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Title: WHY ARE WE SO fat?
By: Newman, Cathy, National Geographic, 00279358, Aug2004, Vol. 206, Issue 2Database: Academic Search Complete
WHY ARE WE SO fat?
Americans enjoy one of the most luxurious lifestyles on Earth: Our food is plentiful. Our work is
automated. Our leisure is effortless. And it's killing us
Finally, after two decades of trying and failing to lose weight with (you name it) Weight Watchers, NutriSystem,
a nutritionist, a personal trainer--not to mention the therapist who derided her for being fat--it has come down to
this: Linda Hay is sitting in an examining room at the Virginia Commonwealth University Medical Center in
Richmond with Harvey Sugerman, the surgeon who will perform a gastric bypass operation on her in two
Gastric bypass is major surgery that shrinks the stomach's capacity from wine bottle to shot-glass size andreconfigures the small intestine. Most patients lose about two-thirds of their excess weight within a year ofsurgery. "Gastric bypass surgery is a tool," Sugerman says. "It reduces the stomach. The patient can't eat asmuch. In most instances, if a bypass patient eats sugar or fatty foods, it provokes a dumping syndrome thatcauses flushing, nausea, sweating." You could say it's almost like Antabuse for the obese. Even so, theoperation fails in 15 percent of cases. Some patients can subvert the surgery. They overeat by snackingcontinuously.
And the surgery is risky. The list of possible complications includes blood clots in the lung, pneumonia,infection, leakage from the reshaped intestinal tract, and--in one out of a hundred cases--death.
Hay, 39, is five feet five and weighs 314 pounds; she is morbidly obese, which makes her a candidate for thesurgery. Her managerial level job in the human resources department of a financial company demands tact,efficiency, and organization--qualities she exudes. She has a dose circle of friends who would do anything forher, a clear sense of who she is, and few illusions of who she is not. She dresses stylishly, has long blond hairswept back by a headband, a classic oval face, and fair complexion. But she is--let's face it--huge.
When I ask about her decision to have surgery, she describes the humiliation of asking for a seat-belt extenderon a plane; her reluctance to go to movies because the seats are too narrow; the time she signed up for adating service, put down as body type "a few extra pounds," got a few responses, and then, opting for honesty,changed it to "large." This time she got none. She lists health problems associated with her weight: high bloodpressure, varicose veins, pain and swelling in her feet and ankles, depression. "You take control for a while,"she says, "then you fail yet again, and you're more depressed than ever."
Linda Hay has considered the risks and decided to have surgery. Nonetheless she is anxious. "No one at theoffice knows I'm going to do this," she confesses. "Someone said, 'Have a good week,' and my mind keptracing to the worst-case scenario.What if?"
It seems, I say, turning to Sugerman, that this is surgery for the desperate.
He nods. "Surgery is a drastic solution," he says, "but then obesity is a drastic problem."
It's become a far too familiar headline: Today one out of three Americans is obese, twice as many as three
decades ago, and enough for the Centers for Disease Control and Prevention to declare obesity an epidemic.
More disturbing are statistics relating to children: 15 percent of children and teens are overweight, a nearlythreefold jump from 1980. Obesity is defined by your body mass index, or BMI, a fancy calculation in whichyour weight is divided by your height. (You can find yours by consulting the chart at left.) If it's 25, you'reoverweight. If it's 30, you're obese. Over 40, you're morbidly obese.
The broadening of America is everywhere you look, or sit. The Puget Sound ferries in Washington haveincreased the width of their seats from 18 to 20 inches to allow squeeze-in room for people with biggerbottoms. In Colorado an ambulance company has retrofitted its vehicles with a winch and a plus-sizecompartment to handle patients weighing up to half a ton. Even the Final Resting Place has had toaccommodate our growing girth. An Indiana manufacturer of caskets now offers a double-oversize model--38inches wide, compared with a standard 24 inches.
Being overweight is associated with 400,000 deaths a year and an increased risk of heart disease, type 2diabetes, and colon, breast, and endometrial cancers. Most poignant is the psychological pain of thosestigmatized by obesity. In one study at Michigan State University, undergraduates said they would be moreinclined to marry an embezzler or cocaine user than an obese person.
How did Americans get so fat? Where did We go wrong? It depends on who you ask. I asked Robert Atkinslast year, a month before the purveyor of today's hottest diet died from a head injury suffered in a fall. He sat inguru-like serenity behind a black leather-top desk in his Manhattan office. His expression remained impassive,with an occasional lapse into wryness. He seemed to float, as if hovering above the storm of contention his dietprovokes.
"We went wrong by allowing the American Medical Association and the United States Department ofAgriculture to say: 'You've got to go on a low-fat diet.' They failed to take into account that when people do that,they increase their carbohydrates."
For breakfast that morning, Atkins (who said he was six feet tall, 189 pounds) had eaten asausage-and-cheese omelet, two ounces of tomato juice, and tea without sugar. His wonderland diet bookssay yes to bacon, eggs, and lobster dripping with butter and tell readers to lay off the bread and fruit. Slashingcarbohydrates and sticking to protein and fat, Atkins claimed, prompts the body to burn fat through a metabolicprocess known as ketosis. Another purported advantage: Remaining in near ketosis makes it easier for peopleto control hunger.
In the post-Atkins era, pork rinds have become a snack sensation, egg consumption has risen, and "doingAtkins" is now synonymous with adhering to a high-protein, low-carb diet. Since 1972 his Diet Revolution andthe updated version published in 1992 have sold 18 million copies. The latest edition has been translated into25 languages. But not, as yet, in Italian. "They didn't want to give up their pasta," he said.
To be sure, Americans are filling up on carbohydrates like pasta, potatoes, and bread. In the early '70s we ate136 pounds of flour and cereal products per capita, and now it's 200 pounds. Most of those products are highlyprocessed grains, like white bread, that are low in fiber and absorbed into the bloodstream more quickly thanhigh-fiber whole grains. Such foods have a high glycemic index, which means they prompt a sharp spike inglucose and trigger a corresponding spike in insulin production from the pancreas. Atkins and other advocatesof low-carbohydrate diets claim that surges in insulin cause blood sugar to plummet, which in turn createscravings for more carbs--and on and on in a spiraling raise-you-one war between glucose and insulin. Thetrouble is, research doesn't back that up: Low blood sugar hasn't been directly linked to hunger. And unlessyou have diabetes, blood sugar remains generally stable anyway.
Not everyone has converted to the Atkins gospel. Dean Ornish, director of the Preventive Medicine ResearchInstitute in Sausalito, California, is one of the original advocates of a low-fat diet as a way to lower heartdisease risk. He contends that following Atkins's diet might help you lose weight in the short run, but at the costof "mortgaging your health." He cites an increased risk of breast cancer, prostate cancer, and heart disease,not to mention headaches, constipation, and even bad breath as the price you pay for the Atkins diet.
"Atkins is right about us eating too many simple carbohydrates," he says. But Ornish argues the solution is toreplace them with complex carbohydrates like whole grains and vegetables, not more fat. "Atkins gets intotrouble when he says to eat bacon and go into ketosis. It's a toxic state. Look, I'd love to tell people it's OK toeat bacon and sausage, but it's not. You can lose weight in ways that aren't good for you. Smoking causes youto lose weight, as do amphetamines. But it's not just about losing weight, it's losing weight in a way that ishelpful. There are no long-term studies to support this diet."
As a closing question for Atkins, I had asked him how he wanted to be remembered. "As a person whochanged mainstream medicine's approach," he replied. "I hope I live long enough to see that." A month afterhis death, the New England Journal of Medicine reported that in the short run, people on the Atkins diet didlose more weight than those on a low-fat diet, and there was no real difference in cholesterol between the twogroups. The catch: Those on Atkins started regaining weight after six months, and by year's end were on parwith the comparison group. The jury is still out on the diet's long-term effects, but the National Institutes ofHealth is funding a five-year study that may render a verdict.
Even so, not even Atkins's death has silenced the critics. "I want to know why he didn't have himself autopsied,so we could see for ourselves what his coronary arteries looked like," one nutrition expert hissed when Ibroached the subject of Atkins's death. "That's what a real scientist would have done."
If even the experts can't agree which diet is best, who are we supposed to believe?
"Me, of course," says Marion Nestle, professor of nutrition, food studies, and public health at New YorkUniversity. "Beyond that, how about using some common sense? It's a simple matter of eating fewer calories.
But nobody wants to talk about calories because doing so does not sell books." She's right. The governmentrecommends 1,600 calories a day for the average sedentary woman and 2,200 for men. In 2000 our reportedper capita daily calorie consumption was 1,877 for women and 2,618 for men-roughly 300 calories more thanwe need.
So in one sense, the obesity crisis is the result of simple math. It's a calories in, calories out calculation. TheFirst Law of Fat says that anything you eat beyond your immediate need for energy, from avocados to ziti,converts to fat. "A calorie is a calorie is a calorie," says Lawrence Cheskin, director of the Johns HopkinsWeight Management Center, whether it comes from fat, protein, or carbohydrate. Cheskin, who is six foot oneand weighs 160 pounds, has never had a weight problem himself. "Who said life is fair?" he observes.
The Second Law of Fat: The line between being in and out of energy balance is slight. Suppose you consumea mere 5 percent over a 2,000-calorie-a-day average. "That's just one hundred calories; it's a glass of applejuice," says Rudolph Leibel, head of molecular genetics at Columbia University College of Physicians andSurgeons. "But those few extra calories can mean a huge weight gain." Since one pound of body weight isroughly equivalent to 3,500 calories, that glass of juice adds up to an extra 10 pounds over a year.
Alternatively, you'd gain 10 pounds if, due to a more sedentary lifestyle--driving instead of walking, taking theescalator instead of the stairs--you started burning 100 fewer calories a day.
"We know people get fat by overeating slightly more than they burn, but we don't know why they do it," Leibelsays. "I'm convinced our overeating is not willful or the result of a deranged upbringing. It's the genes talking,but it's a very complicated language. Genetics are everything."
In the 1960s James V. Neel, a geneticist at the University of Michigan, listened in on one genetic conversation.
In his "thrifty gene" hypothesis, Neel suggested that some of us inherited genes that make us exceptionallyefficient in our intake and use of calories. Our bodies are good at converting food into fat and then hanging onto it. This trait may have helped our ancestors survive when calories were few and far between, Neelspeculated.
But fast-forward to the 21st century, when calorie supply isn't a problem, and genes that favor gaining weighthave outlived their usefulness. Evolution betrays us. We store fat for the famine that never comes. "If weunderstood the genetics well enough," says Anna Mae Diehl, a professor of medicine at Johns Hopkins Schoolof Medicine, "we could fingerprint people when they are born and say: Ah, good genes. Lucky you. You can eatwhatever you want. Or: Uh-oh. Poor kid. Better never have a doughnut."
A team led by Jeff Friedman at Rockefeller University discovered a piece of the genetic puzzle in 1994. Instudies of obese mice, the scientists identified a gene that tells the body how to make leptin, a hormone thatdecreases appetite. Leptin, produced in the fat cell itself, turned out to be part of a thermostat-like system thatmaintains weight at a constant level. Think of it as a watchdog guarding against starvation by monitoring bodyfat. It doesn't wait for you to become skinny; it acts within a few days to correct any perceived imbalance. Loseweight and leptin levels fall, prompting you to eat more and gain back the weight. Put on some extra poundsand leptin goes up; you eat less. It's part of an intricate biochemical and neurological circuitry that flashessignals on and off like a sailor's semaphore: EAT! DON'T EAT! EAT!
So if we take enough leptin, we can all fit into our high school prom outfits? It didn't turn out that way. Injectingleptin into people with a rare congenital inability to produce it does cause them to lose weight, but it wouldn't do
much for the rest of us. In clinical trials, what worked in mice didn't always translate to humans.
The discovery of leptin and a number of other promising hormones has not yet produced a miracle drug. Butgenetic research is providing clues about why some people are more likely to get fat than others. We tend toassume that people who overeat simply lack willpower. What seems increasingly clear, however, is that thedrive to overeat has strong biological underpinnings. People who are genetically susceptible to obesity don'tnecessarily have slow metabolisms that help their bodies hang on to fat. Instead, they may have a strongerbiological drive to eat, especially in an environment where food is tasty, cheap, and plentiful.
The real question, says Friedman, isn't why so many of us are getting fat, but why, in our food-richenvironment, is anyone thin at all?
One morning I click on the tube to see what food messages are reaching America's living rooms. According toa 2001 study published in the Journal of Nutrition Education, the average child in the U.S. will watch nearly10,000 commercials touting food or beverages a year.
A huge bag of Double Delight Oreos swims into view.
Martha Stewart, looking as if she hadn't a care in the world, is making a chocolate ganache.
Finally, amid a sea of sugar, an image of healthy food flashes by:
"We live in a toxic environment," says Kelly Brownell, director of the Yale Center for Eating and WeightDisorders. "It's like trying to treat an alcoholic in a town where there's a bar every ten feet. Bad food is cheap,heavily promoted, and engineered to taste good. Healthy food is hard to get, not promoted, and expensive. Ifyou came down from Mars and saw all this, what else would you predict except an obesity epidemic?"
Brownell favors the intervention of legislation that would, for example, suspend food advertising directed atchildren or remove soft drinks and snack foods from school vending machines. "The parallels with tobacco areinteresting," he says. "We could search for a drug that would cancel out the effects of smoking, or we could goright to the cause and do everything possible to get rid of cigarettes."
Perhaps what this country really needs to fight fat is a morn. Make that a vintage mom, with a gingham aprontied around her waist as she places a bowl of vegetables on the table next to a skinless roast chicken.
"Instead," says Harry Balzer, vice president of NPD, a marketing research firm that has been tracking what andwhere Americans eat for nearly a quarter of a century, "the restaurant has become the ultimate kitchenappliance."
Because I, too, deserve a break today, I am sitting inside a McDonald's in State College, Pennsylvania, withBarbara Rolls, professor of nutritional sciences at the Pennsylvania State University. For twelve dollars andchange, Rolls and I have ordered a Happy Meal with cheeseburger, Coke, and fries; a Big Mac with mediumfries and large Coke; and the Grilled Chicken California Cobb Salad with a packet of Caesar dressing.
Inspection begins. Rolls peers at the Big Mac (600 calories) like an entomologist classifying a new species.
The kid's Happy Meal cheeseburger turns out to be a regular size cheeseburger (330 calories). In total, 2,470calories are sitting on the red plastic tray in front of us; if we clean our plates, we will each have consumed 77percent of our daily caloric requirement in just one meal.
As we talk, I absently reach into a small bag of fries and scarf down the contents. Rolls calls this "mindlesseating." "We pay little attention to the actual need for food," she says. In one experiment she and her studentsfed subjects baked pasta. "Some days we offered a normal portion. Some days we offered a portion 50 percentbigger for the same price. If we served them 50 percent more, they ate it. They just kept eating."
Betrayed by our genes, confused by the experts, we graze in endless pastures of food while the statistics growmore chilling. "Some of the earlier treatments like jaw wiring were extreme, but so is gastric bypass," Rollssays. "It's like the prefrontal lobotomy used to treat mental illness in the past."
Last year surgeons performed gastric bypass operations on 103,200 patients, with a complication rate of 7percent. Linda Hay's four-hour operation was complicated by pneumonia. She stayed in the hospital five dayslonger than expected. A year and a half later, she has lost 162 pounds. She feels full quickly and eatssparingly--a protein shake for breakfast; salad or sandwich for lunch; Lean Cuisine for dinner.
Hay has given away her size 4X clothes, buys size 10 pants, and can climb a flight of stairs without gasping forbreath. "And I've caught the eye of men when I go out--especially in my new convertible."
Short of stapling our stomachs, will we ever solve the problem of fat? Meanwhile the struggle has turnedglobal. For the first time, the Worldwatch Institute reports, there are as many overfed, overweight people in theworld as those who are underfed and underweight.
"There is no feast which does not come to an end," an ancient Chinese proverb warns.
• ARE YOU NUTRITION SAVVY? Are potatoes simple or complex carbohydrates? How many calories are in agram of fat? Is butter more fattening than margarine? Test your diet IQ and find resources atnationalgeographic.com/magazine/0408.
PHOTO (COLOR): BEFORE: Pictured nine months after gastric bypass surgery and 125 pounds lighter, LindaHay (before at 314 pounds) celebrates with new confidence and a new car. Bariatric surgery, which has seen afivefold increase in popularity since 1992, is risky. "We make it clear it doesn't solve all of life's problems," sayssurgeon Harvey Sugerman.
By Cathy Newman, National Geographic
USA: OVERFED NATION
For all the Americans who've blamed bulging bellies on a slow metabolism, the Jig is up. A report earlier thisyear by the Centers for Disease Control and Prevention finally confirms what many of us didn't want toadmit: We're fat because we eat a lot--a whole lot more than we used to--and most of the increase comesfrom carbohydrates. Adult women are now eating 335 more calories per day than they did in 1971, whileadult men have upped their dally Intake by 168 calories.
We're talking excess pounds here--on our bodies and on our plates. We each ate 1,775 pounds of food in2000, up from 1,497 pounds in 1970. At first glance, some of the increase looks good. We're eating morevegetables, just like the USDA's Food Guide Pyramid, issued in 1992, advised. The only problem: Almost athird of these vegetables were iceberg lettuce, french fries, and potato chips. And while we've outdoneourselves in getting even more servings of "grains" than recommended, that doesn't mean we've grown fondof bulgur and millet. The grains we're eating are flour-based items like pasta, tortillas, and hamburger buns,which have little more nutritional value than table sugar. Even the reduction of fat as a percentage of totalcalories isn't real progress. The only reason the percentage is down is that we're eating so much more ofeverything else.
Does the report prove the case of carb-avoiding devotees of the Atkins and South Beach diets? It certainlydoesn't contradict it, says Harvard epidemiologist Meir Stampfer. But he emphasizes that added sugars andprocessed carbs, not high-fiber carbs like whole grains, are the real culprits. The food pyramid guidelinestold Americans to avoid fat and eat grains, so we loaded up on pasta and bread, says Stampfer. "The low-fatmessage backfired."
Obesity is defined in terms of body mass index, or BMI, a measure of body weight relative to height. Aperson with a BMI of 30 or mor is considered obese--and at a higher risk of diseases ranging from head
(stroke) to toe (diabetic foot ulcers). From 1971 to 2000 obesity increased from 14.5 percent to 30.9 percentof the U.S. population, setting the stage for soaring rates of diabetes. Obesity-related diseases cost the U.S.
more than 100 billion dollars annually. next year, being overweight is predicted to surpass smoking as theleading cause of preventable death in the country.
ADDING UP AN EPIDEMIC
Percentage of Americans who were obese in 1971:
Percentage of overweight Americans who say they are "underweight" or "about right":
Number of deaths per year associated with being overweight:
Number of Americans with diabetes in 1980:
Number in 2002:
Percentage of high school students who participated in P.E. classes in 1991:
Percentage in 2001:
Percentage of children ages 12 to 19 who were overweight in 1980:
Teaspoons of added sugars American's are advised not to exceed daily:
Number they actually consume:
Average women's dress size in 1950:
EATING MORE OF EVERYTHING
1970: Pounds consumed per person: 1,497
CARBOHYDRATES (FRUITS, GRAINS, SUGARS, AND VEGETABLES) Sugars 139 lb Vegetables 337 lb Grains 136 lb Fruits 241 lb
2000: Pounds consumed per person: 1,775
CARBOHYDRATES (FRUITS, GRAINS, SUGARS, AND VEGETABLES) Sugars 172 lb Vegetables 425 lb Grains 200 lb Fruits 280 lb
Fats and oils (cooking and salad oils, shortening, table spreads)
Fruits (fresh and processed)Grains (barley, corn, and oat products; rice; rye and wheat flour)Proteins (dairy, eggs, fish, meat, nuts, poultry)Sugars (candy, beet and cane)Vegetables (fresh and processed)
GRAPH: ESTIMATED NUMBER OF BARIATRIC SURGERIES IN U.S.
a widening PROBLEM
In a historical first, there are now as many overnourished people as undernourished around the world. Here'sthe recipe for obesity on such a global scale: Take technology--cars, washing machines, elevators--thatreduces physical exertion. Increase calorie consumption, courtesy of increasing prosperity. Add televisionand video games. Stir in the intensive marketing of candy and fast food, and you have the makings of anepidemic. In countries where the food supply has been unstable, people are getting fat despite far lessabundance than in the United States. The implication? Newly industrialized nations in Asia, Africa, theCaribbean, and Latin America may develop even higher rates of obesity-related health problems than in theU.S.
SOURCES: DEMOGRAPHIC AND HEALTH SURVEY ANALYSIS, BARRY P0PKIN AND CARLOSMONTEIRO; WORLD HEALTH ORGANIZATION GLOBAL DATABASE ON BODY MASS INDEX
States with the highest obesity rates--Mississippi and Alabama-are in the South. The more affluent and
outdoorsy western states of Colorado and Utah have the lowest rates.
more Latin America becomes developed, supermarkets stocked with processed foods have become the
norm, rising from 20 percent of food retail during the 1980s to 60 percent in 2000.
Candy, fast food, and sweetened cereals account for more than half the food ads in ten European Union
nations. In the U.K. snack food consumption rose nearly 25 percent in five years.
In some parts of Africa obesity afflicts more children than malnutrition. In Tunisia the urban population is
shifting from traditional healthy whole grain breads to white bread.
In Shanghai, roads once filled with pedestrians and cyclists are now congested with cars. KFC opened a
drive-through restaurant in Beijing in 2002, with more to come.
Pacific islanders have always valued hefty physiques. Now their shift away from local foods to a high-fat,
Western diet has made them among the world's fattest people.
IT'S NOT ALL ABOUT FOOD
Public health officials now count playing with kids and washing windows as legitimate exercise, but no matterhow much they lower the bar, they can't get most Americans to move a muscle. One in four doesn't get anyexercise at all. Less than a third get the recommended minimum of 30 minutes a day, most days aweek--and that's only what's needed to lower the risk of chronic disease, if you want to lose weight withoutcutting calories, you're looking at even more. That goes for kids too. "It's been a struggle," sighs KristeenDavis, whose son, John, now 9, uses a treadmill and takes tae kwon do but still weighs 134 pounds. Obesityhas reached red alert levels among children and adolescents, almost tripling since 1980--and small wonder.
Suburban sprawl and lack of pedestrian-friendly streets have kids being driven instead of walking to school.
And most schools have cut back on physical education. With losing pounds so difficult, the best strategy is tokeep from gaining weight in the first place. Experts advise building activity into daily life by rebelling againstconvenience. Taking the stairs or grabbing a rake instead of a leaf blower can burn enough extra calories toprevent the added pounds middle-aged people tend to gain over the years.
E-mail colleague (1 min) 2 Walk to colleague's office (1 min) 4Ride elevator (2 mins) 3 Take stairs (2 mins) 19Order take-out (1 min) 1 Cook meal 70Load dishwasher (10 mins) 23 Wash dishes 80Watch TV 35 Play cards 52Go to car wash 35 Wash car at home 104Play video game 53 Play basketball 280Mow lawn/riding mower 88 Mow lawn/power mower 193
CALORIES APPROXIMATED FOR HALF HOUR OF ACTIVITY (UNLESS OTHERWISE STATED) FOR A150-POUND PERSON.
CHANGING portion sizes
When was the last time you ate a burrito the size of a bar of soap? Most of us are clueless about what a
single serving should be, which is why nutritionists suggest using the objects pictured above as a guide.
Portions have exploded since the '70s. Super-sized servings of french fries and sodas are often two to five
times larger than when they were introduced. Jumbo portions may appeal to our pocketbooks, but they
assault our waistlines.
.AND THE REAL
BURGER KING1954: 2.8 oz; 202 calories2004: 4.3 oz; 310 calories
MCDONALD'S1955: 2.4 oz; 210 calories2004: 7 oz 610 calories
HERSHEY'S1900: 2 oz; 297 calories2004: 7 oz; 1,000 calories
COCA-COLA1916: 6.5 fluid oz; 79 calories2004: 16 fluid oz; 194 calories
MOVIE POPCORN1950s: 3 cups; 174 calories2004: 21 cups (buttered); 1,700 calories
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