Nutrition Questions & Answers
It seems like I'm always reading in the paper something new about nutrition, like another supplement or herb that I should take, or a food that I should eat, or that I thought I should eat that now they say I shouldn't, and so on. I just want to stay healthy. Very basically, what am I supposed to eat? How do I figure out these new reports?
--JK, Syracuse, NY
There is so much misinformation and quickly-reported and incomplete information out there, a lot of people wonder about the same thing. I think the best way to make this clear is to break down the nutrients we need into categories.
The macronutrients are those substances that we need the most of: protein, fat, carbohydrates and water. If you get this part right, you probably won't go much wrong elsewhere, because these comprise the bulk of our needs.
To get the appropriate level of macronutrients, we can generally follow the USDA Food Guide Pyramid, as I detail on the previous nutrition page. Make a variety of health-promoting choices in each category, such as whole grains, orange/yellow/dark green vegetables, citrus and non-citrus fruits, lowfat or nonfat dairy products, lean meats, and occasional meat substitutes. Limit added fat and sugar as much as you need to keep your weight under control.
The more harmful carbohydrates are the sugars and processed starches, which have the fiber removed. These tend to be digested quickly, causing blood sugar to rise quickly, with a later large decrease in blood sugar. If you have a condition called impaired glucose tolerance, if you have or are prone to diabetes, or if you are trying to lose weight and tend to be hungry often, these changes in blood sugar can be harmful. For everyone else, you can eat some of these simple carbohydrates, as they are called, but you still need the added vitamins and fiber provided by eating mostly whole grains.
Protein is needed for a variety of substances produced by our bodies, including enzymes, hormones, and immune-function substances, also for building muscle and bone strength. Most Americans get too much protein, which can cause stress to the kidneys. The goal should be a moderate amount of protein, which is equivalent to about two servings of meat or meat alternatives a day, plus adequate dairy intake. Whole grains and other foods provide a tiny amount of our total protein intake.
Fat is also a nutrient, providing substances that build cell membranes, provide immune-enhancing factors, and factors that keep our blood from clotting - or help it clot. The problem is generally again that Americans' intake tends to be too high overall. It is also a problem of balance. Try to cut back on saturated fats, found in fatty meats, whole-fat dairy products, including butter; and trans fats, found in many margarines and processed foods that include "partially hydrogenated" oils in their ingredient list (generally semi-solid vegetable fats and products made from them, such as crackers, cookies, baked goods, etc.; check the labels). Replace these, where possible, with polyunsaturated and monounsaturated oils, such as olive oil and canola oil. Fatty fish such as salmon and tuna have omega-3 oils in them, which have been found to be heart-healthy, and most Americans need more of them. Again, it is a matter of balance; Alaskan native tribes generally have more than enough omega-3 oils in their diet, and may wish to try to get more omega-6 oils such as by adding corn oil to their diets.
Water is a nutrient that we don't think about much, but is vital for many of our body's life processes. Most Americans do not drink enough water, and the problem worsens as we age, since our sense of thirst becomes diminished. The rule of thumb is eight, 8-ounce glasses of water a day, but this should vary according to your size and circumstances. Some medical conditions or medications may require that you drink more or less (check with your doctor or pharmacist), and intake should also vary with whether or not you exercise, how vigorously, and under what climate conditions. In general, drink regularly throughout the day, but stop for a little while if you feel water-logged, or better yet, once your urine is clear or pale yellow. Do be sure to drink before you are thirsty; if you wait until prompted by thirst, you'll be at least slightly dehydrated. Food adds greatly to our total water intake; if you cannot eat because of illness, you should probably drink about twice the recommended amount; but check with your doctor to be sure to get the right amount for YOU. You can drink fluids besides water, but those with caffeine or alcohol do NOT count, because they act as diuretics so you lose more fluid than you gain.
IF you eat according to the Food Guide Pyramid as we have recommended, then chances are you will receive all the micronutrients you need, also. Micronutrients include the vitamins and minerals. However, because so few Americans eat according to the Pyramid (we tend to skimp on fruits and vegetables, eat insufficient fibrous grains, skimp on dairy intake, but eat plenty of meat), that is a huge "IF", and we do generally recommend that people take a multivitamin/multimineral supplement that contains approximately 100% of the daily value for most vitamins and minerals (check the label). Even if you receive approximately 100% of your needs from foods, this additional amount is generally harmless for most people, and will cover any occasional deficiencies. Do not, however, go overboard and take major quantities of supplements beyond the 100% level. Some vitamins and minerals are toxic at relatively low additional doses. If you have heard that you should take higher levels of certain supplements, please e-mail us and ask about specific micronutrients and optimal amounts! Let us know if you want a private reply or placement on the Q&A pages.
As far as the reports that this or that vitamin or herb or other nutritional substance has medicinal properties, can prevent disease, and so on, many of those reports are preliminary and/or controversial. If you have a medical condition, feel free to ask your doctor or certified nutritionist or registered dietitian about a particular nutrient if you read that it may help. The major problem with supplements at this level is the very real possibility of side effects or toxicity. When contemplating using a supplement as a medication, what is called a "pharmacologic dose," treat it with the respect you would any medication. There are benefits and risks, which should be discussed with a knowledgeable professional. We can help if you would like to e-mail us about a particular nutrient at a dose higher than 100% of the recommended daily amount, or a particular herb or other substance that may currently have no daily value.
As for reading about any other substances in the news, it bears repeating that most of these reports are preliminary and/or controversial, and should be treated as such. As mentioned above, the problem with megadoses is the risk of side effects or toxicity, so medical claims for nutrients should be met with a healthy skepticism. IF the possible health benefit outweighs the possible health risk, you may wish to try it, but be aware that you are using yourself as something of a human guinea pig, because the experiments on humans are incomplete. Sometimes this is relatively safe, sometimes it is not, so be sure to ask a knowledgeable professional about the risks.
For example, there is fairly substantial evidence that Vitamin E, at doses several times the recommended daily value, may help decrease the deposit of fats on artery walls that becomes atherosclerosis. If you have cardiovascular disease, therefore, your doctor may recommend supplementation. Amounts that have been found to be effective have ranged from 100 IU to 800 IU daily. So far, there has been only one report of complications that we have seen, which was a man who reported stomach upset after 30 years on 3200 IU. However, as a fat-soluble vitamin that is stored in the body and therefore could build up to harmful levels over time, we would recommend a lower dose in order to avoid most of the toxicity risk, and only with the agreement of your doctor, who can determine if you have any other health conditions that may suggest you have other increased risks. There are medications that should not be taken with Vitamin E. And only people with recognized problems in this area should consider taking E anyway, since if you have only a low likelihood of developing cardiovascular disease, there's little to be potentially gained by supplementing, and so the possible risks would outweigh the likely benefits.
As for the claims made for herbs and other nutrient substances, most of those are unlikely to be needed by most people. They do not form a common part of the normal human diet, and so their usefulness is likely to be limited to specific cases. Again, if you see a nutrient that you wonder about, ask your doctor, a registered dietitian or certified nutritionist, or e-mail us.
A friend introduced me to her nutritionist, who recommends an all-fruit-and-vegetable diet. Is this really healthy?
--DT, Lexington, KY
I don't have complete information on this diet, but the short answer is no, probably not. The claims that are made for this diet have what I call a bad case of the "yabbuts" (i.e., "Yeah, but..."). Many fad and extreme diets give you partial information and try to pass it off as the whole truth and completely supporting their recommendations, when it is not and does not. We will use this diet as an example of this process:
All fruits and vegetables are recommended because it has been reported that those who eat the most fruits and vegetables live the longest, with the fewest health problems.
Yeah, but... those studies primarily compare people who eat according to the Food Guide Pyramid or pretty close to it, use small to moderate quantities of fat and protein such as from dairy and meat sources, and include whole grain foods in their diets, in addition to their high intake of fruits and vegetables; versus people eating a typical American diet, which is high in fat and protein and low in fruits and vegetables and whole grains. THEN the first group is likely to live much longer, with fewer health problems. Fruits and vegetables are important healthful foods, but they are not the only foods that count, and nutrient deficiencies are HIGHLY LIKELY from any diet that completely erases entire food groups. Some good sources of vegetable protein are allowed in this diet, but good sources of iron, zinc, niacin, calcium, etc., are not emphasized, and it would take a concentrated effort to obtain sufficient quantities of these and several other nutrients from vegetables and fruits alone.
The claim is made that since all vegetables have protein, you don't need any other source of protein.
Yeah, vegetables have protein, but... only certain vegetables have enough protein to make a difference in our diets. Humans generally need a minimum of about 0.8 grams of protein per kilogram of body weight per day. Therefore, if a vegetable has a tiny fraction of a gram of protein in a large serving, it will not count for much toward your total needs. If you do not want to eat animal flesh, your meat alternatives include eggs, nuts and seeds, soy products, and beans, peas and lentils. The only allowed substances from this list on this diet are the beans, peas, and lentils, and in this diet they are considered equal to the other vegetables, which clearly do not have enough protein to sustain human functions. Therefore, unless a concerted effort is made to eat more beans, peas and lentils, you will probably also be protein deficient on this diet. This can be serious -- protein substances are used to build muscle, heal wounds, and provide the basis for hormones and enzymes that sustain basic body activities, including immune function.
Fruits and vegetables are heralded for their antioxidant functions, which promotes health and long life.
Yeah, fruits and vegetables contain powerful antioxidants and these are important, but... you need more than antioxidant vitamins for optimal health. As mentioned above, it is important to eat plenty of fruits and vegetables. And much of the reason for this is the quantity and combination of antioxidant substances contained in plant foods. What we disagree with is the notion that these ALONE will provide optimal health. Please see our Nutrition main page under the Food Guide Pyramid for a list of the food groups and what they are good for. Substances that are mostly found in non-plant foods include some that maintain bone strength, activate red blood cells (which provide oxygen to our bodies' cells), support brain function, etc. I think most people would agree that these and many other body functions are as important as the functions of antioxidants, which may help slow aging and boost immune function.
It may also be important to mention that virtually anybody can call himself or herself a nutritionist, with really very little training! Look for state or federal certification or licensure, ask about qualifications and credentials. Anyone who is pushing an unbalanced diet is probably not well trained.
It seems like every time I turn around, another friend is recommending a high-protein diet and claiming huge weight loss. What's the deal? Wouldn't this be unhealthy?
--SS, Lexington, KY
I'm glad I received this question shortly after the preceding one, since I certainly don't want to sound like I'm for high-protein diets. I'm not; they can be very dangerous! The key is moderation -- a nutrition plan fairly high in plant foods, preferably high-fiber, but also with small to moderate amounts of protein foods and dairy products.
The American Heart Association's Nutrition Committee of the Council on Nutrition, Physical Activity and Metabolism has just come out against high-protein diets in a statement published in an October issue of Circulation. The full reference citation is available on our References page (1). This article is also available on-line at circ.ahajournals.org. You can click here to go there directly, if you wish.
In short, these diets also have a bad case of the "yabbuts". For example:
Claims are often made by these authors that we have encouraged high-carbohydrate diets, and the American public is fatter than ever.
Yeah, but... there are a variety of reasons for the continued increase in obesity in the United States, a major reason being a continued decrease in physical activity. Furthermore, in general, people who have decreased their fat intake and increased their physical activity but still cannot lose weight, are probably eating too much sugar and refined grains. This is one reason we emphasize whole grains and vegetables and fruits -- with the increased bulk, you are likely to feel full on fewer calories. Unfortunately, some dieters only heard that they should cut back on fat calories, they thought sugar was OK. It's fine in moderation if you can afford the calories, but it is another dense source of calories.
Claims are made that you can eat as much as you like and still lose weight.
Yeah, but... A low-carbohydrate, extremely-high-protein, high-fat diet is likely to make you nauseous before long, so that you don't want to eat. Imagine eating all the bacon you want, but you can't mix it with other foods; how much would that be, really? Yuck!
It has been clearly shown that when these diets result in weight loss, it is because the diets are low-calorie. If "all you want to eat" is a lot of calories, you will gain weight, just like you would on any high-calorie plan!
As we've mentioned on our Nutrition main page, you can't fool the calorie count. If you lose weight, it's because you eat fewer calories or burn more calories. There's nothing magical about these diets, except that the disgusting menu kills appetite after awhile.
Meanwhile, the American Heart Association expresses sincere concern that these diets will result in an increased incidence of high cholesterol and related cardiovascular problems. Also nutrient deficiencies because of a lack of adequate plant foods. It's not worth the risk! There are more sensible ways to lose weight -- read our pages, and e-mail us with questions specific to your situation.
For further information, please link to the American Heart Association Web site, and/or e-mail us with your questions!
My doctor says I have high levels of homocysteine in my blood, and this can raise my risk of heart attack. Needless to say, he scared me! Why does homocysteine put me at risk, and what if anything can I do about it?
--KL, Lexington, KY
I am sorry to hear that you have this condition. It is fairly rare. How much elevated homocysteine raises the risk of heart attack is still a somewhat controversial question (2,3,5,6)*, since research results have been somewhat inconsistent, so please don't panic. Homocysteine is one of over 200 risk factors that have now been found to be related to heart disease! The most important risk factors discovered so far include blood levels of cholesterol and triglycerides, blood pressure, and cigarette smoking (1). Nevertheless, if your doctor wants you on prescribed medication, by all means follow his advice. We have some nutrition advice below that you can follow in addition, which may also be helpful for you.
*Numbers in parentheses refer to citations on our References page.
Why this increases your risk: Homocysteine is believed to work as an oxidant (4), so that its presence might increase the amount of "bad cholesterol" that is deposited on your artery walls (3), making it more likely that the arteries that send blood to feed the heart might narrow to the point of cutting off the blood supply. This is one way to end up with a heart attack.
What you can do about it: Of course, eating a healthful, lowfat diet helps everyone avoid fat buildup in the arteries, and reasonable intake of antioxidant vitamins may provide some additional protection (4,7). But additionally, for people with abnormally high levels of homocysteine, good intake of vitamins B6, B12 and folate seems to help (3,4,5,6). The recommendations from the American Heart Association (3) are for 2 mg of B6, 6 mcg of B12, and 400 mcg of folate, which are all just 100% of the RDA, so just taking a basic 100% multivitamin every day will do the trick. But you should be quite faithful about taking your supplement EVERY day. Alternatively, you can get the same array of vitamins in a 100% fortified breakfast cereal, which may be important if you have trouble swallowing pills. Unsupplemented or unfortified food sources, however, have not been shown to be much help in this condition, apparently because of some absorption problems. So this is one condition for which the supplement might be better than the food! This is a rare case, however, so keep trying to eat a healthful diet for all the other health-promoting reasons.
For more information than you really want to know -- the full report of the Nutrition Committee of the American Heart Association --please feel free to link here with the 1999 article in Circulation. The recommendations have not changed substantially in the two years since.
I've been told that I should not take my vitamin E with my vitamin C and iron supplements. Is this true? Why not?
--DK, New York
It's fairly well known that vitamin C increases iron absorption, so if you have to take an iron supplement, it helps to take it with C. Do not take supplemental iron, however, without your medical doctor's okay; there is a fine line between too little and too much! Also, some people have an inherited condition that predisposes them to storing too much iron, which can be very damaging.
As for vitamin E, I have not been able to find any medical research, or basic research on nutrient absorption, that suggests any problem with interactions. In fact, one report found that while vitamin E did not interfere with iron absorption, it did help reduce oxidative damage that can occur with excess iron (3)*. Meanwhile, its presence allowed for increased levels of vitamin C in the blood! On the flip side, vitamin C does not seem to affect the absorption of vitamin E (1). These are animal studies, but there just is not a lot of information available in humans. Regardless, the physiology should be very similar. E is a fat soluble vitamin and C is a water soluble vitamin, so their mechanisms of absorption differ. They both, however, appear to protect from some absorption of harmful heavy metals, some of which are unavoidable because of environmental contamination (2). So take your vitamins, approximately 100% of the RDA, any way you can get them! These three, at least, can be taken together. If you are more likely to remember them by taking them all at once, then it is probably best to do so.
I have heard and read that soy products are so healthy, especially for women with menopausal problems. I have thought about trying to eat more soy, but then read that soy can increase estrogen levels. I don't want to do anything that will increase my risk of breast cancer. Do you know if soy does increase estrogen levels, and if so, does it then increase the risk for breast cancer?
--BJ, Terre Haute, IN
Well, after a thorough review of the literature, I'm afraid the answer is not certain at this time (don't you love science?). It's really only been in the last year or two that researchers started looking at this question in depth, including possible mechanisms of action. The most recent review, in the November 2001 issue of the Journal of Nutrition, concludes that it makes no difference, even breast cancer survivors can eat soy if they like it. But "THE" answer will have to wait for the results of longterm (i.e., decades long) studies that have just begun.
Yes, soy has weak estrogen-like properties. However, in most cultures where large quantities of soy are consumed, there is far LESS breast cancer! While there may be other factors involved (i.e., less smoking in these same cultures), it appears that some substances in soy act to block enzymes that produce estrogens in the body. Therefore, the total amount of estrogen in the body may be less when a high-soy diet is consumed.
Other substances in soy appear to act as antioxidants, which generally provide health benefits. Other soy substances appear to affect lipids in the body -- "good" and "bad" fats -- and so may protect heart health. There is also some possibility that soy helps lower risk of osteoporosis.
The vast majority of studies have found a tumor-killing effect of soy substances, but a few have found tumor-promotion effects. But this has been in the cell culture dish. Study after study show that people who eat more soy have less incidence of breast cancer.
All of these associations are weak enough that there has been no official scientific agreement/recommendation yet, although the general trend has been to increasingly recommend soy products.
So, I suggest doing three things:
(1) Check with your physician to see if s/he knows of any reason in your particular case (such as some unusual genetic factor) why you should NOT eat soy products, or if s/he recommends a particular amount.
(2) Eat whole foods, avoid soy supplement pills. Pills can be out of balance in terms of the individual substances that make up the food so that they may not have a protective effect, can even be harmful. These are often the products that are most heavily promoted - ignore those ads, the vast majority of the research in humans has been done with the whole foods.
And (3) enjoy soy foods in moderation; if a harmful effect is ever proven, it is likely to be at extremely low or extremely high levels.
Then check back w/ us any time you want to see if the research shows anything new (probably the biggest change in recommendations will come in 10-20 years! but we hope to still be around then).
I want to lose weight. I don't eat any breakfast. Could that be making me gain weight?
--JG, Fresno, CA
Yes, skipping breakfast has been associated with overweight (3)*. Two major reasons are primarily responsible for this:
1 - Your body acts as if you are in the middle of a famine, learning to do things more efficiently, burning fewer calories, trying to save you from starving to death.
To get your "engine revved", eat something after you get up. If you can't stomach breakfast right away, then maybe a small meal mid-morning will work for you.
2 - If your blood sugar goes too low, you're likely to feel like you're starving later, and hunger pains will prompt you to seek out too much food, most of it higher-fat, higher-sugar, therefore calorie-loaded (4). Better a sensible breakfast than a junk food attack later! In fact, many people who skip breakfast end up binging, eating loads of calories in the evening (2). They therefore end up having more trouble losing weight than those who eat breakfast (1).
So, to have the best shot at losing weight, eat early and eat small meals and snacks often, but plan your meals so that they are high in nutrients and relatively low in calories, with help from the Food Guide Pyramid (on our main Nutrition page) and our e-mail service!
*Numbers in parentheses refer to citations on our References page.
I was just reading about some stuff called "ghrelin" put out by the stomach, which signals for weight lost to be regained. They said that only if the lost weight is due to stomach stapling, then it doesn't increase and weight loss is more likely to be permanent. So, should I get my stomach stapled?
--CR, Louisville, KY
All research on ghrelin (a hormone released by the stomach that appears to attempt to stimulate growth by increasing food intake) is really VERY new and should be regarded as preliminary. It first appeared on the scene, according to our search of the medical literature, in an article in Nature in December, 1999 (2)*. So obviously, there hasn't been time to entirely determine all of its activities and connections to other weight-control systems in the human body. The article you refer to came out just yesterday in the May 23, 2002 issue of The New England Journal of Medicine (1). The authors found that after obese subjects lost weight by dieting, blood levels of ghrelin increased significantly. For those who had undergone gastric bypass (popularly known as stomach stapling) and lost weight, ghrelin levels were very low.
It is our fervent hope, however, that this will NOT result in a rush to surgery! Gastric bypass has certainly been studied far longer than ghrelin, and is accompanied by a whole host of possible complications, including but not limited to pain, breathing problems (3); infection, hernia (4); blood clot in leg veins (6); recurrent vomiting, severe micronutrient deficiencies, protein-calorie malnutrition (5); even death (1-2% risk in patients without complicating respiratory problems)(5). These risks are reduced by use of a laparoscopic procedure, but they are not eliminated (3,4). This is why such surgery is only recommended ethically for patients who are morbidly obese. Granted that the potential benefits are substantial (although not everyone who has a gastric bypass loses weight!), you still have to weigh the potential benefits against the potential risks.
Nevertheless, the above research on ghrelin looks promising. A fruitful line of research will be to try to develop a medication that will block the action of ghrelin, and therefore decrease appetite. The problem with weight-loss drugs so far is their undesirable side effects. This may be one with a more specific action, thus fewer side effects. So keep watching the literature to see what happens with ghrelin, but in the meantime treat yourself well, eat right and stay as physically active as you can. This and other potentially more effective -- and safe! -- weight loss medications may well be on the horizon, but we suggest patience. As more information becomes available, we will keep you posted!
*Numbers in parentheses refer to citations on our References page.
I've recently read that they've found that food is addictive for obese people just like drugs. It has something to do with dopamine in the brain, and the obese have less of it, so they eat to get more. If this turns out to be true and I'm a food addict, doesn't that mean I'm doomed to be fat forever? How can I fight a food addiction?
--AH, Des Moines, IA
Much has been made lately in the popular press of this recent study in the scientific journal Synapse (1)*. These authors and others do suggest that eating is particularly pleasurable, and thus potentially addictive, for the obese, because of dopamine responses in the brain. But no, you are not doomed to be obese because you find eating pleasurable. So what does this study mean for you?
First of all, take some comfort in the knowledge that there may very well be sound neurological reasons for that feeling that you are "addicted" to food. It's not a matter of willpower, it's brain biochemistry. So if you've been kicking yourself for your tendency to eat more than you need, you can stop, and this in itself may be helpful in your quest to lose weight. Often, feeling better about ourselves is the first step toward treating ourselves better.
Secondly, recognize that an "addiction" to food will never be quite like an addiction to alcohol or tobacco or other drugs. You cannot avoid food entirely, as recovering addicts do with drugs, and live. Therefore, it's a pleasurable experience that has to continue to be enjoyed in moderate amounts.
This study and our common sense tells us that meals can be enjoyable and pleasurable. This information is not really all that new. For some of us, there are far too few pleasures that we allow ourselves. This is one reason we emphasize finding the FUN in redesigning your lifestyle to emphasize wellness. You need that pleasure. Keeping pleasure in our diets will mean different things to different people. For some, it will mean eating lots of small meals and snacks throughout the day, so that they always have a background level of appetite satisfaction and aren't going hungry. For others, it will mean maintaining a three-large-meals schedule with family and/or friends gathered around, so that they maximize enjoyment of mealtimes even while they may be changing the types or quantities of foods they eat for better nutrition with fewer calories. For some, it may mean cooking for themselves and others, experimenting with new recipes and cuisines at home. Others would rather be shot than set foot in the kitchen. For them, it may mean eating out at different "healthy" restaurants and trying new menu selections. Whatever works best for you to provide the most pleasure within the confines of your nutrition plan to lose weight, that is what you will want to emphasize doing.
The pleasure issue is also why we emphasize other aspects of wellness, and finding the fun in each. If you just really love your high calorie/low nutrient foods, but realize you have to give them up for the sake of your health, then the answer to long-term success may lie in finding pleasure elsewhere. It is certainly guaranteed that if your only pleasure in life is eating high-fat foods, and we take that pleasure away and put nothing in its place, then you are almost bound to eventually quit your diet and return to eating those high-fat foods. But if you find other activities that can replace eating and take your mind off the powerful attraction of those meals, then you are likely to succeed. So we hope to help you find ways to ENJOY the rest of your life!
Finally, you should be aware that exercise has also been called "addictive". Physical activity releases other neurotransmitters in the brain, the endorphins. Therefore, as you find activities that you can enjoy and engage in them regularly, your brain will be receiving its required dose of pleasure! You may have to get past an initial period when no physical activity seems pleasurable because you are not used to it. If you do more than you are physically ready to do, you will be prone to injury, which is certainly NOT pleasurable. That's why we advise moving ahead slowly, but adding physical activities to your lifestyle regularly. Activity and exercise are excellent substitutes for the pleasure of eating!
If you need further suggestions for making ENJOYABLE changes toward a wellness lifestyle, please e-mail us and let us know!
*Numbers in parentheses refer to citations on our References page.
This page was last updated on 04/22/03.