This week, I plan on taking on something that’s been sitting near the bottom of my “to do list” for several weeks now. Indeed, readers have been sending me links since November or so to what will be the topic of this week’s post, but something somehow has always managed to push it aside each weekend when the time came to sit down and start writing my weekly post for this blog. I was also motivated by noting that, even though we are now entering the fourth year of this blog’s existence (yes, as hard as it is to believe, we started way back in January 2008), no one has done a post specifically about this particular topic, although I have mentioned it in the past, in particular in my discussion of a movie about the Gerson protocol for pancreatic cancer over a year ago.

This time around, I will be discussing a movie as well. Unlike The Beautiful Truth, which was about the Gerson protocol and didn’t feature any big names, this movie, Simply Raw: Reversing Diabetes in 30 Days, features at least a couple of big names. These include Morgan Spurlock, who directed and starred in the 2004 documentary Super Size Me, which featured Spurlock eating nothing but McDonald’s food for 30 days and documented the effects that diet had on him, and actor and “raw food activist” Woody Harrelson. Both were interviewed for the movie, and a longer interview with Spurlock is featured as part of a promotional film series on the web that goes along with Simply Raw.

Here are two trailers for the movie. First, trailer #1:

Then, trailer #2:

And here is the introduction to the Raw for Life DVD, a companion “A-Z encyclopedia” of “live food” veganism that is being sold as a companion piece to Simply Raw:

As you can see, Simply Raw follows the story of six people, four of whom have type II diabetes, one of whom has type I diabetes, and one of whom is presented as having initially been diagnosed with type II diabetes but then diagnosed with type I diabetes. These six show up at The Tree of Life Rejuvenation Center in Arizona to try to reverse their diabetes “naturally” with a “raw food” diet, having answered an advertisement for subjects in a “raw food challenge” to reverse diabetes. The center is described thusly on its website:

The Tree of Life is the world’s leading spiritual, vegan raw and live food retreat center. It was founded in 1993 to promote spiritual awakening and to support an inspiring, healthy and “alive” lifestyle through education and first-hand experience. The Tree of Life serves as an oasis for the realization of whole-person, whole-planet healing. It is a place where people of all ages, nationalities, and religious and spiritual paths come to experience physical, mental, emotional and spiritual renewal and well being.

The “healing modalities” offered at The Tree of Life are listed thusly:

  • Fasting, Juice Fasting & Detoxification Retreats
  • Natural Cure for Diabetes Program
  • Conscious Eating Program
  • Living Modern Essene Way Workshops
  • Modern Essene Minister & Priesthood Training
  • Psycho-spiritual healing with our 4-Day Zero Point Program
  • Mental Wellness program for Healing Brain and Nervous System

Dr. Cousens, the founder of The Tree of Life, describes himself thusly on the website:

Dr. Sir Gabriel Cousens, M.D., M.D.(H), D.D. (Doctor of Divinity), Diplomate of American Board of Integrative Holistic Medicine, Diplomate Ayurveda, a physician of the soul, teaches and lives the sevenfold peace.

To the process of awakening and healing, Gabriel Cousens, M.D., M.D.(H), weaves a background as a holistic physician, medical researcher, world-recognized live-food nutritionist, psychiatrist, family therapist, homeopath, Rabbi, acupuncturist, Ayurvedic practitioner, expert on green juice spiritual fasting and detoxification fasting, ecological leader, Reiki master, internationally celebrated spiritual teacher, author, lecturer, culture-bridger, world peaceworker, to give a unique holistic approach to nurturing the hungry soul.

A homeopath and a reiki master? Is there any woo that Dr. Cousens isn’t into? It sure doesn’t look that way.

Leaving that aside, I’m more interested in what the claims made in this movie are and whether there is any science behind them. However, it is not irrelevant to look briefly at the person promoting these claims, as I have above, because it is clear that his methodology at The Tree of Life is a hodge-podge sampling from a veritable cornucopia of woo. I should also point out that, before I move on, contrary to the claims in the trailer, science-based medicine (SBM) does not dismiss the contention that diet can have a profound effect on health. From the trailer, it appears that the movie argues the typical false dichotomy that irritates the crap out of me, specifically that SBM denies that food matters, that proper eating and a healthy lifestyle can greatly improve health and even reverse some health problems. What SBM demands is the evidence and science supporting claims, and this trailer already has some dubious ones right from the start.

“Raw food” versus vegan and vegetarian diets

Most people know what a vegetarian diet is and what the difference between a vegetarian diet and a vegan diet is. Basically, a vegetarian diet usually means a diet consisting of fruits, vegetables, grains, nuts, and seeds without meat or fish. There are different flavors of vegetarianism, ranging from considering it acceptable to eat animal products that are not actually the flesh of dead animals, such as milk and the cheese that is made from it or eggs, to veganism, which eschews any animal product and may even exclude any product tested on animals. Some examples include:

  • Ovo-vegetarianism: Allows eggs but no dairy products.
  • Lacto-vegetarianism: Allows dairy products but not eggs.
  • Ovo-lacto-vegetarianism (or lacto-ovo vegetarianism): Allows animal/dairy products such as eggs, milk, and honey.
  • Veganism: Excludes all animal flesh and animal products.
  • Raw veganism: Permits only fresh and uncooked fruit, nuts, seeds, and vegetables.

It gets more complicated from there, as there are vegetarians who will eat certain meats and fishes from time to time, for instance limiting themselves only to occasional seafood or poultry products. Be that as it may, Simply Raw is obviously concerning itself with a raw vegan diet. The reasoning behind such extreme vegan diets is often more a matter of philosophy than science. In many (but not all) cases, the rationale is vitalistic-sounding. Note, for instance, the language used to describe The Tree of Life vegan diet. The words “live” and “living” are used frequently. That’s because there really is often a strong element of primitive vitalism at the heart of an embrace of raw food vegan diets. In essence, if you peruse raw food websites, it won’t be long before you find references to cooking as “killing” the food or “removing the life” from the food or to fresh, uncooked food as being “alive.” Perhaps the most hilarious example of this comes from a video I referenced back in 2009 when reviewing a movie (it’s not in Simply Raw, but should be):

The claim in the clip above comes from The Beautiful Truth and argues that the uncooked baby carrot is “alive,” with a photo of a seeming aura of “energy” surrounding it, while the cooked carrot is dead. The conclusion? Cooking and pasteurization “kill” food, and raw food is “living.” Given that Dr. Cousens traces the parentage of his diet all the way back to Max Gerson himself, it wouldn’t surprise me if he saw nothing wrong with the video clip above. Be that as it may, various explanations are postulated for the supposed benefits of “living food,” in particular that cooking destroys enzymes in the “living food,” which is inarguable, but it is also inarguable that stomach acid and the digestive enzymes in the proximal small intestine rapidly reduce proteins, and thus enzymes, into their component amino acids. The sorts of claims that the more woo-ful raw food vegans tend to be along the lines of these excerpts from a FAQ from Living and Raw Foods, which bills itself as the “largest community on the Internet dedicated to educating the world about the power of living and raw foods”:

What are Living and Raw Foods?
Raw and Living Foods are foods that contain enzymes. In general, the act of heating food over 116 degrees F destroys enzymes in food. (Enzymes start to degrade in as little as 106 degrees F). All cooked food is devoid of enzymes, furthermore cooking food changes the molecular structure of the food and renders it toxic. Living and raw foods also have enormously higher nutrient values than the foods that have been cooked.

What are Enzymes?
Enzymes assist in the digestion of foods. They are known to be the “Life-Force” and or “energy” of food.

Another example:

Is there a difference between living foods and raw foods?
Living and Raw foods both contain enzymes. In living foods, the enzyme content is much higher. Raw, unsprouted nuts contain enzymes in a “dormant” state. To activate the enzymes contained in almonds, for example, soak them in water for as just 24 hours. Once the almonds begin to sprout, the enzymes become “active” and are then considered living.

This is, of course, a load of hooey, to use a scientific and skeptical term. Using this rationale, the most “living” food of all would be a test tube containing purified enzymes, similar to what I used to work with back in the 1980s during a laboratory job I had one summer as an undergraduate. Of course, enzymes aren’t all. The other claim, such as this one by one of the “experts” who appear on Simply Raw (Dr. Joel Fuhrman), is that cooking somehow destroys living antioxidants, phytochemicals, and a variety of other compounds, without which the body can’t be healthy and “must break down. He describes processed food as “foods whose life has been taken out of them” and makes the claim that, without these micronutrients, cells accumulate “toxins” that need to be “detoxified,” while touting broccoli and various vegetables as having “incredible medicinal power.”

Far be it from me to denigrate diet as a therapeutic tool for chronic disease, such as type II diabetes, hypertension, and heart disease. There is plenty of evidence in SBM that losing weight and exercising can have a profound positive effect on blood pressure, type II diabetes, and cardiovascular disease. Indeed, the very first thing that physicians do when they diagnose someone with hypertension or type II diabetes is to try to get them to lose weight and eat a healthier diet, knowing that significant weight loss can lower blood pressure and even often reverse partially or completely the elevated blood sugar of type II diabetes. Unfortunately, diet is a very, very hard thing to change, and it’s very hard to change one’s lifestyle. The problem with “complementary and alternative medicine” approaches to diet, such as raw food veganism, is that they often claim far more than they can deliver, while justifying dietary choices using by appealing to vitalism and mystical properties. Simply Raw follows this template.

Simply Raw: Reversing Diabetes in 30 Days

Using my super blogger contacts, I scored a borrowed copy of Simply Raw to watch and review. The movie starts out as one might expect, introducing the six cast members who responded to a Craig’s List add to take a “raw food challenge” and “reverse their diabetes in 30 days.” This cast includes a perfect reality show-ready group of people with disparate backgrounds, including a construction worker, a retired chiropractor, a casino worker, a graduate student, a receptionist, and a postal worker. Following a typical reality show format, each cast member is introduced individually and portrayed making the long journey to Arizona. After everyone has arrived at The Tree of Life Rejuvenation Center, introductions are made, and the drama begins.

What’s particularly irritating is that at the beginning of the 30 days, Dr. Couzens sits down with the six and tells them that “healing diabetes is easy.” He makes claims, such as that adding that cooking food decreases the protein content by 50% (which is utter nonsense; it’s more like 6%), 70-80% of the vitamins (it actually depends on the vitamin), and close to 100% of the phytonutrients (it also depends on the specific phytonutrient). There is even a scene of Dr. Cousens doing what appears to be live cell analysis on a blood sample of one of the six, pointing out what’s wrong with his blood. Live cell analysis, is, as regular readers here should know, rank quackery. Meanwhile, Morgan Spurlock opines that using diet to treat disease is viewed with contempt by modern medicine, a massive exaggeration. He even claims it’s viewed by “conventional” medical practitioners as being “like a witch doctor.” Hearing that, I couldn’t help but think that Spurlock might have a point, just not in the way he thinks. After all, the “live” food movement, with its blend of vitalism tarted up with science-y-sounding terminology, is actually not too far from a witch doctor telling his tribe about a magical spirits, a “life essence,” in food.

Simply Raw is basically a single-arm, uncontrolled clinical trial consisting of six patients. Actually, it’s not even that. It’s basically six anecdotes from six different people of vastly differing ages, races, and backgrounds. As a result, it’s hard to generalize from the results shown in the movie. Five of the six appear to respond very rapidly to Dr. Cousen’s diet, within days, but one woman named Michelle does not. Once she is taken off of her insulin, her blood sugar readings remain, at least initially, between 350 and 400 mg/dl, way too high. As a result, she seriously thinks about leaving, leading the other five to try to persuade her not to go. Not surprisingly, this is a bit of false alarm, although useful drama for the movie, and Michelle–surprise! surprise!–ultimately decides to stay. At the end of the 30 days, she actually does have a good response to the diet.

Another member of the six, Henry, a casino worker and direct descendant of the hereditary chiefs of the Pima tribe, is portrayed having a particularly difficult time with the diet. In fact, he just can’t stick to it, finding it just too hard. He is portrayed suffering from stomach pain, extreme hunger,, fatigue, lethargy, and depression. When Henry finally leaves, it is stated that he had lost 30 lbs, which strikes me as a rather dangerous amount of weight to have lost in two and a half weeks. (Henry went home on day 17.)

Another thing that disturbs me about this movie is the claim that type I diabetes can be cured with diet. Given that type I diabetes results from a failure of the cells in the pancreas responsible for making insulin to produce an adequate amount of insulin to regulate blood sugar, holding out the promise of getting a type I diabetic off of his insulin entirely is dangerous. Even so, the type I diabetic in the group (Austin) does succeed in reducing his daily insulin requirement quite dramatically. This is not anything amazing or spectacular. It’s well known that diet can reduce insulin requirements in type I diabetics, sometimes dramatically, but they still need insulin. In rare–very rare–cases, it might–might–be possible to get a type I diabetic off insulin, but only if his pancreas still makes a little insulin.

In one telling scene in the movie, a staff member named Keith asks Austin what he thinks his chances are of getting off of insulin completely. Austin replies, quite reasonably, “Probably a zero percent chance,” to which Keith replies, “I don’t buy that.” Elsewhere in the movie Dr. Cousens cites without description three cases of type I diabetes that he’s “cured.” (Remember, he claims to have treated many thousands of diabetics; so even if this claim can be taken at face value it’s not particularly impressive.) Not surprisingly, it turns out that Austin isn’t the fourth. For a while, in fact, Dr. Cousen’s diet regimen led Austin’s blood glucose to be even harder to regulate because it would drop so low that he needs to drink orange juice or something with sugar in it to bring it back up again. Ultimately, Austin decides to leave for a day trip to Mexico, where he buys two bottles of tequila, drinks a lot, and gorges on tacos and enchiladas before returning and settling down again. One of the more dramatic scenes occurs when Austin is confronted after Keith finds his plastic bottle hiding his tequila mixed with a soft drink. In any case, I can’t help but notice that Simply Raw, even taken at face value, belies Dr. Cousens’ claim that it’s “easy” to cure diabetes. Three of the six subjects had major problems adhering to the diet, so much so that one left halfway through the program and one “fell off the wagon,” so to speak, while one almost gave up during the first week. One wonders whether, in the long term, the remaining five subjects can maintain such a radical diet.

The end of the movie also belies the claims made in the promotional material and in the movie about how resistant “conventional doctors” supposedly are to treating diabetes with diet. Three days after the 30 day program, Pam (the postal worker) goes to see her primary care doctor, who is very happy with her 25 lb. weight loss, her lower blood pressure, and her controlled blood sugar. He immediately discontinues her insulin, hugs her, and congratulates her heartily for having learned that type II diabetes is best treated by “what you put in your mouth.” Later, this same doctor is filmed asking, “How do we ship all of my patients to Arizona?” That hardly sounds hostile to he concept of diet as a treatment for diabetes to me. Of course, the doctor probably doesn’t realize that Dr. Cousens’ regimen is basically boot camp. People stay at his compound, isolated from their family and friends and interacting only with fellow residents and the center’s staff, eat only the meals Dr. Cousen’s staff makes for them or teaches them how to make, and are subject to serious peer pressure from the other residents there not to give up. Even so, even in this self-selected group, even under a situation of isolation from one’s familiar surroundings, one out of six bolted; one out of six had a relapse, and at least one more almost left.

The Trojan Horse of raw food veganism

When I first sat down to watch Simply Raw, I was expecting a lot more woo. And, yes, there was woo there, but not as much as I expected. Most of it came in the beginning and near the end, when there was a lot of talk of “living” food full of enzymes and the importance of giving up the “dead food” and interviews in which it was claimed that 50% of diseases would “go by the wayside” if everyone started on a raw food diet. There was also one brief scene of Dr. Cousens doing live blood analysis, something that the vast majority of viewers would not have noticed. Surprisingly, the movie actually showed very little of what, exactly, Dr. Cousens’ regimen consists of. There were a few scenes of cooks showing the residents how to make various “live” meals, but the vast majority of the movie focused on the interpersonal relationships between the subjects and the difficulties they had following the raw vegan diet. I think this was intentional. I think this was the typical use of a Trojan horse to sell an alternative medicine world view.

Why do I say this?

The reason I label this film a “bait and switch” is because it takes knowledge that SBM has already developed, namely that it is possible to reverse type II diabetes with weight loss and exercise (indeed, these are almost always the first interventions suggested when a diagnosis of type II diabetes is made), which require a much healthier diet to achieve, and then makes the implication that reversal of type II diabetes can best be accomplished by Dr. Cousens’ raw food vegan diet. The Trojan horse is the co-opting by alt-med practitioners of the idea that diet can have a significant impact on controlling type II diabetes. Within the Trojan horse of diet lies the woo of raw “live” foodism, complete with the idea that cooked food is somehow “dead,” that “living food” is living because it contains enzymes that are destroyed by cooking, and various other mystical and pseudoscientific concepts about raw food, such as that it somehow contains a mystical “life energy” that is destroyed by cooking. True, in the movie, although Dr. Cousens does talk some about the concept of “living food” and their belief that cooking somehow kills food, neither he nor the other “experts” interviewed dwells on this concept, which is surprising, given that Dr. Cousens directed the movie. Instead, the documentary focuses on interpersonal relationships and, in particular, three of the original six who had such difficulty sticking to the plan.

Instead, much of the woo is in the associated promotional materials on the Simply Raw website. For instance, there is the Raw for Life Encyclopedia, which includes “experts” not used in the movie, and there are full length interviews with the “experts” interviewed in Simply Raw, including Morgan Spurlock, and some whose interviews were not featured. These “experts” include Gary Null (yes, that Gary Null!), Mike Adams of, and Dr. Julian Whitaker. Gary Null, as you may recall, is well known in “alt-med” circles for being one of the co-authors of an article entitled Death by Medicine, which basically blames “conventional medicine” for causing in essence as many deaths as lives saved. He’s a promoter of all manner of quackery, HIV/AIDS denialist, and anti-vaccinationist who, ironically, nearly killed himself with his own supplements. Mike Adams is even more out there than Gary Null. For instance, he is a raw food faddist who once attacked Dr. Mehmet Oz for not being sufficiently radical in his dietary recommendations. More recently, he has been blaming psychiatric drugs and the food industry for Jared Lee Loughner’s rampage a week ago during which he shot U.S. Representative Gabrielle Giffords in the head, killed six people, and wounded 20, even going so far as to brand Loughner a “Manchurian candidate” programmed by the government to kill Giffords in order to allow the government to stomp on civil liberties. I kid you not. Finally, Julian Whitaker is Suzanne Somers’ doctor. If you want to get a flavor of what Dr. Whitaker is about, check out this video:

This is the classic example of taking something that’s true (namely that type II diabetes can often be kept under control through diet, exercise, and weight loss) and going right off the rails through exaggeration and distortion. Dr. Whitaker does this by saying that oral hypoglycemic drugs like metformin don’t work (they do) and that IV antibiotics don’t work (they do, but not always) and then taking a bunch of anecdotes to argue that “conventional medicine doesn’t work.” He even advocates acupuncture and chelation therapy for diabetes.

Come to think of it, given that Dr. Cousens is a homeopath and acupuncturist who apparently hasn’t seen a bit of woo that he doesn’t like, one wonders whether he uses pseudoscience like what Dr. Whitaker uses. Indeed, Dr. Cousens has his very own tag on In particular, there are interviews with Dr. Cousens advocating “detox fasts,” where he appears to believe in “cell memory“:

Gabriel: And you may have a genetic tendency to diabetes. Okay, that’s cool. But the phenotype is your actual expression. If you live a live-food lifestyle, you will not express diabetes. You will keep a genotype — a phenotype that’s really healthy. And so what we do with the live-food diet is the foundation of basically turning on the healthy phenotype and turning off the diabetes phenotype, genetic expression. Now that’s the key to the program. That’s why it works.

Kevin: And once it’s turned on, let’s say, someone comes to you and the phenotype is turned on and then you turn it off using live foods and then someone goes back to the culture of death as you were talking about. Is it more readily turned on again?

Gabriel: Yes because the body has some familiarity.

Kevin: Yes. And when people make the switch, transitioning is an interesting experience — went from cooked foods to live foods and emotions come out and things surface. What’s your explanation to that?

Gabriel: Umm…

Kevin: I’m sure you see a lot of it?

Gabriel: Yes, and this is often why we recommend people to just go 80% first because usually with the dead food you’re putting dead food in the dead places.

Kevin: Okay.

Gabriel: You’re suppressing. The more you eat, it’s like a made ego for suppressing your consciousness. You go to live foods and suddenly, you’re putting live food in that place because you’re activating all the suppressed stuff that comes up. So, we like people to get up to 80%.

Okay. And just hold there until they kind of emotionally detox and physically detox because the live food is just forcing out every level of toxin. That’s how we look at it. So, maybe you need it to be refreshed after three months or six months. When people do spiritual fasting and the zero point which follows up which is part of our program here; you know we have right here then that process is greatly excoriated and really fasting on green, this is just probably the fastest way to make a transition because you lose your cell memory for the cooked food but you also detox very quickly.

Kevin: Is that cell memory?

Gabriel: Cell memory for the cooked food, yes.

No wonder Dr. Cousens buried all the real woo behind is raw food regimen in his accompanying encyclopedia. At least he didn’t include his Zeolite detox nonsense.

But there’s more. I’ve been on the Simply Raw e-mail list for over a month now, and I see what sort of dubious medical products the movie’s executive producer Alex Ortner is promoting through his mailing list about his movie. For instance, he seems to be quite enamored of “super immunity,” which is longevity and “detoxification” pseudoscience featuring Joe Mercola and David Wolfe; the tapping solution, which is billed as a form of “meridian tapping” or a variety of emotional freedom technique (EFT), a variety of “thought field therapy,” both of which are utter quackery claiming that finger tapping along meridians “releases the body’s energy flow”: Dr. Joe Vitale’s “blood pressure miracle,” which claims to be able to reverse hypertension “naturally” without drugs; the “seven day back pain cure,” which promises to cure your back pain without drugs, surgery, or much of anything else; and, just yesterday, in my e-mail I found an ad from Ortner hawking a plan from a “holistic” doctor and homeopath named Mark Stenger, who is promoting a method to “balance your hormones” — naturally, of course. (Is there any other way?) In other words, although the movie Simply Raw itself doesn’t delve too deeply into woo, it does make overblown claims for just what diet can do for type II diabetes, and its ancillary materials, such as the DVD encyclopedia and most of the other products Ortner is hyping in addition to his movie, are dubious in the extreme. The movie appears to be “gateway” pseudoscience, designed to suck people in with reasonable-sounding claims about diet and then sell them on a prescientific, vitalistic view of the world wrapped up in the naturalistic fallacy.

Trojan horse, indeed.

The only things live about live food is the living woo

“Live food” faddism resonates with a great many people, because, when stripped of its mystical underpinnings, the concept that eating fresh, unprocessed food makes sense to most people. Also, the naturalistic fallacy, which implies that raw “live food” is somehow more “natural” than processed food, remains very appealing to many people who distrust modern society and science. Moreover, physicians know that one of the most effective methods of treating type II diabetes is through dietary manipulations and weight loss. Certainly, that is the first move that is usually tried. Unfortunately, Simply Raw implies that the only (or, at least, the best) strategy for type II diabetics to achieve the goal of glucose control and getting off their medications is a radical diet that consists of raw vegan food. Implicit in that idea is the belief that cooked and processed food is somehow poisoning us. Of course, countering that is the recently developed concept that cooking might have been a major factor in the increase in human brain size during evolution, the reason being that raw “live” food of the type featured in Simply Raw is far less energy rich than meat and takes more energy to digest. In any case, the entire premise of Simply Raw is an exaggeration. There’s no reason why a raw food vegan diet alone should be necessary to have a major positive impact on type II diabetes, much less should it be necessary to adopt the dubious concept that you need to eat “living food.”

Of course, that is not the message conveyed by Simply Raw. It’s quite clear that the message of the movie is that the best way to reverse diabetes is through a raw vegan diet of “living” food. Worse, although it features what Peter Lipson likes to call the “quack Miranda warning,” the movie also suggests strongly that diet can reverse type I diabetes. Representing what is in essence a set of anecdotes from six, self-selected diabetics, all with no science, it’s also highly effective propaganda. No one, least of all me, argues that diet isn’t incredibly important as a therapeutic modality for type II diabetes, but the entire Simply Raw package goes far beyond that, promoting vitalism and other dubious concepts as part and parcel of what is necessary to reverse type II diabetes.



Posted by David Gorski

Dr. Gorski's full information can be found here, along with information for patients. David H. Gorski, MD, PhD, FACS is a surgical oncologist at the Barbara Ann Karmanos Cancer Institute specializing in breast cancer surgery, where he also serves as the American College of Surgeons Committee on Cancer Liaison Physician as well as an Associate Professor of Surgery and member of the faculty of the Graduate Program in Cancer Biology at Wayne State University. If you are a potential patient and found this page through a Google search, please check out Dr. Gorski's biographical information, disclaimers regarding his writings, and notice to patients here.