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As with any diet, physical activity is essential in establishing your a healthy lifestyle. Even light exercise, such as walking or yoga, is enough to get your heart rate up and benefit your overall well-being. We recommend finding a routine you're likely to stick to, like a nightly stroll with your family after dinner or a spin class with your best friend.
The 2019 rankings include 41 of today’s most popular diets. New to the list this year is the Nordic Diet, a plant-heavy eating plan that incorporates Scandinavian traditions and ranked 9th best overall. Here’s how the rest of the rankings shook out this year, and what experts have to say about the good, the bad, and the trendy. (Here’s a hint: They’re still not crazy about keto.)
The ketogenic diet has been studied in at least 14 rodent animal models of seizures. It is protective in many of these models and has a different protection profile than any known anticonvulsant. Conversely, fenofibrate, not used clinically as an antiepileptic, exhibits experimental anticonvulsant properties in adult rats comparable to the ketogenic diet. This, together with studies showing its efficacy in patients who have failed to achieve seizure control on half a dozen drugs, suggests a unique mechanism of action.
Hello everyone. I was diagnosed as a diabetic in 2010. I followed the ADA diet while taking metformin and lnsulin and could never get by glucose readings below 135. Most mornings it was at 175 or higher. In mid 2017 I had to find a new doctor. I ran out of meds in Semtember of that year but could not find a doctor due to not accepting new patients and or my health insurance. I broke my foot at work on the last workday in December. Was instructed to stay off foot for 6 to 9 months . In the mean time I finally got to see my new family practitioner on March 28 2018. Represcribed meds and ordered blood work. A1c was ar 14.1. With my new glucose meter my readings were 375. Due to basically being bedridden while my foot heals I was concerned about diabetic complications an weight gain as I was already overweight. After doing research online I learned about the keto diet. I began the diet on 3/29 /2018 along with intermittent fasting. I weighed 265#. As of 4/26/2008 I am at 245#. My glucose readings have been on average 73 to 98 and a couple of times 111. I stopped all my medication about a week ago just to see if they would increase. They have not so far and I check 4 times daily. I sleep better and do not crave sweets. I feel full . The first two weeks were tough but now I can go 2-3 days without being hungry. I am looking forward to the results of my next blood test in June. This diet fits my circumstances and I do plan on to exercise when I am able to. I want to reach my weight to height ratio also. When I achieve this goal I may tweak my diet at that time but for right now that is what is working for me. I may never be able to eat some of the things I used to but considering the complications of diabetes it is one hell of incentive for willpower to stay on the diet.I will repost again after my next blood test or if there are any significant changes.
Upon starting the diet, some patients report symptoms like fatigue, headaches, and muscle aches. However, these short-lived symptoms are, in fact, a sign that the diet is working, and the body is switching over from burning glucose as fuel to burning fat. This transition involves upregulating certain enzymes and down-regulating others; it is a profound shift for the human body that can have uncomfortable symptoms. However, these side effect usually last only 3-4 weeks. They can be ameliorated in most cases, by drinking several cups of bouillion broth during the day until the transition is completed.15
Cyrus Khambatta earned a PhD in Nutritional Biochemistry from UC Berkeley after being diagnosed with type 1 diabetes in his senior year of college at Stanford University in 2002. He is an internationally recognized nutrition and fitness coach for people living with type 1, type 1.5, prediabetes and type 2 diabetes, and has helped hundreds of people around the world achieve exceptional insulin sensitivity by adopting low-fat, plant-based whole foods nutrition.
Eat More Produce. Eating lots of low-calorie, high-volume fruits and vegetables crowds out other foods that are higher in fat and calories. Move the meat off the center of your plate and pile on the vegetables. Or try starting lunch or dinner with a vegetable salad or bowl of broth-based soup, suggests Barbara Rolls, PhD, author of The Volumetrics Eating Plan. The U.S. government's 2005 Dietary Guidelines suggest that adults get 7-13 cups of produce daily. Ward says that's not really so difficult: "Stock your kitchen with plenty of fruits and vegetables and at every meal and snack, include a few servings," she says. "Your diet will be enriched with vitamins, minerals, phytonutrients, fiber, and if you fill up on super-nutritious produce, you won't be reaching for the cookie jar."
Type 2 diabetes is one of the most pressing challenges of our time and its ultimate cause has not been fully understood. Ketogenic diets, which are low in carbohydrate and high in fat, are known to lead to weight loss and have been considered to be healthy. These findings raise new questions about ketogenic diets and whether or not they are actually healthy.
Short-term results for the LGIT indicate that at one month approximately half of the patients experience a greater than 50% reduction in seizure frequency, with overall figures approaching that of the ketogenic diet. The data (coming from one centre's experience with 76 children up to the year 2009) also indicate fewer side effects than the ketogenic diet and that it is better tolerated, with more palatable meals.
The keto diet did jump considerably in one specific category, however: This year it tied with several other diets for No. 2 in Best Fast Weight-Loss Diets (after the HMR Diet, a commercial plan that replaces most meals with pre-packaged nutrition bars and shakes), up from No. 13 last year. “Yes, you can do this for quick weight loss,” says Dr. Katz, “but I wouldn’t recommend it.”
Blood specimens were obtained at weeks 0, 8, and 16 after the participant had fasted overnight. The following serum tests were performed in the hospital laboratory using standardized methods: complete blood count, chemistry panel, lipid panel, thyroid-stimulating hormone, and uric acid. A non-fasting specimen was also drawn at weeks 4 and 12 to monitor electrolytes and kidney function.
The Keto diet emphasizes weight loss through fat-burning. The goal is to quickly lose weight and ultimately feel fuller with fewer cravings, while boosting your mood, mental focus and energy. According to Keto proponents, by slashing the carbs you consume and instead filling up on fats, you safely enter a state of ketosis. That’s when the body breaks down both dietary and stored body fat into substances called ketones. Your fat-burning system now relies mainly on fat – instead of sugar – for energy. While similar in some ways to familiar low-carb diets, the Keto diet’s extreme carb restrictions – about 20 net carbs a day or less, depending on the version – and the deliberate shift into ketosis are what set this increasingly popular diet apart.
The MIND diet, or Mediterranean-DASH Intervention for Neurodegenerative Delay, is a sort of hybrid between the DASH diet and the Mediterranean diet. It features foods meant to slow the progression or development of Alzheimer’s disease, the most common form of dementia and an incurable neurodegenerative condition that more than 5 million Americans are living with, according to the Alzheimer’s Association. (12) Some research backs up this notion, including a study published in September 2016 in Alzheimer’s Dementia that found a link between following the MIND Diet and a reduced risk of the disease. (13)
The Mediterranean diet isn’t a regimented plan, like South Beach, the Blood Type Diet or any others; it’s more a way of eating. After World War II, researchers began studying the eating patterns of 13,000 middle-aged men in the US, Japan, Italy, Greece (including Crete), the Netherlands, Finland and Yugoslavia. They noticed that those in countries whose diets had been restricted by the deprivations of the war had lower rates of heart disease compared to American men. Moreover, residents of Crete enjoyed the best cardiovascular health, leading scientists to conclude that their diet — fruits, vegetables, grains, legumes and fish — played a major role.
If you’re science oriented, you can also try his 2008 book “Good Calories, Bad Calories”. For a more journalistic view on the events that led to fat phobia starting in the 1950’s (as well as the joke that is the Mediterranean Diet), there is also Nina Teicholz’s 2014 book “The Big Fat Surprise.” Be sure to check out youtube for some of these folks’ lectures and discussions. They are not advocating whacky stuff.
There isn't "a" Mediterranean diet. Greeks eat differently from Italians, who eat differently from the French and Spanish. But they share many of the same principles. Working with the Harvard School of Public Health, Oldways, a nonprofit food think tank in Boston, developed a consumer-friendly Mediterranean diet pyramid that offers guidelines on how to fill your plate – and maybe wineglass – the Mediterranean way.
You’ve enjoyed hearty eating during the 28 days of your meal plan, but you may need an occasional snack to get you through a long afternoon of work or school. Choose an ounce of nuts or dried apricots; a cup of low-fat cottage cheese sprinkled with black pepper and a dash of salt; or an ounce of herbed goat cheese with a handful of whole-grain crackers. If you need something sweet after dinner, have a piece of fruit or 1/2 cup of fresh-fruit sorbet.
Trim Portions. If you did nothing else but reduce your portions by 10%-20%, you would lose weight. Most of the portions served both in restaurants and at home are bigger than you need. Pull out the measuring cups to get a handle on your usual portion sizes, and work on paring them down. Get instant portion control by using small bowls, plates, and cups, says Brian Wansink, PhD, author of Mindless Eating. You won't feel deprived because the food will look plentiful on dainty dishware.
I agree!! I too..have /had Diabetes II..at age 66 and retired RN, we were taught for so long the WRONG way to eat and I taught that way, the high carb, grains, etc, way to eat. KETO saved me. Dropped my A1C and I feel great. The author of this page is wrong when saying 5-10 percent of our diet, carb eating, should be root veggies like ‘carrots”…so wrong. For goodness sakes, get KETO right by educating yourself, Tammy Shiflet~ Horribly wrong! There are so many studies and physicians, brain scientists, etc out here who understand what this diet is about. Read, and educate yourself….Please! Diabetes is a symptom of the Government’s education mistakes. Sugar, Wheat, Grains…horrible for us. Get with it, we live in 2018 and the information is out there; if you need a list, just ask.
I would love to join a study! Could you recommend where to go to find one? I have done 30 or less total carbs a day for almost 2 years and feel great. I have NEVER EVEN ONCE gone over 40 total so I do follow it and I do not cheat on high carb foods, although I do occasionally over-eat on low carb foods resulting in a bit over 30 maybe 1 -2 times a month. I do feel that time will provide more support and think that the medical community should educate on this as another alternative. It isn’t for everyone because it is a bit more problematic if a person does fall of the straight and narrow too often but it can be done!
I LOVE your recipes and entire program! You simplify eating healthfully and your recipes look delicious. I have arthritis and must eat a restricted diet that is anti-inflamatory. I can easily see ways to adapt some of your recipes. The diet forbids grains, beans, wheat, chick peas, potatoes, pasta, or any fruits or vegetables with seeds, etc. I was skeptical about this diet at first but if I stick to the diet, I really do experience less pain. I would so wish to have your recipes adapted for the home cook with substitutions of allowed foods for the forbidden. For instance, I am going to try to make your phyllo recipe using almond flour, and in other recipes using only pasture grazed dairy such as goat and sheeps milk cheeses, yogurts, eggs etc. Thank your for your inspiration and I would be so grateful if you would turn your gifted cooking attention to helping those of us in pain to adapt your delicious and healthful diet to include anti-inflamation recipes. There is a huge and eager market for this.
The best low-cal diet plan isn't a diet so much as it is a method. CICO stands for "calories in, calories out" and is based on the mathematically sensible principle that as long as you're burning more calories than you're eating, you'll lose weight. All you need to get started is a way to track your calories—there are plenty of apps on the market although a pen and paper works great too—and a food scale to keep you honest about your portion sizes. (Also read this guide on how to safely cut calories to lose weight.) People love the simplicity and straightforwardness of the plan. And while it may not be the fastest way to lose weight, you're guaranteed to have success long term. (Just know that some weight-loss experts actually don't recommend calorie counting.)
I picked up this book because I had heard in several places that the DASH diet was currently the diet most recommended by doctors. So far the books have been disappointing. This book basically lays out a low carb diet, low fat diet that I'm not sure is mainstream DASH or just the program used by this particular author. I can see where the diet would result in weight loss for someone eating the Standard American Diet (SAD) but I can't think that sugar-free jello and flavored yogurt and low-fat pr ...more
Also, as I believe is mentioned, this diet has been around for along time and was the only way to treat diabetes. And some people did die. However, people still end up dead from t2d even after all the diet advice from educators and with all that pharmacy has to offer. An industry which gains nothing if people just choose to eat less. But has lots to gain if we just keep taking the tablets.
Yancy WS Jr, Westman EC, McDuffie JR, Grambow SC, Jeffreys AS, Bolton J, Chalecki A, Oddone EZ, “A randomized trial of a low-carbohydrate diet vs orlistat plus a lowfat diet for weight loss,” Arch Intern Med. 2010 Jan 25;170(2):136-45. http://www.ncbi.nlm.nih.gov/pubmed/20101008?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum&ordinalpos=2.
The Mediterranean Diet was identified in the 1960s as research continued to show populations from Mediterranean regions, particularly Southern Italy, the isle of Crete, and Greece, were considerably healthier, with less incidence of disease and longer lifespans than seen in other regions. Studies indicated that the way these populations ate seemed to be the common denominator and through research, the Mediterranean diet was formally born.
Check the nutrition labels on all your products to see if they’re high in carbs. There are hidden carbs in the unlikeliest of places (like ketchup and canned soups). Try to avoid buying products with dozens of incomprehensible ingredients. Less is usually healthier.Always check the serving sizes against the carb counts. Manufacturers can sometimes recommend inconceivably small serving sizes to seemingly reduce calorie and carb numbers.
The ketone bodies are possibly anticonvulsant; in animal models, acetoacetate and acetone protect against seizures. The ketogenic diet results in adaptive changes to brain energy metabolism that increase the energy reserves; ketone bodies are a more efficient fuel than glucose, and the number of mitochondria is increased. This may help the neurons to remain stable in the face of increased energy demand during a seizure, and may confer a neuroprotective effect.
If you've never given farro a try, this pretty bowl of goodness will have you stopping by the grocery store on your way home tonight. Farro has basically zero fat, is a great source of fiber, and an even better source of bone-boosting calcium. It's a little denser than brown rice and is a bit more substantial than quinoa. This bowl takes only 35 minutes to make—perfect for meal-prep days. Obsessed? Try these healthy recipes featuring high-fiber foods.)
The DASH diet has sometimes even been described as an Americanized version of the famous Mediterranean diet, according to the official DASH diet website. But as healthy as the DASH diet is, it's certainly not restrictive. It includes an eating plan rich in fruits, vegetables, low-fat and nonfat dairy, lean meats, fish, poultry, nuts, beans, seeds, heart-healthy fats, and limited amounts of whole grains. These delicious and nutritious foods join forces together to help your overall health improve. An added perk? You can also shed some unwanted pounds on the DASH diet — especially if you follow the DASH Diet Weight-Loss Solution plan.
"The eating plan focuses on reducing sodium intake and eating more fruits and vegetables," says Amy Gorin, MS, RDN, owner of Amy Gorin Nutrition in the New York City area. "It also emphasizes eating whole foods — such as fruits, vegetables, whole grains, fish, poultry, beans, nuts, and vegetable oils — and limits foods high in saturated fat. That includes fatty meats, full-fat dairy, and tropical oils like palm kernel oil, palm oil, and coconut oil. It also limits sugar-sweetened beverages and foods."
During the 1920s and 1930s, when the only anticonvulsant drugs were the sedative bromides (discovered 1857) and phenobarbital (1912), the ketogenic diet was widely used and studied. This changed in 1938 when H. Houston Merritt, Jr. and Tracy Putnam discovered phenytoin (Dilantin), and the focus of research shifted to discovering new drugs. With the introduction of sodium valproate in the 1970s, drugs were available to neurologists that were effective across a broad range of epileptic syndromes and seizure types. The use of the ketogenic diet, by this time restricted to difficult cases such as Lennox–Gastaut syndrome, declined further.
The ketogenic diet is a high-fat, adequate-protein, low-carbohydrate diet that in medicine is used primarily to treat difficult-to-control (refractory) epilepsy in children. The diet forces the body to burn fats rather than carbohydrates. Normally, the carbohydrates contained in food are converted into glucose, which is then transported around the body and is particularly important in fueling brain function. However, if there is little carbohydrate in the diet, the liver converts fat into fatty acids and ketone bodies. The ketone bodies pass into the brain and replace glucose as an energy source. An elevated level of ketone bodies in the blood, a state known as ketosis, leads to a reduction in the frequency of epileptic seizures. Almost half of children and young people with epilepsy who have tried some form of this diet saw the number of seizures drop by at least half, and the effect persists even after discontinuing the diet. There is some evidence that adults with epilepsy may benefit from the diet, and that a less strict regimen, such as a modified Atkins diet, is similarly effective. The most common adverse effect is constipation, affecting about 30% of patients—this was due to fluid restriction, which was once a feature of the diet, but this led to increased risk of kidney stones and is no longer considered beneficial.
It’s low in saturated fat. You’re not going to feel hungry eating this way, because you can build in a variety of healthy fats. But by limiting large amounts of red or processed meats and relying heavily on monounsaturated fatty acids, like avocado, nuts, or olive oil, you’ll keep saturated fat levels low. These fats don't lead to high cholesterol the same way saturated fats do. Healthful sources of fat include olive oil, fish oils, and nut-based oils, Cohen explains.
Coffee jumpstarts your metabolism, making the non-decaf stuff a worthy weight loss ally. According to a study published in the journal Physiology & Behavior, the average metabolic rate of people who drank caffeinated coffee was 16 percent higher than that of those who drank decaf. In addition to caffeinating your coffee, it’s also crucial to keep it black and avoid adding any unhealthy creamers and artificial sweeteners, both of which are enemies of weight loss.
Choice #1: Lathero Dish (seasonal vegetables or beans cooked with olive oil, herbs, and tomato sauce accompanied by bread and cheese). This is what you will have 3-4 times a week. Typically this is green beans, peas, spanakorizo (spinach-rice) and cauliflower cooked in this way. This is accompanied by a slice of bread and feta. Click for lathera recipes. Please note that one serving consists of 3-4 servings of vegetables.
DASH is based on the following foods: fruits, vegetables, low fat milk, whole grains, fish, poultry, beans, and nuts. It recommends reducing sodium, foods and beverages with added sugars, and red meat. The diet is heart-friendly as it limits saturated and trans fat, while increasing the intake of potassium, magnesium, calcium, protein, and fiber, nutrients believed to help control blood pressure.
I am in the uk and a diagnosed t2d. I am also a nurse, although I am in end of life care. Up until my diagnosis I am ashamed to say the I believed in exactly th.e same things as the writer of this article. Our health service actively promotes a carb rich diet for t2d. Not an excessive amount of calories, but a “healthy” amount of whole grains, fruit, whole rice etc. It was not until I did some actual research and looked at the science that I came to see that what I had been taught and what I really did believe to be the best advice was quite simply wrong.
In September 2018, researchers at Harokopio University in Athens released a study that suggests adhering to the Mediterranean diet can promote better sleep, specifically in older adults. While more research needs to be conducted to determine exactly how and why the Mediterranean diet improves sleep quality, senior study author Dr Mary Yannokoulia suggested that the connection could have to do with the presence of the sleep-promoting hormone melatonin in foods like olive oil, fish and fruit.
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Financial disclosures: There were no conflicts of interest reported except for Dr Bernstein who has received royalties for books on the management of diabetes (which were used by members of the online social media group surveyed in this study). Dr. Hallberg who holds stock options and receives research support from Virta Health, and consulting fees from Atkins. Dr. Rhodes is the site principal investigator in clinical trials for pediatric type 2 diabetes that are sponsored by Merck and AstraZeneca. Dr. Westman has an ownership interest in companies using low-carbohydrate principles, and he receives royalties for books related to low-carbohydrate diets. Dr. Ludwig has received royalties from books on nutrition and obesity; and Dr. Galati is author of Eating Yourself Sick: How to stop obesity, fatty liver, and diabetes from killing you and your family (2018).
Lele Jaro has been on a ketogenic diet for over two years to help with her type 2 diabetes, and has successfully got off insulin. She’s been documenting her health journey on Instagram with keto-friendly food ideas, keto tips, and workout motivation. She’s lost over 80 pounds on her journey, and inspires others to try keto to improve their health. Connect with her on her YouTube channel or Facebook.
One study from 2005 followed 22 people with Type 1 Diabetes for 12 months. The difference here however is they consumed 70-90 grams of carbohydrates per day versus the restrictive less than 20 grams per day on the Ketogenic Diet. Remember my motto? Moderation is the key! The results were positive; less hypoglycemia, insulin requirements were reduced and their A1c dropped from 7.5% to 6.4%.
You say keto is a highly controversial topic. For those of us following a keto diet, there is no controversy whatsoever because the diet proves itself efficacious very quickly. I think the real controversy comes in because the ADA has been recommending dangerous levels of carbs for decades now, and they would lose face if they had to change their recommendation and admit they’ve been wrong for so long. You say there are not many studies on the keto diet, and I disagree with you. You’ll find the evidence if you look for it. Eric Westman, Steve Phinney, Jeff Volek and many other researchers have written volumes about this.
Physicians of ancient Greece treated diseases, including epilepsy, by altering their patients' diet. An early treatise in the Hippocratic Corpus, On the Sacred Disease, covers the disease; it dates from c. 400 BC. Its author argued against the prevailing view that epilepsy was supernatural in origin and cure, and proposed that dietary therapy had a rational and physical basis.[Note 3] In the same collection, the author of Epidemics describes the case of a man whose epilepsy is cured as quickly as it had appeared, through complete abstinence of food and drink.[Note 4] The royal physician Erasistratus declared, "One inclining to epilepsy should be made to fast without mercy and be put on short rations."[Note 5] Galen believed an "attenuating diet"[Note 6] might afford a cure in mild cases and be helpful in others.
Many diets, including Atkins and the keto diet, fit into this umbrella. A typical low-carb diet limits carbs to less than 60 g daily, but this can vary, according to the Mayo Clinic. (15) In a September 2015 review published in PLoS One, people following low-carb diets saw modest weight loss — although study authors note that long-term effects of the diet require further research. (16)
On the flip side, hypos can be an issue, especially early on…and if you treat them too aggressively, they could knock you out of ketosis. I remember my first 3 weeks on keto, my CGM trend line hugged a blood sugar of around 80. It was glorious, but I had to reduce insulin substantially through trial and error and felt like I was low every five seconds.
Hi, Esther! Thank you so much for your kind comment. I am so glad you found The Mediterranean Dish and hope you’ll enjoy cooking some of the recipes here! I should preface my answer here by saying that I am not a dietitian or a nutritionist, what I share here is mainly from my experience as someone who grew up in the Mediterranean area and have continued to eat the Mediterranean way now as an adult living in the USA. So please always check with your health care provider or a registered dietitian if you are looking for professional advice or a specific diet plan to follow. But I’ll answer your questions as best as I know how.
Where is the science? And if insolin intolerance is a diabetic problem why keep trying to regulate insolin? The stuff isn’t working because your patients are not getting better just deteriorating slower while you make more money keeping them on drugs!!!!! Your hole point is ketosis is bad cause they don’t have to see you after they adjust off the medication that keeps them having to see people like you!!! I have been eating keto for 6 months and feel amazing!!! These people are twisting the truth to keep you sick for there own pockets!!!!!!
Why was the DASH diet been ranked as the best diet, the healthiest diet, and the best diet for diabetes, 8 years in a row? The expert panel of physicians assembled by US New & World Reports chose DASH because it is proven to improve health, has a balance of healthy food groups, and it actually works. And now the Mediterranean diet has jumped out in front. So delicious and heart healthy. DASH has been proven to lower blood pressure and cholesterol, and is associated with lower risk of several types of cancer, heart disease, stroke, heart failure, kidney stones, reduced risk of developing diabetes, can slow the progression of kidney disease, and now is associated with reduced risk of depression.
Spinach is a great source of iron, which is a key component in red blood cells that fuel our muscles with oxygen for energy. But researchers in Sweden identified another way in which these greens might keep you charged: Compounds found in spinach actually increase the efficiency of our mitochondria, the energy-producing factories inside our cells. That means eating a cup of cooked spinach a day may give you more lasting power on the elliptical machine (or in your daily sprint to catch the bus).
Basically, the effect of exercise on our weight is vastly overrated. That’s why it’s only number 15 on this list. There are other things you need to take care of first. It’s not a good idea to eat bad food, drink sugar water (so-called “sports drinks”) or be on medications which force you to exercise for hours daily just to compensate. Metaphorically that’s like digging a hole, into which you put your ladder, on which you stand and paint the basement-level windows of your house.
In 2008, researchers conducted a 24-week study to determine the effects of a low-carbohydrate diet on people with type 2 diabetes and obesity. At the end of the study, participants who followed the ketogenic diet saw greater improvements in glycemic control and medication reduction compared to those who followed a low-glycemic diet. A study from 2017 found the ketogenic diet outperformed a conventional, low-fat diabetes diet over 32 weeks in regards to weight loss and A1c. A 2013 review reports again that a ketogenic diet can lead to more significant improvements in blood sugar control, A1c, weight loss, and discontinued insulin requirements than other diets.
A: You’ll find a detailed menu earlier in this article (also, recipes from Everyday Health!), but generally, you’ll want to make plants and whole grains the stars of your plate. If you look at a Mediterranean diet food pyramid, sweets are up top (indicating they should make up only a small part of your diet), followed by meat and dairy, and then fish. Last are fruit, veggies, and whole grains (suggesting they can be eaten liberally). Also, enjoying food with friends and family is a tenet of the eating approach, so make your meals a social affair!
Children who discontinue the diet after achieving seizure freedom have about a 20% risk of seizures returning. The length of time until recurrence is highly variable but averages two years. This risk of recurrence compares with 10% for resective surgery (where part of the brain is removed) and 30–50% for anticonvulsant therapy. Of those that have a recurrence, just over half can regain freedom from seizures either with anticonvulsants or by returning to the ketogenic diet. Recurrence is more likely if, despite seizure freedom, an electroencephalogram (EEG) shows epileptiform spikes, which indicate epileptic activity in the brain but are below the level that will cause a seizure. Recurrence is also likely if an MRI scan shows focal abnormalities (for example, as in children with tuberous sclerosis). Such children may remain on the diet longer than average, and it has been suggested that children with tuberous sclerosis who achieve seizure freedom could remain on the ketogenic diet indefinitely.


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domain: design


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Chipping Barnet MP Theresa Villiers has welcomed extra funding to help the Metropolitan Police fight crime in the capital. In recent weeks, Theresa has lobbied the Prime Minister and the Chancellor for an increase police numbers for Barnet.
The police funding settlement for 2019/20 gives an extra 46m in Government grant funding to protect the police budget in real terms, and a further £45.7m to help with increased pension costs.
£81 million more will be available if the London Mayor opts to use a new power to add £2 a month to council tax to support policing. That would mean the total increase in funding for the Metropolitan Police next year could be as much as £172m.
“Many constituents have told me they are worried about crime, particularly burglary. This funding settlement should help address those concerns and will be the most generous since 2010,” said Theresa.
“I have made the case to ministers that more funding needs to be available for policing in London and this has been not only heard, but acted on.
“The police do a vital job in difficult and sometimes dangerous circumstances, and this funding will help them do that job more effectively.
“The police also need to ensure these new resources are used as efficiently as possible. I support the Government in asking the Metropolitan Police and other forces to employ more detectives, work to save money from back office functions to spend on the frontline, help officers be more productive by investing in digital technology, and co-ordinate work to tackle serious and organised crime.”
The Met will also receive £90m to tackle serious and organised crime threats, including cybercrime, and an additional £160m for counter-terrorism policing as part of its national policing role.
Theresa Villiers was present in Parliament for the announcement on police funding yesterday by police minister Nick Hurd. In November, she raised police funding with Theresa May during Prime Minister’s Question Time. The Barnet MP was also part of a delegation that recently met the Prime Minister to make the case for more police resources for London.

domain: sociology


The Pennsylvania Game Commission recently approved the use of semi-auto shotguns statewide for deer, bear and elk hunting.
The Pennsylvania Board of Game Commissioners unanimously approved a bill to allow semi-auto shotguns for big-game hunting throughout the state.
Prior to the approval, hunters were only allowed to use semi-automatic shotguns within specific areas near Pittsburgh and Philadelphia, and only for deer and bear. Shotguns must be 12 gauge or bigger for elk hunting.
The new regulation will take effect this year.
The regulation stipulates that shotgun ammunition must be slugs, as buckshot won't be allowed.
A handful of states mandate "shotgun-only" firearm deer seasons. Shotguns were once thought to be safer than centerfire rifles, in that the a shotgun slug didn't travel as far as a rifle slug. But with the development of modern rifled shotgun slugs, no discernible difference in safety between the two firearms is apparent.
As of this time, the Pennsylvania Hunting and Trapping Digest hasn't made updates to reflect the new regulation.
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text:
At the Swiss Hotel Management School students learn the traditions of Swiss hoteliers in an authentic environment. Students at the international Swiss hotel school can choose from a broad range of programmes in Hotel Operations, Events, Resort and Spa Management or Food & Beverage and Restaurant Management.
Hotel School Based on Tradition
The Swiss Hotel Management School offers an exciting range of programmes founded upon the internationally recognized Swiss traditions and focuses on global trends, business strategy and operational leadership. Students who join the international hotel school learn the art of Swiss Hospitality Management and develop the principles of the Swiss Hospitality Touch.
Inspiring Environment of a Swiss Hotel Management School
Students from more than 80 nationalities are found studying in two exceptional settings, which offer a unique learning environment, steeped in the heritage of the Swiss hospitality tradition. The historic Caux Palace campus overlooks the Swiss Riviera and the Leysin campus, housed in two former hotels in the stunning Swiss Alps.
Excellent Operational Facilities
At the Swiss Hotel Management School students gain hands-on experience in operational facilities including a restaurant open to the public, a spa with a public section, a culinary arts studio and an events gallery. These facilities at the Swiss hotel school are designed to replicate real-life situations and ensure that graduates have a high level of employability.
SHMS Swiss Hotel Management School is Switzerland’s largest English-speaking Hotel Management School. SHMS offers a wide range of world-class hospitality education programs for undergraduates and postgraduates in Hospitality, Restaurant, Events, Spa and Resort Management. Education programs combine academic study with practical experience through SMHS' management theory and strategy.
As a member of the Swiss Education Group, SHMS is 100% Swiss owned ensuring that its students receive top quality education with a distinctive Swiss style which is renowned worldwide. The two SHMS campuses in Caux and Leysin welcome students from over 65 nationalities making student’s life a truly international experience. Caux is a unique place close to the lively city of Montreux. SHMS' campus is located in the historic Caux Palace. Leysin is an international ski resort providing students with a wide range of recreational and sporting activities.
SHMS Swiss Hotel Management School offers two intakes each year in February and September. For students who need to improve their English language skills prior to beginning the academic year, the school provides an English Foundation education programme. Students at SHMS Swiss Hotel Management School receive the best possible preparation for their future in the exciting international world of hospitality management. Know More Here

domain: travel


text:
Reconstructions of ocean oxygenation are critical for understanding the role of respired carbon storage in regulating atmospheric CO2. Independent sediment redox proxies are essential to assess such reconstructions. Here, we present a long magnetofossil record from the eastern Indian Ocean in which we observe coeval magnetic hardening and enrichment of larger, more elongated, and less oxidized magnetofossils during glacials compared to interglacials over the last ~900 ka. Our multi-proxy records of redox-sensitive magnetofossils, trace element concentrations, and benthic foraminiferal Δδ13C consistently suggest a recurrence of lower O2 in the glacial Indian Ocean over the last 21 marine isotope stages, as has been reported for the Atlantic and Pacific across the last glaciation. Consistent multi-proxy documentation of this repeated oxygen decline strongly supports the hypothesis that increased Indian Ocean glacial carbon storage played a significant role in atmospheric CO2 cycling and climate change over recent glacial/interglacial timescales.
- Physics and Astronomy(all)
- Biochemistry, Genetics and Molecular Biology(all)

domain: geography


text:
Black rose succulent is a plant of the Crassulaceae family and it is not actually a rose but a succulent. It can be propagated by cuttings.
How To Propagate Black Rose Succulent
Here is the complete process explained in detail on how to propagate black rose succulent:
1. Step 1
1. Start by cutting a 4-inch piece of stem from the tip of the black rose succulent.
2. Step 2
2. Remove all leaves and thorns from the bottom inch of the stem, then cut it into 3-inch sections with a clean, sharp knife or pruning shears.
3. Step 3
3. Place each section in a small pot filled with cactus soil (or other well draining soil) and water well.
4. Step 4
4. Place in bright, indirect light and keep warm (but not too hot).
5. Step 5
5. Keep soil moist but not wet and wait for new plantlets to sprout!
Tips for How To Propagate Black Rose Succulent
Here are 5 things to take care of with respect to how to propagate black rose succulent:
1. You will need a rose stem with a few leaves on it. You can remove the leaves if you want to, but this isn’t necessary.
2. Try to find a stem that has a node on it. This is where new growth will be located, so it is important that you get one with a node on it!
3. Cut the stem at the base of the node and put it in water as described above for preserving roses.
4. Put your rose stem in a dark place where they won’t get too hot or cold for too long!
5. Water your rose stems every week or so unless you notice them drying out, in which case you should water them more often!
Interesting Facts About Roses
Here are 5 things you should know about roses:1. Roses are the most popular flower in the world, and that’s for a good reason. They’re pretty, they smell good, they symbolize love and romance, and they last a long time.
2. Rose petals are edible! You can add them to salads or cook with them.
3. Roses have many meanings: purity (white), innocence (yellow), joy (pink), gratitude (red), admiration (orange) and more. Matching your rose color to your message is important to make sure you get the right meaning across!
4. Roses come in different shapes and sizes: there are climbing roses, shrubs, miniature roses and hybrid teas, just to name a few! There are also different types of flowers within each type of rose – for example, there are over 100 different varieties of red roses out there!
5. The oldest known rose bush was planted in Persia around 4,000 years ago! It still grows today on the grounds of the University of Tehran!
How do you propagate black Aeonium?
Propagating a black Aeonium is easy, but it will take time. You can start by dividing the plant into sections and replanting them in new pots. Once they are large enough to transplant, you can plant them in their permanent location.
Aeoniums like full sun and well-drained soil. They also need little water once they are established. If you have an aeonium that is growing in a container, be sure to repot it every three years or so to prevent root rot from occurring.
How do you propagate a rose from a succulent?
You can take cuttings from healthy succulent plants, but it is best to leave a few leaves on the cutting so that it has food while it roots. The leaves will also help to protect the cutting from drying out.
The best time to take rose cuttings is in the spring, when they are actively growing. You can also take cuttings in late summer and early fall, but they may not root as quickly.
To prepare your rose cuttings, remove all of the leaves except for two or three at the top of each cutting. Make sure that you have removed all of the thorns from your cuttings before planting them. If you have any questions about how to do this, please see our article on preparing rose cuttings for planting.
Once you have prepared your rose cuttings, you can plant them in pots or directly into your garden bed. To plant them in pots, place a few inches of potting soil into a container and bury each cutting up to its base in the soil. Keep them evenly moist until they start to grow roots and new leaves. Once they are growing well, you can transplant them into your garden bed or give them away as gifts!
Can you propagate Aeonium from Leaf?
Yes, Aeonium can be propagated from leaf. In fact, it is one of the easiest succulents to propagate by leaf cuttings. All you need to do is take a leaf and plant it in a container filled with cactus mix soil or perlite. You can also use sand or gravel as well. Make sure that the leaves are not touching each other because they will rot if they are in contact with each other.
You can also collect cuttings from the edges of the rosette as well. These cuttings should be planted in small individual pots so that they don’t get disturbed when watering them.
How to care for an Aeonium?
Aeoniums are easy to care for and are perfect for beginner gardeners who want to start growing succulents but don’t know where to begin with. They have very few requirements and thrive in most conditions so there’s really no reason why you shouldn’t grow Aeoniums! Here are some tips on how you should care for your Aeonium:
Can you propagate Aeonium from stem?
Aeonium is propagated from stem or from leaf. The easiest way to propagate Aeonium is from leaf, which is also called ‘leaf pullings’. You can easily do this by removing a single leaf from the plant (don’t remove too many leaves at one time) and potting it in a pot with soil. Leave the leaf on top of the soil in the pot and place it under sunlight where you will be able to see it growing. The leaves will grow roots and eventually become a new plant! If you want to grow Aeonium from stem, simply cut off a piece of stem that has at least two leaves on it. Remove the bottom leaves and then place the stem in a pot with soil so that only one leaf remains above the soil level. Place it under sunlight and watch as it grows into a new plant!

domain: agronomy


text:
Gorgeous Earrings In Labrodarite & Pearls
Beauty is an trendy style and with our Gorgeous Earrings In Labrodarite & Pearls earrings you can follow that trend.
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|Materials||Brass with 18k micron plating|
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text:
City Commission supports commuter rail service
The St. Augustine City Commission voted 4-1 in favor of a resolution Monday that expressed support of a proposed commuter train service route in St. Johns County.
Commissioner Nancy Sikes-Kline said the vote was important to establish St. Augustine as a leader in what would surely be a long process to establish the service.
A study done in 2009 identified a line between Jacksonville and St. Johns County as one of three potential routes for the commuter rail. The others were between Jacksonville and Green Cove Springs and Jacksonville and Yulee.
James Boyle of the Jacksonville Transit Authority spoke to the Commission. He said the federal government would most likely be willing to fund half of the project, which is estimated to cost $193.3 million. The state, county and city would have to provide the rest.
In casting his dissenting vote, Commissioner Donald Crichlow said the cost would be more than he was willing to absorb.
"I just don't think that's where I want to put my tax dollars," he said.

domain: economics


Why does the USD 247 Board of Education want a Capital Outlay tax?
1) Continues to free up funding for educating students
Every dollar taken away from the General and Supplemental Funds is less money that can be spent directly on educating students. Capital Outlay is set aside specifically for capital expenses (computers, building maintenance, buses, etc.). Without a Capital Outlay tax, those funds must come from other sources, instruction in particular.
2) Costs increase while state cuts possible
Technology, transportation, maintenance, and nearly every other expense continues to rise at a time the state is threatening to cut funding. School districts across the state, especially rural school districts with a large number of students living in poverty, face possible cuts due to flat economy and some state legislators are advocating funding changes that could cost USD 247 as much as $450,000.
The only way to generate additional revenue is using a Capital Outlay tax. It would be for specific types of purchases, most of which are mandatory expenses regardless of the size of the district.
3) State offering to partially match funds raised locally for Capital Outlay
In addition to increasing funding through the local tax base, the State of Kansas matches a portion of those funds. As a poorer community, this school year the state would match about 40% of the local dollars generated – more than $98,000 in 2014-2015. KSDE expects the state aid to continue and not be just a one year arrangement.
The USD 247 Board of Education is asking voters for the authority to collect up to 8 mils annually specifically for Capital Outlay. How much they would actually collect would be up to the board members each year. In the past the board has had the authority to collect Capital Outlay but chose not to because funding from the state was enough to cover the budget. State legislators today have not made education a priority, but future representatives could change that. State funding has always been and will always be a wildcard. Having a locally collected Capital Outlay allows school districts to set aside money specifically for capital items – computers, buses, annual repairs/maintenance and save for large scale repairs (ie parking lots, track surface). This allows districts to have that money set aside and ready to go, regardless of what the state does for instructional funding.


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This Republican congressman is fighting to avoid a government shutdown
MARY LOUISE KELLY, HOST:
We are nine days away from what is looking more and more likely to be a government shutdown. Over the coming days, we will be reporting on the real consequences if a shutdown does come to pass, from veterans who don't receive their benefits to federal employees who get furloughed to your flight getting canceled if the FAA and TSA are not at full strength. The chief obstacle to moving spending bills forward is not partisan bickering - not this time - but infighting among Republicans, specifically among Republicans in the House. They control that chamber but cannot reach agreement on how best to cut spending. Well, one moderate Republican is calling this seemingly intractable situation, quote, "a clown show." That Republican is Mike Lawler of New York. Congressman Lawler, welcome to ALL THINGS CONSIDERED.
MIKE LAWLER: Thanks for having me.
KELLY: A clown show. Explain what you mean.
LAWLER: Well, listen. The American people elected a House Republican majority to serve as a check and balance on the Biden administration and to rein in reckless spending and to rightsize our government. But in order to do that, we have to work cohesively within the House caucus to do it. And unfortunately, we have some folks who are refusing to cooperate in a serious and meaningful way to find compromise within the caucus. You need 218 votes. And some of these people are just stuck on this mindset that it's their way or the highway and that if they don't get what they want, they're going to stomp their feet and, you know, throw a temper tantrum until they do so.
KELLY: The clowns in this analogy are the far-right members of your party.
LAWLER: It's not even whether they're far right or not. I mean, it's a handful of people who, throughout the course of the year, have proven themselves time and again to operate like this. And it's just totally inappropriate when you're within a conference. You know, these are the same people who voted against Kevin McCarthy despite the majority of the conference supporting him. These are the same people that have continually voted down rules despite, you know, a rule not failing in, you know, nearly 20 years. They don't care. And so as far as I'm concerned, when that's the situation, they basically leave people that are reasonable with very little choice but to find ways to work across the aisle.
KELLY: When speaking of accomplishing things or not accomplishing things, we are seeing news that the House is giving up on negotiations and about to dismiss and go home until Tuesday. Is that right?
LAWLER: That seems to be the report. But, you know, look. I don't think we should be going home at this point. We have a lot of work to do between now and September 30. I think, you know, frankly, these folks who, once again, after agreeing to move an appropriations bill, stalled it once more - you know, they should be here, working like everyone else. And so, you know, my feeling is that we should stay and we should work on these issues.
KELLY: The context here is, of course, that Speaker McCarthy enjoys only a four-vote margin in the House. Your colleagues are threatening, if they don't get their way, to put a process in motion to oust him. How much, Congressman - how much of what we're watching in Congress this week is Speaker McCarthy looking out for his own political future?
LAWLER: I don't think that's a fair assessment at all. I mean, the speaker has been working tirelessly to get the members to work as a conference. He's but one voice. And, you know, unlike Nancy Pelosi, who controlled everything with an iron grip, he has allowed the rank-and-file members to play a role in crafting legislation in the process. And so, you know, obviously it's messy at times. This is messier than I think anybody would want, including the speaker. But I don't think it's fair to say that he's putting his own interests ahead of the conference - not in the least.
KELLY: Is any of this raising questions in your mind about your party's ability to govern?
LAWLER: No. You're talking about a handful of people who right now are, you know, trying to exert pressure on the conference to get what they view as, you know, what the spending cuts should be and what the numbers should be. But I think as a conference, we have been able to advance a lot of legislation in the first nine months. We have been able to continue...
KELLY: Although just today you all failed to advance the defense spending bill. That was - in the previous shutdown under the Trump administration, Congress at least got that done - not this time.
LAWLER: Well, we still have nine days left. Obviously, we would like to see that bill debated and moved, and we'll continue to push for that. But this Congress has been serving as a check and balance on the Biden agenda. It's been able to stop a lot of the reckless spending. Obviously, the spending levels that this administration would like to continue at are not going to happen. And so that's, you know, a big part of what this debate and discussion is about. But ultimately, we're going to have to find compromise both within the conference and certainly working with the Senate and the White House to get to final appropriations bills. That's the objective. And that's what I and most of my colleagues will continue to work towards.
KELLY: A last question, and you can answer it in a word. How likely do you believe a shutdown is after September 30 - scale of 1 to 10?
LAWLER: Well, I'm not going to put a likelihood on it. I am going to do everything I can to avoid that. And I think most of my colleagues would like to avoid that. So we're going to keep working over the next nine days to make sure that that doesn't happen.
KELLY: Republican Congressman Mike Lawler of New York. Congressman, thank you.
LAWLER: Thanks. Transcript provided by NPR, Copyright NPR.

domain: news


text:
Asked by Andy Blackwell in Uncategorized
What causes equine distemper?
We need you to answer this question!
If you know the answer to this question, please register to join our limited beta program and start the conversation right now!
Can humans get equine distemper?
Asked in Veterinary Medicine, Horse Health
Is there a vaccination for Equine Distemper?
Equine Distemper, also called "Strangles", can be vaccinated against, however the vaccines available are not highly effective at protecting against the disease and come with a higher risk of serious adverse reactions than other equine vaccines. In fact, vaccination against Strangles is only recommended for horses at high risk. It is therefore recommended that horse owners discuss the risks vs. rewards of vaccinating against Strangles with their veterinarian and take other steps such as quarantine and disinfection of buckets and feeders to help reduce the risk of infection with the bacteria that causes Strangles.
What is equine distemper and can it be cured?
Equine Distemper is the same thing as strangles (the common name), it is a disease that causes swelling in the nasal tissue as well as pus filled abcesses in the lymph nodes. Most times it works itself out when the abcesses rupture and then the horse recovers without a problem, the only reason to treat it with anitbiotic or by draining the abcess is when a horse is doing very badly and if not treated will die. There are many websites on the subject and it would be worth your while to look some up. I hope this has helped.
what causes equine flue in horses?
How do you use the word distemper in a sentence?
Asked in Cat Health
What does a distemperment shot do for cats?
Asked in Home Improvement, Painting and Staining
What is difference between synthetic and acrylic distemper?
Asked in Medication and Drugs, Animal Life, Antibiotics
What antibiotic is used for the treatment for canine distemper?
Asked in Care of Horses, Veterinary Medicine
What is equine vernicular?

domain: medical


text:
Buyers offer to buy Steimatzky operations without taking on debt
We don’t want creditors taking a 'haircut,' says Ardelan CEO.
The sale of the Steimatzky book store chain is still not a done deal, as the two sides spar over the price and other terms.
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Sixth & I – Sanctuary
- This event has passed.
From their days playing together as teenagers while growing up in the Washington, DC area, to their current gig playing acoustic and electric blues, Rock and Roll Hall of Famers Jorma Kaukonen and Jack Casady—the duo behind Hot Tuna—have consistently led American music for the last 50 years.
While in The Jefferson Airplane, putting together the soundtrack of the 60s, the pair remained loyal to the blues, jazz, bluegrass, and folk influences of the small clubs and larger venues they had learned from years before. While in San Francisco and even in hotel rooms on the road, they would play together and worked up a set of songs that they would often play at clubs in the Bay Area and while on the road, often after having played a set with the Airplane. This led to a record contract; in fact, they had an album recorded before they decided to name their band Hot Tuna.
After two decades of acoustic and electric concerts and albums, the 1990s brought a new focus on acoustic music to Hot Tuna. Maturity also brought the desire to do things not instead of but in addition to being a touring band. Both had become interested in teaching, passing along what they had learned and what they had uniquely developed to a new generation of players.
More Info: Artist's Website
Video: "Hesitation Blues"
Sep 25, 2023 • 8:00 am ET
Sep 28, 2023 • 7:00 pm ET
If Books are Banned: Reading Between the Lines
Oct 1, 2023 • 6:00 pm ET
In Conversation with Mehdi Hasan
Oct 4, 2023 • 7:00 pm ET
Keegan-Michael Key and Elle Key
In Conversation with Helena Andrews-Dyer
Oct 11, 2023 • 7:00 pm ET
In Conversation with Carla Lalli Music and Andy Baraghani
Oct 12, 2023 • 7:00 pm ET
In Conversation with Juanita Tolliver
Oct 18, 2023 • 7:00 pm ET
In Conversation with Daniela Galarza
Oct 21, 2023 • 7:30 pm ET
Avi Avital, mandolin, and Hanzhi Wang, accordion
Oct 28, 2023 • 7:30 pm ET
In Conversation with Olga Massov
Nov 1, 2023 • 8:00 pm ET
Nov 2, 2023 • 7:00 pm ET
Nov 7, 2023 • 7:00 pm ET
In Conversation with Daniel Silva

domain: artistic


text:
SHROOM3 is a novel candidate for heterotaxy identified by whole exome sequencing
Genome Biology volume 12, Article number: R91 (2011)
Heterotaxy-spectrum cardiovascular disorders are challenging for traditional genetic analyses because of clinical and genetic heterogeneity, variable expressivity, and non-penetrance. In this study, high-resolution SNP genotyping and exon-targeted array comparative genomic hybridization platforms were coupled to whole-exome sequencing to identify a novel disease candidate gene.
SNP genotyping identified absence-of-heterozygosity regions in the heterotaxy proband on chromosomes 1, 4, 7, 13, 15, 18, consistent with parental consanguinity. Subsequently, whole-exome sequencing of the proband identified 26,065 coding variants, including 18 non-synonymous homozygous changes not present in dbSNP132 or 1000 Genomes. Of these 18, only 4 - one each in CXCL2, SHROOM3, CTSO, RXFP1 - were mapped to the absence-of-heterozygosity regions, each of which was flanked by more than 50 homozygous SNPs, confirming recessive segregation of mutant alleles. Sanger sequencing confirmed the SHROOM3 homozygous missense mutation and it was predicted as pathogenic by four bioinformatic tools. SHROOM3 has been identified as a central regulator of morphogenetic cell shape changes necessary for organogenesis and can physically bind ROCK2, a rho kinase protein required for left-right patterning. Screening 96 sporadic heterotaxy patients identified four additional patients with rare variants in SHROOM3.
Using whole exome sequencing, we identify a recessive missense mutation in SHROOM3 associated with heterotaxy syndrome and identify rare variants in subsequent screening of a heterotaxy cohort, suggesting SHROOM3 as a novel target for the control of left-right patterning. This study reveals the value of SNP genotyping coupled with high-throughput sequencing for identification of high yield candidates for rare disorders with genetic and phenotypic heterogeneity.
Congenital heart disease (CHD) is the most common major birth defect, affecting an estimated 1 in 130 live births . However, the underlying genetic causes are not identified in the vast majority of cases [2, 3]. Of these, approximately 25% are syndromic while approximately 75% are isolated. Heterotaxy is a severe form of CHD, a multiple congenital anomaly syndrome resulting from abnormalities of the proper specification of left-right (LR) asymmetry during embryonic development, and can lead to malformation of any organ that is asymmetric along the LR axis. Heterotaxy is classically associated with heart malformations, anomalies of the visceral organs such as gut malrotation, abnormalities of spleen position or number, and situs anomalies of the liver and/or stomach. In addition, inappropriate retention of symmetric embryonic structures (for example, persistent left superior vena cava), or loss of normal asymmetry (for example, right atrial isomerism) are clues to an underlying disorder of laterality [4, 5].
Heterotaxy is the most highly heritable cardiovascular malformation . However, the majority of heterotaxy cases are considered idiopathic and their genetic basis remains unknown. To date, point mutations in more than 15 genes have been identified in humans with heterotaxy or heterotaxy-spectrum CHD. Although their prevalence is not known with certainty, they most likely account for approximately 15% of heterotaxy spectrum disorders [4, 7–9]. Human X-linked heterotaxy is caused by loss of function mutations in ZIC3, and accounts for less than 5% of sporadic heterotaxy cases . Thus, despite the strong genetic contribution to heterotaxy, the majority of cases remain unexplained and this indicates the need for utilization of novel genomic approaches to identify genetic causes of these heritable disorders.
LR patterning is a very important feature of early embryonic development. The blueprint for the left and right axes is established prior to organogenesis and is followed by transmission of positional information to the developing organs. Animal models have been critical for identifying key signaling pathways necessary for the initiation and maintenance of LR development. Asymmetric expression of Nodal, a transforming growth factor beta ligand, was identified as an early molecular marker of LR patterning that is conserved across species [10–12]. Genes in the Nodal signaling pathway account for the majority of genes currently known to cause human heterotaxy. However, the phenotypic variability of heterotaxy and frequent sporadic inheritance pattern have been challenging for studies using traditional genetic approaches. Although functional analyses of rare variants in the Nodal pathway have been performed that confirm their deleterious nature, in many cases these variants are inherited from unaffected parents, suggesting that they function as susceptibility alleles in the context of the whole pathway [7, 8].
More recent studies have focused on pathways upstream of Nodal signaling, including ion channels and electrochemical gradients [13–15], ciliogenesis and intraflagellar transport , planar cell polarity (Dvl2/3, Nkd1) [17, 18] and convergence extension (Vangl1/2, Rock2) [19, 20], and non-transforming growth factor beta pathway members that interact with the Nodal signaling pathway (for example, Ttrap, Geminin, Cited2) [21–23]. Relevant to the current study, we recently identified a rare copy number variant containing ROCK2 in a patient with heterotaxy and showed that its knockdown in Xenopus causes laterality defects . Similar laterality defects were identified separately with knockdown of Rock2b in zebrafish . The emergence of additional pathways regulating LR development has led to new candidates for further evaluation. Given the mutational spectrum of heterotaxy, we hypothesize that whole-exome approaches will be useful for the identification of novel candidates and essential for understanding the contribution of susceptibility alleles to disease penetrance.
Very recently, whole-exome analysis has been used successfully to identify the causative genes for many rare disorders in affected families with small pedigrees and even in singlet inherited cases or unrelated sporadic cases [25–29]. Nevertheless, one of the challenges of whole-exome sequencing is the interpretation of the large number of variants identified. Homozygosity mapping is one approach that is useful for delineating regions of interest. A combined approach of homozygosity mapping coupled with partial or whole-exome analysis has been used successfully in identification of disease-causing genes in recessive conditions focusing on variants within specific homozygous regions of the genome [30–32]. Here we use SNP genotyping coupled to a whole-exome sequencing strategy to identify a novel candidate for heterotaxy in a patient with a complex heterotaxy syndrome phenotype. We further evaluate SHROOM3 in an additional 96 patients from our heterotaxy cohort and identify four rare variants, two of which are predicted to be pathogenic.
Previously we presented a classification scheme for heterotaxy in which patients were assigned to categories, including syndromic heterotaxy, classic heterotaxy, or heterotaxy spectrum CHD . Using these classifications, patient LAT1180 was given a diagnosis of a novel complex heterotaxy syndrome based on CHD, visceral, and other associated anomalies. Clinical features include dextrocardia, L-transposition of the great arteries, abdominal situs inversus, bilateral keratoconus, and sensorineural hearing loss (Table 1). The parents of this female proband are first cousins, suggesting the possibility of an autosomal recessive condition.
Chromosome microarray analysis
LAT1180 was assessed for submicroscopic chromosomal abnormalities using an Illumina genome-wide SNP array as well as exon-targeted array comparative genomic hybridization (aCGH). Copy number variation (CNV) analysis did not identify potential disease-causing chromosomal deletions/duplications. However, several absence-of-heterozygosity regions (homozygous runs) were identified via SNP genotyping analysis (Table 2 and Figure 1), consistent with the known consanguinity in the pedigree. These regions have an overwhelming probability to carry disease mutations in inbred families .
Following SNP microarray and aCGH, the exome (36.5 Mb of total genomic sequence) of LAT1180 was sequenced to a mean coverage of 56-fold. A total of 5.71 Gb of sequence data was generated, with 53.9% of bases mapping to the consensus coding sequence exome (accession number [NCBI: SRP007801]) . On average, 93.3% of the exome was covered at 10× coverage (Table 3 and Figure 2), and 70,812 variants were identified, including 26,065 coding changes (Table 4). Overall, our filtering strategy (Materials and methods) identified 18 homozygous missense changes with a total of 4 coding changes occurring within the previously identified absence-of-heterozygosity regions (Table 2 and Figure 1). These included one variant each in CXCL2 (p.T39A; chr4:74,964,625), SHROOM3 (p.G60V; chr4:77,476,772), CTSO (p.Q122E; chr4:156,863,489), and RXFP1 (p.T235I; chr4:159,538,306).
Previously, we developed an approach for prioritization of candidate genes for heterotaxy spectrum cardiovascular malformations and laterality disorders based on developmental expression and gene function . In addition, we have developed a network biology analysis appropriate for evaluation of candidates relative to potential interactions with known genetic pathways for heterotaxy, LR patterning, and ciliopathies in animal models and humans (manuscript in preparation). Using these approaches, three of the genes, CXCL2, CTSO, and RXFP1, are considered unlikely candidates. CXCL2 is an inducible chemokine important for chemotaxis, immune response, and inflammatory response. Targeted deletion of Cxcl2 in mice does not cause congenital anomalies but does result in poor wound healing and increased susceptibility to infection . CTSO, a cysteine proteinase, is a proteolytic enzyme that is a member of the papain superfamily involved in cellular protein degradation and turnover. It is expressed ubiquitously postnatally and in the brain prenatally. RFXP1 (also known as LRG7) is a G-protein coupled receptor to which the ligand relaxin binds. It is expressed ubiquitously with the exception of the spleen. Mouse Genome Informatics shows that homozygous deletion of Rfxp1 leads to males with reduced fertility and females unable to nurse due to impaired nipple development. In contrast, SHROOM3 is considered a very strong candidate based on its known expression and function, including its known role in gut looping and its ability to bind ROCK2.
Further analysis of the SHROOM3 gene confirmed a homozygous missense mutation (Table 4 and Figure 3) in a homozygous run on chromosome 4. These data support the recessive segregation of the variant with the phenotype. This mutation was confirmed by Sanger sequencing (Figure 4c) and was predicted to create a cryptic splice acceptor site, which may cause loss of exon 2 of the gene.
The homozygous mutation p.G60V in SHROOM3 was predicted to be pathogenic using the bioinformatic programs Polyphen-2 , PANTHER , Mutation Taster  and SIFT . Glycine at position 60 of SHROOM3 as well as its respective triplet codon (GGG) in the gene are evolutionarily conserved across species, suggesting an important role of this residue in protein function (Figure 4a, b). Mutation Taster  predicted loss of the PDZ domain (25 to 110 amino acids) and probable loss of remaining regions of SHROOM3 protein due to the cryptic splicing effect of the c.179G > T mutation in the gene (Figure 5). Variants in CTSO, RFXP1, and CXCL2 were predicted to be benign by more than two of the above bioinformatic programs.
SHROOM3 was analyzed in 96 sporadic heterotaxy patients with unknown genetic etiology for their disease using PCR amplification followed by Sanger sequencing. Four nonsynonymous nucleotide changes were identified (Table 5 and Figure 6) that were not present in the HapMap or 1000 Genomes databases, indicating they are rare variants. Each variant was analyzed using PolyPhen, SIFT, and PANTHER. Both homozygous variants p.D537N and p.E1775K were predicted to be benign by all programs, whereas the heterozygous variants p.P173H and p.G1864D were identified as damaging by all programs.
In the present study, we investigated a proband, LAT1180, from a consanguineous pedigree with a novel form of heterotaxy syndrome using microarray-based CNV analysis and whole-exome sequencing. Our initial genetic analysis using two microarray-based platforms (Illumina SNP genotyping and exon-targeted Agilent aCGH) failed to identify any potential structural mutation. However, we observed homozygous regions (absence-of-heterozygosity) from SNP genotyping data, suggesting that homozygous point mutations or small insertion/deletion events within these regions could be disease associated. Subsequently, whole-exome analysis resulted in the identification of a novel homozygous missense mutation in the SHROOM3 gene on chromosome 4. Additional sequencing in a cohort of 96 heterotaxy patients identified two additional patients with homozygous variants and two patients with heterozygous variants. Although in vivo loss of function analyses have demonstrated the importance of SHROOM3 for proper cardiac and gut patterning, specific testing of the variants identified herein will be useful to further establish pathogenicity and the most common mode of inheritance. This study demonstrates the usefulness of high-throughput sequencing and SNP genotyping to identify important candidates in disorders characterized by genetic and phenotypic heterogeneity.
SHROOM3 encodes a cytoskeletal protein of 1,996 residues that is composed of 3 main domains with distinct functions (Figure 5). SHROOM3, an actin binding protein, is responsible for early cell shape during morphogenesis through a myosin II-dependent pathway. It is essential for neural tube closure in mouse, Xenopus, and chick [40–42]. Early studies in model species showed that Shroom3 plays an important role in the morphogenesis of epithelial sheets, such as gut epithelium, lens placode invagination, and also cardiac development [43, 44]. Recent data indicate an important role for Shroom3 in proper gut rotation . Interestingly, gut malrotation is a common feature of heterotaxy and is consistent with a laterality disorder. In Xenopus, Shroom3 is expressed in the myocardium and is necessary for cellular morphogenesis in the early heart as well as normal cardiac tube formation with disruption of cardiac looping (Thomas Drysdale, personal communication, manuscript in revision). Downstream effector proteins of Shroom3 include Mena, myosin II, Rap1 GTPase and Rho Kinases [40–42, 44, 46].
Shroom3 may play an important role in LR development acting downstream of Pitx2. Pitx2 is an important transcription factor in the generation of LR patterning in Xenopus, zebrafish, and mice [47–49]. Recently it was shown that Pitx2 can directly activate expression of Shroom3 and ultimately chiral gut looping in Xenopus . Gut looping morphogenesis in Xenopus is most likely driven by cell shape changes in gut epithelium . The identification of Shroom3 as a downstream effector fills an important gap in understanding how positional information is transferred into morphogenetic movements during organogenesis. The presence of a Pitx2 binding-sites upstream of mouse Shroom3 combined with the similar gut looping phenotypes of mouse Pitx2 and Shroom3 mutants supports the interactive mechanism for these two proteins [41, 43, 51].
Studies from snails, frogs and mice suggest cell-shape/arrangement regulation and cytoskeleton-driven polarity is initiated early during development, establishing LR asymmetry [19, 52–55]. Recent data from our lab and others demonstrated that rho kinase (ROCK2), a downstream effector protein of SHROOM3, is required for LR and anteroposterior patterning in humans, Xenopus and zebrafish [20, 24]. In animal models, either overexpression or loss of function may cause similar phenotypes. These results led us to suggest that this pathway (Figure 7), which is a central regulator of morphogenetic cell shape changes, may be a novel target for the control of LR patterning. Sequencing of these newly identified genes downstream of the canonical Nodal signal transduction pathway will be necessary to determine their importance for causing heterotaxy in a larger number of patients. We predict whole-exome sequencing will become an important modality for the identification of novel disease-causing heterotaxy genes, candidate genes, and disease-associated rare variants important for disease susceptibility.
SHROOM3 is a novel candidate for heterotaxy-spectrum cardiovascular malformations. This study highlights the importance of microarray-based SNP/CNV genotyping followed by exome sequencing for identification of novel candidates. This approach can be useful for rare disorders that have been challenging to analyze with traditional genetic approaches due to small numbers, significant clinical and genetic heterogeneity, and/or multifactorial inheritance.
Materials and methods
DNA of proband LAT1180 was extracted from whole peripheral blood leukocytes following a standard protocol. Screening of SHROOM3 was performed using DNA samples from 96 additional sporadic heterotaxy patients. The heterotaxy cohort has been reported previously [7, 9]. DNA samples with previous positive genetic testing results were not used in the current study. This study was approved by the Institutional Review Boards at the Baylor College of Medicine and Cincinnati Children's Hospital Medical Center (CCHMC). Written informed consent for participation in this study as well as publication of clinical data of the proband was obtained. All the methods applied in this study conformed to the Declaration of Helsinki (1964) of the World Medical Association concerning human material/data and experimentation  and ethical approval was granted by the ethics committee of the Baylor College of Medicine and CCHMC.
Genome-wide SNP genotyping was performed using an Illumina HumanOmni-Quad Infinium HD BeadChip. The chip contains 1,140,419 SNP markers with an average call frequency of > 99% and is unbiased to coding and noncoding regions of the genome. CNV analysis was performed using KaryoStudio Software (Illumina Inc.).
Array comparative genomic hybridization
The custom exon-targeted aCGH array was designed by Baylor Medical Genetics Laboratories  and manufactured by Agilent Technology (Santa Clara, CA, USA). The array contains 180,000 oligos covering 24,319 exons (4.2/exon). Data (105 k) were normalized using the Agilent Feature Extraction software. CNVs were detected by intensities of differentially labeled test DNA samples and LAT1180 DNA samples hybridized to Agilent array containing probes (probe-based). Results were interpreted by an experienced cytogeneticist at the Baylor College of Medicine. The Database of Genomic Variants  and in-house cytogenetic databases from the Baylor College of Medicine and CCHMC were used as control datasets for CNV analysis.
Genomic DNA (3 μg) from proband LAT1180 was fragmented and enriched for human exonic sequences with the NimbleGen SeqCap EZ Human Exome v2.0 Library (2.1 million DNA probes). A total of approximately 30,000 consensus coding sequence genes (approximately 300,000 exons, total size 36.5 Mb) are targeted by this capture, which contains probes covering a total of 44.1 Mb. The resulting exome library of the proband was sequenced with 50 bp paired-end reads using Illumina GAII (v2 Chemistry). Data are archived at the NCBI Sequence Read Archive (SRA) under an NCBI accession number [NCBI: SRP007801] . All sequence reads were mapped to the reference human genome (UCSC hg 19) using the Illumina Pipeline software version 1.5 featuring a gapped aligner (ELAND v2). Variant identification was performed using locally developed software 'SeqMate' (submitted for publication). The tool combines the aligned reads with the reference sequence and computes a distribution of call quality at each aligned base position, which serves as the basis for variant calling. Variants are reported based on a configurable formula using the following additional parameters: depth of coverage, proportion of each base at a given position and number of different reads showing a sequence variation. The minimum number of high quality bases to establish coverage at any position was arbitrarily set at 10. Any sequence position with a non-reference base observed more than 75% of the time was called a homozygous variant. Any sequence position with a non-reference base observed between 25% and 75% of the time was called a heterozygous variant. Amino acid changes were identified by comparison to the UCSC RefSeq database track. A local realignment tool was used to minimize the errors in SNP calling due to indels. A series of filtering strategies (dbSNP132, 1000 Genomes project (May 2010)) were applied to reduce the number of variants and to identify the potential pathogenic mutations causing the disease phenotype.
Mutation screening and validation
Primers were designed to cover exonic regions containing potential variants of SHROOM3 and UGT2A1 genes in LAT1180. For screening additional heterotaxy patients, primers were designed to include all exons and splice junctions of SHROOM3 (primer sequences are available upon request). A homozygous nonsense variant (p.Y192X) was confirmed in the UGT2A1 gene within the same homozygous region on chromosome 4 but was later excluded because of its presence in the 1000 Genomes project data. PCR products were sequenced using BigDye Terminator and an ABI 3730XL DNA Analyzer. Sequence analysis was performed via Bioedit Sequence Alignment Editor, version 6.0.7 . All positive findings were confirmed in a separate experiment using the original genomic DNA sample as template for new amplification and bi-directional sequencing reactions.
array comparative genomic hybridization
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copy number variation
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We thank the heterotaxy patients and families for their cooperation. We thank Dr Thomas Drysdale for discussions and sharing data on Shroom3 in cardiac morphogenesis. We also thank the Genetic Variation and Gene Discovery Core (GVGDC) at CCHMC for providing genotyping and high-throughput sequencing facilities. This project was supported by a Burroughs Wellcome Fund Clinical Scientist Award in Translational Research #1008496 (SMW).
MT performed experiments, bioinformatics/mutational analysis and Sanger validation and wrote the manuscript. JWB performed clinical diagnosis. SMW performed clinical diagnosis, designed the project, received funding and wrote the manuscript. SL and TS evaluated and interpreted SNP microarray and aCGH data. All authors read and approved the final manuscript for publication.
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Tariq, M., Belmont, J.W., Lalani, S. et al. SHROOM3 is a novel candidate for heterotaxy identified by whole exome sequencing. Genome Biol 12, R91 (2011). https://doi.org/10.1186/gb-2011-12-9-r91
- Congenital Heart Disease
- Heterotaxy Syndrome
- Copy Number Variation Analysis
- Homozygous Missense Mutation