is his closing statement?
As physicians, we often forget that we are scientists. Our testing and therapies should be based on science, not opinion. Yet, neither Dr. Oz nor his guest presented any scientific data to support their statements in favor or opposition. So, allow me to do the job that Dr. Oz and his guest did not.
Intravenous nutritional therapy has been around since IV vitamin C was first used for treatment of polio in 1949. Is it something everyone needs? Of course not. Should everyone take insulin? You get my point.
At Seasons, we evaluate a client’s needs based on symptoms. The symptoms lead us to extensive metabolic testing to determine the specific presence and severity of deficiencies of amino acids, fatty acids, vitamins, minerals, etc. Only then do we recommend IV nutritional therapies using the metabolic test results combined with the client’s symptoms. That is what medicine is all about – using the art and science of medicine for the patient’s benefit.
Another reason to use IV nutritional therapy is that for most Americans, our guts are a wreck (and that is putting it mildly). Absorption problems are a major concern for Americans. If you can’t absorb a vitamin or nutrient, it doesn’t matter how good the source or the dosage of therapy is, it just won’t be absorbed. If you are dealing with severe deficiencies, then you’ll never catch up.
How about an analogy to paint a clearer picture? A patient seeks help from a physician for severe dehydration. The patient just can’t keep anything down. Is the physician going to give the patient a pat on the back, tell them to just drink more water, and send them on their way? Of course not. The physician knows that the patient cannot tolerate oral therapy at that point. The deficiency is severe. The physician knows that he/she must catch the patient up, and then instruct the client to drink more water. And how does the physician “catch” the patient up? Well, IVs of course.
Does Dr. Oz question the safety, validity, and benefits of this therapy? Of course not. That is because it is standard practice. Standard practice is defined as: whatever everyone else is doing. I remember my mom often asking me, So…if everyone else jumps of a cliff, are you going to do that too?
And the testing to determine dehydration? Very limited. Usually, a urinalysis, complete blood count test (CBC), maybe a general chemistry, and of course a physical exam. From experience and training, I can tell you that the IV fluids are started based on the physical exam, before the test results get back. That is not how we approach IV nutritional therapy at Seasons. Dr Oz gave the impression that people just walk into a Doctor’s office to order IVs as one would a hamburger at a fast food drive-through. We customize therapy to specific needs and match it with their specific metabolic demand.
So, what does the science say about IV nutritional therapy? The science is overwhelmingly in favor of IV nutritional therapy.
The research below looks at surgical patients. It is well known that poor nutritional status of the patient undergoing surgery effects outcome. These studies showed that IV nutritional therapy improved outcomes. This is not total peripheral nutrition (TPN). TPN is therapy to replace all nutrition. Intravenous nutritional therapy is just to replace vitamins, minerals, and maybe some targeted macronutrients.
- Bellantone R, Doglietto G, Bossola M, Pacelli F, Negro F, Sofo L, Crucitti F. Preoperative parenteral nutrition of malnourished surgical patients. Acta Chir Scand. Apr 1988;154(4):249-51.
- Rham D. A guide to perioperative nutrition. Aesthetic Surgery Journal. July-August 2004;24)4):385-390.
- Xu J. Yunshi Z, Li R. Immunonutrition in Surgical Patients. Current Drug Targets. Aug 2009;10(8):771-777.
- Beier-Holgersen R, Boesby S. Influence of postoperative enteral nutrition on postsurgical infections. Gut. 1996;39:833-835.
So, what about the other benefits of IV nutritional therapy?
- Wolk RA, Rayburn WF. Parenteral nutrition in obstetric patients. Nutr Clin Pract. Aug 1990;5(4):139-52.
- Rayburn W, Wolk R, Mercer N, Roberts J. Parenteral nutrition in obstetrics and gynecology. Obstet Gynecol Surv. Apr 1986;41(4):200-14.
- Russo-Stieglitz KE, Levine AB, Wagner BA, Armenti VT. Pregnancy outcome in patients requiring parenteral nutrition. J Maternal Fetal Med. 199;8:164-7.
- Zibell-Frisk, Jen KL, Rick J. Use of parenteral Nutrition to maintain adequate nutritional status in hyperemesis gravidarum. J Perinatol. 1990;10:390-5.
First trimester miscarriage
- Acacio B et al. Pregnancy outcome after intralipid infusion among women experiencing recurrent pregnancy loss. Fertility & Sterility. Apr 2008;89(4):S11.
- Roussev RG et al. Duration of intralipid’s suppressive effect on NK cell’s functional activity. Am J Reprod Immunol. Sep 2008;60(3):258-63.
- Klenner FR. Massive doses of vitamin C and the virus diseases. J So Med & Surg. April 1951;113(4).
- Schencking M, Vollbracht C, Weiss G, Lebert J, Biller A, Goyvaerts B, Kraft K. Intravenous vitamin C in the treatment of shingles: results of a multicenter prospective cohort study. Med Sci Monit. Apr 2012;18(4):CR215-24.
- Gorton HC, Jarvis K. The effectiveness of vitamin C in preventing and relieving the symptoms of virus-induced respiratory infections. J Manipulative Physiol Ther. Oct 1999;22(8):530-3.
- Tanaka H, Takayoshi M et al. Reduction of resuscitation fluid volumes in severely burned patients using ascorbic acid administration. Arch Surg 2000;135.326-331.
- Crimi E et al. The beneficial effects of antioxidant supplementation in enteral feeding in critically ill patients: a prospective, randomized, double, blind, placebo- controlled trial. A & A. Sept 2004;99(3):857-863.
- Dentico P et al. Glutathione in the treatment of chronic fatty liver disease. Recnti Prog Med. Jul-Aug 1995;86(7):7-8):290-3.
- Smith SW, Howland MA, Hoffman RS, Nelson LS. Acetaminophen overdose with altered acetaminophen pharmacokinetics and hepatotoxicity associated with premature cessation of intravenous N-acetylcysteine therapy. Ann Pharmacother. Sep 2008;42(9):1333-1339.
- Mitchell JR et al. Acetaminophen-induced hepatic necrosis. IV protective role of glutathione. JPET. Oct 1973;187(1):211-217.
- Chen JY, Chu CC, So EC, Hsing CH, Hu ML. Treatment of postherpectic neuralgia with intravenous administration of vitamin C. Anesth Analg. 2006;103:1616-1617.
- Schencking M, Sandholzer H, Frese T. Intravenous administration of vitamin C in the treatment of herpetic neuralgia: two case reports. Med Sci Monit. 2010;16:58-61.
- Chen JY, Chang CY, Feng PH, Chu CC, So EC, Hu ML. Plasma vitamin C is lower in postherpetic neuralgia patients and administration of vitamin C reduces spontaneous pain but not brush-evoked pain. Clin J Pain. Sep 2009;25(7):562-9.
- Riordan HD et al. A pilot clinical study of continuous intravenous ascorbate in terminal cancer patients. P R Health Sci J. Dec 2005;24(4):269-76.
- Mikirova N, Casciari J, Rogers A, Taylor P. Effect of high-dose intravenous vitamin C on inflammation in cancer patients
- Ohno S, Ohno Y, Suzuki N, Soma G, Inouse M. High-dose vitamin C (ascorbic acid) therapy in the treatment of patients with advanced cancer. Anticancer Research. Mar 2009;29(3):809-815.
- Chen Q et al. Pharmacologic ascorbic acid concentrations selectively kill cancer cells: Action as a pro-drug to deliver hydrogen peroxide to tissues. PNAS. Sept 20 2005;102(38):13604-13609.
- Juraschek SP, Guallar E, Appel LJ, Miller ER III. Effects of vitamin C supplementation on blood pressure: a meta-analysis of randomized controlled trials. Am J Clin Nutr. May 2012;95(5):1079-1088.
- Schneider MP et al. Superoxide scavenging effects of N-actylcysteine and vitamin C in subjects with essential hypertension. Am J Hypertens. 2005;18:1111-1117.
- Mikirova N, Rogers A, Casciari J, Taylor P, Effect of high dose intravenous ascorbic acid on the level of inflammation in patients with rheumatoid. Modern Research in Inflammation. 2012;1(2):26-32.
- Sechi G et al. Reduced intravenous glutathione in the treatment of early parkinson’s disease. Progress in Neuro-Psychopharmacology and Biological Psychiatry. Oct 1996;20(7):1159-1170.
- Hauser RA, Lyons KE, McClain T, Carter S, Perlmutter D. Randomized, double- blind, pilot evaluation of intravenous glutathione in Parkinson’s disease. Mov Disord. May 15 2009;24(7):979-83.
- Kuwabara S et al. Intravenous methylcobalamin treatment for uremic and diabetic neuropathy in chronic hemodialysis patients. Intern Med. Jun 1999;38(6):472-5.
- Ziegler D et al. Alpha-lipoic acid in the treatment of diabetic polyneuropathy in Germany: current evidence from clinical trials. Exp Clin Endocrinol Diabetes. 1999;107(7):421-30.
As you can see, the benefits of IV nutritional therapy are abound. That is not my opinion, but scientific fact.
How safe is IV nutritional therapy? The studies below showed the safety of IV nutritional therapies in all states of health, including pregnancy.
- Greenspoon JS, Rosen DJ, Ault M. Use of peripherally inserted central catheter for parenteral nutrition during pregnancy. Obstet Gynecol. May 1993;81(f (Pt2)):831-4.
- Valencia E, Hardy G. Practicalities of glutathione supplementation in nutritional support. Current Opinion in Clinical Nutrition & Metabolic Care. May 2002;5(3): 321-326.
- Padayatty SJ et al. Vitamin C: Intravenous use by complementary and alternative medicine practitioners and adverse effects. PLos ONE 5(7):e11414.
Just because Dr. Oz (the great and powerful, Dr. Oz) says it is so doesn’t make it so. I hope I’ve helped pull back the curtain and expose the real science supporting IV nutritional therapy.
My pre-60th birthday journey to improve my previous test results from Seasons of Farragut continues! This month I decided to focus on the first tenet in our Seasons wellness regimen – nutrition!
About two years ago I took the ALCAT test and was astonished at my lengthy list of reactive foods! The ALCAT is a fascinating food sensitivity test in which white blood cells are introduced to a variety of foods, chemicals, and herbs. The severity of the reaction determines if a substance is mild, moderate, severe, or normal within my body. Since knowledge is power, I decided to receive the news that gluten and dairy were on my “severe list” as a positive indicator rather than “buyers’ remorse” for having performed the test!