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Bounce rate is always a big problem for bloggers particularly for these reasons:
1.) High bounce rate means that readers do not engage with their blog too often; a sign of poor blogging quality.
2.) Higher bounce rate can correlate with low blog income because visitors view more pages resulting in less page views. Higher page views are always important for increased blog income or conversion rate.
Well there a lot of classic techniques to reduce bounce rate which you should already be implementing:
1.) Improving faster website loading.
2.) Quality content.
3.) Good website design.
It is recommended to focus on the first three techniques above before proceeding with the rest of the tips discussed in this tutorial. There are lot of great tutorials that you can find on the web.
OK let's discuss some rare tips on how you can minimize blog bounce rate. These methods have been tested to work.
Tip#1: Increase your overall blog post font size by 1px or 2px
Benefit: Around 0.5% to 1% reduction in Bounce rate
Details: Sounds so simple isn't it? The concept is that smaller font size discourages your readers to engage/read in the blog too often, simply because it's very hard to read. Of course they can zoom it out with their browser, but this is not the way most of your users would behave.
To improve your font size:
1.) Install Firebug in your Firefox browser.
2.) Go to any of your blog posts and load them completely.
3.) In your Firefox, go to Web Developer � Firebug. Enable click an element to inspect and go to your existing blog post paragraph. On the right, it will return the CSS affected line used by blog post with the font size. Scroll down until you see like this:
Since its 12px try changing it to 14px. You will immediately notice that the content appears more readable than before. To permanently implement these changes, edit your CSS file and upload it back to your server.
Note: While increasing font sizes are good, too much of it can be detrimental. So use your eyes to decide whether the readability of your post would improve or worsen with increasing font sizes.
Also blend the increase of font size in your post with the font sizes used in your sidebar, ads, etc. to maintain a consistent look and feel in your blog.
Tip#2: Reduce the height of your header
Benefit: Around 1% to 3% reduction in Bounce rate
When your pages loads slow in some instances (slow connection in the part of your user) and your header section is very high. Chances are users do not immediately see the content and bounce back to where they came. You need to reduce this height to a minimum. It simply takes a simple CSS work. For example, this is the original header (enclosed in yellow):
The height of that is 90px. Now this is the reduced version (around half of the original height). It now looks cleaner and simple. The RSS feed which is not so useful has also been removed.
One reason why reducing header height can reduce bounce rate is that your most important content and links should now be more visible above the fold.
Tip#3: Show related & popular posts above the fold
Benefit: Around 3% to 5% reduction in Bounce rate
When user are reading your posts, sometimes they need to find out more information relating to that post. So show them all the related and popular posts in your blog for better user experience. It is important to show them above the fold so that users can get an immediate idea what are your other blog important contents. This would make them stick longer to your blog resulting in a lower the bounce rate.
To show them:
1.) Download YARRP and activate the plugin.
2.) Download WordPress popular post plugin and activate it also. Configure to return graphics for more eye catching popular post
2.) Make sure both related and popular post links are viewable above the fold. Use this above the fold tool to check.
Tip#4: Reduce Ads above the fold
Benefit: Around 3% to 10% reduction in Bounce rate
This is self-explanatory but if you have a lot of ads above the folds; it will tend to scare serious readers in your blog. It is because you are giving them an impression that your blog is made for advertisement and not for showcasing serious content.
Therefore, reduce the ads. It is recommended to have at least one solid ads above the fold (Google Adsense for example). The big rectangle ads besides your content. Configure it to return thelargest font size for biggest impact. If you using Google Adsense, adhere to the best practices of Google AdSense placement.
If you are using in-text advertising such as Infolinks, consider limiting the number of links to at most 3 per post.
Tip#5: Open all external links in new window
Benefit: Around 1% to 3% reduction in Bounce rate
This is self-explanatory. External links contribute to your bounce rate because once the user clicks on it, they are technically leaving the site.
However, by opening all external links in new window; your visitors is still on your site. To do this easily, you will be using the open external links in new window plugin. Simply upload and activate them in your WordPress admin. You do not need to set any settings.
Tip#6: Show "Next" post at the bottom or interactively
Benefit: Around 3% to 10% reduction in Bounce rate
One classic technique implemented by New York Times is that you will be presented with "Next post" which will animated at the bottom of the post. This looks like this:
This can be realized by downloading upPrev Previous Post Animated Notification plugin.
Upload the plug-in; activate then do the following:
1.) In your Worpress post single template. Add this somewhere at the end of your posts:

2.) Then in the upPrev configuration in your WordPress admin settings, configure as shown in the screenshot:
Tip#7: Internal linking power
Benefit: Around 3% to 5% reduction in Bounce rate if your blog have a lot of posts and lot of internal links.
Finally; when you are writing or editing posts; do not forget to link to your other posts naturally. Internal linking is a long proven method of reducing bounce rate.
The following are the tips:
1.) Link using consistent anchor text throughout the blog. For example, if you link to post X using widget as the anchor text. Then make sure that in all of your other post; you are linking to post X using widget as the anchor text.
This consistent linking cannot only help reduce bounce rate but it helps the ranking of post X in search engines for the keyword X.
2.) Make sure that you know your strong ranking keywords in search engines and what are the ranking WordPress posts. Then implement strategy#1 to interlink your posts using those keywords and ranking blog posts.
As a summary if you have completely implemented the seven tips in this tutorial. You should be expecting a 5% to 10% overall reduction in bounce rate in most cases.


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Fuji S9600 digital camera review
Fuji has a wide range of digital cameras from compacts to bridge cameras . The S9600 is one of the best bridge cameras ever made . Instead of reinventing the hugely successful Fuji S9500, the S9600 sees the introduction instead of some carefully-chosen improvements. Improving LCD size, image sharpness and low light autofocus, the new camera acts as a definite upgrade to its predecessor. The camera has a very impressive zoom lens; covering the crucial 28-300mm range, and crafted from the highest standard Fujinon optics, this is a built-in lens that has been engineered to work perfectly with the camera's sensor technology

subset: commoncrawl


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- +6221 8650962
- Office Hours: 08:30 - 17:00
- email@example.com
PT. NAPINDO MEDIA ASHATAMA prides itself in delivering real benefits and results to all our exhibitors, visitors and delegates. Establish in 1989, PT. Napindo Media Ashatama has since built up a portfolio of market leading exhibitions and conferences in major industry sectors including communications, multimedia and information technology, water & wastewater, presentation technology, electrical engineering/power and livestock.
Our success is credited to an experienced team of staff dedicated to providing the best service and support to our exhibitors, visitors, speakers and delegates. In addition, PT. Napindo Media Ashatama work closely with key government ministries and departments, embassies, associations and institutions in ensuring that the events organised contribute positively to the related industries.
PT. Napindo Media Ashatama is a leading exhibition & conference organizer in Indonesia responsible for Internetworks Indonesia Expo & Forum, Indo Telecom Expo & Forum, Indo Water Expo & Forum, IVAC Expo & Forum, Indo Wireless Expo & Forum, IndoCommIT Expo & Forum, Indo Livestock Expo & Forum, Indo Security Expo & Forum, Indo Firex Expo & Forum, Indo Meelex Expo & Forum, Indo Waste Expo & Forum, Indo Renergy Expo & Forum, Aspacpol Expo & Forum, Indo Marine Expo & Forum, Indo Aerospace Expo & Forum and Indo Defence Expo & Forum.
Jl. Raya Kalimalang, Ruko Green Terrace Blok 9 F
Pondok Kelapa, Jakarta Timur 13450, Indonesia
Jl. Kelapa Sawit XIV Blok M1 No. 10
Kompleks Billy & Moon, Pondok Kelapa
Jakarta 13450, Indonesia
Tel: 62-21 8650962, 8644756, 8644785
Fax: 62-21 865 0963
Indo Firex Expo & Forum organised by PT Napindo Media Ashatama


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Domus Organizer is a tool for real estate agencies. Stop simply displaying your properties and start managing them.
In addition to its own property, your agency will be able to organize and manage customers and their requests.
Do you have a potential buyer looking for a nice apartment with air condition, garden, lift, recently renovated?
Or you have a property and you want to look for if any of your customers are interested?
With Domus Organizer you can save everything and manage it appropriately.
You can find a public area, updated automatically every time you change an info.
Do you want to unpublish an item and manage it internally?
Simply click on a link and it's done!
Every time you add a new image to the property, the public slideshow will be updated; the map on the admin area allows you to set up the position accurately.
Don't be afraid of customizations!
Everything is achieved using CSS, so simply override the stylesheet with template overrides and you're done!
Moreover you can manage everything from the frontend, so you don't have to allow co-workers to login to the backend.
Remember: this is not a simply extension, but a powerful tool for real estate agencies.
*** Now dynamic fields are supported! You can customize your own installation as you wish!
Domus Organizer
- Version:
- 4.2.1
- Developer:
- Davide Tampellini
- Last updated:
Nov 23 2017
6 years ago - Date added:
- Nov 19 2014
- License:
- GPLv2 or later
- Type:
- Free download
- Related extension :
- Domus Organizer Professional
- Includes:
- c m p
- Compatibility:


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Caffeine Kicks
ZoOm Hungary
Budapest's brand of dark, bitter coffee was a staple during communist years and is still enjoyed by many. A new breed of coffee shops selling barista-made creations is challenging the city's old guard.
By Charles Hebbert, for CNN
"What kind of coffee do you have?"
"Well, black, or with milk," comes the grumpy reply.
This is the delightfully retro Bambi bar, where the interior and the grumpiness of the service haven't changed for 50 years. Nor has the coffee -- a drink that's always played a central role in Budapest life. Through the communist years those shots of dark, bitter coffee in small glasses, served by scowling waitresses, were a staple start to the day. While coffee's importance hasn't changed, a new wave of coffee bars -- where competitive baristas know their ristretto from their cortado -- is shaking up the scene. The buzz word is "kezmuves" -- it roughly translates as handmade, or craft.
There are three keys to the new craft coffee bars -- talented staff (with the certificates to prove it), slick design and carefully chosen ingredients. The coffee is sometimes described locally as "third wave," meaning it's fairly sourced and roasted on a smaller scale, giving it a lighter, less bitter taste than Italian beans.
"In new wave coffee you discover the real qualities of the coffee beans, like the fruity, citric qualities of African beans or the chocolate of Brazilian beans," says Peter Repka, manager of the Madal craft coffee bar.
Despite the interest in new wave, both old- and new-style coffee houses compete to deliver Budapest its caffeine kicks.
Here are some of the best:
Indian philosopher Sri Chimnoy, whose childhood name was Madal, must have loved his coffee. Inspired by his calmness, the friendly, capped baristas here earnestly go about their work, explaining the different beans and roasts available and serving beautifully presented cups.
They also bake their own sweet and savory croissants.
3 Hollan Erno St.
Espresso Embassy
This is one of the largest and best designed craft coffee bars -- it's staffed by an array of award-winning baristas. The brick-vaulted interior was done by the firm that designed two of the stations on the city's new metro line. An excellent cake selection includes croissants, cheesecakes and brownies.
15 Arany Janos St.
My Little Melbourne
Pioneer of the craft coffee movement, this minute coffee bar in the center of town is a busy breakfast place. Inspired by the Australian travels of owners Dia and Peti, it serves some of Budapest's best coffee and pastries.
3, Madach Imre St.
This one's even smaller than My Little Melbourne, but aficionados speak of Fekete with great respect. With a couple of tables on the pavement in front, Fekete (meaning "black" in Hungarian) is all about coffee, and very little else.
5 Muzeum korut
Tamp & Pull
This is the smaller of the T&P shops, but it's the most central, down the road from the Central Market Hall. The name refers to two moves in the barista's work -- tamp and pull -- which they do so well here they run courses on the art of coffee. A board on the wall details the beans on offer each day -- where they were grown, who farmed them and at what altitude.
3 Czuczor St.
Cafe Alibi
Breakfast is the best time to visit Cafe Alibi, a quietly hip square in the heart of Budapest. It's often buzzing with the local students enjoying the superb coffee and freshly squeezed orange juice. Cafe Alibi has its own roasting machine, offering customers a choice of beans and coffee type.
2 Egyetem ter
At this large cafe/restaurant in the heart of Budapest's partying Seventh District, the baristas roast their own beans. The coffee is superb, and so is the food -- after all those small coffee bars, you'll enjoy the space.
25 Dob St.
Coffee Cat
There's no craft coffee here, but the baristas in this busy breakfast joint know how to make an excellent brew. There's also a great selection of baguettes, with fillings such as caponata, roasted squash or chicken salad, from the sandwich specialists at the Delibaba workshop.
44 O St.
Zockni, or "Socks," isn't the obvious name for a cafe, particularly one placed across the road from one of Budapest's big tourist draws -- the magnificent Great Synagogue. It was the owner's nickname in his taxi driving days. More importantly, the baristas turn out top coffee and the cakes are delicious.
1/b Dohany St.
Finally, across the Buda river to old Budapest, to the glorious Bambi. No new coffee here. No fancy baristas, either. The retro feel hasn't been put together in a design studio -- it's always looked this way. It's one of the great survivors of the past. Here you can enjoy a strong black coffee in an old-style glass, sit on red plastic seats and watch old men playing cards. Just don't ask for a cortado.
2-4 Frankel Leo St.


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Coconut: In Support of Good Health In The 21st Century
by Mary G. Enig, Ph.D., F.A.C.N.
Coconuts play a unique role in the diets of mankind because they are the source of important physiologically functional components. These physiologically functional components are found in the fat part of whole coconut, in the fat part of desiccated coconut, and in the extracted coconutoil.
Lauric acid, the major fatty acid from the fat of the coconut, has long been recognized for the unique properties that it lends to nonfood uses in the soaps and cosmetics industry. More recently, lauric acid has been recognized for its unique properties in food use, which are related to its antiviral, antibacterial, and antiprotozoal functions.
Now, capric acid, another of coconut's fatty acids has been added to the list of coconut's antimicrobial components. These fatty acids are found in the largest amounts only in traditional lauric fats, especially from coconut. Also, recently published research has shown that natural coconut fat in the diet leads to a normalization of body lipids, protects against alcohol damage to the liver, and improves the immune system's anti-inflammatory response.
Clearly, there has been increasing recognition of health- supporting functions of the fatty acids found in coconut. Recent reports from the U.S. Food and Drug Administration about required labeling of the trans fatty acids will put coconut oil in a more competitive position and may help return to its use by the baking and snack food industry where it has continued to be recognized for its functionality. Now it can be recognized for another kind of functionality: the improvement of the health of mankind.
Functional Properties Of Lauric Fats As Antimicrobials
As a functional food, coconut has fatty acids that provide both energy (nutrients) and raw material for antimicrobial fatty acids and monoglycerides (functional components) when it is eaten. Desiccated coconut is about 69% coconut fat, as is creamed coconut. Full coconut milk is approximately 24% fat.
Approximately 50% of the fatty acids in coconut fat are lauric acid.
Lauric acid is a medium chain fatty acid, which has the additional beneficial function of being formed into monolaurin in the human or animal body.
Monolaurin is the antiviral, antibacterial, and antiprotozoal monoglyceride used by the human or animal to destroy lipid-coated viruses such as HIV, herpes, cytomegalovirus, influenza, various pathogenic bacteria, including listeria monocytogenes and helicobacter pylori, and protozoa such as giardia lamblia. Some studies have also shown some antimicrobial effects of the free lauric acid.
Also, approximately 6-7% of the fatty acids in coconut fat are capric acid.
Capric acid is another medium chain fatty acid, which has a similar beneficial function when it is formed into monocaprin in the human or animal body. Monocaprin has also been shown to have antiviral effects against HIV and is being tested for antiviral effects against herpes simplex and antibacterial effects against chlamydia and other sexually transmitted bacteria.
The food industry has, of course, long been aware that the functional properties of the lauric oils, and especially coconut oil, are unsurpassed by other available commercial oils. Unfortunately, in the U.S., both during the late 1930s and again during the 1980s and 1990s, the commercial interests of the U.S. domestic fats and oils industry were successful in driving down usage of coconut oil.
As a result, in the U.S. and in other countries where the influence from the U.S. is strong, the manufacturer has lost the benefit of the lauric oils in its food products. As we will see from the data I will present in this talk, it is the consumer who has lost the many health benefits that can result from regular consumption of coconut products.
The antiviral, antibacterial, and antiprotozoal properties of lauric acid and monolaurin have been recognized by a small number of researchers for nearly four decades: this knowledge has resulted in more than 20 research papers and several U.S. patents, and this past year it resulted in a comprehensive book chapter, which reviewed the important aspects of lauric oils as antimicrobial agents (Enig 1998).
In the past, the larger group of clinicians and food and nutrition scientists has been unaware of the potential benefits of consuming foods containing coconut and coconut oil, but this is now starting to change.
Kabara (1978) and others have reported that certain fatty acids (FAs) (e.g., medium-chain saturates) and their derivatives (e.g., monoglycerides (MGs)) can have adverse effects on various microorganisms: those microorganisms that are inactivated include bacteria, yeast, fungi, and enveloped viruses. Additionally, it is report-ed that the antimicrobial effects of the FAs and MGs are additive, and total concentration is critical for inactivating viruses (Isaacs and Thormar 1990).
The properties that determine the anti-infective action of lipids are related to their structure: e.g., monoglycerides, free fatty acids.
The monoglycerides are active; diglycerides and triglycerides are inactive. Of the saturated fatty acids, lauric acid has greater antiviral activity than either caprylic acid (C-8), capric acid (C-10), or myristic acid (C-14). In general, it is reported that the fatty acids and monoglycerides produce their killing/inactivating effect by lysing the plasma membrane lipid bilayer.
The antiviral action attributed to monolaurin is that of solubilizing the lipids and phospholipids in the envelope of the virus, causing the disintegration of the virus envelope. However, there is evidence from recent studies that one antimicrobial effect in bacteria is related to monolaurin's interference with signal transduction (Projan et al 1994), and another antimicrobial effect in viruses is due to lauric acid's interference with virus assembly and viral maturation (Hornung et al 1994).
Recognition of the antiviral aspects of the antimicrobial activity of the monoglyceride of lauric acid (monolaurin) has been reported since 1966. Some of the early work by Hierholzer and Kabara (1982) that showed virucidal effects of monolaurin on enveloped RNA and DNA viruses was done in conjunction with the Center for Disease Control of the U.S. Public Health Service.
These studies were done with selected virus prototypes or recognized representative strains of enveloped human viruses. The envelope of these viruses is a lipid membrane, and the presence of a lipid membrane on viruses makes them especially vulnerable to lauric acid and its derivative monolaurin.
The medium-chain saturated fatty acids and their derivatives act by disrupting the lipid membranes of the viruses (Isaacs and Thormar 1991; Isaacs et al 1992). Research has shown that enveloped viruses are inactivated in both human and bovine milk by added fatty acids and monoglycerides (Isaacs et al 1991), and also by endogenous fatty acids and monoglycerides of the appropriate length (Isaacs et al 1986, 1990, 1991, 1992; Thormar et al 1987).
Some of the viruses inactivated by these lipids are
- measles
- herpes simplex (HSV-1)
- vesicular stomatitis virus
- visna virus
- cytomegalovirus (CMV)
Many of the pathogenic organisms reported to be inactivated by these antimicrobial lipids are those known to be responsible for opportunistic infections in HIV-positive individuals. For example, concurrent infection with cytomegalovirus is recognized as a serious complication for HIV+ individuals (Macallan et al 1993).
Thus, it would appear to be important to investigate the practical aspects and the potential benefit of an adjunct nutritional support regimen for HIV-infected individuals, which will utilize those dietary fats that are sources of known antiviral, antimicrobial, and antiprotozoal monoglycerides and fatty acids such as monolaurin and its precursor lauric acid.
Until now, no one in the mainstream nutrition community seems to have recognized the added potential of antimicrobial lipids in the treatment of HIV-infected or AIDS patients. These antimicrobial fatty acids and their derivatives are essentially nontoxic to man; they are produced in vivo by humans when they ingest those commonly available foods that contain adequate levels of medium-chain fatty acids such as lauric acid.
According to the published research, lauric acid is one of the best "inactivating" fatty acids, and its monoglyceride is even more effective than the fatty acid alone (Kabara 1978, Sands et al 1978, Fletcher et al 1985, Kabara 1985).
The lipid-coated (envelope) viruses are dependent on host lipids for their lipid constituents. The variability of fatty acids in the foods of individuals as well as the variability from de novo synthesis accounts for the variability of fatty acids in the virus envelope and also explains the variability of glycoprotein expression, a variability that makes vaccine development more difficult.
Monolaurin does not appear to have an adverse effect on desirable gut bacteria, but rather on only potentially pathogenic microorganisms.
For example, Isaacs et al (1991) reported no inactivation of the common Escherichia coli or Salmonella enteritidis by monolaurin, but major inactivation of Hemophilus influenzae, Staphylococcus epidermidis and Group B gram positive streptococcus.
The potentially pathogenic bacteria inactivated by monolaurin include Listeria monocytogenes, Staphylococcus aureus, Streptococcus agalactiae, Groups A,F & G streptococci, gram-positive organisms, and some gram-negative organisms if pretreated with a chelator.
Decreased growth of Staphylococcus aureus and decreased production of toxic shock syndrome toxin-1 was shown with 150 mg monolaurin per liter (Holland et al 1994). Monolaurin was 5000 times more inhibitory against Listeria monocytogenes than ethanol (Oh & Marshall 1993). Helicobacter pylori is rapidly inactivated by medium-chain monoglycerides and lauric acid, and there appears to be very little development of resistance of the organism to the bactericidal effects (Petschow et al 1996) of these natural antimicrobials.
Important: A number of fungi, yeast, and protozoa are inactivated or killed by lauric acid or monolaurin. The fungi include several species of ringworm (Isaacs et al 1991). The yeast reported is Candida albicans (Isaacs et al 1991). The protozoan parasite Giardia lamblia is killed by free fatty acids and monoglycerides from hydrolyzed human milk (Hernell et al 1986, Reiner et al 1986, Crouch et al 1991, Isaacs et al 1991). Numerous other protozoa were studied with similar findings; these findings have not yet been published (Jon J. Kabara, private communication, 1997).
Research continues in measuring the effect of the monoglyceride derivative of capric acid monocaprin as well as the effects of lauric acid. Chlamydia trachomatis is inactivated by lauric acid, capric acid, and monocaprin (Bergsson et al 1998), and hydrogels containing monocaprin are potent in vitro inactivators of sexually transmitted viruses such as HSV-2 and HIV-1 and bacteria such as Neisseria gonorrhoeae (Thormar 1999).
Origins Of The Anti-Saturated Fat Agenda
The coconut industry has suffered more than three decades of abusive rhetoric from the consumer activist group Center for Science in the Public Interest (CSPI), from the American Soybean Association (ASA) and other members of the edible oil industry, and from those in the medical and scientific community who learned their misinformation from groups like CSPI and ASA. I would like to review briefly the origins of the anti-saturated fat, anti-tropical oil campaigns and hopefully give you some useful insight into the issues.
When and how did the anti-saturated fat story begin?
It really began in part in the late 1950s, when a researcher in Minnesota announced that the heart disease epidemic was being caused by hydrogenated vegetable fats. The edible oil industry's response at that time was to claim it was only the saturated fat in the hydrogenated oils that was causing the problem. The industry then announced that it would be changing to partially hydrogenated fats and that this would solve the problem.
In actual fact, there was no change because the oils were already being partially hydrogenated, and the levels of saturated fatty acids remained similar, as did the levels of the trans fatty acids. The only thing that really changed was the term for hydrogenation or hardening listed on the food label.
During this same period, a researcher in Philadelphia reported that consuming polyunsaturated fatty acids lowered serum cholesterol. This researcher, however, neglected to include the information that the lowering was due to the cholesterol going into the tissues, such as the liver and the arteries.
As a result of this research report and the acceptance of this new agenda by the domestic edible oils industries, there was a gradual increase in the emphasis on replacing "saturated fats" in the diet and on the consuming of larger amounts of the "polyunsaturated fats."
As many of you probably know, this strong emphasis on consuming polyunsaturates has backfired in many ways: the current adjustments being recommended in the U.S. by groups such as the National Academy of Sciences replace the saturates with monounsaturates instead of with polyunsaturates and replace polyunsaturates with monounsaturates.
Early promoters of the anti-saturated fat ideas included companies such as Corn Products Company (CPC International) through a book written by Jeremiah Stamler in 1963, with the professional edition published in 1966 by CPC. This book took some of the earliest pejorative stabs at the tropical oils.
In 1963, the only tropical fat or oil singled out as high in saturated fats was coconut oil. Palm oil had not entered the U.S. food supply to any extent, had not become a commercial threat to the domestic oils, and was not recognized in any of the early texts. An observation by the editorial staff of Consumer Reports noted that
"…in 1962…one writer observed, the average American now fears fat (saturated fat, that is) 'as he once feared witches.'"
In 1965, a representative of Procter and Gamble told the American Heart Association to change its Diet/Heart statement, removing any reference to the trans fatty acids. This altered official document encouraged the consumption of partially hydrogenated fats.
In the 1970s, this same Procter and Gamble employee served as nutrition chairman in two controlling positions for the National Heart Lung and Blood Institute's Lipid Research Clinic (LRC) trials and as director of one of the LRC centers. These LRC trials were the basis for the 1984 NIH Cholesterol Consensus Conference, which in turn spawned the National Cholesterol Education Program (NCEP).
This program encourages consumption of margarine and partially hydrogenated fats, while admitting that trans should not be consumed in excess. The official NCEP document states that "…coconut oil, palm oil, and palm kernel oil…should be avoided…"
In 1966, the U.S. Department of Agriculture documents on fats and oils talked about how unstable the unsaturated fats and oils were.
There was no criticism of the saturated fats. That criticism of saturated fat was to come later to this agency when it came under the influence of the domestic edible fats and oils industry, and when it developed the U.S. Dietary Guidelines.
These Dietary Guidelines became very anti-saturated fat and remain so to this day. Nevertheless, as we will learn later in my talk, there has started some reversal of the anti- saturated fat stance in the works in this agency in 1998.
In the early 1970s, although a number of researchers were voicing concerns about the trans fats, the edible oil industry and the U.S. Food and Drug Administration (FDA) were engaging in a revolving-door exchange that would:
- promote the increasing consumption of partially hydrogenated vegetable oils
- would condemn the saturated fats
- hide the trans issue
As an example of this "oily" exchange, in 1971 the FDA's general counsel became president of the edible oil trade association, and he in turn was replaced at the FDA by a food lawyer who had represented the edible oil industry.
From that point on, the truth about any real effects of the dietary fats had to play catch-up. The American edible oil industry sponsored "information" to educate the public, and the natural dairy and animal fats industries were inept at countering any of that misinformation.
Not being domestically grown in the U.S., coconut oil, palm oil, and palm kernel oil were not around to defend themselves at that time.
The government agencies responsible for disseminating information ignored those protesting "lone voices," and by the mid-1980s, American food manufacturers and consumers had made major changes in their fats and oils usage — away from the safe saturated fats and headlong into the problematic trans fats.
The Damaging Role Of The U.S. Consumer Activist Group CSPI
Some of the food oil industry (especially those connected with the American Soybean Association (ASA)) and some of the consumer activists (especially the Center for Science in the Public Interest (CSPI) and also the American Heart Savers Association) further eroded the status of natural fats when they sponsored the major anti-saturated fat, anti- tropical oils campaign in the late 1980s.
Actually, an active anti-saturated fat bias started as far back as 1972 in CSPI. But beginning in 1984, this very vocal consumer activist group started its anti-saturated fat campaign in earnest. In particular, at this time, the campaign was against the "saturated" frying fats, especially those being used by fast-food restaurants. Most of these so-called saturated frying fats were tallow based, but also included was palm oil in at least one of the hotel/restaurant chains.
Then in a "News Release" in August 1986, CSPI criticized what it called "Deceptive Vegetable Oil Labeling: Saturated Fat Without The Facts," referring to "palm, coconut, and palm kernel oil" as "rich in artery-clogging saturated fat."
CSPI further announced that it had petitioned the Food and Drug Administration to stop allowing labeling of foods as having "100% vegetable shortening" if they contained any of the "tropical oils." CSPI also asked for mandatory addition of the qualifier "a saturated fat" when coconut, palm or palm kernel oils were named on the food label.
In 1988, CSPI published a booklet called "Saturated Fat Attack." This booklet contained lists of processed foods "surveyed" in Washington, DC supermarkets. The lists were used for developing information about the saturated fat in the products.
Section III is entitled "Those Troublesome Tropical Oils," and it contains statements encouraging pejorative labeling. There were lots of substantive mistakes in the booklet, including errors in the description of the biochemistry of fats and oils and completely erroneous statements about the fat and oil composition of many of the products.
At the same time CSPI was conducting its campaign in 1986, the American Soybean Association began its anti-tropical oil campaign by sending inflammatory letters, etc., to soybean farmers. The ASA took out advertisements to promote a "Tropical Fat Fighter Kit." The ASA hired a Washington DC "nutritionist" to survey supermarkets to detect the presence of tropical oils in foods.
Then early in 1987, the ASA petitioned the FDA to require labeling of "Tropical Fats," and by mid-1987, the Soybean Digest continued an active and increasing anti-tropical oils campaign.
At about the same time (June 3, 1987), the New York Times published an editorial, "The Truth About Vegetable Oil," in which it called palm, palm kernel, and coconut oils "the cheaper, artery-clogging oils from Malaysia and Indonesia" and claimed that U.S. federal dietary guidelines opposed tropical oils, although it is not clear that this was so. The "artery-clogging" terminology was right out of CSPI.
Two years later in 1989, the ASA held a press conference with the help of the CSPI in Washington DC in an attempt to counter the palm oil group's press conference of March 6. The ASA "Media Alert" stated that the National Heart Lung and Blood Institute and National Research Council "recommend consumers avoid palm, palm kernel and coconut oils."
Only months before these press conferences, millionaire Phil Sokolof, the head of the National Heart Savers Association (NHSA), purchased the first of a series of anti-saturated fats and anti-tropical fats advertisements in major newspapers. No one has found an overt connection between Sokolof (and his NHSA) and the ASA, but the CSPI bragged about being his advisor.
What About Heart Disease And Coconut Oil?
The research over four decades concerning coconut oil in the diet and heart disease is quite clear: coconut oil has been shown to be beneficial. This research leads us to ask the question, "should coconut oil be used to both prevent and treat coronary heart disease?"
This statement is based on several reviews of the scientific literature concerning the feeding of coconut oil to humans. Blackburn et al (1988) have reviewed the published literature of "coconut oil's effect on serum cholesterol and atherogenesis" and have concluded that when "…[coconut oil is] fed physiologically with other fats or adequately supplemented with linoleic acid, coconut oil is a neutral fat in terms of atherogenicity."
After reviewing this same literature, Kurup and Rajmohan (1995) conducted a study on 64 volunteers and found "…no statistically significant alteration in the serum total cholesterol, HDL cholesterol, LDL cholesterol, HDL cholesterol/total cholesterol ratio and LDL cholesterol/HDL cholesterol ratio of triglycerides from the baseline values…" A beneficial effect of adding the coconut kernel to the diet was noted by these researchers.
Kaunitz and Dayrit (1992) have reviewed some of the epidemiological and experimental data regarding coconut-eating groups and noted that the "available population studies show that dietary coconut oil does not lead to high serum cholesterol nor to high coronary heart disease mortality or morbidity."
They noted that in 1989 Mendis et al reported undesirable lipid changes when young adult Sri Lankan males were changed from their normal diets by the substitution of corn oil for their customary coconut oil.
Although the total serum cholesterol decreased 18.7% from 179.6 to 146.0 mg/dl and the LDL cholesterol decreased 23.8% from 131.6 to 100.3 mg/dl, the HDL cholesterol decreased 41.4% from 43.4 to 25.4 mg/dl (putting the HDL values very much below the acceptable lower limit of 35 mg/dl) and the LDL/HDL ratio increased 30% from 3.0 to 3.9.
These latter two changes are considered quite undesirable. Mendis and Kumarasunderam (1990) also compared the effect of coconut oil and soy oil in normolipidemic young males, and again the coconut oil resulted in an increase in the HDL cholesterol, whereas the soy oil reduced this desirable lipoprotein. As noted above, Kurup and Rajmohan (1995), who studied the addition of coconut oil alone to previously mixed fat diets, had reported no significant difference from baseline.
Previously, Prior et al (1981) had shown that islanders with high intakes of coconut oil showed "no evidence of the high saturated fat intake having a harmful effect in these populations." When these groups migrated to New Zealand, however, and lowered their intake of coconut oil, their total cholesterol and LDL cholesterol increased, and their HDL cholesterol decreased.
Statements that any saturated fat is a dietary problem is not supported by evidence (Enig 1993).
Studies that allegedly showed a "hypercholesterolemic" effect of coconut oil feeding, usually only showed that coconut oil was not as effective at lowering the serum cholesterol as was the more unsaturated fat to which coconut oil was being compared. This appears to be in part because coconut oil does not "drive" cholesterol into the tissues as does the more polyunsaturated fats.
The chemical analysis of the atheroma shows that the fatty acids from the cholesterol esters are 74% unsaturated (41% of the total fatty acids is polyunsaturated) and only 24% are saturated. None of the saturated fatty acids were reported to be lauric acid or myristic acid (Felton et al 1994).
There is another aspect to the coronary heart disease picture. This is related to the initiation of the atheromas that are reported to be blocking arteries. Recent research shows that there is a causative role for the herpes virus and cytomegalovirus in the initial formation of atherosclerotic plaques and the reclogging of arteries after angioplasty. (New York Times 1991)
What is so interesting is that the herpes virus and cytomegalovirus are both inhibited by the antimicrobial lipid monolaurin, but monolaurin is not formed in the body unless there is a source of lauric acid in the diet. Thus, ironically enough, one could consider the recommendations to avoid coconut and other lauric oils as contributing to the increased incidence of coronary heart disease.
Chlamydia pneumoniae, a gram-negative bacteria, is another of the microorganisms suspected of playing a role in atherosclerosis by provoking an inflammatory process that would result in the oxidation of lipoproteins with induction of cytokines and production of proteolystic enzymes, a typical phenomena in atherosclerosis (Saikku 1997).
Some of the pathogenic gram-negative bacteria with an appropriate chelator have been reported to be inactivated or killed by lauric acid and monolaurin as well as capric acid and monocaprin (See above, Bergsson et al 1997 and Thormar et al 1999).
However, the microorganisms most frequently identified as probable causative infecting agents are in the herpes virus family and include cytomegalovirus, type 2 herpes simplex (HSV-2), and Coxsackie B4 virus. The evidence for a causative role for cytomegalovirus is the strongest (Ellis 1997, Visseren et al 1997, Zhou et al 1996, Melnick et al 1996, Epstein et al 1996, Chen & Yang 1995), but a role for HSV-2 is also shown (Raza-Ahmad et al 1995).
All members of the herpes virus family are reported to be killed by the fatty acids and monoglycerides from saturated fatty acids ranging from C-6 to C-14 (Isaacs et al 1991), which include approximately 80% of the fatty acids in coconut oil.
In spite of what has been said over the past four or more decades about the culpability of the saturated fatty acids in heart disease, they are ultimately going to be held blameless. More and more research is showing the problem to be related to oxidized products. One protection man has against oxidized products is the naturally saturated fats such as coconut oil.
The Latest On the Trans Fatty Acids
Both the United States and Canada will soon require labeling of the trans fatty acids, which will put coconut oil in a more competitive position than it has been in the past decade. A fear of the vegetable oil manufacturers has always been that they would have to label trans fatty acids. The producers of trans fatty acids have relied on the anti-saturated fat crusade to protect their markets. However, the latest research on saturated fatty acids and trans fatty acids shows the saturated fatty acids coming out ahead in the health race.
It has taken this last decade, from 1988 to 1998, to see changes in perception. During this period, the trans fatty acids have taken a deserved drubbing. Research reports from Europe have been emerging since the seminal report by Mensink and Katan in 1990 that the trans fatty acids raised the low density lipoprotein (LDL) cholesterol and lowered the high density lipoprotein (HDL) cholesterol in serum. This has been confirmed by studies in the U.S. (Judd et al 1994, Khosla and Hayes 1996, Clevidence 1997).
In 1990, the lipids research group at the University of Maryland published a paper (Enig et al 1990) correcting some of the erroneous data sponsored by the food industry in the 1985 review by the Life Sciences Research Office of Federation of American Societies for Experimental Biology (LSRO-FASEB) (Senti 1985) of the trans fatty acids.
Also, in 1993, a group of researchers at Harvard University, led by Professor Walter Willett, reported a positive relationship between the dietary intake of the trans fatty acids and coronary heart disease in a greater than 80,000 cohort of nurses who had been followed by the School of Public Health at Harvard University for more than a decade.
Pietinen and colleagues (1997) evaluated the findings from the large cohort of Finnish men who were being studied for a cancer prevention study. After controlling for the appropriate variables including several coronary risk factors, the authors observed a significant positive association between the intake of trans fatty acids and the risk of death from coronary disease.
There was no association between intakes of saturated fatty acids, or dietary cholesterol and the risk of coronary deaths.
This is another example of the differences between the effects of the trans fatty acids and the saturated fatty acids and further challenge to the dietary cholesterol hypothesis.
The issue of the trans fatty acids as a causative factor in remains underexplored, but recent reports have found a connection. Bakker and colleagues (1997) studied the data for the association between breast-cancer incidence and linoleic acid status across European countries since animal and ecological studies had suggest a relationship.
They found that the mean fatty acid composition of adipose did not show an association with omega-6 linoleic acid and breast, colon or prostate cancer. However, cancers of the breast and colon were positively associated with the trans fatty acids. Kohlmeier and colleagues (1997) also reported that data from the EURAMIC study showed adipose tissue concentration of trans fatty acids having a positive association with postmenopausal breast cancer in European women.
In 1995 a British documentary on the trans fatty acids aired on a major television station in the U.K. This documentary included an expose of the battle between the edible oil industry and some of the major researchers of the trans fatty acids. Just this year, this same documentary has been aired on television in France where it was requested by a major television station.
Several of the early researchers into the trans problems, Professor Fred Kummerow and Dr. George Mann, have continued their research and/or writing (Mann 1994). The popular media has continued to press the issue of the amounts of trans in the foods, for which there are still no comprehensive government data bases, and a recent published paper from a U.S. Department of Agriculture researcher states:
"Because trans fatty acids have no known health benefits and strong presumptive evidence suggests that they contribute markedly to the risk of developing CHD, the results published to date suggest that it would be prudent to lower the intake of trans fatty acids in the U.S. diet."(Nelson 1998).
Professor Meir Stampfer from Harvard University refers to trans fats as "one of the major nutritional issues of the nation," contending that "they have a large impact" and "…we should completely eliminate hydrogenated fats from the diet" (Gottesman 1998).
Lowering the trans fatty acids in the foods in the U.S. can only be done by returning to the use of the natural unhydrogenated and more saturated fats and oils.
Predictions can be made regarding the future of the trans fatty acids. Our ability to predict has been pretty good; for example when Enig Associates started producing the marketing newsletter Market Insights written by Eric Enig, we predicted that trans fatty acids would eventually be swept out of the market. It appears that this prediction may be close to coming true.
Also in the early 1990s, Market Insights predicted that CSPI would change its mind about the trans fatty acids, which it had spent years defending. CSPI did change its mind, and in fact went on the attack regarding the trans, but CSPI never admitted that it had originally been promoting the trans or that the high levels of trans found in the fried foods in the fast food and other restaurants and in many other foods are directly due to CSPI lobbying.
While its change was welcome, CSPI's revisionist version of its own history of support of partially hydrogenated oils and trans fatty acids would have fit perfectly into George Orwell's "1984"
Comparison Of Saturated Fats With The Trans Fats
The statement that trans fatty acids are like saturated fatty acids is not correct for biological systems. A listing of the biological effects of saturated fatty acids in the diet versus the biological effects of trans fatty acids in the diet is in actuality a listing of the good (saturated) versus the bad (trans).
When one compares the saturated fatty acids and the trans fatty acids, we see that:
saturated fatty acids raise HDL cholesterol, the so-called good cholesterol, whereas the trans fatty acids lower HDL cholesterol (Mensink and Katan 1990, Judd et al 1994);
saturated fatty acids lower the blood levels of the atherogenic lipoprotein ,
whereas trans fatty acids raise the blood levels of lipoprotein (Khosla and Hayes 1996, Hornstra et al 1991, Clevidence et al 1997);
saturated fatty acids conserve the elongated omega-3 fatty acids (Gerster 1998), whereas trans fatty acids cause the tissues to lose these omega-3 fatty acids (Sugano and Ikeda 1996);
saturated fatty acids do not inhibit insulin binding, whereas trans fatty acids do inhibit insulin binding;
saturated fatty acids are the normal fatty acids made by the body, and they do not interfere with enzyme functions such as the delta-6-desaturase, whereas trans fatty acids are not made by the body, and they interfere with many enzyme functions such as delta-6-desaturase;
some saturated fatty acids are used by the body to fight viruses, bacteria, and protozoa, and they support the immune system, whereas trans fatty acids interfere with the function of the immune system.
What About The Unsaturated Fats?
The arteries of the heart are also compromised by the unsaturated fatty acids. When the fatty acid composition of the plaques (atheromas) in the arteries has been analyzed, the level of saturated fatty acids in the cholesterol esters is only 26 percent compared to that in the unsaturated fatty acids, which is 74 percent.
When the unsaturated fatty acids in the cholesterol esters in these plaques are analyzed, it is shown that 38 percent are polyunsaturated and 36 percent are monounsaturated. Clearly the problem is not with the saturated fatty acids.
As an aside, you need to understand that the major role of cholesterol in heart disease and in cancer is as the body's repair substance, and that cholesterol is a major support molecule for the immune system, an important antioxidant, and a necessary component of neurotransmitter receptors. Our brains do not work very well without adequate cholesterol. It should be apparent to scientists that the current approach to cholesterol has been wrong.
The pathway to cholesterol synthesis starts with a molecule of acetyl CoA that comes from the metabolism of excess protein forming ketogenic amino acids and from the metabolism of excess carbohydrate, as well as from the oxidation of excess fatty acids.
Grundy in 1978 reported that the degree of saturation of the fat in the diet did not affect the rate of synthesis of cholesterol. Research reported in 1997 (Jones 1997), however, showed that the polyunsaturated fatty acids in the diet increase the rate of cholesterol synthesis relative to other fatty acids. Furthermore, research reported in 1993 (Hodgsons et al 1993) had shown that dietary intake of the omega-6 polyunsaturated fatty acid linoleic acid was positively related to coronary artery disease.
Thus, those statements made by the consumer activists in the United States to the effect that the saturated fatty acids increase cholesterol synthesis is without any foundation.
What happens when there is an increase or a decrease of cholesterol in the serum is more like a shift from one compartment to another as the body tries to rectify the potential damage from the excess polyunsaturated fatty acids. Research by Dr. Hans Kaunitz reported in 1978 clearly showed the potential problems with excess polyunsaturated fatty acids.
Research Showing Beneficial Effects Of Eating The More Saturated Fats
One major concern expressed by the nutrition community is related to whether or not people are getting enough elongated omega-3 fatty acids in their diets. The elongated omega-3 fatty acids of concern are eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA).
Some research has shown that (the basic omega-3 fatty acid) -linolenic acid is not readily converted to the elongated forms in humans or animals, especially when there is ingestion of the trans fatty acids and the consequent inhibition of the delta-6-desaturase enzyme.
One recent study (Gerster 1998), which used radioisotope-labeled -linolenic acid to measure this conversion in adult humans, showed that if the background fat in the diet was high in saturated fat, the conversion was approximately 6% for EPA and 3.8% for DHA, whereas if the background fat in the diet was high in omega-6 polyunsaturated fatty acids (PUFA), the conversion was reduced 40-50%.
Nanji and colleagues (1995) report that a diet enriched in saturated but not unsaturated fatty acids reversed alcoholic liver injury in their animals, which was caused by dietary linoleic acid. These researchers conclude that this effect may be explained by the down- regulation of lipid peroxidation.
This is another example of the need for adequate saturated fat in the diet. Cha and Sachan (1994) studied the effects of saturated fatty acid and unsaturated fatty acid diets on ethanol pharmacokinetics. The hepatic enzyme alcohol dehydrogenase and plasma carnitines were also evaluated. The researchers concluded that dietary saturated fatty acids protect the liver from alcohol injury by retarding ethanol metabolism, and that carnitine may be involved.
Hargrove and colleagues (1999) noted the work of Nanji et al and postulated that they would find that diets rich in linoleic acid would also cause acute liver injury after acetaminophen injection. In the first experiment, two levels of fat (15 g/100 g protein and 20 g/100 g protein) were fed using corn oil or beef tallow.
Liver enzymes indicating damage were significantly elevated in all the animals except for those animals fed the higher level of beef tallow. These researchers concluded that "diets with high [linoleic acid] may promote acetaminophen-induced liver injury compared to diets with more saturated and monounsaturated fatty acids."
Research Showing General Beneficial Effects From Feeding Coconut Oil
Research that compares coconut oil feeding with other oils to answer a variety of biological questions is increasingly finding beneficial results from the coconut oil.
Obesity is a major health problem in the United States and the subject of much research. Several lines of research dealing with metabolic effects of high fat diets have been followed. One study used coconut oil to enrich a high fat diet and the results reported were that the "coconut-oil enriched diet is effective in…[producing]…a decrease in white fat stores." (Portillo et al 1998)
Cleary et al (1999) fed genetically obese animals high fat diets of either safflower oil or coconut oil. Safflower oil-fed animals had higher hepatic lipogenic enzyme activities than did coconut oil fed animals. When the number of fat cells were measured, the safflower oil- fed also had more fat cells than the coconut oil-fed.
Many of the feeding studies produce results at variance with the popular conception. High fat diets have been used to study the effects of different types of fatty acids on membrane phospholipid fatty acid profiles. When such a study was performed on mice, the phospholipid profiles were similar for diets high in linoleic acid from high-linoleate sunflower oil relative to diets high in saturated fatty acids from coconut oil.
However, those animals fed the diets high in oleic acid (from the high-oleate sunflower oil) or high in elongated omega-3 fatty acids (from menhaden oil) were not only different from the other two diets, but they also resulted in enlarged spleens in the animals. (Huang and Frische 1992)
Oliart-Ros and colleagues (1998), Instituto Technologico de Veracruz, Mexico, reported on effects of different dietary fats on sucrose-induced cardiovascular syndrome in rats. The most significant reduction in parameters of the syndrome was obtained by the n-3 PUFA- rich diet.
These researchers reported that the diet thought to be PUFA-deficient presented a tissue lipid pattern similar to the n-3 PUFA-rich diet (fish oil), which surprised and puzzeled them. When questioned, it turned out that the diet was not really PUFA-deficient, but rather just a normal coconut oil (nonhydrogenated), which conserved the elongated omega-3 and normalized the omega-6-to-omega-3 balance.
A recent study measured the effect of high-fat diets, fed for more than three months to the neonatal pig, on the HMG-CoA reductase enzyme's function and gave some surprises. There were two feeding protocols: one with the added cholesterol and one without added cholesterol, but both with coconut oil.
The hepatic reductase activity, which was the same in all groups at the beginning of the feeding on the third day and similar on the 42nd day, was increased with and without added cholesterol on the 13th day and then decreased on the 25th day.
The data was said to suggest that dietary cholesterol suppressed hepatic reductase activity in the young pigs regardless of their genetic background, that the stage of development was a dominant factor in its regulation, and that both dietary and endogenously synthesized cholesterol was used primarily for tissue building in very young pigs. (McWhinney et al 1996) The feeding of coconut oil did not in any way compromise the normal development of these animals.
When compared with feeding coconut oil, feeding two different soybean oils to young females caused a significant decrease in HDL cholesterol. Both soybean oils, one of which was extracted from a new mutant soybean thought to be more oxidatively stable, were not protective of the HDL levels (Lu Z et al 1997).
Trautwein et al (1997) studied cholesterol-fed hamsters on different oil supplements for plasma, hepatic, and biliary lipids. The dietary oils included butter, palm stearin, coconut oil, rapeseed oil, olive oil, and sunflowerseed oil.
Plasma cholesterol concentrations were higher (9.2 mmol/l) for olive oil than for coconut oil (8.5 mmol/l), hepatic cholesterol was highest in the olive oil group, and none of the diet groups differed for biliary lipids. Even in this cholesterol-sensitive animal model, coconut oil performed better than olive oil.
Smit and colleagues (1994) had also studied the effect of feeding coconut oil compared with feeding corn oil and olive oil in rats and measured the effect on biliary cholesterol. Bile flow was not different between the three diets, but the hepatic plasma membranes showed more cholesterol and less phospholipid from corn and olive oil feeding relative to coconut oil feeding.
Several studies (Kramer et al 1998) have pointed out problems with canola oil feeding in newborn piglets, which result in the reduction in number of platelets and the alteration in their size. There is concern for similar effects in human infants. These undesirable effects can be reversed when coconut oil or other saturated fat is added to the feeding regimen (Kramer et al 1998).
Research has shown that coconut oil is needed for good absorption of fat and calcium from infant formulas. The soy oil (47%) and palm olein (53%) formula gave 90.6% absorption of fat and 39% absorption of calcium, whereas the soy oil (60%) and coconut oil (40%) gave 95.2% absorption of fat and 48.4% absorption of calcium (Nelson et al 1996). Both fat and calcium are needed by the infant for proper growth. These results clearly show the folly of removing or lowering the coconut oil in infant formulas.
Research Showing A Role For Coconut In Enhancing Immunity And Modulating Metabolic Functions
Coconut oil appears to help the immune system response in a beneficial manner. Feeding coconut oil in the diet completely abolished the expected immune factor responses to endotoxin that were seen with corn oil feeding. This inhibitory effect on interleukin-1 production was interpreted by the authors of the study as being largely due to a reduced prostaglandin and leukotriene production (Wan and Grimble 1987).
However, the damping may be due to the fact that effects from high omega-6 oils tend to be normalized by coconut oil feeding. Another report from this group (Bibby and Grimble 1990) compared the effects of corn oil and coconut oil diets on tumor necrosis factor-alpha and endotoxin induction of the inflammatory prostaglandin E2 (PGE2) production.
The animals fed coconut oil did not produce an increase in PGE2, and the researchers again interpreted this as a modulatory effect that brought about a reduction of phospholipd arachidonic acid content. A study from the same research group (Tappia and Grimble 1994) showed that omega-6 oil enhanced inflammatory stimuli, but that coconut oil, along with fish oil and olive oil, suppressed the production of interleukin-1.
Several recent studies are showing additional helpful effects of consuming coconut oil on a regular basis, thus supplying the body with the lauric acid derivative monolaurin. Monolaurin and the ether analogue of monolaurin have been shown to have the potential for damping adverse reactions to toxic forms of glutamic acid (Dave et al 1997).
Lauric acid and capric acid have been reported to have very potent effects on insulin secretion (Garfinkel et al 1992). Using a model system of murine splenocytes, Witcher et al 1996 showed that monolaurin induced proliferation of T cells and inhibited the toxic shock syndrome toxin-1 mitogenic effects on T cells.
Monserrat and colleagues (1995) showed that a diet rich in coconut oil could protect animals against the renal necrosis and renal failure produced by a diet deficient in choline (a methyl donor group). The animals had less or no mortality and increased survival time as well as decreased incidence or severity of the renal lesions when 20% coconut oil was added to the deficient diet. A mixture of hydrogenated vegetable oil and corn oil did not show the same benefits.
The immune system is complex and has many feedback mechanism to protect it, but the wrong fat and oils can compromise these important mechanisms. The data from the several studies show the helpful effects of coconut fat. Additionally, there are anecdotal reports that consumption of coconut is beneficial for individuals with the chronic fatigue and immune dysfunction syndrome known as CFIDS.
U.S. Patents For Medical Uses Of Lauric Oils, Medium-Chain Fatty Acids, And Their Derivatives Such As Monolaurin
A number of patents have been granted in the United States for medical uses of lauric oils, lauric acid, and monolaurin. Although one earlier patent was granted to Professor Kabara more than three decades ago, the rest of these patents have been granted within the past decade.
In 1989 a patent was issued to the New England Deaconess Hospital (Bistrian et al 1989) for the invention titled "Kernel Oils and Disease Treatment." This treatment required lauric
acid as the primary fatty acid source with lauric oils constituting up to 80% of the diet "using naturally occurring kernel oils."
In 1991 and 1995, two patents were issued to the group of researchers whose work has been reviewed above. The first invention (Isaacs et al 1991) was directed to antiviral and antibacterial activity of both fatty acids and monoglycerides, primarily against enveloped viruses.
The claims were for "a method of killing enveloped viruses in a host human…wherein the enveloped viruses are AIDS viruses…[or]…herpes viruses…[and the]…compounds selected from the group consisting of fatty acids having from 6 to 14 carbon atoms and monoglycerides of said fatty acids…[and]…wherein the fatty acids are saturated fatty acids."
The second patent (Isaacs et al 1995) was a further extension of the earlier one. This patent also included discussion of the inactivation of envelop viruses and specifically cited monoglycerides of caproic, caprylic, capric, lauric, and myristic acid. These fatty acids make up more than 80% of coconut oil. Also included in this patent was a listing of susceptible viruses and some bacteria and protozoa.
Although these latter patents may provide the owners of the patents with the ability to extract royalties from commercial manufacturers of monoglycerides and fatty acids, they cannot require royalties from the human gastrointestinal tract when it is the "factory" that is doing the manufacturing of the monoglycerides and fatty acids.
Clearly though, these patents serve to illustrate to us that the health-giving properties of monolaurin and lauric acid are well-recognized by some individuals in the research arena, and they lend credence to our appropriate choice of lauric oils for promoting health and as adjunct treatment of viral diseases.
How Can We Get Sufficient Coconut Fat Into The Food Supply In The U.S. And Other Countries That Need Its Benefits?
I would like to review for you my perception of the status regarding the coconut and coconut products market in the North American countries such as the United States and Canada at the end of the 20th century and the beginning of the 21st century.
Coconut products are trying to regain their former place in several small markets. The extraction of oil from fresh coconut has been reported in the past decade and my impression is that this is being considered as a desirable source of minimally processed oil, which produces an oil with desirable characteristics for the natural foods market.
There have been some niche markets for coconut products developing during the past half-decade. These are represented primarily by the natural foods and health foods producers. Some examples are the new coconut butters produced in the U.S. and Canada by Omega Nutrition and Carotec, Inc. And, this is no longer as small a market as it has been in past years.
Desiccated coconut products, coconut milk, and even coconut oil are appearing on the shelves of many of these markets. After years of packaging coconut oil for skin use only, one of the large suppliers of oils to the natural foods and health foods stores has introduced coconut oil for food use, and it has appeared within the last few months on shelves in the Washington, DC metropolitan area along with other oils. I believe I indirectly had something to do with this turn of events.
Conclusions And Recommendations
Coconut products for inedible and especially edible uses are of the greatest importance for the health of the entire world.
Some of what I have been telling you, most of you already know. But in saying these things for the record, it is my intention to tell those who did not know all the details until they heard or read this paper about the positive properties of coconut.
Coconut oil is a most important oil because it is a lauric oil. The lauric fats possess unique characteristics for both food industry uses and also for the uses of the soaps and cosmetic industries. Because of the unique properties of coconut oil, the fats and oils industry has spent untold millions to formulate replacements from those seed oils so widely grown in the world outside the tropics.
While it has been impossible to truly duplicate coconut oil for some of its applications, many food manufacturers have been willing to settle for lesser quality in their products. Consumers have also been willing to settle for a lesser quality, in part because they have been fed so much misinformation about fats and oils.
Desiccated coconut, on the other hand, has been impossible to duplicate, and the markets for desiccated coconut have continued. The powdered form of desiccated coconut now being sold in Europe and Asia has yet to find a market in the U.S., but I predict that it will become an indispensable product in the natural foods industry. Creamed coconut, which is desiccated coconut very finely ground, could be used as a nut butter.
APCC needs to promote the edible uses of coconut, and it needs to promote the reeducation of the consumer, the clinician, and the scientist. The researcher H. Thormar (Thormar et al 1999) concluded his abstract with the statement that monocaprin "…is a natural compound found in certain foodstuffs such as milk and is therefore unlikely to cause harmful side effects in the concentrations used."
It is not monocaprin that is found in milk, but capric acid. It is likely safe at most any level found in food. However, the levels in milk fat are at most 2 percent whereas the levels in coconut fat are 7 percent.
One last reference for the record. Sircar and Kansra (1998) have reviewed the increasing trend of atherosclerotic disease and type-2 diabetes mellitus in the Indians from both the subcontinent of India and abroad.
They note that over the time when there has been an alarming increase in the prevalence of these diseases, there has been a replacement of traditional cooking fats with refined vegetable oils that are promoted as heart-friendly, but which are being found to be detrimental to health. These astute researchers suggest that it is time to return to the traditional cooking fats like ghee, coconut oil, and mustard oil.
There are a number of areas of encouragement. The nutrition community in the United States is slowly starting to recognize the difference between medium chain saturated fatty acids and other saturated fatty acids. We predict now that the qualities of coconut, both for health and food function, will ultimately win out.
Mary G. Enig, Ph.D., F.A.C.N.
12501 Prosperity Drive
Suite 340
Silver Spring, MD, 20904-1689 USA
Tel: (301) 680-8600 Fax: (301) 680-8100


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It shouldn't be news to anyone that cyber threats are on the increase, and the requirement to have an effective security solution has never been more pressing as advanced hacking techniques continue to proliferate in the wild.
With the market awash with vendors making bold claims and news stories making even bolder headlines, it can be hard to separate the fact from the fiction. If you're new to endpoint security, here's the five basic things to ensure that you get right about the options available.
1. Viruses Aren't the Only Threat
Security threats have evolved beyond all recognition from the early days of the computer virus, but most security solutions still carry the term "anti-virus" in their name, which is really something of a misnomer in the modern threatscape.
The reality is that cyber attacks take many different forms that have nothing to do with being a virus, and they can range from the indiscriminate to the highly targeted. These include ransomware, spear-phishing, drive-by attacks and both software and hardware vulnerabilities that can lead to loss of customer and corporate data.
And don't fall into the trap of thinking your business is too small to be targeted. Attackers are now weaponizing machine learning to produce highly-targeted campaigns, at low cost to themselves.
Also, don't forget that threats can come from within; disgruntled employees know the weaknesses of your system better than any outsider. Good endpoint security needs to be able to detect bad behaviour no matter the point of origin.
2. Malicious Files Aren't the Whole Story
Most people think that security software works by scanning files on the local computer and deciding whether they are malicious or not. Like the term 'anti-virus', that's a bit of an old-fashioned way of thinking about it. Although there are still legacy AV programs that primarily work in that way, even they will usually offer some additional functions such as blocking malicious websites or detecting excessive use of resources typically used by ransomware and crypto-miners.
However, for truly effective protection, you should be looking at security solutions that do more than that. Today's cyber criminals are able to leverage fileless attacks, change DNS settings to re-route your network traffic and inject code into legitimate processes. A legacy AV solution that primarily focuses on scanning for malicious files is, like last week's soup, well past its sell-by-date.
3. Trust is a System Weak Point
As we hinted in the previous point, untrusted software is not the only danger on your endpoint. Even first-party and established software brands can be leveraged to breach your system.
While MS Office Macro attacks have a long history, Macro-less attacks such as DDE can exploit vulnerabilities that will bypass many security solutions because they appear to be coming from trusted applications. Similarly, most businesses will likely have a need for legitimate PowerShell operations, and yet PowerShell-powered attacks are becoming increasingly common. You need a security solution that's smart enough to allow PowerShell to maintain your productivity, but also able to ensure that it can tell the difference between malicious and legitimate behaviour.
Modern malware can also run without interference on many systems running AV solutions if it is able to operate with system-level privileges, whether through a privilege escalation vulnerability or other methods of infection. This is because many AV packages take the wrong approach by granting trust by identity, rather than by behaviour. When security solutions take this kind of "whitelisting" approach, the endpoint is left vulnerable to supply chain attacks and fake certificates.
4. There's Power in Simplicity
Security software doesn't have to be hard to use, and you shouldn't have to be a security expert to manage it. Unfortunately, a lot of security software gives business owners just that impression, overcomplicating things with diagnostic tools and components that require specialist training courses to master. Be sure to choose an endpoint solution that minimizes maintenance tasks, presents a clean, easy-to-understand interface and provides one-click remediation.
You want a solution that anyone in your team can quickly learn and operate. It's important for business continuity that knowledge of your security solution is not tied to specially-trained members of staff. Who knows how long before they move on, taking their expert knowledge of your security solution with them?
5. Security is a Mindset, Not a Product
Probably the biggest thing you can get wrong about AV software is believing that it can solve all your security issues in one fell swoop. Threats come in many shapes and forms: from indiscriminate ransomware attacks to disgruntled employees. What's your plan of action when (don't think "if") a breach occurs? How will you respond? Failure to have a response plan in place could mean greater damage to your customers, your data and your reputation.
This is why you need an endpoint solution that can be part of your entire response plan. A cross-platform solution like SentinelOne can provide deep visibility into even encrypted traffic across your network, one-click remediation and rollback, and a single, holistic agent that's simple to use.
Our Takeaway
Ignore the stereotype of sophisticated cybercriminals targeting billion-dollar businesses. Most attacks are opportunistic and target not the wealthy or famous, but the unprepared. According to a 2018 SentinelOne survey of US companies, 56 percent suffered a ransomware attack in the last year. Given that the majority of organisations will be hacked over their lifetime, it is imperative that organisations have the necessary tools to spot and stop an attack quickly and effectively.
This is why you need an endpoint solution that can be part of your entire response plan. A cross-platform solution like SentinelOne, provided by Custodian360 can provide deep visibility into even encrypted traffic across your network, one-click remediation and rollback, and a single, holistic agent that's simple to use.
This blog was first posted by Migo Kedem


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Strain Information
Name | EG8865 View On Wormbase |
Species | C. elegans |
Genotype | unc-119(ed3) III; oxTi911 V. |
Description | oxTi911 [eft-3p::GFP::2xNLS::tbb-2 3'UTR + Cbr-unc-119(+)] V. Strain is healthy. NOTE: This strain is not necessarily homozygous - please verify before using. Nuclear green fluorescence is broadly expressed (in most cells) and visible under dissection microscope. This strain can be used for mapping or to facilitate genetic crosses. Integration site: (V:4.95). Insertion into dhc-3. Please see wormbuilder.org for exact insertion site. miniMos insertion of pCFJ1661 into unc-119(ed3)(11x outcrosss) with Cbr-unc-119(+) selection. |
Mutagen | Mos1 transposon |
Outcrossed | x0 |
Made by | C. Frokjaer-Jensen |
Laboratory | EG |
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By Gareth Jenkins
September 19, 2017
Since the failed coup of July 2016, Turkey's spiralling descent ever deeper into authoritarianism has been characterized by arbitrary arrests and widespread abuses of even the draconian powers afforded the regime under the continuing State of Emergency. In addition, the government's domination of the media has meant that, for the mass of the Turkish public, the reality of what is happening in the country is submerged beneath a cacophony of distortions, delusions, untruths and febrile conspiracy theories.
By Halil M. Karaveli (vol. 5, no. 4 of the Turkey Analyst)
The authority of Prime Minister Recep Tayyip Erdoğan has been challenged by the security apparatus, the police and parts of the judiciary that enjoy the backing of the brotherhood of the Islamic preacher Fethullah Gülen. The unprecedented challenge compels Erdoğan to circumscribe the power of his erstwhile ally, which thrives with the application of oppressive security measures. Whether Erdoğan will now see the strong incentive to seek a democratic, negotiated solution to the Kurdish issue, or continue to concentrate power in his own hands, remains to be seen.
By M. K. Kaya (vol. 8, no. 9 of the Turkey Analyst)
The Gülenists have lost the battle over the control of the state. Most damningly for them, they have been exposed as ruthless power grabbers. It has been of critical importance for the AKP government in its fight against the Gülenists that other groups within the judiciary have rallied to it. The lessons that the present Turkish government has had to learn the hard way are not going to be lost on future governments. One can assume that they are going to be very careful not to offer the Gülenists any leeway.
Ali Bayramoğlu in Yeni Şafak writes that AKP's otherwise legitimate struggle against the Gülen fraternity will remain flawed from a democratic perspective until the party acknowledges its own responsibility for the acts of the "cemaat" when the two were still allies. Fatih Yaşlı in Yurt writes that Turkish intellectual and political life suffers from a predilection for what he calls "easy opposition" that does not question who one is allied with as long as the cause is deemed to be good, which today blinds the opponents of AKP to the responsibility of the Gülenists in bringing about the present authoritarian rule. Murat Yetkin in Radikal writes that the talk in political circles is that AKP is preparing for a coalition with MHP after the general election in June. Orhan Bursalı in Cumhuriyet writes that Erdoğan is distancing himself from the Kurds, and is instead teaming up with the military. Umut Özkırımlı on the news site Diken writes that AKP's, and generally the Islamists' lasting legacy is a generalized hatred that has become a permanent, defining feature of Turkey's society.
On the 8th anniversary of the assassination of Armenian-Turkish editor Hrant Dink, Rober Koptaş in Agos noted that the AKP government has recently started to emphasize that police officers close to the Gülenist fraternity were implicated in the 2007 assassination. Aydın Engin in Cumhuriyet called on the opponents of the AKP regime not to put any faith in dissensions within the governing party leading to the fall of the regime. Kadri Gürsel in Milliyet similarly wrote that Prime Minister Ahmet Davutoğlu is never going to put up a fight against President Recep Tayyip Erdoğan.
The Turkey Analyst is a publication of the Central Asia-Caucasus Institute & Silk Road Studies Joint Center, designed to bring authoritative analysis and news on the rapidly developing domestic and foreign policy issues in Turkey. It includes topical analysis, as well as a summary of the Turkish media debate.
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Use this diagram to repair, or replace the motor, in your 2100 Electrolux canister vacuum cleaner. This diagram is also applicable to the Diplomat, Diplomat XL, Lux 5000, Lux 2000, Lux 5500 Electrolux models.
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Being in a hospital bed in a Medicare-participating hospital is no guarantee that a Medicare beneficiary is an inpatient. In our December 11, 2008 Alert, the Center for Medicare Advocacy described the increasingly common practice of placing Medicare beneficiaries in acute care hospital beds and calling them outpatients.[1]
Beneficiaries who remain in hospital beds for multiple days, or even weeks, receiving physician and nursing services, tests, medications, food, and supplies, are in many instances nevertheless identified as outpatients. One major consequence of outpatient status is that beneficiaries are denied coverage for a subsequent stay in a skilled nursing facility (SNF) on the grounds that they have not been inpatients in the hospital for three or more consecutive days. Beneficiaries receiving outpatient observation services, which are covered under Medicare Part B, are also billed for services such as prescription drugs that would ordinarily be covered under Medicare Part A during an inpatient hospital stay. Placement in observation services has the effect of shifting significant health care costs that should be covered under Medicare Part A from the Medicare program to Medicare beneficiaries.
At the same time that the use of observation services is becoming more extensive by hospitals throughout the country, some beneficiaries who have appealed the denials of their hospital stays have been successful. This article describes a new brochure from the Centers for Medicare & Medicaid Services (CMS) – CMS's first description of observation services for beneficiaries. It also discusses three recent favorable decisions – two at the Administrative Law Judge level of appeal and a third at the level of the Qualified Independent Contractor (QIC), Maximus Federal Services. A fourth case, which is not about observation services, addresses the InterQual criteria and process that are used by hospitals to determine whether a patient is receiving inpatient care.
What are Observation Services?
Observation services are defined in Medicare's manuals as:
a well-defined set of specific, clinically appropriate services, which include ongoing short term treatment, assessment, and reassessment, that are furnished while a decision is being made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital.[2]
The Manuals suggest that a patient may not remain in observation status for more than 24 or 48 hours.[3] Since 2004, CMS has authorized hospitalization utilization review (UR) committees to change a patient's status from inpatient to outpatient, retroactively, if (1) the change is made while the patient is still hospitalized; (2) the hospital has not submitted a claim to Medicare for the inpatient admission; (3) a physician concurs in the UR committee's decision; and (4) the physician's concurrence is documented in the patient's medical record.[4] CMS anticipated that retroactive reclassifications would occur infrequently, "such as a late-night weekend admission when no case manager is on duty to offer guidance."[5]
A new six-page CMS brochure entitled "Are You a Hospital Inpatient or Outpatient?"[6] begins with the statement, "Did you know that even if you stay in the hospital overnight, you might still be considered an 'outpatient'?" The brochure suggests that patients who are in the hospital for "more than a few hours" ask their doctor or hospital staff if they are inpatients or outpatients.
The brochure incorrectly suggests in two places that decisions to place a beneficiary in observation are made by the beneficiary's own physician.[7] In fact, CMS allows any physician to confirm a decision by a hospital's UR committee to reverse an inpatient admission decision made by an attending physician.
Even more significant, while the brochure may give beneficiaries notice of their status as observation patients, it does not give them any rights to challenge their placement in observation. The brochure's discussion of "rights" says only that beneficiaries have the right to "get a review of (appeal) certain decisions about health care payment, coverage of services."
The brochure may have the effect of discouraging beneficiaries from appealing their placement in observation services if they erroneously believe that their attending physician ordered observation services. As discussed below, the Center encourages beneficiaries and their advocates to appeal observation decisions, regardless of whether the decisions are made by attending physicians or hospitals' UR committees. Moreover, despite the lack of clarity about beneficiary appeal rights,[8] some beneficiaries have filed appeals and prevailed.
In January 2010, Administrative Law Judge (ALJ) P. Arthur McAfee overruled a decision by Maximus Federal Services and held that a Medicare beneficiary's entire five-day stay in an acute care hospital should have been covered by Medicare Part A.[9]
The beneficiary's physician had ordered that she be admitted "for inpatient care secondary to a diagnosis of an L1 compression fracture." Her condition was "fair" and she required monitoring, assessment, and intravenous fluids, including multiple doses of intravenous morphine. On her third day in the hospital, October 25, 2008, she was notified that her status was being changed from inpatient to outpatient. On appeal, the Quality Improvement Organization (QIO) found that inpatient coverage was appropriate for days three through five, October 25-27. The QIO did not review the beneficiary's observation status for the first two days of her hospital stay. On appeal, Maximus issued an unfavorable decision, finding that the claim had already been processed for payment.
The ALJ cited the Medicare statute and two Manual provisions as guiding his analysis. First, he cited the Medicare Benefit Policy Manual, which describes
the decision to admit a patient [as] a complex medical judgment which can be made only after the physician has considered a number of factors, including the patient's medical history and current medical needs, the types of facilities available to inpatients and to outpatients, the hospital's by-laws and admissions policies, and the relative appropriateness of treatment in each setting.[10]
Relevant factors to be taken into consideration include "the severity of the signs and symptoms exhibited by the patient," "the medical predictability of something adverse happening to the patient," "the need for diagnostic studies that appropriately are outpatient services," and "the availability of diagnostic procedures at the time when and at the location where the patient presents."[11] He also cited Chapter 1, §10 of the MBPM, which uses "a 24-hour period as a benchmark" and wrote, "physicians should order admission for patients who are expected to need hospital care for 24 hours or more."
The second Manual relied on by the ALJ was the QIO Manual, which gives guidance to QIOs on reviewing inpatient hospital admission decisions and directs a physician reviewer to "consider, in his/her review of the medical record, any preexisting medical problems or extenuating circumstances that make admission of the patient medically necessary."[12] Inpatient care is "required only if the patient's medical condition, safety, or health would be significantly and directly threatened if care was provided in a less intensive setting."
Applying these criteria, the ALJ reversed Maximus's denial of inpatient status for the beneficiary's entire five-day stay, finding "The documentation provides no foundation to go against the judgment of the admitting physician."
A second favorable decision, issued by Maximus on November 10, 2009, involved "a 79-year old man who presented to the emergency room (ER) from his assisted living facility with progressive altered mental status over the prior week."[13] The man had been "fully oriented," but at the time he was brought to the ER, he was "quite disoriented" or delirious.
The Maximus decision recognized that "Delirium represents an acutely life-threatening condition, evaluation and management of which can be complex and extended." Although it turned out that the management of the patient was not complex, Maximus wrote, "it was not reliably predictable at the time of admission that the necessary work-up of the balance of the differential diagnosis would have been able to be completed within a reasonable period of hospital observation." Relying on the Medicare Benefit Policy Manual, Pub. 100-2, Chapter 1, §10, the same provision relied on by the ALJ in the decision discussed above, and on the Program Integrity Manual, Pub. 100-8, Chapter 8, §6.5.2,[14] Maximus authorized inpatient hospital coverage for the entire five-day period.
A third decision addressed the denial of coverage for a 30-day stay in a SNF because of the absence of a three-day prior hospital stay, despite the fact that the beneficiary, classified as an outpatient receiving observation services, had been hospitalized for 13 days. Following a telephone hearing, ALJ Michael D. Bartko ruled both that the beneficiary met the three-day qualifying hospital stay required for SNF coverage and that she needed and received Medicare-covered care in the SNF.[15]
The fourth decision addressed whether a Medicare Advantage beneficiary's inpatient hospital admission ended, as set out in the Notice of Denial of Medicare Coverage, or should continue.[16] The ALJ discussed the hospital's reliance on InterQual criteria, which are also used in observation cases to determine whether a beneficiary should be classified as an inpatient.
At the ALJ level, the hospital was required to produce the patient's complete medical records, the CareEnhanced Review Manager Enterprise (CERME), and the InterQual/McKesson Manual. The ALJ found "a significantly limited independent review of the approximately 6000 pages of medical records in this case [italics in original]" by the QIO physician who cited physical therapy notes, wound care notes, and a single physician note in upholding the discharge notice. He then described the InterQual Manual and CERME as proprietary tools that are used for various purposes, including "coverage denial management programs." He wrote, "Information is obtained from patient medical charts and from other captured data which is input into a software program that generates a summary report." Although the ALJ sealed the InterQual and CERME documents because they were proprietary, he found that "the inputs are very subjective" and that, in this case, they were "inconsistent with the known medical treatment" provided to the patient, as described in her medical records. He concluded that the patient's inpatient stay was medically necessary and that Medicare coverage properly continued after the beneficiary received the notice denying further coverage.
What Should Beneficiaries and Their Advocates Do?
The Center for Medicare Advocacy suggests that beneficiaries file an appeal from any hospital notices describing their observation status and any subsequent Advanced Beneficiary Notice/Notice of Exclusion from Medicare Benefits they receive from a SNF.[17] In the likely absence of any notice, particularly from a hospital, the Center recommends that beneficiaries appeal when they receive the Medicare Summary Notice, which sets out all health care services received by a beneficiary in the prior quarter.
In all cases, beneficiaries and their advocates should gather the complete medical records from the hospital to establish the entire set of services and treatments that were received during the period of hospitalization. Advocates should request copies of all documents used by the hospital, its UR committee, and outside consultants to determine beneficiaries' status. Advocates should present the medical and nursing facts and cite any physician support for inpatient status to demonstrate that the beneficiary met Medicare's criteria for an inpatient stay. If SNF coverage is also at issue, advocates must demonstrate not only that the beneficiary met the criteria for Medicare-covered care in the SNF but also that the beneficiary received Medicare-covered care in the SNF.
Advocates should not be discouraged if they lose at the early stages of appeal: reconsideration, QIO, and QIC review. Three of the four cases discussed in this Alert were won later, at the ALJ level.
The increasing use of administratively-created observation services is undermining the Medicare Part A hospital benefit, which authorizes inpatient hospital care for both diagnosis and treatment,[18] by essentially redefining diagnosis as observation under Part B. Observation services also violate the Medicare statute by allowing hospital UR committees to issue retroactive and binding determinations that a patient, admitted to inpatient status by the patient's attending physician, is instead receiving observation services.[19]
The Center for Medicare Advocacy is interested in hearing from advocates and beneficiaries about their experiences with observation services, including issues stemming from the lack of notice and the inability to use existing appeals processes.
[1] "When Is a Hospital Stay Not a Hospital Stay? When the Patient Is in 'Observation Status," (Dec. 11, 2008 Weekly Alert), https://medicareadvocacy.org/InfoByTopic/SkilledNursingFacility/SNF_08_12.11.ObservationStatus.htm.
[2] Medicare Benefit Policy Manual, CMS Pub. 100-02, Chapter 6, §20.6; same language in Medicare Claims Processing Manual, CMS Pub. 100-04, Chapter 4, §290.1.
[3] Id.
[4] Medicare Claims Processing Manual, CMS Pub. No. 100-04, Chapter 1, §50.3, originally issued as CMS, "Use of Condition Code 44, 'Inpatient Admission Changed to Outpatient,'" Transmittal 299, Change Request 3444 (Sep. 10, 2004).
[5] CMS, "Clarification of Medicare Payment Policy When Inpatient Admission Is Determined Not To Be Medically Necessary, Including the Use of Condition Code 44: 'Inpatient Admission Changed to Outpatient,'" MedLearn Matters (Sep. 10, 2004), now at Medicare Claims Processing Manual, CMS Pub. No. 100-04, Ch. 1, §50.3. "Use of Condition Code 44 is not intended to serve as a substitute for adequate staffing of utilization management personnel or for continued education of physicians and hospital staff about each hospital's existing policies and admission protocols. As education and staffing efforts continue to progress, the need for hospitals to correct inappropriate admissions and to report condition code 44 should become increasingly rare." Question and Answer 3.
[6] CMS Product No. 11435 (Dec. 2009), http://www.medicare.gov/Publications/Pubs/pdf/11435.pdf
[7] "Your doctor may order 'observation services' to help decide whether you need to be admitted to the hospital as an inpatient or can be discharged," page 4; and fifth example in the chart, page 3, indicates that if "your doctor" admits you as an in-patient and the hospital later changes your status to out-patient, "your doctor must agree."
[8] The Center's December 11, 2008 Weekly Alert addressed various notices that beneficiaries might receive advising them of appeal rights. See footnote 1, supra.
[9] ALJ Appeal No. 1-517883673 (Jan. 8, 2010), available at: www.medicareadvocacy.org\InfoByTopic\ObservationStatus\Decisions\VT_ALJ_01.10.pdf.
[10] Pub. No. 100-2, chapter 1, §10.
[11] Id.
[12] Pub. No. 100-10, chapter 4, §4110.
[13] Medicare Appeal No. 1-496442359 (Nov. 10, 2009), available at: www.medicareadvocacy.org\InfoByTopic\ObservationStatus\Decisions\MN_Maximus_11.09.pdf.
[14] The ALJ described the Manual as requiring medical reviewers to "consider any pre-existing medical problems or extenuating circumstances that make admissions of the beneficiary medically necessary."
[15] ALJ Appeal No. 1-380068132 (April 9, 2009) available at: www.medicareadvocacy.org\InfoByTopic\ObservationStatus\Decisions\WI_ALJ_04.09.09.pdf.
[16] ALJ Appeal No. 1-424979831 (Dec. 9, 2009), available at: www.medicareadvocacy.org\InfoByTopic\ObservationStatus\Decisions\CA_ALJ_inpatient_InterQual_12.09.pdf.
[17] http://www.cms.gov/BNI/Downloads/CMS20014.pdf
[18] The Medicare statute defines "hospitals" as providing both diagnostic and treatment services to inpatients. 42 U.S.C. §1395x(e)(1)(A). It similarly defines "inpatient hospital services" to include diagnostic or treatment services. 42 U.S.C. §1395x(b)(3).