Low Carbohydrate Nutrition – the World is Not Flat
Low Carbohydrate Nutrition – the World is Not Flat
Introduction
Once upon a time everyone knew that the world was flat. After we discovered that this was incorrect, everyone still knew that the sun and other planets orbited the earth. Well, er, no, actually, we were wrong.
Science is fantastic, but we always gain new information. Perhaps it is now time to question whether our fast-held beliefs in ‘correct’ nutrition are actually correct. There is growing acceptance in the wider public that low-carbohydrate diets promote weight-loss. This phenomenon is dismissed by many in the academic area as being pop-cultural nonsense... “it’s all about energy in versus energy out”, they cry. But can low-carbohydrate diets be dismissed so lightly?
That ‘a calorie is a calorie’ was once thought of as a universal truth. Several researchers (Volek, et al., 2004; Manninen, 2006) challenge this assumption and now present compelling research to the contrary. It may now be time to accept that ‘a calorie is not just a calorie.’
This controversy is the subject of this essay. It will examine some of the growing literature researching low-carbohydrate diets and their effects on the human body. It will address the science behind low-carbohydrate diets and why they appear to actually work so well. It will examine the message being given to the public and question the validity of this.
Ultimately the objective of this essay is to present the scientific other side of the story about low carbohydrate nutrition choices.
Definitions
This essay will define diets that are between 50g-150g/day of carbohydrate as ‘low carbohydrate diets’ (LCD). Diets that include carbohydrate above 50g/day do not usually cause measureable ketone bodies to be present in urine (Westman, et al., 2007). This essay will define diets that are below 50g/day of carbohydrate as ‘low carbohydrate ketogenic diets’ (LCKD). These definitions are taken from the review article by Westman et al (2007).
Literature Review
In the current (September 2009) issue of North and South magazine, there is an article about fat people (Wayne, 2009). This article, while not from any scientific journal, interviews scientists undertaking cutting-edge research about gene expression and the role this plays on adiposity. This article is not specifically about low carbohydrate diets, but it does present to a very receptive public the view that optimal nutrition and nutritional choices are not as cut and dried as they have been led to believe.
There is a large body of research pertaining to low carbohydrate diets and nutrition.
Westman et al (2007) prepared a review article examining research on LCD and LCKD from 2002 through to 2006. They found that LCDs improve glycemic control and insulin resistance in both healthy people and people with type 2 diabetes. When no set calorie intake is specified, a reduction in carbohydrate results in a voluntary and spontaneous reduction in total calories consumed. In controlled trials for weight loss they found that LCD diets achieves weight loss, and improves the blood lipid profile of participants. They question if dietary carbohydrate is actually an essential nutrient, and if dietary fat actually causes heart disease. Similar finding are reported from Volek et al (2004), in the discussion portion of their research paper.
Mozaffarian et al (2004) researched the effect of dietary fat, carbohydrate and the progression of atherosclerosis in postmenopausal women. They only investigated postmenopausal women (235 subjects) with established coronary heart disease, so their findings cannot be applied to other populations. However they found some surprising results. They found that dietary intake of saturated fat actually slowed the progression of atherosclerosis. They also found that when carbohydrate intake increased (with a corresponding decrease in saturated and monounsaturated fat) the rate of progression of atherosclerosis increased. This study found that when total fat, especially monounsaturated and saturated fats, were lowered in the diet (usually replaced with more carbohydrates), risk factors for CHD increased in these women.
Volek et al (2004) compared the effects of LCKD and low fat (LF) diets for weight loss. The LCKD had a percentage ratio of carbs:fat:protein of 9:63:28, and the LF diet 58:22:20. This makes it a very low carbohydrate diet compared with some other studies (Westman, et al., 2007). They found that reductions in body mass, fat mass and trunk fat mass in the LCKD group was significantly greater than in the LF diet for the male subjects, and slightly greater for female subjects.
Questions have been raised about the ability of LCKDs to preserve lean muscle mass during dieting. Manninen (2006) provides a commentary on this issue. In the studies he reviewed, he found that contrary to the idea that muscle mass is lost during LCKDs, muscle mass is in fact preserved. Greater weight is lost through fat, and in some cases lean muscle mass was gained.
Another interesting study by Jonsson et al (2009) compared the effects of a ‘paleolithic’ (paleo) diet and a diabetic diet. The paleo diet is based on meat, fish, vegetables, fruits, eggs and nuts. It excludes grains, legumes, salt, sugar, refined fats and dairy. The diabetic diet was designed in line with current dietary guidelines for diabetics. The average daily intake of carbohydrate from the paleo diet was 125g compared with 196g in the diabetic diet. The intake of food was not restricted in either diet; however those following the paleo diet consumed less calories. The findings of this study were that the paleo diet caused blood lipid profiles to improve, diastolic BP decreased and weight and waist circumference decreased compared to the diabetes diet. Glucose and insulin levels declined during the paleo diet. While this study is not strictly a comparison of low carbohydrate diets, it does illustrate that more favourable outcomes can be achieved when using ‘non-conventional’ nutrition ideas than when using conventional guidelines.
These studies demonstrate that there is strong evidence that low-carbohydrate diets can provide benefits to many people in our societies. Those who may specifically benefit from their use are diabetics, those with CHD risk-factors, those with insulin resistance and the obese and overweight (Westman, et al., 2007). While LCKD are not appropriate for long-term use, they appear to work extremely well for rapid weight-loss (especially fat loss) and improvement of blood lipid profiles (Westman, et al., 2007; Volek, et al., 2004; Manninen, 2006).
Further research is required around the issue of more life-style based LCDs, such as the paleo diet investigated by Jonsson et al (2009). This research is most interesting in that it compared a grain-free diet to a conventional diabetic diet. It would be interesting to see if the more sustainable intake of 125g/day of carbohydrate in combination with a grain-free diet works in the long-term to prevent lifestyle related disease.
It is clear that low-carbohydrate diets should not be dismissed out of hand by those working with people to improve their lifestyles through nutrition.
Why Low Carbohydrate Diets Work
This section will examine the likely mechanisms through which LCDs work in the body.
The exact science of how LCDs and LCKDs work is still somewhat controversial in the literature.
There appears to be an effect of spontaneous reduction of energy intake when people switch to LCDs. This effect is most notable in LCKD. It has been shown that an increase in ketone levels inhibits appetite (Volek, et al., 2004). Protein is also usually increased in LCKDs, and protein is known to reduce appetite when consumed in meals (Westman, et al., 2007). The presence of ketone bodies also appears to assist in preventing the breakdown of muscle tissue (Manninen, 2006).
The preservation of muscle mass seen in the studies (Westman, et al., 2007; Manninen, 2006) also suggests that LCDs are superior to low-fat diets in maintaining lean body tissue. The mechanisms for this are suggested to be the presence of ketone bodies (as mentioned above), increased growth hormone production and increased dietary protein intake. Growth hormone production increases when low blood sugar levels are present (Manninen, 2006) although studies have not confirmed that growth hormone levels always rise when LCDs are used (Manninen, 2006). The availability of increased amounts of dietary protein as almost always found in LCDs may increase the synthesis of protein by the increase of systemic amino acid availability.
Protein intakes on LCDs and especially in LCKDs tend to be higher than in conventional diets. It has been previously thought that only minimum dietary protein is needed in order to fulfil protein requirements, and any excess is simply wasteful (Layman, 2009). Protein has been considered an expensive and wasteful nutrient source. However this perception are based on animal feeding protocols, whereby all nutrients are calculated on a cost/benefits analysis, wanting maximum growth for minimum price, regardless of the long-term benefits of greater quantities of protein (Layman, 2009). Current dietary guidelines are based on minimums, not on optimal protein levels. New studies are being undertaken that look at dietary protein and the role it plays in amino acid metabolism, thermogensis and gylcemic control, rather than just looking at nitrogen balance (Layman, 2009).
LCDs tend to also be low GI, thus acting to prevent inconsistencies in blood glucose. This effect can prevent hypoglycaemia from occurring, assisting with appetite regulation (Volek, et al., 2004).
LCDs have a greater percentage of their calories coming from protein and fat (Westman, et al., 2007). The advantages of LCDs over low-fat diets may come from the greater thermogenic effect of protein, the ability to excrete some excess energy as ketones via sweat, urine and defecation, and the demand of protein turnover for gluconeogenesis.
Studies are required that look at LCDs and LCKDs from carefully controlled feeding and metabolic studies, with large numbers of subjects, encompassing comprehensive physiological measurements to identify the mechanisms behind the effects that LCDs have on the body (Volek, et al., 2004).
Awareness and Campaigns
There is much public awareness of lifestyle diseases, and some rather confused public awareness about LCDs. However the public awareness of LCDs mostly comes from magazines written by journalists who are not scientists. The public appears to be receptive to LCDs, most likely because they actually work, and work better than traditional low fat diets.
There are many official organisations that promote health to the public, such as the National Heart Foundation and Diabetes New Zealand. However these organisations do not generally promote LCDs as good options, and are firmly on the ‘fat is bad, saturated fat causes heart disease etc etc’ bandwagon (National Heart Foundation, 2009; Diabetes NZ, 2008). The assumptions around carbohydrates, fats and protein must be addressed, because nutritional science does not have a conclusive answer to the questions now being raised about the role of carbohydrates, fat and protein in the diet. These organisations lead the public to believe that nutritional science is set in stone and that they must eat according to the official recommendations or else face crippling lifestyle diseases.
While these organisations are surely operating on good faith, they are unfortunately operating on simplistic and outdated science, as demonstrated above in this essay.
Conclusion
It can be safely said that LCDs and LCKDs work very well in the capacity of improving blood lipid profiles, increasing insulin sensitivity and weight-loss whilst preserving lean muscle mass (Manninen, 2006; Jonsson, et al., 2009; Westman, et al., 2007; Volek, et al., 2004). LCKDs are not viable as lifestyle diets due to the very low carbohydrate requirement, which excludes almost all fruit and vegetables. As a short-term treatment for the above mentioned conditions they seem to have a place and could very well be recommended.
LCDs in the ranges of 100-150g/day of carbohydrate seem viable as long-term lifestyle options; however research on their long-term viability is lacking (Jonsson, et al., 2009).
There is much more to optimal nutrition than most people have been led to believe. Science is not conclusive on several important matters, especially on the role of carbohydrate and its contribution to current lifestyle disease (Westman, et al., 2007). It is time for the academic world to accept that science is a process that does not have an end. New information is constantly being discovered that challenges commonly-held belief systems.
Just as we now know that the world is not flat, we are now beginning to understand that we have only just begun to scrape the surface of nutritional science. Perhaps it is now time to examine our love-affair with carbohydrates in light of our rapidly declining health, and question if eating they way we are told is really good for us.
Bibliography
Diabetes NZ. (2008). Food and Nutrition. Retrieved September 8, 2009, from Diabetes NZ: http://www.diabetes.org.nz/food_and_nutrition
Jonsson, T., Granfeldt, Y., Ahren, B., Branell, U.-C., Palsson, G., Hansson, A., et al. (2009). Beneficial effects of a paleolithic diet on cardiovascular risk factors in type 2 diabete: A randomized cross-over pilot study. Cardiovascular Diabetology, 8(35). doi: 10.1186/1475-2840-8-35
Layman, D. (2009). Dietary Guidelines should reflect new understandings about adult. Nutrition and Metabolism , 6(12). doi:10.1186/1743-7075-6-12
Manninen, A. (2006). Very-low-carbohydrate diets and presevation of muscle mass. Nutrition and Metabolism , 3(9). doi: 10.1186/1743-7075-3-9
Mozaffarian, D., Rimm, E., & Herrington, D. (2004). Dietary fats, carbohydrate, and progression of coronary atherosclerosis in postmenopausal women. The American Journal of Clinical Nutrition , 80, 1175-1184.
National Heart Foundation. (n.d.). National Heart Foundation. Retrieved September 8, 2009, from Eating and Nutrition: http://www.nhf.org.nz/index.asp?pageID=2145828145
Volek, J., Sharman, M., Gomez, A. J., Rubin, M., Watson, G., Sokmen, B., et al. (2004). Comparison of energy-restricted very low-carbohydrate and low-fat diets on weight loss and body composition in overweight men and women. Nutrition and Metabolism , 1(13). doi 10.1186/1743-7075-1-13
Wayne, J. (2009, September). The article every skinny person should read. North and South , pp. 31-37.
Westman, E., Feinman, R., Mavropoulos, J., Vernon, M., Volek, J., Wortman, J., et al. (2007). Low-carbohydrate nutrition and metabolism. American Journal of Clinical Nutrition , 86, 276-284.
© Samantha Gentry, 2009, all rights reserved, article cannot be distributed or used without written permission.
Introduction
Once upon a time everyone knew that the world was flat. After we discovered that this was incorrect, everyone still knew that the sun and other planets orbited the earth. Well, er, no, actually, we were wrong.
Science is fantastic, but we always gain new information. Perhaps it is now time to question whether our fast-held beliefs in ‘correct’ nutrition are actually correct. There is growing acceptance in the wider public that low-carbohydrate diets promote weight-loss. This phenomenon is dismissed by many in the academic area as being pop-cultural nonsense... “it’s all about energy in versus energy out”, they cry. But can low-carbohydrate diets be dismissed so lightly?
That ‘a calorie is a calorie’ was once thought of as a universal truth. Several researchers (Volek, et al., 2004; Manninen, 2006) challenge this assumption and now present compelling research to the contrary. It may now be time to accept that ‘a calorie is not just a calorie.’
This controversy is the subject of this essay. It will examine some of the growing literature researching low-carbohydrate diets and their effects on the human body. It will address the science behind low-carbohydrate diets and why they appear to actually work so well. It will examine the message being given to the public and question the validity of this.
Ultimately the objective of this essay is to present the scientific other side of the story about low carbohydrate nutrition choices.
Definitions
This essay will define diets that are between 50g-150g/day of carbohydrate as ‘low carbohydrate diets’ (LCD). Diets that include carbohydrate above 50g/day do not usually cause measureable ketone bodies to be present in urine (Westman, et al., 2007). This essay will define diets that are below 50g/day of carbohydrate as ‘low carbohydrate ketogenic diets’ (LCKD). These definitions are taken from the review article by Westman et al (2007).
Literature Review
In the current (September 2009) issue of North and South magazine, there is an article about fat people (Wayne, 2009). This article, while not from any scientific journal, interviews scientists undertaking cutting-edge research about gene expression and the role this plays on adiposity. This article is not specifically about low carbohydrate diets, but it does present to a very receptive public the view that optimal nutrition and nutritional choices are not as cut and dried as they have been led to believe.
There is a large body of research pertaining to low carbohydrate diets and nutrition.
Westman et al (2007) prepared a review article examining research on LCD and LCKD from 2002 through to 2006. They found that LCDs improve glycemic control and insulin resistance in both healthy people and people with type 2 diabetes. When no set calorie intake is specified, a reduction in carbohydrate results in a voluntary and spontaneous reduction in total calories consumed. In controlled trials for weight loss they found that LCD diets achieves weight loss, and improves the blood lipid profile of participants. They question if dietary carbohydrate is actually an essential nutrient, and if dietary fat actually causes heart disease. Similar finding are reported from Volek et al (2004), in the discussion portion of their research paper.
Mozaffarian et al (2004) researched the effect of dietary fat, carbohydrate and the progression of atherosclerosis in postmenopausal women. They only investigated postmenopausal women (235 subjects) with established coronary heart disease, so their findings cannot be applied to other populations. However they found some surprising results. They found that dietary intake of saturated fat actually slowed the progression of atherosclerosis. They also found that when carbohydrate intake increased (with a corresponding decrease in saturated and monounsaturated fat) the rate of progression of atherosclerosis increased. This study found that when total fat, especially monounsaturated and saturated fats, were lowered in the diet (usually replaced with more carbohydrates), risk factors for CHD increased in these women.
Volek et al (2004) compared the effects of LCKD and low fat (LF) diets for weight loss. The LCKD had a percentage ratio of carbs:fat:protein of 9:63:28, and the LF diet 58:22:20. This makes it a very low carbohydrate diet compared with some other studies (Westman, et al., 2007). They found that reductions in body mass, fat mass and trunk fat mass in the LCKD group was significantly greater than in the LF diet for the male subjects, and slightly greater for female subjects.
Questions have been raised about the ability of LCKDs to preserve lean muscle mass during dieting. Manninen (2006) provides a commentary on this issue. In the studies he reviewed, he found that contrary to the idea that muscle mass is lost during LCKDs, muscle mass is in fact preserved. Greater weight is lost through fat, and in some cases lean muscle mass was gained.
Another interesting study by Jonsson et al (2009) compared the effects of a ‘paleolithic’ (paleo) diet and a diabetic diet. The paleo diet is based on meat, fish, vegetables, fruits, eggs and nuts. It excludes grains, legumes, salt, sugar, refined fats and dairy. The diabetic diet was designed in line with current dietary guidelines for diabetics. The average daily intake of carbohydrate from the paleo diet was 125g compared with 196g in the diabetic diet. The intake of food was not restricted in either diet; however those following the paleo diet consumed less calories. The findings of this study were that the paleo diet caused blood lipid profiles to improve, diastolic BP decreased and weight and waist circumference decreased compared to the diabetes diet. Glucose and insulin levels declined during the paleo diet. While this study is not strictly a comparison of low carbohydrate diets, it does illustrate that more favourable outcomes can be achieved when using ‘non-conventional’ nutrition ideas than when using conventional guidelines.
These studies demonstrate that there is strong evidence that low-carbohydrate diets can provide benefits to many people in our societies. Those who may specifically benefit from their use are diabetics, those with CHD risk-factors, those with insulin resistance and the obese and overweight (Westman, et al., 2007). While LCKD are not appropriate for long-term use, they appear to work extremely well for rapid weight-loss (especially fat loss) and improvement of blood lipid profiles (Westman, et al., 2007; Volek, et al., 2004; Manninen, 2006).
Further research is required around the issue of more life-style based LCDs, such as the paleo diet investigated by Jonsson et al (2009). This research is most interesting in that it compared a grain-free diet to a conventional diabetic diet. It would be interesting to see if the more sustainable intake of 125g/day of carbohydrate in combination with a grain-free diet works in the long-term to prevent lifestyle related disease.
It is clear that low-carbohydrate diets should not be dismissed out of hand by those working with people to improve their lifestyles through nutrition.
Why Low Carbohydrate Diets Work
This section will examine the likely mechanisms through which LCDs work in the body.
The exact science of how LCDs and LCKDs work is still somewhat controversial in the literature.
There appears to be an effect of spontaneous reduction of energy intake when people switch to LCDs. This effect is most notable in LCKD. It has been shown that an increase in ketone levels inhibits appetite (Volek, et al., 2004). Protein is also usually increased in LCKDs, and protein is known to reduce appetite when consumed in meals (Westman, et al., 2007). The presence of ketone bodies also appears to assist in preventing the breakdown of muscle tissue (Manninen, 2006).
The preservation of muscle mass seen in the studies (Westman, et al., 2007; Manninen, 2006) also suggests that LCDs are superior to low-fat diets in maintaining lean body tissue. The mechanisms for this are suggested to be the presence of ketone bodies (as mentioned above), increased growth hormone production and increased dietary protein intake. Growth hormone production increases when low blood sugar levels are present (Manninen, 2006) although studies have not confirmed that growth hormone levels always rise when LCDs are used (Manninen, 2006). The availability of increased amounts of dietary protein as almost always found in LCDs may increase the synthesis of protein by the increase of systemic amino acid availability.
Protein intakes on LCDs and especially in LCKDs tend to be higher than in conventional diets. It has been previously thought that only minimum dietary protein is needed in order to fulfil protein requirements, and any excess is simply wasteful (Layman, 2009). Protein has been considered an expensive and wasteful nutrient source. However this perception are based on animal feeding protocols, whereby all nutrients are calculated on a cost/benefits analysis, wanting maximum growth for minimum price, regardless of the long-term benefits of greater quantities of protein (Layman, 2009). Current dietary guidelines are based on minimums, not on optimal protein levels. New studies are being undertaken that look at dietary protein and the role it plays in amino acid metabolism, thermogensis and gylcemic control, rather than just looking at nitrogen balance (Layman, 2009).
LCDs tend to also be low GI, thus acting to prevent inconsistencies in blood glucose. This effect can prevent hypoglycaemia from occurring, assisting with appetite regulation (Volek, et al., 2004).
LCDs have a greater percentage of their calories coming from protein and fat (Westman, et al., 2007). The advantages of LCDs over low-fat diets may come from the greater thermogenic effect of protein, the ability to excrete some excess energy as ketones via sweat, urine and defecation, and the demand of protein turnover for gluconeogenesis.
Studies are required that look at LCDs and LCKDs from carefully controlled feeding and metabolic studies, with large numbers of subjects, encompassing comprehensive physiological measurements to identify the mechanisms behind the effects that LCDs have on the body (Volek, et al., 2004).
Awareness and Campaigns
There is much public awareness of lifestyle diseases, and some rather confused public awareness about LCDs. However the public awareness of LCDs mostly comes from magazines written by journalists who are not scientists. The public appears to be receptive to LCDs, most likely because they actually work, and work better than traditional low fat diets.
There are many official organisations that promote health to the public, such as the National Heart Foundation and Diabetes New Zealand. However these organisations do not generally promote LCDs as good options, and are firmly on the ‘fat is bad, saturated fat causes heart disease etc etc’ bandwagon (National Heart Foundation, 2009; Diabetes NZ, 2008). The assumptions around carbohydrates, fats and protein must be addressed, because nutritional science does not have a conclusive answer to the questions now being raised about the role of carbohydrates, fat and protein in the diet. These organisations lead the public to believe that nutritional science is set in stone and that they must eat according to the official recommendations or else face crippling lifestyle diseases.
While these organisations are surely operating on good faith, they are unfortunately operating on simplistic and outdated science, as demonstrated above in this essay.
Conclusion
It can be safely said that LCDs and LCKDs work very well in the capacity of improving blood lipid profiles, increasing insulin sensitivity and weight-loss whilst preserving lean muscle mass (Manninen, 2006; Jonsson, et al., 2009; Westman, et al., 2007; Volek, et al., 2004). LCKDs are not viable as lifestyle diets due to the very low carbohydrate requirement, which excludes almost all fruit and vegetables. As a short-term treatment for the above mentioned conditions they seem to have a place and could very well be recommended.
LCDs in the ranges of 100-150g/day of carbohydrate seem viable as long-term lifestyle options; however research on their long-term viability is lacking (Jonsson, et al., 2009).
There is much more to optimal nutrition than most people have been led to believe. Science is not conclusive on several important matters, especially on the role of carbohydrate and its contribution to current lifestyle disease (Westman, et al., 2007). It is time for the academic world to accept that science is a process that does not have an end. New information is constantly being discovered that challenges commonly-held belief systems.
Just as we now know that the world is not flat, we are now beginning to understand that we have only just begun to scrape the surface of nutritional science. Perhaps it is now time to examine our love-affair with carbohydrates in light of our rapidly declining health, and question if eating they way we are told is really good for us.
Bibliography
Diabetes NZ. (2008). Food and Nutrition. Retrieved September 8, 2009, from Diabetes NZ: http://www.diabetes.org.nz/food_and_nutrition
Jonsson, T., Granfeldt, Y., Ahren, B., Branell, U.-C., Palsson, G., Hansson, A., et al. (2009). Beneficial effects of a paleolithic diet on cardiovascular risk factors in type 2 diabete: A randomized cross-over pilot study. Cardiovascular Diabetology, 8(35). doi: 10.1186/1475-2840-8-35
Layman, D. (2009). Dietary Guidelines should reflect new understandings about adult. Nutrition and Metabolism , 6(12). doi:10.1186/1743-7075-6-12
Manninen, A. (2006). Very-low-carbohydrate diets and presevation of muscle mass. Nutrition and Metabolism , 3(9). doi: 10.1186/1743-7075-3-9
Mozaffarian, D., Rimm, E., & Herrington, D. (2004). Dietary fats, carbohydrate, and progression of coronary atherosclerosis in postmenopausal women. The American Journal of Clinical Nutrition , 80, 1175-1184.
National Heart Foundation. (n.d.). National Heart Foundation. Retrieved September 8, 2009, from Eating and Nutrition: http://www.nhf.org.nz/index.asp?pageID=2145828145
Volek, J., Sharman, M., Gomez, A. J., Rubin, M., Watson, G., Sokmen, B., et al. (2004). Comparison of energy-restricted very low-carbohydrate and low-fat diets on weight loss and body composition in overweight men and women. Nutrition and Metabolism , 1(13). doi 10.1186/1743-7075-1-13
Wayne, J. (2009, September). The article every skinny person should read. North and South , pp. 31-37.
Westman, E., Feinman, R., Mavropoulos, J., Vernon, M., Volek, J., Wortman, J., et al. (2007). Low-carbohydrate nutrition and metabolism. American Journal of Clinical Nutrition , 86, 276-284.
© Samantha Gentry, 2009, all rights reserved, article cannot be distributed or used without written permission.
Comments