I appreciate this is not in itself a thyroid issue, but nonetheless, might be of some interest to members:
The Case for Keto review – why a full-fat diet should be on the menu
The investigative journalist Gary Taubes is known for his painstakingly researched and withering demolitions of the “eat less, move more” diet orthodoxy, but his latest book is personal. The Case for Keto is aimed at “those of us who fatten easily”. Taubes locates himself in this beleaguered group, “despite an addiction to exercise for the better part of a decade” and a diet of “low-fat, mostly plant ‘healthy’ eating”. “I avoided avocados and peanut butter because they were high in fat and I thought of red meat, particularly steak and bacon, as an agent of premature death. I ate only the whites of egg.” Yet still he remained overweight.
Taubes started to shed those pounds when he realised that one-size-fits-all diet advice fails, among other reasons, because people are metabolically different. Some of us can eat fattening carbohydrates and sugar and get away with it; others can’t.
Those who claim to have “a sluggish metabolism” are too often seen as making lame excuses for their weakness and indulgence. This punitive view – that fat people could easily be thin people if only they would eat less and exercise more diligently – is wrong, says Taubes. It amounts to what the philosopher Francis Bacon called “wishful science”, based on “fancies, opinions and the exclusion of contrary evidence”.
Rest of this article-cum-book-review freely accessible here:
I've seen very mixed commentary from people about whether keto is truly suitable for those with thyroid disease, or women for that matter. I'd be curious to know the general consensus of HU on it to be fair.
For women, the argument is that parts of the cycle benefit from a slightly higher carb intake, for the thyroid in general, it's supposedly about conversion and gut flora.
No one says high carb is better, just that extremely low carb isn't as beneficial for us.
I'm looking forward to reading this book at some point this year. Reading "Why We Get Fat" some years ago was a revelation to me, especially because Taubes appears to be the only writer on the science of low carb and keto diets who considers the plight of that most hard-to-help creature: the post-menopausal woman who cannot lose weight, no matter what. I'm hoping there'll be an update in the new book on the science of the group of hormones, including Hormone-Sensitive Lipase (HSL), that put a brake on the metabolism of adipose tissue in a low-oestrogen environment.
Taubes has never had very much to say about the thyroid though, and it seems to be a major gap in the writings on low carb diets. If you have a look at websites like dietdoctor.com, the spiel on the thyroid and the treatment of thyroid disorders (at least, the last time I looked) is utterly conventional, and wrong in the ways you might therefore expect.
Thought you might enjoy my retort to endo: when I managed to finally [after 12 yrs of the best efforts of any human ] lost that weight [see way below] and wth HbA1c down from 71 to 39 in 4 months; not even intermittent fasting, just 14:10 Leptin Reset, eating VLC/HF/MP every 5 hrs x 3 a day.
The bizarre endo who UN_diagnosed me after 5+ years of a hypothyroid dx (ludicrous story), said: "This is remarkable... etc, etc" yet in his letter to GP said, "Lost weight through trying". Worse still, he is not a typical diabetic endo who dabbles with thryoid matters, but specialises in non-standard obesity, so I responded to his letter:
“She has lost a lot of weight through trying”: indeed you told me that you were “most impressed” and “had never seen anything like it”. A good doctor, a curious human, would have listened and asked how? Not you! Your mind is so closed that I now see why your department is criticized… you have all shut yourselves off to so much around you, basking in this unimaginative, hackneyed aura, where there is no wood (certainly none burning), let alone trees. No Dr *&$%, it is your department that is ‘trying’; that you seem both unable and unwilling to get its head around the fact that hormones = metabolism, so there seems little hope in these times for anyone.
😲😵 Wow! Congratulations on actually writing the kind of retort I've longed to make following yet another pointless encounter with yet another incurious and oblivious (and highly paid) doctor. 🤘 xx 🤘
Another encounter with him: I'll stop now! This was from 2015 - 2016. And, as my amazing paternal G'mother [maternal was too] used to say, "Best be hung for a sheep..."
"You appeared to think it amusing to attempt to ‘throw back at me’ my document on the flawed notion of CI-CO, scoffing at my comments on ‘thermodynamics as portrayed by medics’. For anyone in your position, who will see many with complex hormonal problems being unable to lose weight, it would be usual to listen to someone who had actually achieved a good result quite rapidly. My own struggle, especially since pre-diabetic, of eating exactly as I do now, with exercise that would put most of your department, including you, to shame, yet with medicine unable to offer anything but shoddy advice and insults. The low fat and carbs rubbish pushed by doctors for years [even to diabetics] continues to damage… but it does keep patients coming through the doors. Even with remarkable results, your conduct towards me was unbelievably deplorable! Oh but there are many like me who must also be simply mistaken about our own bodies and how we react to different foods and exercise. You, of course, must know better!"
Shoot,! I should have done it with my Endo that I had beef with that she put lies on my record!!! (Basically about me possibly being negligent and refusing to listen to advice!!!
Many of us, particularly the older ones, remember people eating bacon, sausage, egg, butter (with a sigh of relief they could avoid that awful margarine from war-time years), etc. Plus bread with most meals.
That is, diets with lots of fat and lots of carbs.
They might not have been quite as healthy as they could have been, but many lived to a good age.
I have always felt that anyone who argues for a substantially different diet has to demonstrate that it is, or is at least likely to be, better than the traditional diets.
Going from that to a diet using egg whites only, etc., is a radical change. It seems to assume that if a 10% reduction of fat intake gives you a 10% "improvement", however assessed, a 100% reduction will give you a 100% improvement. The thirsty person drinks a glass of water and feels better for it. Would ten glasses be ten times better? No! (And don't try it - excess water is dangerous.)
That is, an adjustment to fat and/or carb intake might well be beneficial for some. Plus or minus 10% of either - give it a try! But 100% (or as near as you can manage), pretty much never.
It concerns me when someone switches from one extreme to the other. Didn't they question the first extreme sufficiently before they embarked on trying to attain it? Didn't they wonder that as they went 10%, 20%, 30%, ... that they didn't see the improvement they predicted?
The grains that people consumed in the first half of the 20th century (particularly wheat) are very different from the grains people consume now. Even without GMO, wheat has undergone crossbreeding, heat treatments and high radiation treatment to cause genetic changes and mutations, all to increase yields and profits. The flipside is that the proteins in grains are more inflammatory than they used to be. It's simply not possible to eat the same diet as our ancestors, but it makes sense to get as close as you can.
When it comes to grains in general, humans did not consume them much beyond 10,000 to 12,000 years ago, and neither have we evolved to eat them in such a short time. If we are suited to eat them (which many will claim we are not) it'll be through coincidence rather than evolution.
I think one problem common to many food products is that sugar and carbs are hidden away in the most unexpected places.
I bought some beef burgers recently (Tesco's Finest, allegedly) and on the back of the packet it said that they contained rice flour, dehydrated potato, sugar and dextrose (as well as beef and a few other things). I'm sure Tesco's online shopping site used to have all the ingredients listed for all products. But not any more, as I discovered just today.
I think they do have to make ingredient information accessible online.
When selling food online, all the label information – apart from the durability date – must also be available, at no extra cost to consumers, before they make an online purchase.
However, Tesco Finest 4 British Beef Steak Burgers 454G appears to use one exemption to an explicit ingredients list, that of putting all ingredients into the Description:
Succulent beef, simply seasoned with sea salt and black pepper. Gluten free.
Trouble is, some comments suggest that the product does actually have other ingredients. Not having any to hand ( ) and not being in a Tesco right now, I can't check!!!
However, in this case, I don't think it is the making or buying beefburgers themselves so much as a major retailer appearing to fail in their legal obligations. If they do not list the ingredients properly for this product, they are likely to do so on others.
I agree. My husband has an allergy to lactose and so I have to check ingredient labels carefully (why are they often printed in such small type?). When I used to go shopping, I would sometimes ask assistants to read the labels and they would often think that eggs are dairy products!
Recalling the case of the death of that young woman who ate a sandwich at an airport which didn’t list an allergen...
All the Fancy expensive named yoghurts are trash so many squeal "Low fat/Fat Free" Yet to bolster what would constitute Urine in a pot they add let me see? Tapioca Starch.Rice Flour and more so they have robbed you/removed all the beneficial elements of the yoghurts and replaced with rubbish and if your diabetic it isn't what you need/want.
Natural Fats don't make you put weight on there a readily burnable source of energy where as messed about fats/foods does make you put weight on as the Body say's HUH whats the junk you have stuffed into me so shoved it to one side ie belly line and that's where it stays and increases as we stuff more into our faces.
Just like Green/wet wood on a fire little heat lot's of smoke and wood pile just grows bigger and bigger with each delivery!.Where as nice Dry Seasoned Wood Burns nicely little smoke lot's of heat/Energy and wood pile is small/reducing!
I agree with him that we are very different! I don’t need to try to lose weight luckily. I think I struggle to process vast amounts of fat from dairy and wonder if I read something about that with Hashimotos and whether the source was credible...
I have accidentally lost weight when eating lots of protein for body building (and I mean lots, like 100g a day - I weigh about 9st at 5,9) and when on AIP. What both had in common in terms of what I ate, was low fat dairy and no dairy. I was trying to get some carbs in with the weight lifting but probably not enough... I found that I am not at all hungry if I eat a lot of protein, so on a personal level, it is what I would turn to to lose weight in the future if necessary. In both cases the weight loss was accidental, so I guess I was lucky to stumble on it!
I find that carbs make me hungry for more carbs in some kind of addictive circle kind of way, but do find they give me energy. When I am eating lots of carbs I probably eat more calories in general and I wonder if either eating more calories or carbs in particular has a positive impact on conversion from T4 to T3 in my case... I am out in a limb and guessing there... Feeling full / losing weight is a different issue; I tend to be lower on carbs when weightlifting to accommodate all that protein and of course, the same goes with AIP... But I think it is the drop in dairy fat which does it, rightly or wrongly! I guess I know how terrible I feel after attacking a decent cheese board - one of my favourite things
Yes, all of that is absolutely accepted. Once, however, menopausal + hypothyroid [cold! at times temp 34.5C in a room 26.4C] hits... where I did the heaviest of exercise, pushing and pushing myself beyond... with weights/resistance + Pilates + low cardio (too much cardio can make you fat - stress increases cortisol - which brought about my initial weight gain). I also had an exemplary diet due to being unable to lose any weight for 12 yrs - I had never been overweight - so took this badly and didn't veer from 'doing the right thing'. Mid-2015, a high T2D blood result, where it took very LC/HF/Mod Protein to make weight loss happen and with NO exercise + more calories... it took the opposite to standard 'medical advice' to lose IRO 50 lbs (49.?) in 4 months with an Hb1Ac down from 71 to 39 [dropped again to 37).
I got ill with dreadful vertigo [now controlled... I loathe any meds but must use betahistine] and weight came back within only, maybe 3 weeks, of dietary changes*. Having lost, effortlessly, almost 50 lbs - GP said *'starches only' due to incessant vertigo vomiting - I WAS SO STUPID to listen - I'd have done better fasting entirely. It took only those few weeks to alter my year plus of maintaining great weight loss. In no time10 lbs went back on, from weeks of small amounts of porridge and tiny bits of mashed potato and then I went back to my great dietary habits. Weight kept on climbing and climbing - NO MATTER WHAT I DID - up to 60 lbs just piled on and I was back to the 12 years of being unable to lose weight. Finally 28 lbs down but that's four years on; gutted to say the least! So many doctors simply have no clue and where our metabolic systems are so idiosyncratically different - not only from one another - but even within our own self.
All this—and—when I was a kid (I’m now 51), you had potatoes and bread with your meals. You didn’t have pasta or rice or pizza—I didn’t start having any of those things until the mid-eighties onwards.
I also walked 2 miles to school and back. My Dad had a car but we certainly couldn’t have afforded 2 cars so if you wanted to go somewhere, you walked. Some of my friends’ parents didn’t have a car at all.
Portion sizes have got bigger and bigger throughout my lifetime in part because food is now an awful lot less expensive than it used to be (or at least, junk food is...)
Funny how we all have different backgrounds. I remember rice and spaghetti (but no other pasta) from the early 1960s. Parents used to have a curry quite regularly. A little later, macaroni.
But bread with a meal was not usual at home - except for mopping up gravy or fried bread at breakfast. When visiting, I was always surprised when a plate full of sliced bread, usually buttered, arrived. The oddest, though, was a full Scottish high tea. Hot dish, bread and butter (with or without jam), then lots of cakes.
For five of us my mother baked four loaves of bread every day and six loaves every other day. We got through a lot of butter and a gallon of milk a day. We had a dairy farm. Milk was unpasteurised and butter often homemade. Eggs were from our free range chicken and vegetables from a large garden. There was always cake in the tin and we always had a pudding. We were all lean. I seem to recall that meat was a lot fattier in those days; I can’t get dripping off a joint of beef now. (There was always a large bowl of beef dripping in the dairy which we would have on toast with salt.). Perhaps it was all the exercise we had which offset the diet. There was no TV but then as children we were hardly ever indoors. My father worked from morn ‘til night every day of the year but died young at 75, which I put down to stress; my mother went on until 96. I’m hoping to make at least 100, but only if I still have my marbles and that’s not certain as I’ve mislaid some already.
It’s sometimes hard for us, I think, to appreciate that previous generations had only just enough food to keep going. Farmers were luckier than a lot of people during the last wars as they could grow so much themselves. My father told me that they would butcher their own meat, which he didn’t like to do and was happy when it became the job of the slaughter house. Even with all that we are dealing with today, we are so much luckier than previous generations. For a start, there is no conscription.
Wow, I never knew a Scottish high tea was an actual thing, I thought it was a strange meal we went for occasionally, called “<name of establishment’s> high tea”. It was a strange pub that only served this particular meal. I think there were a few main meal options but I don’t think anyone ever had anything but steak pie as it was amazing. Every day’s a school day!
Thank you, I think I will read this book. I find this subject fascinating. Before thyroid problems I could always lose weight with reducing carbs. Then when I had undiagnosed thyroid problems this easy fix didn’t apply anymore. I am now trying to find the right balance with carbs. I feel 100% in control of what I eat if I don’t touch GF bread or any GF pasta, except brown rice pasta. If I eat those things I get hungry very quickly straight after, so suspect I need to control blood sugars. But I can go too far I’m not eating enough carbs - I know I have done this when my vision goes a bit blurry. So searching for the sweet spot! Wish I could do keto but am dairy free - cheese was my favourite food and all the recipes appeal to the cheese lover in me. But I love all the other good high fat stuff. Thanks for the post!
Thank you for this link - so many are struggling - due to a dreadful lack of GP/endo advice. To this day, many doctors still cling to the CI-CO (Calories In-Calories Out) nonsense, which is demonstrably false for many. Of course there are exceptions, but anyone with a stubborn metabolic problem certainly needs to look elsewhere. Leptin and Ghrelin are key hormones re our eating and - once those are in shape - insulin seems to then become 'whipped into shape' and this is where KETO comes into its own: "We seem to need fat to lose fat".
Dr Jason Fung, MD, is a nephrologist and expert in the use of intermittent fasting and low-carbohydrate diets for the treatment of Type 2 diabetes. He trained in Los Angeles and Toronto as a kidney specialist. He has made so many video links: check them out on youtube.
Dr. Jason Fung: To Lose Weight, You MUST control Insulin
Many people can 'get away with' carbs - others can't if they seek to lose weight. And, as helvella said, there's no 'one-size-fits-all' due to so many individual factors. ENJOY!
I could never be extreme with my diet but I do have a natural tendency for meat and veg and eating once a day. But Keto wouldn’t be for me, it’s too specific.
Lockdown has me spun out of my natural diet habits and I’ve ‘let myself go’ 😩 less exercise and more carbs (ie alcohol).
Rice is my main vice also! White rice! It’s probably one of the plainest foods out there but it tastes like heaven to me! I have mine with petit pois and a tin of mackerel or tuna with all the oil too.
White rice really is a vice! Lol It has very little nutritional value as it’s so processed. It’s an empty carb I’m afraid, very little fibre. Although some add in some vitamins.
I don’t consider rice ‘bad’ I don’t consider any foods bad. There’s just some that I tolerate more than others. And by tolerate I mean, some add bloat and fat to my body and some I could eat all day. Everything in moderation for me, it’s just sometimes my moderation is a little higher than normal 😜
White rice isn't completely useless because it is soluble fibre. Soluble fibre absorbs water (helping everything to pass through the colon), and can help keep cholestreol down.
I actually hate rice and only eat it in moderation if it is mixed with something else. I blame school dinners when we were forced to eat rice pudding ... yuk!
I detest rice too and I always have noodles instead... to me rice looks and feels like maggots and I haven’t touched it since I left my mum’s home many, many years ago! (She was a rice-with-anything type cook) Hubby and some of my kids eat it happily but I don’t!🤢
I just made the mistake of reading below the line under the Guardian article...Why do I do this? Never a good idea. 🙄 Lots of young "meat is bad for you", "keto is a fad diet" vegan ideologues.
Perhaps you need to be a bit longer in the tooth to realise that until the late 1970s - when US influence on UK public health advice began to have an impact - the standard advice for losing weight was to cut out sugar and starch! We have a copy of Marguerite Patten's Bedsit Cookery, used by my husband when he was a student c.1980, containing exactly this advice. As does the Good Housekeeping cookbook from the same period.
My farming relatives ate some starchy food of course, but only in the amounts necessary to soak up the gravy and meat fat. 😋 Huge lunchtime meat pasties eaten outside had their sturdy pastry support, but the thickest part, the crimp, would be thrown away (or thrown to the dog).
I think I first came across high fat low carb dieting from the books by Barry Groves, such as "Eat Fat Get Thin" and "Trick and Treat - how 'healthy eating' is making us ill"
Googling for 'obesity statistics uk' I find that 'Adult obesity in England has risen from 15% in 1993 to 29% in 2017'. I think that for all of that time we were being advised to eat low fat products and of course the food manufacturers joined in. It certainly seems as if the official advice on healthy eating has actually had the opposite effect.
Weight-reducing diets are a very personal thing. Everybody is different. I am male, 66, used to do triathlons and cycling. I put on weight very easily because I eat too much. To reduce it I have to eat less - It has been relatively easy over the last 16 months and I have lost 30kg. Using a balanced diet of everything. I have tried most things in the past include low carb but nothing works better for me than eating less.
When I was growing up my mum was low fat obsessed! Lol She finds it so strange that we eat ALL natural fats in our diet! I buy the 20% fat mince and she’s worried if she can’t get the 5% one 😂 Goose fat is one of our favourites 😋
Many years ago, the food industry had a huge move towards low-sugar products. Initially I had some hope. So many products even then were too sweet. Think yogurts where the fruit flavouring was mostly sugar.
I'd have been quite happy to see the sugar content reduced, and pretty much nothing else done.
The reality was a move from sugar (sucrose) to multiple sugars (fructose, glucose, etc.) and sweeteners. Often ending up as sweet or sweeter than the original product.
Personally a keto diet works for my body. I am 0+ blood so caveman blood in origin and that’s why I think it works for me. Biologically my ancestors would eat meat and non starchy carbs like fruit and fats from nuts and meats but I said that already. No rice, no potatos etc . I have done many bodybuilding competitions and this diet works works for me. I think it is personal. Before people go and talk about restrictive eating, when I’m not competing I have a cheat MEAL. One meal where I can eat anything I want and as much as I can for in my belly. I have one hour to do this. What does this do? It satisfies cravings, stops binge eating but most importantly it tricks the body into thinking it’s not being starved and actually increases metabolism. I only diet in competition season. Fats are very important to stave off depression. Fats are not the enemy and fats make everything taste good. Food is good for us in MODERATION and that’s what we all forget today, maybe not us thyroid members, but we do t have famine or food shortages so we don’t know what it is to go without. If you’re hungry these days you just go and get what you want. That’s part of the obesity problem. Food is in plentiful supply.
Hmm, I agree with most of what you say. We're certainly all individual in terms of the specifics of diet, the proportions of each food group we process most efficiently, and so forth - something thyroid disorders can muck up in all sorts of ways, of course.
I think I part company with you on the point of over-supply, and obsesity being mainly, or even partly a consequence of that. I think our main problems now are that carbs are cheap, filling in the short term, but only until they spike insulin. The temptation to buy these products preferentially, if you're short of money and short of time, may be overwhelming.
Thereafter, the hormone cascade that pushes excess blood glucose into fat cells as triglycerides, and then drives the release of adrenalin, has led to record numbers of the insulin-resistant and the frankly diabetic. It's a genuine health crisis, but I agree that going very low carb or even keto will not be the saviour of everyone.
Agreed too many starching carbs cause blood sugars to spike and laying down fat. But I go back to what I said in that no food is bad is moderation. Everybody’s body is different and there are foods that are better for you than others. No one today in the western world is without food. Our portion sizes are too big. Food on a plate should be one quarter protein, on a plate should be one quarter starchy carbs and half non starchy carbs like brocolli, spinach, pumpkin etc.
I think I part company with you on the short of money and time. We have to be responsible for our food choices and that means making time to make food from scratch and this includes sauces etc.
Having grown up in a household short on money and being short of money myself at times, it isn’t money that stops healthy eating but knowledge and time. I used to be able to make a good, sustaining meal for £1 not so long ago but then I was taught to cook on a shoestring.
For all those that have joined the Low/no Fat Fetish it = Ill health because if you cut out Fats you become low/deficient in Vitamins A.D.E as there what's termed Fat soluble while B & C are water soluble.
So without fats in your foods the body can't assimilate the vitamins from your food so just passes through your system Which = Low vitamin levels Which =more problems as everything is connected in our bodies.
The Human body needs a mixture of things as we are not Herbivores ie Solely Veg/plant/Grass eaters Nor Carnivores ie Meat Eaters But Omnivores which means a mixture of all to survive well.
For one we have Molars and can masticate our jaws like a Cow for one but also have cutting and ripping teeth like Cats and dogs and a Bear is more in line with us.
Did all this when did my Sports Science/coaching Courses.
When did class about Diabetes we got to the subject of fat! Now had been Lectured by Quacks nurse about it all but what she said was all old hat!=Dangerous.
What Specialists are saying is for one about Milk go with Blue/Full Fat because forone when they mess with it taking fat out it removes Goodness.
Also Red has highest sugar Blue lowest!
It's also high Sugar that damages Cells
The Fats to avoid are Hydrogenated and modified fats etc Read the Labels and if prints too tiny to read or mumbo jumbo'd very often trying to hide something so get's left where i found it!
The other Killer is Soya increasing Cancers if you look at it from a distance as many say i know so many with cancers!
Soya from southern Hemisphere ie Asia is different though as that is a Natural Fermented soya which removes the Phytoestrogens!
Now Soya in the Western World is a cheap "Filler/Bulker" Soya That's GMO and "NON/UnFermented which is full of Phytoestrogens which are a bad type of sort of Synthetic Bad Estrogen which overloads your own Hormonal system causing many issues inc Free Radical cells which promote Cancers.
You also find Phytoestrogens in things like plasticisers/Cleaning Products and many other things overload your body with a bad type and in men Corrupt Testosterone.
So always be mindful with life always be prepared to look and learn
I also read on here someone saying avoid likes of Peanut Butter! Peanut butter is one of the best things to eat/spread on things as the fats in it are so beneficial to us and all nuts are very good for us and most of the fat passes through our system anyway but the advantages of nuts outweighs any Calories but not saying you need to stuff bags of them in your face a day but a hand full of them is Top!
Many would point out that peanuts are not strictly nuts but legumes (like peas, beans, lupins, etc.). Though they do have some things in common with true nuts so the division is not quite as clear as we might wish!
For all you Keto folks - I'm currently enjoying day 4 of the Quit Sugar Summit - no sugar no flour. It's great. It's put me back on track.
And for LindaC - I went from 82kg to 71kg on Keto and my endo's only comment was 'if you continue to lose weight I will reduce your T3 prescription' - despite the fact that my T3 measurement was 3.1 when bottom of the range was 3.0!
Sitting here pretty chuffed since I’m on Keto and really don’t care what docs tend to tell me.I have T1D and I find that Keto is the only way to manage blood sugars. It helps with insulin resistance and i notice that even if I introduce small and moderate amount of carbs now and then my overall insulin requirements go up (not just insulin for food) and values are always all over the place! It’s quite weird!
But my diabetic dieticians disagree and say “no evidence of benefit of low carb” and especially, “we don’t have data on long term health effects and impact”.
So when they ask me about diet I just say I eat a bit less carbs than usual and don’t mention fat at all. 😂🙈
If asked… I say I calorie count. And if asked again, I lie, and say I’m very careful about fat 😂😂 which is kind of true as I try to only eat “good fats”!
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) and not being in a Tesco right now, I can't check!!!
I still use her book sometimes.
How do you manage(enjoy) your food when you have Hashimoto’s/ hypothyroidism?
Keto or just low carbs
Eat more lose more? How does that work...
A review paper showing the complex action of T3 on cardiac function
