If your doctor did not tell you that arthritis is an inflammatory condition, then they are not much of a doctor. “Arthritis (from Greek arthro-, joint + -itis, inflammation; plural: arthritides) is a form of joint disorder that involves inflammation of one or more joints” says Wikipedia. So the fact that arthritis is a condition causing inflammation of the joints is plainly not the thing doctors don’t tell you.
Researchers at Stanford University have made an explosive discovery that threatens to show how medicine got it all wrong when it comes to osteoarthritis. Doctors have long assumed that the disease is largely caused by traumatic injury or mechanical problems of ‘wear and tear’, like a piece of worn-out machinery. But as the Stanford research suggests, the disease and what appears to be mechanical wear may in fact be largely driven by low-grade inflammation.
OK, so this is not what doctors don’t tell you, but what doctors tell you might be correct, contradicting what other doctors have long thought in the absence of any better data. In other words, this is an early scientific finding. Such findings are usually wrong, but certainly not always (hence Marshall and Warren’s Nobel prize).
However, this is not so radically different to current knowledge. NHS Choices has this to say:
In people affected by osteoarthritis, the cartilage (connective tissue) between their bones gradually wastes away, leading to painful rubbing of bone on bone in the joints. The most frequently affected joints are in the hands, spine, knees and hips. Osteoarthritis often develops in people who are over 50 years of age. However, it can develop at any age as a result of an injury or another joint-related condition.
Rheumatoid arthritis is a more severe, but less common, form of arthritis than osteoarthritis. It occurs when the body’s immune system attacks and destroys the affected joints, causing pain and swelling to occur. This can lead to a reduction in movement and the breakdown of bone and cartilage.
So already the idea that this new hypothesis is completely at odds with current understanding, is on shaky ground. Rheumatoid arthritis (RA) is known to be an autoimmune disease, not caused by age or wear and tear, though it is exacerbated by these. Osteoarthritis may be triggered by trauma or age, but there is no indication that it is asserted to be caused solely by these.
In 2011, associate professor of immunology and rheumatology William Robinson and his colleagues at Stanford carried out studies showing that osteoarthritic joint tissues contain larger numbers of migratory inflammatory cells that secrete certain substances early on in the progression of the disease.
The presence of these substances triggers the ‘complement cascade’, a chain of molecular events that eventually escalates into an attack—mounted by the body’s own defense systems, usually only deployed against invading microorganisms—against the joint itself.
Reference 1: There is a reference that covers this, but rather bizarrely it’s cited to a story on Stanford’s school of Medicine News website, rather than to the subsequently-cited published paper in Nature Medicine – Identification of a central role for complement in osteoarthritis, Nature Medicine 17, 1674–1679
What this means is that the finding is interesting but far from being a settled issue. There is a lot more science to be done before it can be stated with any confidence that the factors identified are indeed significant, and it’s already evident that despite the Kuhn fans’ favourite phrase – “paradigm change” – this is not revolutionary but evolutionary. It may explain a trigger for the autoimmune responses known to be implicated in RA, and may link RA and osteoarthritis (OA) with a single autoimmune cause.
Then follows a reasonably straightforward account of the research, which we won’t repeat for reasons of brevity and copyright, the gist of which is that the researchers found evidence of a cluster of proteins known as the complement membrane attack complexW (MAC) in the joints of arthritic patients. These compounds are a part of the body’s immune system, that are used to attack the membranes of pathogenic cells.
It’s entirely plausible that MAC would be involved in an autoimmune disorder causing attrition of cartilage. The issue of cause and effect remains unresolved, but this could well unite OA and RA as a single complex. As the paper’s authors say:
“This low-grade complement activation contributes to the development of degenerative diseases, including Alzheimer’s disease and macular degeneration. Our results suggest that osteoarthritis can be added
to this list,”
Note that the headline claim that arthritis is due to inflammation not age, is actually contradicted here, as all these conditions’ incidence increases with age.
The current medical view is that osteoarthritis is incurable and the usual recommendations are to lose weight, exercise and take numerous drugs to manage pain and supposedly inflammation too (see box, page 39), and look forward to joint-replacement surgery. The course of treatment is a tightrope walk between reducing pain without bringing about a load of toxic effects on the heart and liver.
This is a classic piece of framing. The “numerous drugs” vary between none and one or two, for most patients, though RA patients may be given immunosuppressant or other therapies.
These new findings also have huge implications for how medicine deals with osteoarthritis. Rather than treating it as an inevitable part of growing old, the Stanford research suggests that an individual’s lifestyle might be analyzed to determine what’s causing the chronic inflammation and what sorts of natural compounds might help lower it to inhibit progression of the cycle.
That is not the conclusion of the study, but rather a hypothesis, possibly from the fringes (note the word “natural”, for example). It would not be the first time the SCAM industry had exploited an early finding to promote a treatment based on speculative extrapolation.
What’s quite interesting here is to compare WDDTY’s treatment of two treatments for arthritis: NSAIDs and glocosamine / chondroitin. The former is a product of Big Pharma, the latter of Big Herba, the $38bn supplement industry. In both cases current evidence indicates marginal benefit if that, particularly in OA.
|NSAIDs||Glucosamine and chondroitin|
|If you’re less than happy with the drugs you take for osteoarthritis, Dr Peter Gøtzsche, head of the Scandinavian arm of the Cochrane Collaboration and one of its founders, believes he knows why. He has made the extraordinary charge that non-steroidal antiinflammatory drugs (NSAIDs) don’t reduce inflammation.|
“The idea of an antiinflammatory effect of NSAIDs is a hoax, like so many other myths about drugs that the drug companies have invented and marketed,” he states uncategorically in his latest book, Deadly Medicines and Organised Crime: How Big Pharma has Corrupted Healthcare (Radcliffe Publishing, 2013; see News Focus, page 18).
Gøtzsche has conducted extensive studies into nonsteroidal anti-inflammatories, beginning from the time he was medical director at Astra-Syntex in 1977. Astra had produced naproxen, an early NSAID and, when Gøtzsche investigated the actions of various NSAIDs, he discovered that drug companies were manipulating information about this entire class of drugs and giving doctors the impression, through inference and with no supporting data, that NSAIDs were better than paracetamol (acetaminophen) because they didn’t just reduce pain, but also reduced inflammation.
When Gøtzsche and a group of orthopaedic surgeons carried out their own independent study of naproxen, they found that the drug had no effect on reducing inflammation in patients with twisted ankles; patients recovered faster simply by moving the affected limb. After studying some 244 NSAID trials, Gøtzsche uncovered an overwhelming amount of bias favouring any given sponsoring company’s drug over the control drug.1 Then, in his own studies, the drugs failed to work as antiinflammatories; when compared with placebos, they had no effect on swollen finger joints in patients with rheumatoid arthritis.
But the most scandalous aspect of the NSAID trials, he says, was that dangers of the drugs, many of which cause gastrointestinal bleeding and heart attacks, were minimized. Furthermore, Gøtzsche discovered that doubling the dose, as patients have often been encouraged to do with all NSAIDs, produced negligible benefits, yet twice the amount of harm, including an increased risk of bleeding ulcers and death.
|Glucosamine is the major building block of proteoglycans, large molecules in cartilage that give it elasticity and maintain joint lubrication and flexibility by
trapping water in the cartilage matrix. Chondroitin, an even larger cartilage molecule, helps to maintain joint fluidity, while slowing cartilage destruction and helping with its repair.
Although the medical community has disparaged these supplements after several studies showed glucosamine to have no effects, those trials have since been criticized as having serious flaws and poor study design, while many other studies have shown that these supplements can be highly effective.
Taken orally, these two agents take only four hours to be taken up by the joints and, in laboratory tests, they’ve increased the protective effects of cartilage and can even spur cartilage growth. One theory is that they work by improving the quality of the synovial fluid surrounding the joints. In addition, clinical trials (in people) show that glucosamine appears to be a natural anti-inflammatory able to inhibit progression of the disease, while chondroitin helps reduce cartilage loss and arthritis of the knee and fingers, helping to reduce cartilage loss in as little as six months after starting supplements.
Suggested daily dosage: Glucosamine sulphate: up to 3,200 mg; chondroitin:
up to 3,600 mg
|Dan Med Bull, 1990; 37: 329–36|
2 Clin Evid, 2004; 12: 1702–10
|11. Altern Med Rev, 2004; 9: 275–9612
12. Altern Med Rev, 2011; 16: 228–38; http://umm.edu/health/medical/altmed/supplement/glucosamine;
Ann Rheum Dis, 2011; 70: 982–9
|12b includes: "so far studies have not shown conclusively that glucosamine helps repair or grow new cartilage, or stops cartilage from being further damaged. Glucosamine is often taken with chondroitin, another supplement thought to be effective in treating OA. Like glucosamine, chondroitin also has conflicting results in studies." This contradicts the claim supposedly based on it.|
McTaggart quotes Gøtzsche, her idol of the week, whose latest book follows in the footsteps of Ben GoldacreW’s Bad PharmaW in publicising abuse of the scientific process by pharmaceutical companies. NSAIDs are shown no mercy. Supplements, by contrast, get a soft ride with unnamed sources having “criticized” the science as “having serious flaws and poor study design” – though in fact the criticisms appear to emanate almost exclusively from those selling the treatment, funnily enough. We’re not pointed to these criticisms, though we are pointed to a sources for uncontroversial facts and alt-med sources for speculation based on the uncontroversial facts.
As usual, the difference in the treatment of medicine and SCAM is illuminating particularly in this instance since the evidence indicates that both medicine and SCAM are likely to be a waste of money. Note that only one of the two is advertised in the pages of WDDTY. Follow the money, as they say.
These new findings offer the first laboratory confirmation of what many practitioners of functional medicine have found to be the case in clinical practice. Dr John Mansfield, author of Arthritis: The Allergy Connection (Chivers Press, 1991), who successfully treated several thousands of arthritis patients in the UK at his clinic in Surrey before recently retiring, believes that most forms of arthritis are environmentally induced” by an intolerance to food or certain environmental chemicals and that some 90 per cent of patients can be improved or fully cured just by making certain lifestyle changes.
And off we go down the rabbit hole. Mansfield is on the fringes, very firmly. That’s not to say he is wrong, but his views are far short of receiving anything close to scientific consensus. Here’s a worthless anecdote for you: a 45-year-old man had suffered for a long time with irritable bowel syndrome, migraines and asthma. He was diagnosed with coeliac disease and switched to a gluten-free diet. The IBS vanished, as did the migraines. But not the asthma. Mansfield would have you believe that all were caused by food intolerance. Maybe, maybe not.
What we see here, though, is another WDDTY theme: if you want to support a proposed link between A and B, go to someone who thinks everything in the world is caused by A, and whose work is published in “miracle health” books not the scientific literature. As far as I can tell, Mansfield does not have a license to practise (though he may be retired). He is an advertiser in WDDTY.
Finding out what in your lifestyle is causing inflammation in your body is a matter of doing a bit of detective work. Ideally you should carry out this investigation with a qualified and experienced nutritional practitioner, who can help you find the cause and choose from among a plethora of natural treatments that have been shown to work as well as, and sometimes even better than, drugs.
NO! NO! NO! A “qualified and experienced nutritional practitioner” is a weasel word for a nutritionist. These are the unlicensed, unregulated, often untrained alternative to trained, licensed, regulated dieticians. Of all the forms of quackery, nutritionists are among the most unreliable. Remember media nutritionist and copromancer “Dr” Gillian McKeithW, aka “The Awful Poo Lady”?
Are you overweight?
Carrying too much weight does increase the load on joints and seems to be one of the major factors in advancement of the disease. Common targets for osteoarthritis in overweight people include not only the weight-bearing joints of the body like the knees, but the finger joints too, suggesting that the link between obesity and osteoarthritis is due to factors other than just biomechanical loading.
Researchers at the Department of Orthopaedic Surgery at Washington University School of Medicine in St Louis, Missouri, believe that fat tissue is a major source of proinflammatory mediators like cytokines, chemokines and adipokines, metabolic factors known to have inflammation-boosting properties that help to ‘orchestrate’ the process of osteoarthritis.3
Reference 3a: Crit Rev Eukaryot Gene Expr, 2011; 21: 131–42, Inflammatory mediators: tracing links between obesity and osteoarthritis. Rai MF, Sandell LJ.
Reference 3b: Basic Clin Pharmacol Toxicol, 2013; Leptin – A Link between Obesity and Osteoarthritis. Applications for Prevention and Treatment, Katriina Vuolteenaho*, Anna Koskinen, Eeva Moilanen,
See the bait and switchW here? The sources note a possible role of pro-inflammatory mediators of obesity, in arthritis. This is largely uncontroversial. However, the implication in WDDTY is that this, not weight (i.e not wear and tear) is the cause; in fact the sources unambiguously attribute a majority of the disease effects to wear and tear, but note the possible role of another factor:
The obesity connection may have more to do with a patient’s overall diet and lifestyle, and how they contribute to insulin resistance and metabolic imbalances—the so-called ‘metabolic syndrome’, which is connected with atherosclerosis, diabetes and other modernday degenerative diseases. The major contributors are too much sugar, processed foods and fried foods, which release oxidizing free radicals into the system that, in excess, can damage the tissues around joints.
The agenda emerges. A “natural” diet will fix your problems, according to WDDTY. No matter that a “natural” diet may be anything from mainly fruits to mainly nuts to mainly fat with virtually no fruit, depending on where in the world you live.
What to do about it: Get off fried foods and the white stuff—refined sugars and carbs and all processed foods. Adopt a plant-based Mediterranean diet that’s low in saturated fats, and include generous amounts of inflammation-reducing foods like citrus and dark leafy greens (both as fresh as possible). Citrus fruits are high in antioxidants and the greens are rich in vitamin K, another natural anti-inflammatory.
I wonder if Lynne McTaggart has ever been to the Mediterranean? Has she ever heard of pasta? Pitta bread? And why does McTaggart think that there is only one “Mediterranean diet”? That is grossly oversimplistic.
Do you have an imbalance of fatty acids? Today’s processed diets feature too-high intakes of omega-6 fatty acids, known to lead to inflammation and, in turn, joint destruction, swelling and pain, and too-low intakes of omega-3 fatty acids.4
Reference 4: Omega-6 fatty acids – not peer-reviewed.
This may be correct but refers primarily to the North American diet, which is significantly different from the British diet, especially the diet of the middle-class people who form McTaggart’s core demographic (I can’t help feeling that Waitrose and Sainsbury’s were more important to WDDTY than Tesco).
Patients with osteoarthritis also suffer from dysfunctional mitochondria, the power packs of our body’s cells that supply the energy needed for cells to do their jobs.5
Reference 5: Arthritis Rheum. 2012 Sep;64(9):2927-36. Mitochondrial dysfunction increases inflammatory responsiveness to cytokines in normal human chondrocytes. Vaamonde-García C, Riveiro-Naveira RR, Valcárcel-Ares MN, Hermida-Carballo L, Blanco FJ, López-Armada MJ.
Conclusion: Our findings indicate that mitochondrial dysfunction could amplify the responsiveness to cytokine-induced chondrocyte inflammation through ROS production and NF-κB activation. This pathway might lead to the impairment of cartilage and joint function in OA.
See the important word there? could.
But what’s emerging here is a pretty clear pattern. Current research supports the idea that OA, like RA, is primarily autoimmune. The biochemical pathways are being understood. The SCAM community is positioning itself to benefit from this emerging science by fitting interpretations of their pre-existing beliefs to the science. In practice, the most likely outcome will be a drug that reduces the autoimmune response, and a SCAM cottege industry that claims you can “cure your arthritis” using the diet / supplement / other unevidenced treatment of preference.
What to do about it: Balance your intake of omega-6 to omega-3 fats to the ideal ratio of 1:1 to 5:1 by supplementing with omega-3s. Suggested daily dosage: 1,400 mg of EPA and 1,000 mg of DHA.
This is a crap idea. If the balance of omega-3 to omega-6 is wrong, why not just eat fewer of the things containing omega-6 and more of those containing omega 3?
If your agenda is to bring in advertisers from the supplement industry, then promoting supplements is a great idea. If your agenda is to help readers make sound health choices, wouldn’t balancing the diet be a better choice? After all, don’t omega-3 supplements increase the risk of prostate cancer? This is the danger of following the bleeding edge in science and layering a bunch of SCAM on top of it: you spend your life chasing the endless succession of contradictory statements thrown up by the media’s agenda of dangerfying everything.
Do you have a food intolerance?
Many nutritional specialists such as nutritional doctors and naturopaths find that osteoarthritis is often caused by food allergies or intolerances, and that a majority of arthritis patients are sensitive to nightshades. This food family includes white potatoes, eggplant (aubergine), sweet and hot peppers like cayenne and paprika (not the black and white kind sprinkled on food), tomatoes and tobacco.
The entire nightshade family (the Solanaceae plant family) contains many of the natural toxic chemicals of belladonna (deadly nightshade). In a survey of 5,000 arthritis sufferers, 68 per cent reported complete or substantial relief after eliminating nightshades from their diets.6
Reference 6a: J Intern Acad Prev Med, 1979; 7: 31–7 A relationship of arthritis to the Solanaceae (nightshades), Childers N.F.
Reference 6b: J Neurol Orthop Med Surg, 1993; 12: 227–31, 3. An apparent relation of nightshades (Solanaceae) to arthritis, Childers NF, Margoles MS.
Perfect example. SolanaceaeW is the family that includes potatoes and tomatoes. 7/12 of the 2012 issues and 4/12 of the 2013 issues promote lycopeneW as a miracle cure, now it’s a deadly member of the “nightshade family”. This is exactly what you expect when you allow your content to be driven by first one then another competing crank theory of the One True Cause of all disease.
In reality, most things have a mix of good and bad. The classic advice of “eat food, not too much, mostly plants” remains correct, the fad-of-the-week approach will always result in chasing a chimaera.
Norman Childers was a horticulturist who promoted a diet to “cure” arthritis for many decades. I hardly need tell you about the power of belief and the vulnerability of sufferers from chronic disease to false inference.
What are these ancient sources doing in this article? To illuminate this question, try Googling the papers, and see where they are cited.
The late San Francisco-based Dr Collin H. Dong, himself a victim of arthritis, developed a ‘cavemantype’ diet to deal with his own crippling arthritis. Within a few months he was free of symptoms and able to return to playing golf.
OK, so maybe we do need to run over this familiar ground once more.
Arthritis tends to have variable symptoms, waxing and waning. People seek treatment when the symptoms are worst. Give them a sugar cube, it’s likely they will soon improve (regression toward the meanW).
The Dong diet was devised to avoid many of the most common allergens, including artificial ones, and avoids meat, fruit (including tomatoes), dairy, vinegar and other acids, all varieties of pepper, hot spices, chocolate, dry-roasted nuts, all alcohol and particularly wine, soft drinks, and all additives, preservatives and chemicals, especially monosodium glutamate (MSG). Because it avoids meat, the diet is naturally high in fish, and fish oils are now widely recommended as good for arthritis patients.
Not sure by whom, but the diet is high in rice – the “white stuff”. As usual, when your primary goal is promoting the “medicine bad, nutritionists and supplements good” mantra, a lot of conflicting unevidenced assertions get swept under the carpet.
What to do about it: Suspect an allergy if you have: weight issues (either over- or underweight); swelling of the hands, eyes, ankles or abdomen; excessive sweating, even with no exertion; constant fatigue despite adequate sleep; and a too-rapid heart rate, especially after meals. Work with an experienced nutritional therapist to carry out food-allergy tests, and try an elimination diet, the intradermal provocative-neutralization (skin-prick) method or the enzyme potentiated desensitization (EPD) technique developed by Dr Len McEwen, formerly of the department of allergy at St Mary’s Hospital in London. With neutralization techniques (favoured by Mansfield and subject to many more safety tests), the patient is given (by either injection or drops under the tongue) tiny amounts of various triggering agents, and any reactions (usually skin wheals) suggest that the person is intolerant of that agent. Remove those foods from your diet or get yourself desensitized to them.
Fringe stuff. End of, really. McEwen’s treatment uses products from a company called Epidyme (proprietor: L. McEwen). Supporting studies are co-authored by such luminaries as George Lewith.
Is your gut leaky?
Increased intestinal permeability (so-called leaky gut) leads to the absorption of incompletely digested proteins through the gut wall, which has been linked to many diseases, including arthritis and joint roblems.7
Well, that’s one way of looking at it. Another is:
‘Leaky gut syndrome’ is a proposed condition some health practitioners claim is the cause of a wide range of long-term conditions, including chronic fatigue syndrome and multiple sclerosis.
Proponents of ‘leaky gut syndrome’ claim that many symptoms and diseases are caused by the immune system reacting to germs, toxins or other large molecules that have been absorbed into the bloodstream via a porous (‘leaky’) bowel.
There is little evidence to support this theory, and no evidence that so-called ‘treatments’ for ‘leaky gut syndrome’, such as nutritional supplements and a gluten-free diet, have any beneficial effect for most of the conditions they are claimed to help.
Reference 7: Clin Exp Rheumatol, 1990; 8: 75–83, A short review of the relationship between intestinal permeability and inflammatory joint disease. Rooney PJ, Jenkins RT, Buchanan WW.
Needless to say this does not support or prove the existence of “leaky gut syndrome”, which is primarily a quack diagnosis that translates as “give me your money and I will persuade you I am curing you”.
If you’ve been taking non-steroidal anti-inflammatory drugs (NSAIDs) over the long term, then you almost certainly have a leaky gut as these drugs are known to adversely affect intestinal permeability. Just a single dose of, for example, aspirin or indomethacin can increase permeability in the gut wall by blocking synthesis of the protective lipid compound prostaglandin.8
Not as such, no. As above, leaky gut syndrome is at best speculative.
Long-term NSAID use as occurs with osteoarthritis leaves the gut very inflamed and highly permeable and so perpetuates the problem.
Reference 8: Br J Rheumatol, 1987; 26: 103–7, Increased intestinal permeability in patients with rheumatoid arthritis: a side-effect of oral nonsteroidal anti-inflammatory drug therapy? Jenkins RT, Rooney PJ, Jones DB, Bienenstock J, Goodacre RL.
A 25-year-old paper which raises a question rather than claiming to answer it, and states “It has not been determined beyond doubt whether this finding is due to disease process or therapy with oral NSAIDs”, is used to support the claim that NSAIDs cause a condition that sounds like, but is not, “leaky gut syndrome”, which has never been shown to actually exist. How many red flags do you see waving here?
What to do about it: Take the lactulose/ mannitol challenge test for gut permeability (available from the Biolab Medical Unit in London or Genova Diagnostics in North Carolina in the US), then follow our ‘7 Steps to a Good Gut’ (in the October 2013 issue of WDDTY). Be sure to take probiotics, shown to improve gut permeability, and pick a brand that includes lactobacilli, bifidobacteria, Saccharomyces boulardii and non-disease-causing strains of Escherichia coli and streptococci.
A commercial provider of non-standard diagnostics is given uncritical treatment. No attempt is made to explore whether they might be following ideology rather than science. WDDTY standard practice.
Are you sensitive to a chemical?
Oh yes, I am sure you are sensitive to many chemicals. The only solution is never to consume anything made up of chemicals, and ideally never to come into contact with anything comprised of chemicals.
I especially recommend you avoid chemicals made up of elements. They are the worst kind.
Besides food, Dr Mansfield finds that numerous environmental chemicals such as tobacco smoke, pesticides, perfume and even hair spray can bring on arthritis, as can house dust, dust mites and moulds.
I’m sure he does. His entire business is founded on it.
The late Dr Theron Randolph of Chicago, Illinois, who first developed the theory of chemical sensitivity, found that household gas, formaldehyde and the pesticides found in food supplies also contributed to many cases of arthritis. Indeed, many of Dr Mansfield’s patients proved to be allergic to household gas, and immediately improved or entirely resolved their symptoms when they switched from gas to electricity for cooking.
Let’s hope there was no electrosmog in the electricity. Maybe they should use an open fire. Or eat raw food. There’s a WDDTY story: “Natural gas, it’s green but is it safe?” that begs to be picked apart. Aside from anything else, what’s green about natural gas? It’s less environmentally destructive than coal gas, and that’s about the best that can be said for it. Theron RandolphW was a smart man, but he also kept bad company (e.g. Ralph W. Moss) and was a darling of the nutrition quacks. Handle with care.
What to do about it: Besides cooking gas and petrol fumes, suspect the chemicals in personal toiletries and home-cleaning products. Breast implants and other silicone prostheses may also cause arthritis-like symptoms like joint swelling and promote antibodies to collagen, which then collect in susceptible tissues.9
Some women have seen their arthritic symptoms disappear after having their implants removed. Intradermal neutralization treatment can also be used for chemical or inhaled allergies or intolerance (available at the Burghwood Clinic in Banstead, Surrey; tel: 01737 352 245; www.burghwoodclinic.co.uk).
The Burghwood Clinic is Mansfield’s business.
In any reputable magazine, this would have been tagged as an advertorial.