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להמשיך להמליץ על חלב כמקור תזונתי

קשה להסיק מסקנות נגד צריכת חלב בשל סכנה לסרטן הכבד כתוצאה ממחקר מצומצם שנעשה בקרב 122 נבדקים בלבד

החלב ומוצריו הם מקור תזונתי חשוב ביותר, הכולל ריכוז גדול עם ספיגה מצוינת של סידן ו-ויטמין D. למרות זאת, בכתבות שונות ובשידורי הרדיו והטלוויזיה יוצאים רופאים מסוימים, במיוחד אלטרנטיוויים, כנגד צריכת חלב ומוצריו. לפי טענתם, צריכת חלב ומוצריו מעלה את הסיכון לשברים, למחלות קרדיו-וסקולריות ולסרטן.

בסקירה שלי שפורסמה בגיליון מאי של Isr J Fam Med, אני מפריך אחת לאחת את ההטעיות, לפחות לגבי המערכת הגרמית, הקרדיו-וסקולרית והגסטרואנטרולוגית.

חלב ומוצריו הם המקור הטוב ביותר לסידן וחומרי מזון אחרים, כמו אשלגן ומגנזיום, עם השפעות חשובות על בריאות העצם. למרכיבים ביו-אקטיביים שנמצאים במוצרי חלב כמו החלבון הבסיסי יש תפקיד חיוני במטבוליזם של העצם.

"אני מציע לעמיתיי הרופאים להמשיך ולהמליץ על צריכה רגילה ולא מוגזמת של חלב ומוצריו דלי-השומן בגלל יתרונותיו הבריאותיים"

ההשפעה החיובית של חלב ומוצריו על בריאות העצם מבוססת על ראיות ממחקרים אקראיים ומבוקרים, בהם נמצאו השפעות חיוביות וחיוניות על מסת העצם בגיל הילדות ובהתבגרות ועל התפתחות תקינה של העצם. לא נמצאה כל השפעה של צריכת חלב על הגדלת הסיכון לשברים אוסטיאופורוטיים, כמו של מפרק הירך.

קיימות ראיות ממחקרים רבים שצריכת חלב ומוצריו, בעיקר דלי השומן וגם לאחר בישול או פיסטור, נמצאת ביחס הפוך לטרשת העורקים, ליתר לחץ דם, למחלה כלילית, לשבץ מוחי ולסוכרת מסוג 2.

כאשר ערכתי חיפוש ב-Pubmed לגבי הקשר בין חלב ומוצריו לסרטן מצאתי עשרות מחקרים, שחלקם דיווחו על עלייה בסיכון לסרטן בצריכת סוגים ומוצרים שונים של חלב ואילו באחרים לא נמצא כל קשר ביניהם. תוצאות המחקר האירופי הגדול European Prospective Investigation into Cancer and Nutritionי (EPIC), שבו נכללו מעל חצי מיליון משתתפים מ-23 מרכזים ב-10 מדינות באירופה (רובם בגיל 35-70), שפורסם בשנת 2010 מצאו כי:

- סרטן הקיבה נמצא ביחס הפוך לרמה גבוהה של ויטמין C בפלסמה, קרוטנואידים, רטינול, טוקופרול-אלפה, צריכה גדולה של סיבי דגניים ודביקות גדולה לתזונה ים תיכונית (בתוכה חלב דל-שומן). צריכת בשר אדום ובשר מעובד קשורים בסיכון מוגבר לסרטן זה.

- צריכה מוגברת של סיבים, דגים, סידן וריכוז גבוה של ויטמין D בפלסמה (שני האחרונים נמצאים בכמות גדולה בחלב) קשורים בירידה בסיכון לסרטן המעי הגס והחלחולת בעוד שעלייה בסיכון קשורה בצריכת בשר אדום, בבשר מעובד, באלכוהול, ב-BMI גבוה ובהשמנה בטנית.

- צריכה מוגברת של פירות וירקות במעשנים קשורה בסיכון נמוך לסרטן הריאה.

- עלייה בסיכון לסרטן השד קשורה בצריכה מוגברת של שומן רווי (כמו חלב עתיר-שומן) ובצריכת אלכוהול. BMI גבוה בנשים לאחר חדילת אורח היה קשור בסיכון גבוה לסרטן השד ואילו פעילות גופנית היתה קשורה בסיכון נמוך.

"קשה להסיק ממספר קטן של משתתפים על הסיבתיות בין מוצרי חלב וסרטן הכבד גם לאחר שנשללה פגיעה קודמת בכבד"

בעיבוד נוסף של אותה קבוצת מחקר שפורסם בשנת 2013 נמצא חיזוק לראיה שלמוצרי חלב יש כנראה תפקיד הגנתי לסיכון לסרטן המעי הגס והחלחולת ללא כל קשר לתכולת השומן בחלב ומוצריו.

במחקר נוסף של אותה קבוצת מחקר שפורסם בימים אלו נמצאה עלייה בסיכון לסרטן בכבד ע"י צריכת חלב וגבינה ולא ע"י יוגורט, לאחר מעקב של 11 שנה בקרב 122 משתתפים. קשה להסיק ממספר קטן של משתתפים על הסיבתיות בין מוצרי חלב וסרטן הכבד גם לאחר שנשללה פגיעה קודמת בכבד.

למעשה, קשה להסיק מסקנות על הקשר בין חלב ומוצריו לסרטן מכיוון שאין כל מחקר אקראי, מבוקר ופרוספקטיבי שנועד אך ורק לבחון קשר זה. קיימת אולי סבירות מה לגבי הקשר בין צריכה מוגזמת של חלב ומוצריו (בעיקר עתירי-שומן כמו גבינות קשות שמהוות מקור מזון שכיח באירופה) לגבי עליית הסיכון לסרטן הערמונית והשד ואולי גם של הכבד. מצד שני, צריכה זו מורידה את הסיכון לסרטן במערכת העיכול.

אני מציע לעמיתיי הרופאים להמשיך ולהמליץ על צריכה רגילה ולא מוגזמת של חלב ומוצריו דלי-השומן בגלל יתרונותיו הבריאותיים הגדולים לכל מערכות הגוף, ולהתעלם מכל המלעיזים על אחד מהמקורות התזונתיים החשובים ביותר.

נושאים קשורים:  דעות,  סרטן הקיבה,  סרטן הכבד,  סרטן הערמונית,  חלב,  לקטוז,  תזונה,  סרטן,  מחקר EPIC,  סרטן שד
תגובות
רופא
24.07.2014, 20:58

אהבתי

ד"ר צדיק
25.07.2014, 00:17

גם אני אהבתי.

ד"ר ברגמן
25.07.2014, 22:50

מה לגבי מחקר סין?
בספר מתוארים מספר מחקרים המדגימים את הקשר בין צריכת חלבוני חלב לסרטן ולמחלות אוטואימוניות.
כמו כן הוכח קשר בין צריכת חלב פרה (או פורמולה מבוססת חלב פרה) בשנה הראשונה לחיים לבין התפתחות סכרת סוג 1 במהלך השנים.
יש להתייחס גם לכך שמוצרי חלב פוגעים בספיגת הברזל ועלולים לגרום לאנמיה.
המקור הטוב ביותר לויטמין D הוא חשיפה לשמש.
בישראל צריכת מוצרי החלב גבוהה ביותר ועדיין רמות ויטמין D נמוכות יחסית.
לגבי המחקרים על סרטן המעי הגס- מדובר על צריכת סידן. צריך להדגיש כי סידן במזון מגיע גם ממקורות אחרים: קטניות, סויה, קינואה, עלים ירוקים, שקדים, תאנים, אצות.

ד"ר דן קרת
27.07.2014, 14:48

מצרף מאמר על הבעייתיות בצריכת חלב שנשלח ל- IMJ אך לא פורסם. אני אחד מהרופאים האלטרנטיבים שאתה ממליץ לא להקשיב להם. המאמר שכתבתי הוא כולו REFERENCED , לרוב מחקרים גדולים ומשמעותיים. להנאת הפתוחים והבלתי משוחדים שביניכם
ד"ר דן קרת M.D., N.D

Is milk a healthy part of a diet?
Reconsidering Dairy as an essential part of the human diet.

Dairy foods, on an evolutionary time scale, are relative newcomers to the human diet. The first direct chemical evidence for dairying dates to 6100 to 5500 before present 1. The human evolutionary adaptation, keeping lactase in our gastrointestinal tract beyond breastfeeding years, is one of the very few changes our genome went through as we moved from the Paleolithic era, living as hunters and gatherers, and not consuming dairy, to the Neolithic era, and modern life as we know it. This evolutionary change is at least partially responsible for the success of the white race, flourishing in colder climates, where less vegetation and meat is available during the harsher winters of Europe.
Since then, gradually, dairy became a greater part of our diet due to its' taste, variation, accessibility and increase in standard of living. This process happened especially in western, affluent, white societies. Some reasons for dairy to not become a major and significant part of the diet among the black, yellow and red races, is due to the high rate of lactose intolerance and less availability of refrigeration in less affluent societies around the world.
Today dairy is estimated to be nearly a quarter (23%) of the American diet 2. In Israel, dairy is responsible for about 18% of the diet (per weight) 3.
Maybe due to its increasing use, the change in the diet of cows (from grass rich in N-3 to grains rich in n-634-36) or other additions to dairy in industrial societies, dairy has become a dietary risk factor for many diseases. I'll discus each one and bring the research that supports this claim.

Osteoporosis:
The research I'm about to present, states the opposite of what we all thought was solid facts. "… the highest rates of fractures are found in countries with high dairy consumption, and large prospective studies have not shown a lower risk of fractures among those who eat plenty of dairy products.” 4 Not only we don't get protection for our bones from dairy, respectable researchers point to hazards from too much dairy consumption. " Yet another concern regarding the USDA pyramid is that it promotes over consumption of dairy products, recommending the equivalent of 2-3 glasses of milk a day… ... but dairy consumption should be limited to 1-2 servings a day. “5 The Harvard Nurses’ Health Study, which followed more than 75,000 women for 12 years, showed no protective effect of increased milk consumption on fracture risk. In fact, increased intake of calcium from dairy products was associated with a higher fracture risk. 6 Australian study7 showed the same results. Additionally, other studies 8,9 have also found no protective effect of dairy calcium on bone. Another study from Harvard's Nurses study states that “Neither milk nor a high-calcium diet appears to reduce risk. “(for hip fractures. DK). 10 A review that examined the relations between dairy and bone health states that “Of the few stronger-evidence studies of dairy foods and bone health, most had outcomes that were not significant.” 11 When it comes to children and adolescents, the researches conclude that "…scant evidence supports nutrition guidelines focused specifically on increasing milk or other dairy product intake for promoting child and adolescent bone mineralization.” 12. The most important factor determining the future bone health is physical activity 13. To improve bone health we should reduce consumption of sodium and animal protein and increase consumption of fruits and vegetables, exercising, and ensuring adequate calcium intake from plant foods such as leafy green vegetables and beans, as well as calcium-fortified products such as breakfast cereals and juices. 14. More trials, one of them coming from the Framingham study, conclude that high fruit and vegetable intake appears to be protective in men and in adolescent boys and girls (16–18 y), young women (23–37 y), and older men and women (60–83 y). High candy consumption was associated with low BMD in both men and women. 15,16. There are at least 2 mechanisms that explain these phenomena. Textbook in nutrition states that: "The average protein intake in many industrialized countries is at least 50% above recommended levels. Excess protein intake has been proposed as a reason for the high incidence of osteoporosis in such populations despite moderate –to-high average calcium intakes. The proposed mechanism is the calciuric effect of protein. Over a wide range of protein intake, an average increase in dietary protein of 1 gram results in the loss of an additional 1 mg of calcium in the urine. The effect of protein is rapid and is not balanced by a change in calcium absorption.” 17. In Israel the average consumption of protein is 110 grams per day which is double the RDA for protein for an average person weighing 70 Kg. (70kg * 0.8gr/kg = 56 gr) 3. Harrison on osteoporosis states that “Another factor implicated in bone loss is the possibility that excessive acid intake, particularly in the form of high-protein diets, results in “dissolution” of bone in an attempt to buffer the extra acid.” 18. Second mechanism from the textbook of nutrition explains that “Increased phosphorus has an opposing effect on calcium balance… A diet high in phosphorus and low in calcium produced an increase in PTH secretion 17. Milk is the richest source of phosphorus in the diet17. An epidemiological observation that supports the above claims is found in China. The rate of osteoporosis in china is half the rate in the United states. Calcium consumption in China is half that of the USA. Protein consumption in the USA is 50% higher, and what is more interesting, is that 70% of the protein in the US diet comes from the animal kingdom (70 grams out of 95) while only 10% of the protein consumed in China comes from animals and their products (7 out of 64). Dairy is nonexistent in rural China, where this huge trial was taking place 19. In South Africa , Hip fractures among black women from rural areas are rare. The rate in black women living in cities is tenth the rate of white women. These rates remain although black women have low calcium consumption, have more pregnancies and breastfeed longer. They also consume less protein and exercise more than the white women 20,21.

Cancer:
Important epidemiologists worn us not to consume too many milk products. " What is more, we cannot assume that high dairy consumption is safe: in several studies, men who consumed large amounts of dairy products experienced an increased risk of prostate cancer, and in some studies, women with high intakes had elevated rates of ovarian cancer. …” 22. They advocate getting our calcium from other sources, including supplements, which are cheaper and less dangerous means of getting the calcium we need. The EPIC study found a relationship between dairy and prostate cancer risk. A high intake of dairy protein was associated with an increased risk. A 35-g day increase in consumption of dairy protein was associated with an increase in the risk of prostate cancer of 32%. Calcium from dairy products was also positively associated with risk, but not calcium from other foods. The results support the hypothesis that a high intake of protein or calcium from dairy products may increase the risk for prostate cancer 23. Textbook of Nutrition also makes the connection- “Higher intake of meat and dairy products has been associated with greater risk of prostate cancer, which may be related to their saturated fat content” 24. More researchers and a meta-analysis also found an increased risk of prostate cancer with increased dairy consumption 25,26,27.Men with the highest dairy consumption have a 2-4 fold risk for metastatic or fatal disease. The mechanisms known to participate in this increased risk are:
Insulin-like Growth-Factor 1 (IGF-1):
Men with the highest levels had more than four times the risk of prostate cancer compared with those who had the lowest levels. IGF-I is found in cow’s milk and has been shown to occur in increased levels in the blood by individuals consuming dairy products on a regular basis 28-31. More studies also showed this trend (risk is 5 fold)and added that if at the same time, the level of IGF binding protein-3 is low, the risk goes up to 9.5 fold 32.
Vitamin D:
High calcium intake, including calcium of dairy origin, may increase prostate cancer risk by lowering circulating vitamin D 1,25(OH)2, which regulates growth and differentiation in multiple normal and malignant cell types 33,34
Saturated fat: In a large case-control study among various ethnic groups within the US, consistent association with prostate cancer risk were seen for saturated fat, but not with other types of fat.”35
A trial that followed people from their childhood to their adult lives, found that High childhood total dairy intake was associated with a near-tripling in the odds of colorectal cancer compared with low intake, independent of meat, fruit, and vegetable intakes and socioeconomic indicators. They concluded that a family diet rich in dairy products during childhood is associated with a greater risk of colorectal cancer in adulthood 36.

Coronary heart disease:

Milk fat , like other kinds of animal fat, is a rich source for saturated fatty acids, part of the group of cholesterol-raising fatty acids known to enhance atherosclerosis. Textbook in nutrition states that Milk fat is more hypercholesterolemic than meat fat because of its higher content of cholesterol-raising fatty acids 37. Cow A1 beta-casein per capita supply in milk and cream (A1/capita) was significantly and positively correlated with IHD in 20 affluent countries five years later over a 20-year period--providing an alternative hypothesis to explain the high IHD mortality rates in northern compared to southern Europe. They raise the possibility that intensive dairy cattle breeding may have emphasized a genetic variant in milk with adverse effects in humans 38.

The metabolic syndrome:

Milk, yogurt, and ice cream, despite having relatively low glycemic load, are highly insulinotropic, with insulin indexes comparable with white bread 39. Adding milk to a spaghetti meal with low glycemic index can increase significantly the Secretion of insulin after the meal. Adding 200 ml of milk increases the secretion of insulin to levels comparable to white bread 40. Scientists don't know why dairy cause an increase in the secretion of insulin. They guess that the proteins in dairy encourage the secretion of insulin because they were intended to feed young mammals. Insulin is an anabolic hormone that is intended to increase the entry of building materials into the cell- not just glucose, but also amino acids and fatty acids, the building blocs of new tissues. Milk has a unique combination of amino acids that together cause an increase secretion of insulin, more than each alone 41. Milk products deviate from other carbohydrate-containing foods in that they produce high insulin responses, despite their low GI. The insulinotropic mechanism of milk has not been elucidated. This article concludes that food proteins differ in their capacity to stimulate insulin release, possibly by differently affecting the early release of incretin hormones and insulinotropic amino acids. Milk proteins have insulinotropic properties; the whey fraction contains the predominating insulin secretagogue 42. Researchers in Boston examined 12,829 adolescents at the ages of 9-14 and 3 years later. They found that children who drank the most milk gained more weight. Drinking large amounts of milk may provide excess energy to some children 43. The mechanism is through somatotropic hormones like growth hormone (GH), insulin-like growth factor I (IGF-I), and raising the ratio of IGF-I to its binding protein, IGFBP-3. Milk drinking may cause increases in these hormones' levels in prepubertal girls and boys. The finding that milk intake may raise GH levels is novel, and suggests that nutrients or bioactive factors in milk may stimulate endogenous GH production 44. In 2267 French adults, similar trends were observed. Positive relations were found between milk consumption and Waist Circumference change in overweight women and between yogurt consumption and weight change in normal-weight women. This research found a trend toward increases in weight with high dairy calcium intakes in normal-weight women 45.

Longevity and milk:
Societies around the world known for their longevity and good health hardly consume dairy or consume it in small to moderate amounts. In Okinawa, with the highest longevity in the world, and the lowest rates of heart disease, cancer, and osteoporosis, dairy in not a significant part of the diet. High calcium foods like seaweed and dairy comprise 2% of the diet 46. In Crete, the origin of the Mediterranean diet, dairy is consumed in small to moderate amounts. It comes from a variety of animals : goat, sheep, buffalo, cow, and camel. Because refrigeration was lacking and the climate was often hot, milk was preserved and consumed as yogurt and cheese. Grating small amounts of high fat, full flavored cheese over pasta is an example of incorporating these foods in a healthful yet good tasting manner, while keeping overall consumption of dairy products low to moderate 47.

Milk as a risk factor for autoimmune diseases:
IDDM- A study from Finland shows that drinking cow's milk is associated with getting juvenile diabetes and the earlier children start to drink milk and the more they drink, they more likely they are to develop diabetes. According to a report in Diabetes, exposure early in life to cow's milk may increase the lifetime risk of developing diabetes in high-risk children 48,49. More recent study concludes that an enhanced humoral immune response to various cow milk proteins in infancy is seen in a subgroup of those children who later progress to Type1 Diabetes. Accordingly, a dysregulated immune response to oral antigens is an early event in the pathogenesis of T1D.
Multiple Sclerosis: a worldwide correlation between milk consumption and multiple Sclerosis was found 50.
Other conditions:
Alzheimer Disease(AD):
Two studies identified similar dietary patterns strongly associated with lower AD risk: compared with subjects in the lowest tertile of adherence to this pattern, the AD hazard ratio for subjects in the highest DP tertile was 0.62 (P = .01). This dietary pattern was characterized by higher intake of salad dressing, nuts, fish, tomatoes, poultry, grains ,cruciferous vegetables, fruits, and dark and green leafy vegetables and a lower intake of high-fat dairy products, red meat, organ meat, eggs, sugar and butter 51, 52.
Avoiding iron deficiency anemia in infants:
From the Policy statement of the American Academy of Pediatrics about "Breastfeeding and the Use of Human Milk", Infants weaned before 12 months of age should not receive cow’s milk but should receive iron-fortified infant formula 53.

Acne:
Two studies found a positive association between milk consumption in adolescents and acne. This finding supports earlier studies and suggests that the metabolic effects of milk are sufficient to elicit biological responses in consumers 54,55.

The future:
I think the future lies in the feed of the animals who's milk we consume. Peoples around the world who used milk from animals who grazed on grass, were able to have healthy and long life. As the feed of the animals changed to grains, that is where the change in health outcomes started to decline. When we'll demand as consumers to have milk from grazing animals, the market will start to produce them. This is where the future lies. This way we'll have dairy without compromising our health 34-36,47.

References:
1. Loren Cordain, S Boyd Eaton, et al. Origins and evolution of the Western diet: health implications for the 21st century. Am J Clin Nutr Vol 81, No 2, 341-354, Feb 2005.
2. U.S. cohort of the Seven Countries Study from Keys A 1980 Seven countries: a Commonwealth Fund Book. Boston: Harvard University Press.
3. CBS, statistical abstract of Israel, 2009, Food supply and nutrients 2007. pp 770.
4. W.Willet, L. Giovannucci. Eat, drink and be healthy. The Harvard Medical school guide to healthy eating. Pub. Simon & Schuster, 2001.
5. Walter C. Willett, Meir J. Stampfer. Rebuilding the food pyramid. Scientific Americam, Jan 2003, 58-59.
6. Feskanich D, Willet WC, Stampfer MJ, Colditz GA. Milk, dietary calcium, and bone fractures in women: a 12-year prospective study. Am J Public Health 1997;87:992-7.
7. Cumming RG, Klineberg RJ. Case-control study of risk factors for hip fractures in the elderly. Am J Epidemiol 1994;139:493-505.
8. Huang Z, Himes JH, McGovern PG. Nutrition and subsequent hip fracture risk among a national cohort of white women. Am J Epidemiol 1996;144:124-34.
9. Cummings SR, Nevitt MC, Browner WS, et al. Risk factors for hip fracture in white women. N Engl J Med 1995;332:767-73.
10. Feskanich D, et al. Calcium, vitamin D, milk consumption, and hip fractures: a prospective study among postmenopausal women. Am J of Clin Nutr, Vol. 77, No. 2, 504-511, February 2003.
11. Weinsier R, Ksumdieck CL. Dairy foods and bone health:Examination of the evidence. Am J Clin Nutr 2000;72:681-89
12. Lanou AJ, et al. Calcium, Dairy Products, and Bone Health in Children and Young Adults: A Reevaluation of the Evidence . PEDIATRICS Vol. 115 No. 3 March 2005, pp. 736-743.
13. Frank R. Greer, Bone Health: It’s More Than Calcium Intake. PEDIATRICS Vol. 115 No. 3 March 2005, pp. 792-794.
14. Tucker KL, Hannan MR, Chen H, Cupples LA, Wilson PWF, Kiel DP. Potassium, magnesium, and fruit and vegetable intakes are associated with greater bone mineral density in elderly men and women. Am J Clin Nutr 1999;69:727-36.
15. Tucker KL, et al. Bone mineral density and dietary patterns in older adults: the Framingham Osteoporosis Study.. Am J Clin Nutr, Vol. 76, No. 1, 245-252, July2002.
16. Celia J Prynne et al. Fruit and vegetable intakes and bone mineral status: a cross-sectional study in 5 age and sex cohorts. Am J Clin Nutr, Vol. 83, No. 6, 1420-1428, June 2006 (Cambridge UK)
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לאה
29.07.2014, 16:03

האמת המדעית הנקייה מכל אינטרסים כלכליים אודות ניזקי החלב לבריאותנו, היא קשה ואפילו מזעזעת. אמת זו מוסתרת מהציבור הרחב בזכות עמל וכסף רב שמשקיעה תעשיית החלב בעולם.
אני מאמינה שקרוב היום בו אמת מרה זו תצא לאור והציבור הרחב יוכל סוף סוף להגן טוב יותר על בריאותו. אנשי מקצוע יקרים כמו ד"ר דן קרת וד"ר ברגמן ורבים נוספים, עושים עבודת שליחות אמתית שתורמת לקרוב היום בו האמת תצא לאור.

דניאל
08.09.2014, 16:52

הכל כסף.

איפה שיש הרבה כסף, שם נמצאים "המחקרים הטובים" למוצר, ושם גם נמצאים כל הרופאים "המומחים" שממליצים על אותו מוצר ומשבחים אותו (הם מעולם לא שמעו על הנזקים שאותו מוצר גורם).

זה לא רק בחלב ומוצריו.

בכלל כל זמן שהרפואה הקונבנציונלית מסתמכת, מתפרנסת וממומנת מחב' התרופות, אז מבחינת הרופאים, אין כל פתרון אחר בעולם פרט לתרופות קונבנציונליות, למרות שהם יודעים שאין תרופה שעושה רק טוב וללא כל נזק (אין דבר כזה).
הסיכוי שרופאים שכאלה ימליצו על טיפול אלטרנטיבי הוא אפסי, ויתרה מכך, אין להם כל עניין לפגוע בפרנסתם הממומנת מחב' התרופות.

הגיע הזמן לקרוא לילד בשמו.