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Sugar, Prescription charges, Thrush, Iron and strokes

Dr Mark Porter presents a weekly quest to demystify the health issues that perplex us.

Is sugar really addictive? As the Chief Medical Officer for England suggests that it is and a 'sugar tax' may have to be introduced, leading experts debate whether the white stuff on our table is really habit forming.

How 40 year old research hidden away in a book has thrown new light on a link between iron deficiency and stroke.

And why the clue to solving recurrent thrush maybe getting the diagnosis right in the first place.

Plus concern about the increase in prescription charges just announced by the government.

Available now

28 minutes

Programme Transcript - Inside Health

Downloaded from www.bbc.co.uk/radio4 

THE ATTACHED TRANSCRIPT WAS TYPED FROM A RECORDING AND NOT COPIED FROM AN ORIGINAL SCRIPT.  BECAUSE OF THE RISK OF MISHEARING AND THE DIFFICULTY IN SOME CASES OF IDENTIFYING INDIVIDUAL SPEAKERS, THE BBC CANNOT VOUCH FOR ITS COMPLETE ACCURACY.

 

 

INSIDE HEALTH

           

Programme 8.

 

TX:  11.03.14  2100-2130

 

PRESENTER:  MARK PORTER

 

PRODUCER:  ERIKA WRIGHT

 

 

Porter

Coming up in today’s programme: Prescription charges – it has just been announced that they are to rise again in England to more than £8 an item from the beginning of next month. More revenue for the cash strapped NHS but at what cost?

 

Recurrent thrush – an expert thinks women are suffering unnecessarily because they are being misdiagnosed.

 

And iron and strokes. I meet the woman behind new research linking iron deficiency to sticky blood, doubling the risk of clots in the brain.

 

But first sugar which is back in the headlines after the World Health Organisation advised we should halve our intake, the Chief Medical Officer for England suggested that it is addictive, and that a “sugar tax” may have to be introduced to curb consumption.

 

Proposals welcomed by Professor Robert Lustig, an eminent anti-sugar campaigner, who is already convinced that millions of us are addicted to the stuff.

 

Lustig 

Sugar has toxic effects unrelated to its calories and sugar has addictive effects as well and about 20% of the US population and I venture to say the UK population are sugar addicts and it’s one of the reasons why this problem continues to increase.

 

Porter

And you’re pointing the finger at sugar in particular?

 

Lustig

In particular, now people say a calorie is a calorie but you know that actually doesn’t take into account the difference in how the body metabolises calories.  We actually burn energy differently based on where it came from.

 

Porter

If you’re right how would you like policy makers to react now?

 

Lustig

Well compounds that are both toxic and addictive are subject to regulation – tobacco and alcohol being the prime examples, cocaine, heroin – we have personal interventions which we can call rehab and we have societal interventions which we call laws, rehab and laws, for sugar we have nothing, the problem is we’re going to need both – we’re going to need personal intervention, we need something you might as well call sugar rehab, especially for the people who are addicted and we’re going to need societal intervention.  We have to reduce availability, if we reduce the availability of sugar and try to get some of the sugar out of all of this processed food that was put there specifically for the food industry and not for us we could start making some headway in this chronic metabolic disease epidemic.

 

Porter

One of the big problems of course with sugars is that they are often hidden and a lot of people will have no idea how much sugar there is in their soft drink, their juice and indeed their processed foods.  How aware do you think people are of the scale of the problem?

 

Lustig

Oh I think that they don’t understand it at all and the reason is because the food industry doesn’t want them to understand it.

 

Porter

Robert Lustig from the University of California who you could never accuse of sitting on the fence. But is sugar really addictive? Not everyone agrees. 

 

Paul Fletcher is Professor of Health Neuroscience at the Department of Psychiatry at the University of Cambridge. And Peter Rogers is Professor of Biological Psychology at the University of Bristol.

 

Rogers

Well I think sugar isn’t addictive and also I don’t think it’s particularly meaningful or very helpful to think of sugar as addictive.  I mean I’d give an example is we don’t find ourselves raiding the sugar bowl, stuffing sugar into our mouths, consuming sugar lumps in excess.  Sugar is actually part of foods and we have to see sugar in that context.

 

Porter

Paul Fletcher would you agree with that?

 

Fletcher

I agree I don’t believe that there’s any strong evidence that sugar itself is addictive, indeed I think if we’re to look at the question of whether food overall is addictive I don’t think there’s a great deal of evidence and it certainly wouldn’t be the case that sugar on its own could be addictive.

 

Porter

You’ve done a review of this area, can you give me a sort of broad overview of your take on that, what you found?

 

Fletcher

Sure, well I reviewed this from the point of view really of the neuroscience, the brain science, and we took each of the pieces of evidence that had been mustered in favour of the food addiction idea and those include work in rats, they include the fact that there seems to be some clinical overlap between addiction to particular substances like cocaine and things like binge eating disorder, they also include the brain imaging studies in humans.  And really what we concluded was that apart from the fact that in certain very specific circumstances in the way rats are fed there’s actually very little consistent believable evidence that food addiction, as a whole, is a proven concept in humans.

 

Porter

This term addiction is banded around an awful lot, what does it mean to you, what criteria does something have to fulfil to be regarded as being truly addictive?

 

Fletcher

Well as a clinician addiction means several rather broadly defined ideas that somebody loses control over their intake of some substance, that is they struggle against it but fail in that struggle and they become tolerant to it so they need bigger and bigger doses, they can experience withdrawal symptoms when they have no longer access to it and also that it has negative effects on their lives.  So that’s a sort of broad description of how a clinician might diagnose addiction.  There is some evidence that’s emerged over the last couple of decades from neuroscientific work suggesting that there may be ways of identifying addictive processes by looking at changes in the reward systems in the brain but currently we wouldn’t diagnose addiction in those ways.

 

Porter

Peter, do you think the term addiction is helpful or a hindrance in the way it’s being used to talk about sugar?

 

Rogers

In general I don’t think it’s helpful at all, it’s not a very meaningful description of eating and eating sugar containing foods, nor is it helpful to those who might want to reduce their eating because addiction implies being helpless in the face of a compulsion to consume, that our brain chemistry is in control of our will, if you like, and that makes me feel then pessimistic about trying to change my behaviour.  So actually if my eating is labelled as addictive that probably makes me think I feel rather helpless, that I can’t change that behaviour, it’s actually my brain chemistry is out of control here and in a rather hopeless state.  So in that sense I think it’s unhelpful.

 

Porter

Paul, sugar is unique amongst nutrients in that it’s the fuel that’s essential for the brain’s activity, it’s the only fuel that the brain can use properly, does the brain respond to sugar differently from other nutrients, what do we know about how the brain responds to it?

 

Fletcher

Well we know in the human brain that if somebody has a sugary treat that there will be activity in certain key regions that we largely define as the reward system and sugar can certainly drive that system, as has been shown with functional brain imaging studies in humans.  I think if you just took a handful of other studies we’ve seen that the system gets very excited when people get the chance of winning money, when they’re shown humorous cartoons, when they’re making social comparisons to other people.  So it’s a system that gets activated by sugar but the fact that it’s activated by sugar and by drugs, one must say, doesn’t necessarily mean that that activation signifies addictive potential of sugar.

 

Porter

And do we know of any other nutrients that have that same effect on the reward centre?

 

Fletcher

Anything that’s palatable really and that would probably produce activation in most people in those regions.  There has been some recent work suggesting that sugar may show slightly elevated or produce slightly elevated activity compared to fat but we also know that combinations of sugar and fat are pretty powerful drivers of that system.  It’s also worth mentioning that it has been suggested that in people, particularly with obesity, that they have slightly under-reactive reward systems, possibly because of over-consumption, and that they therefore need more to drive that reward system to the same level.  Actually the evidence in favour of this is very, very scanty from humans and there’s possibly a slight logical difficulty, for me at least, that if you don’t find something rewarding why would you just then consume more and more.

 

Porter

We know that sugar lights up this reward centre, does it make any difference how you take that sugar, I’m thinking there’s the other thing that we have a big problem with our diet today is high fat content, is there a particularly potent combinations with sugar and fats?

 

Fletcher

It’s been suggested that actually that neither sugar nor fat alone could be considered an addictive substance and it’s the enhanced palatability that you get when you combine them.  Now that’s an interesting suggestion but I think there’s still no evidence in humans that the fat sugar combination, nice though it most certainly is, is actually addictive in a true and meaningful sense.

 

Rogers

And I would add to that that the effects of even that most hedonically liked combination of fat and sugar is still much less powerful than the effects of addictive drugs.

 

Porter

You don’t see people with their hands in the sugar bowl munching cubes of granulated sugar but you do hear people talking about cravings for sugar, what do you think of that?

 

Rogers

Well I think we do report craving for sweet foods.  In general cravings typically arise when we’re trying to actually cut down on our eating, in this case, so I’m trying to restrain my eating, I’m trying to not eat that food that looks and I know will taste nice.  By stopping doing that I start thinking more about the food and it’s that sort of wrestling with shall I, shan’t I consume this food that give rise to feelings that I would typically label as a craving.

 

Porter

But that’s a feature that you might see in someone who’s addicted to a drug, for instance, as well, I shouldn’t be doing this and I’m trying not to but I really would like to.

 

Rogers

Yes indeed but because cravings occur in both situations it doesn’t follow that there’s food addiction.  So we use the word addiction and craving in very sort of almost light-hearted ways some of the time, I might even say I’m addicted to soap operas, for example, that just means perhaps I feel I spend too much time watching the TV but this is nothing like as serious as being addicted to psychoactive drugs.

 

Fletcher

And I would add that addiction, whether it’s a helpful term, might be judged by how useful it is for treatment.  But actually when we take people who suffer from binge eating disorder, who perhaps could be most closely likened to the addictive state, actually the treatments that work are ones that do not do what a treatment for addiction would do, so instead of complete abstinence, which is of course impossible with food, but instead of completely abstaining from the high fat or high sugar foods, successful treatments involve learning to gain control of them, learning to be around them, to consume them in smaller amounts and I think that’s very important because if the treatments that were suggested by defining food over consumption as addiction if they worked, if they were suitable, then perhaps we would more inclined to try and go with it but actually they don’t seem to be the treatments that work.

 

Porter

Paul Fletcher and Peter Rogers, who don’t think sugar is addictive.

 

The government’s just announced another rise in prescription charges to £8.05 per item from the beginning of next month, and to £8.25 in April 2015, up from the current £7.85.  So much for rumours that England could soon follow Northern Ireland, Scotland and Wales and abolish the charge, offering free prescriptions to all.

 

The charges may raise revenue for the NHS but they are not popular with the public, or most doctors and pharmacists. Neil Patel is Head of Communications at the Royal Pharmaceutical Society.

 

Patel

We’re hugely concerned about the impacts of prescription charges on people with long term conditions, so people with serious illnesses that now have to pay quite a high charge – we’re talking about £7.85 per item and these are people with lifelong illnesses like asthma, multiple sclerosis, severe mental health issues and they’re having to stump up a charge when they’ve already got a serious diagnosis and we know because of the recession people are struggling to make ends meet.

 

Porter

And do you think that’s impacting on their care, is there evidence that they’re either not picking up their medicines at all or not picking up as many as they should do?

 

Patel

That’s right, there’s strong evidence that people who have to pay the charge actually a third of those will not collect an item because of the cost.  And then if you ask questions about what impact that has, around three quarters say it will impact on their health, around 10% have said they’ve been admitted to hospital because of that.

 

Porter

And there’s no rhyme or reason as to who gets free prescription charges and who doesn’t, I’m thinking one example is you have diabetes you don’t pay a prescription charge but if you have asthma you do.

 

Patel

That’s right, the charges were brought in in 1968 and really there’s been absolutely no reform of those charges, apart from people with cancer, people with cancer now don’t have to pay for their prescriptions but no other changes and no real look at what impact this has on people’s health since then and we think it’s really time for that reform to happen.

 

Porter

The defence from the Department of Health is always that most people don’t pay prescription charges, what proportion do?

 

Patel

Well the evidence from the Department of Health, and it’s worth saying the Department of Health don’t give us numbers which are particularly helpful, there’s around 90% of items are exempt from charges, which is about 60% of people they tell us.  But a concern about the people who are on low incomes, probably want multiple items for a long term condition and that’s the group that’s really been penalised here.

 

Porter

And it’s a problem that’s been compounded by the trend really in the last five or six years towards monthly prescriptions.  So let’s use the example of somebody with asthma who might be on two inhalers a month, it might have been previously that he or she was given three months’ supply, so six inhalers at a time, but now we’re being asked to prescribe monthly, so that’s hitting them even harder in a way.

 

Patel

That’s right, when we spoke to people about what impact that had they said, firstly, yes it has impacts on costs but also it’s an impact on how they access their medicines as well, that’s quite a lot of trips to the pharmacy, trips to the doctor to pick up repeat prescriptions, so it’s also about people’s lifestyles and actually filling that in is quite difficult sometimes.

 

Porter

Well you have to dispense them, I have to sign the prescription and the patient has to pick them up, I mean there’s a lot involved having that done every month, what’s the rationale behind?

 

Patel

The move was really about medicines waste, so we’re all familiar with the fact that a lot of medicines aren’t used by patients and if someone has perhaps an unstable condition if you prescribe a large amount to that patient in one go unfortunately that might end up in the bin ultimately.  So the idea was to try and reduce the amount that was prescribed in one go, just in case things changed or perhaps the patient’s condition got better so those medicines weren’t wasted.  I think perhaps what we’ve seen is rather a blanket adoption of that policy, rather than what should really be a starting point of a conversation between a doctor and a patient about well let’s also talk about affordability when it comes to how much we’re going to supply on this prescription and that’s perhaps a conversation that isn’t happening at the moment.

 

Porter

So to be clear – if I’m prescribing one asthma inhaler that lasts a month, my patient pays £7.85 for that, if I prescribe three that would last them three months they still would just pay £7.85?

 

Patel

That’s right, exactly right.

 

Porter

Inside Health’s Margaret McCartney’s here as well, Margaret does it affect the way that you prescribe because of the prescription charge?

 

McCartney

Well of course I work in Scotland where we don’t have any prescription charges, which of course is excellent because it means that…

 

Porter

But you have had prescription charges.

 

McCartney

We certainly have had prescription charges and I was always very aware of the fact that every time I made a new prescription that was going to be more cash that my patient would have to find.  So I think there’s always – always good practices not to prescribe drugs unnecessarily, not to prescribe things that are not going to be useful.  But when it comes to the fact that your patient is saying to you actually I won’t be able to afford to get all of these things you are making pretty serious decisions on behalf of the economy and the Department of Health rather than in the best interests of the patient.

 

Porter

Well let me redirect my question – Margaret, since the abolition of prescription charges in Scotland has it changed your prescribing habits, what have you noticed, do you prescribe more medicines because you don’t worry about the costs patients have to pay?

 

McCartney

No but I think that I would feel less concerned about the impact of prescriptions on patients’ personal economies, their personal finances, so that’s less of a concern.  But I suppose what has come in in its place is the direction that we’re being asked to prescribe things for shorter periods of time, so 28 days, so that has a cost but it’s not necessarily a financial cost because the prescription isn’t paid for but the time and effort and energy that a patient needs to organise themselves to get that prescription more regularly isn’t often accounted for.

 

Porter

Margaret McCartney and Neil Patel.

 

There is some good news: the cost of pre-payment certificate –  a sort of season ticket that entitles holders to free prescriptions while they are valid – are unchanged at £29.10 for a three month one, and just over £100 for the annual one.  An excellent way to cut costs if you are on long term medication, anyone who needs more than one prescribed item a month will save money. Assuming they can afford to pay in advance.

 

More details on the Inside Health page of the Radio 4 website where you can also listen again to the programme and find details on how to get in touch.

 

One listener e-mailed to ask us to look into thrush - vaginal candidiasis - she has attacks on a regular basis despite her doctor prescribing repeated anti-fungal treatments.

 

Consultant obstetrician and gynaecologist Austin Ugwumadu runs a thrush clinic at St George’s Hospital in Tooting.

 

Ugwumadu

Thrush is an infection caused by a fungus, the most common fungus being candida albicans.  It kind of colonises our body or our body’s gotten used to the presence of thrush so we can’t get rid of it or kill it but it doesn’t kill us either, so there’s some relationship between them.

 

Porter

So it’s living on us all of the time but we don’t get attacks of what we would regard as thrush regularly so what’s happening there?

 

Ugwumadu

Well what has happened is there is a certain degree of tolerance of the presence of thrush by our body, sometimes it increases in number and sometimes it decreases but it’s almost always there and we reckon at least about 30% of women carry thrush, in fact if you examine the back passage it goes up to about 40-50%.

 

Porter

Why do some women get attacks of discomfort?

 

Ugwumadu

We reckon that most women will get at least one attack in their lifetime and it usually will present as itching and discomfort in the vagina associated with a very cheesy type discharge.  In severe cases there may be a rash which spreads into the inner thighs but that’s very unusual.  But most women will be aware of itching discomfort, burning, irritation as well as the discharge.

 

Porter

What’s triggering the attack?

 

Ugwumadu

Ah I think that’s where the sort of action is.  There are a number of things that can trigger it.  Usually for any reason the thrush organisms increase in their number and one of the things that can lead to that is the use of antibiotics, so a lot of women will relate to having thrush attacks after they’ve just been exposed to antibiotics, particularly broad spectrum antibiotics.

 

Porter

And the link there is what – what’s actually happening?

 

Ugwumadu

And what is happening is as you kill the other organisms that compete with thrush organisms for food and resources then the thrush tend to just explode in numbers and that then triggers the symptoms that women get.  One of the common things we find is thrush usually will exist in two forms – one form of which is a yeast, or the inactive form and the other form which invades the skin and that’s the form that produces the symptoms.  So whatever triggers the attack of thrush should be able to change the thrush from the yeast form into the hyphae or the invasive form.  Therefore when you do tests, for example, and you find the yeast form it may not actually be responsible for the symptoms but this is how most women get labelled as having thrush when in actual fact the thrush is just a bystander as it would have been in 50% of women.

 

Porter

So we’re doing a swab and we’re finding thrush there but that might just be an innocent bystander?

 

Ugwumadu

It’s a red herring most of the time.

 

Porter

So it’s important to get the diagnosis right?

 

Ugwumadu

Exactly.  A lot of women who think that they’ve got thrush didn’t have thrush in the first place but obviously once they nip across to the local pharmacy get anti-thrush medication, particularly the cream, it makes the symptoms go away for a few days and then it comes right back and then they think oh my thrush is back.

 

Porter

So how should we be making the diagnosis, I mean most of these women are being seen by GPs not by specialists like you, is there anything I can do when I see them at the start to make sure the diagnosis is correct?

 

Ugwumadu

I think a thorough history is probably the most important, so for some women who are sufficiently vigilant to sort of relate the attacks of what they call thrush to certain exposures that probably will give the doctor some idea that this may not actually be thrush.  So, for example, the use of perfumed soaps, the use of bath products and some of the products that women use for their hygienic practices, a whole load of women that do have sensitivities to those agents but they don’t know it.

 

Porter

So just to be clear, a local reaction to perhaps a soap, it’s not actually causing thrush it’s mimicking thrush?

 

Ugwumadu

Yes there are two things there.  First of all it mimics thrush, there is no – an individual woman will not be able to make the distinction that these symptoms are due to an allergic reaction compared to these symptoms are due to thrush, that’s one thing.  But even more importantly the sort of proteins that govern that reaction tend to suppress the local immunity in a way that allows thrush to flare up.

 

Porter

Right, so not only is it mimicking but it can actually trigger it as well.  The key message for anyone listening to this is probably at step one it’s confirming that you’ve actually got thrush in the first place?

 

Ugwumadu

That is always the starting point because for most women whatever itches down there, irritates down there, tingles down there is thrush and half the time they will have self-treated themselves and decided that they get recurrent thrush and most times the GPs will buy into it because once they’ve done a sample it comes back showing yeast or whatever and then the yeast gets blamed for this but it’s not necessarily the case.

 

Porter

When a doctor or nurse takes a swab it gets sent off to the local lab for analysis, but what do they look for? And can they differentiate between active thrush and innocent bystanders?

Elizabeth Johnson runs the Public Health England Mycology Reference Laboratory in Bristol.

 

Johnson

We’re looking for budding yeast cells which are little oval cells and the yeast candida albicans, which is the most common cause of vaginal candidiasis, replicate by a mother cell forming a little projection on the side, little oval buds.

 

Porter

So if when you look at the yeast that’s budding does that mean that it’s active and alive effectively?

 

Johnson

It means it’s alive yes, it doesn’t mean it’s necessarily acting invasively.  If we only see a few little budding yeasts then it may be there as part of the natural flora of the human body.  Sometimes instead of a bud forming it will form a little projection, which elongates and forms a much longer strand, particularly when it’s acting invasively and these filaments are known as hyphae.

 

Porter

So these tubules effectively that they’re putting out is a sign that they’re active and causing trouble?

 

Johnson

Yes, the germ tube that it forms, which leads on to produce the hyphae, helps the organism to penetrate tissues and to stick to tissues.

 

Porter

And it’s these branching strands, is that a sign of active….?

 

Johnson

That would be a sign that this was acting invasively.

 

Porter

Elizabeth Johnson.  And yes it is complicated, but the take home message is simple. Just because a swab tests positive for thrush causing candida does not mean you have thrush despite most people thinking it does. If in doubt your doctor or nurse can ask the lab to help differentiate recurrent candida infection from other problems that can mimic it. Or, to put it another way, could your recurrent thrush not be responding to anti-fungal treatment because you have been misdiagnosed? For more advice visit our website.

 

Now new research linking stroke to one of the most common nutritional deficiencies in the UK. Scientists at Imperial College London have shown that a shortage of iron can make blood stickier increasing the risk of stroke. The fact that people with low iron levels – both adults and children – are more likely to have a stroke is not a new discovery in itself, but up until now doctors have struggled to explain the connection. 

 

Dr Claire Shovlin led the study.

 

Shovlin

I was trying to work out why the people who I saw were having their strokes, they didn’t seem to have the normal sorts of risk factors that we would know about and it became clear that there was probably going to be a link with low iron levels.  And this was emerging through the general literature, probably over the last 10, 20 years or so there’s been a steady story of links between people having been short of iron and perhaps having more strokes.  But none of the mechanisms we knew of at the time made sense to me.

 

Porter

So people had spotted that there was some relationship but they didn’t know why.

 

Shovlin

Yes, so there are studies from as far afield as America, the United States and Taiwan, studies in children as well as in adults.  And everybody had been sort of suggesting that the link might be because with having low iron levels people were less able to make haemoglobin, they were anaemic and so they weren’t getting oxygen to the brain properly but that didn’t quite make sense.

 

Porter

Haemoglobin being the protein that carries oxygen round the blood.

 

Shovlin

That’s right, so I’ve always realised there’s a tremendous repository of information in books that have been published long ago that we can’t get by doing our internet searches.  So what I decided to do was to consult a back catalogue of books from a scientific establishment that always captured the state of the art in a particular point in time and found there’d been a symposium back in 1976 on iron metabolism, so I ordered the proceedings of that symposium.  When the book arrived I opened it up and in the book there was a chapter that said it was entitled Iron Metabolism and Platelets, I can’t begin to tell you how exciting that was because we now know that platelets are the key cells in terms of causing strokes because we prevent strokes by dampening down the platelets, by giving aspirin and other such drugs.  And what these authors had shown was that if people were short of iron their platelets were stickier and that clearly, even though nobody had spotted it for nearly 40 years, could be the answer that we were looking for.

 

Porter

So here’s something that’s been collecting dust in the archives for nearly four decades, how does it relate to the research that you’re doing now?

 

Shovlin

Well the first thing we had to do was obviously prove the link, the study had shown some extra stickiness of blood in patients who were short of iron, so we had to replicate those findings and that I did in conjunction with my haematology colleagues at Hammersmith Hospital.

 

Porter

Of course the other big question is what are we going to do about it?  If this link does indeed prove as important as you think it is do we know that giving iron reverses that stickiness?

 

Shovlin

No, no, no, so there’s two important things.  First of all that’s a study that has to be done and it will take several years at least for that to be achieved.  But the other thing is we shouldn’t just be going around giving extra iron because having too much iron can be as harmful as having too little, we need just the right amount.  So people shouldn’t be going and getting iron tablets trying to put something right.  The sensible way forward is to have a healthy diet.

 

Porter

Claire Shovlin from the National Heart and Lung Institute at Imperial College. And her findings, prompted by that 40 year old research, have, judging by the response to her paper, rung bells with quite a few other doctors puzzled by the link between stroke and iron deficiency. Isn’t hindsight a wonderful thing?  And there is a link to Dr Shovlin’s research on our website.

 

Next week I will be looking at the latest advances in surgery, a keyhole technique that leaves no visible scar.  And while what we eat can definitely affect our health, how about when we eat? I will be finding out if there is any truth in popular belief that eating late is bad for your waistline.

 

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