Thursday, April 17, 2008

Mr.Harrelson... Aint It A Wonderful World?


Why is there a sudden focus in the media on waist circumferences of 40 inches or greater for men? 36 inches or greater for Asian, Indo-Asian, Pacific-Rim men...

Why is it associated with everything not good for us... Dementia ... Parkinson's Disease... Alzheimer's... Metabolic syndrome... Kidney Disease... Diabetes Mellitus... Heart disease...

And also... erectile dysfunction ? ? It appears that may be the case...

Bacon CG, Mittleman MA, Kawachi I, Giovannucci E, Glasser DB, Rimm EB. A prospective study of risk factors for erectile dysfunction. J Urol. 2006 Jul;176(1):217-21.
Department of Nutrition, Harvard School of Public Health, Boston, MA 02115, USA.

PURPOSE: We examined the impact of obesity, physical activity, alcohol use and smoking on the development of erectile dysfunction.
MATERIALS AND METHODS: Subjects included 22,086 United States men 40 to 75 years old in the Health Professionals Followup Study cohort who were asked to rate their erectile function for multiple periods on a questionnaire mailed in 2000. Men who reported good or very good erectile function and no major chronic disease before 1986 were included in the analyses.
RESULTS: Of men who were healthy and had good or very good erectile function before 1986, 17.7% reported incident erectile dysfunction during the 14-year followup. Obesity (multivariate relative risk 1.9, 95% CI 1.6-2.2 compared to men of ideal weight in 1986) and smoking (RR 1.5, 95% CI 1.3-1.7) in 1986 were associated with an increased risk of erectile dysfunction, while physical activity (RR 0.7, 95% CI 0.7-0.8 comparing highest to lowest quintile of physical activity) was associated with a decreased risk of erectile dysfunction. For men in whom prostate cancer developed during followup, smoking (RR 1.4, 95% CI 1.0-1.9) was the only lifestyle factor associated with erectile dysfunction.
CONCLUSIONS: Reducing the risk of erectile dysfunction may be a useful and to this point unexploited motivation for men to engage in health promoting behaviors. We found that obesity and smoking were positively associated, and physical activity was inversely associated with the risk of erectile dysfunction developing.

When I first started working as a pharmacist, Viagra had just come out. The NP I was working with asked that I consult one of her patients. She asked me about the drug's indications, side effects and contraindications... and we used scientific terminology... like... plumbing... tent-in-the-pants... morning w**d... Then I went and met with the patient to review how to properly take the medication (yeah... fun). At the time, it was not realized that this class of medications (known as PDE inhibitors) had more serious side effects like rare blindness and (more rare) hearing loss. Oddly, one may also change blue-eyes to brown (unfortunately not the other way around).

Viagra, Levitra, or Cialis typically need to be taken prior to ... uhh... provocation. In other words, they don't just work while standing at the kitchen counter chopping vegetables... particular thoughts need to occur first.

Is it necessary to rely on these medications?

Why not prevent vascular disease early in the 20's and 30's and 40's?

Would you want to wait around for E.D. (erectile dysfunction) and vasculature obstructions to affect the function of reproductive organs? Or brain? Or heart?

Some evidence shows that ED may be equivalent to coronary artery disease and plaque.

Just as we are aware in the TYP program that plaque is modifiable (as Dr. Davis recently presented at the FASEB meeting), several trials have shown that ED is measurably modifiable. I think to myself... what a wonderful world? Solutions for reversible conditions exist in the TYP plan including erectile dysfunction.

Factors that have been shown to improve ED are:
  1. Exercise -- promotes improved circulation, increases the body's inherent antioxidants and reduces systemic inflammation
  2. Smoking cessation
  3. Losing weight
  4. Reducing excessive alcohol
  5. Relaxation
  6. L-Arginine (a special amino acid/protein supplement)
  7. Anything that reverses coronary plaque (ie, the TYP program including all the above)



    • Mallika V, Goswami B, Rajappa M. Atherosclerosis pathophysiology and the role of novel risk factors: a clinicobiochemical perspective. Angiology. 2007 Oct-Nov;58(5):513-22.
    • Francavilla S, Bocchio M, Pelliccione F, Necozione S, Francavilla F. Vascular aetiology of erectile dysfunction.Int J Androl. 2005 Dec;28 Suppl 2:35-9.
    • Jackson G, Rosen RC, Kloner RA, Kostis JB. The second Princeton consensus on sexual dysfunction and cardiac risk: new guidelines for sexual medicine. J Sex Med. 2006 Jan;3(1):28-36; discussion 36.

    • -------------------------------------------
    • Masuda H. Significance of nitric oxide and its modulation mechanisms by endogenous nitric oxide synthase inhibitors and arginase in the micturition disorders and erectile dysfunction.
      Int J Urol. 2008 Feb;15(2):128-34.
    • Bivalacqua TJ, Hellstrom WJ, Kadowitz PJ, Champion HC. Increased expression of arginase II in human diabetic corpus cavernosum: in diabetic-associated erectile dysfunction. Biochem Biophys Res Commun. 2001 May 18;283(4):923-7.
    • Baylis C. Nitric oxide deficiency in chronic kidney disease. Am J Physiol Renal Physiol. 2008 Jan;294(1):F1-9.

    Read the TYP report for more erectile dysfunction and CAD.

    Or DR. Davis's article

    Sarah Brightman:
    What A Wonderful World

    Live in Vegas, Courtesy of

    Gams, lambs, dam... damsel/princess/fairy-goddess! Here she is again, Sarah Brightman. The video is not-extremely-nsfw, but... your w**dy... will be...

    Monday, April 14, 2008

    Passion For Eradication: Part Deux

    Why does low carb, saturated fat Paleo work? (Part 2)

    The coronary risk factors have all been discovered and discussed in major medical journals by well-known experts in the field for a decade now, but a complete package of viable solutions (and manners of identification of heart disease) have seemed to fail to come to fruition in national consensus guidelines that would effectively improve care in primary and secondary cardiovascular disease prevention.


    Beyond bandaid-statins and common coronary surgeries, which do little to correct underlying disease processes, what exists that actually works? Why is coronary artery disease still the #1 killer in America... and strokes #3? Why aren't these stats changing (and seem to get worse, especially for women)? Why is CAD not being broadly reversed with the huge resources and high-tech approaches currently available in our great country??

    The use of a convenient, low-radiation diagnostic tool --- the EBT heart scans --- to guide and dictate therapy, the only plan and protocol for effective plaque reversal that has a true TRACK record of success.

    Is seeing is not believing when plaque is present? Usually unfortunately... affirmative... (unless you're symptomatic with anginal pain or erectile dysfunction (future blog topic)).

    These are subsequently quenched... For a lifetime…

    Proatherogenic mechanisms and progression pattern
    from initial artery injury through clinically manifest disease

    Lists of potential CAD risk factors were discussed for the past 10 years:
    These physicians above all have brought up a variety of coronary risk factors which are strong nasty plaque-builders. They did an immense service by listing new variables in the equation for heart disease. In addition, Drs. McCarron and Oparil et al demonstrated in a controlled trial that a comprehensive nutrition program was spectacularly powerful in lowering BP, insulin, glucose, LDL, LDL/HDL ratio, homocysteine and other drivers of heart disease. McCarron DA, Oparil S, et al. Comprehensive nutrition plan improves cardiovascular risk factors in essential hypertension. Am J Hypertens. 1998 Jan;11(1 Pt 1):31-40.

    The below publication from 2002 was produced from the AACE , the venerable group of brilliant forward-thinking experts which I mentioned earlier (updated recently in 2006 to take into account the Heart Protection Study and other landmark trials).
    The American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for the Diagnosis and Treatment of Dyslipidemiaand Prevention of Atherogenesis 2002 (Amended Version)

    The first thing that blew me away about these guidelines was the demonstration of the utilization of CT scan scoring is on Table 16 on p.195 for an evaluation of a CAD patient case study (although I believe truly 'normal' is a zero score). Back in 2002 even CT scan results provided value to the AACE as a standard of practice for detecting high risk heart disease and the presence of plaque.


    Isn’t that interesting? Back in 2002...

    This is why I like the AACE…

    Personally, in my opinion the pictures also are fantastic. Please see if you're into the pathogenesis of pro-atherogenic lipoproteins:
    • Fig 1, 2, 3 on p.175
    • Fig 4 on p.176
    • Fig 5 on p.180

    The AACE also identified the below Risk Factors for Coronary Artery Disease (Table S-1 on pg.166) which enumerate the same ones listed in the above medical journal articles.

    Coronary Risk Factors
    High total cholesterol or LDL-C
    Small, dense LDL
    Low HDL-C
    Advancing age
    Type 2 diabetes mellitus
    Cigarette smoking
    Family history of CAD
    Increased levels of Lp(a) lipoprotein
    Factors related to blood clotting, including increased levels of fibrinogen and PAI-1
    Certain markers of inflammation, including C-reactive protein

    And… this is why I really REALLY like the AACE:

    1. Other risk factors for heart disease were additionally identified -- PCOS, hypothyroidism, SLE/lupus, Cushing's disease, etc (common theme: inflammation, insulin resistance)
    2. A moderate, lower-carb diet is favored over a typically AHA high-carb diet (on p.196; first 1-2 paragraphs) for a patient with elevated triglyerides (which is 50% of all Americans according to the NHANES data, although I'd predict that would probably be about 70% now)
    3. Can the AACE top their already prescient anti-atherogenesis guidelines?? Absolutely... A brief cost-benefit analysis (on p.196 Fig 6) of the resources conserved when cardiac events, surgeries and hospitalizations are successfully averted with lifestyle/medical/nutritional therapy.

    The AACE are surprisingly one of the most progressive group of classic, systemic heart disease and prevention experts (btw they are not Cardiologists – wonder why is that?).

    So who... can possibly... trump the AACE??

    Strategies for control and reversal of vascular calcifications (HTN, carotid, peripheral, renal, coronary, ED, etc):

    Plaque-BuildersFood/Supp StrategyGoals For Health
    Blood pressureL-Arginine, Vitamin D3, exercise, IBW, weight loss, carb restriction, cocoa extracts, etcNormalization: BP = 110/70 Pulse 60
    Vitamin D3 DeficiencySupplementation of D3 (cholecalciferol in oil gel capsules)Normalization: 25(OH)D3 = 60 ng/ml
    Presence of Small LDLWheat elimination, carb restriction, Niacin, Vitamin D3, Oat bran, Intermittent Fasting, etcSmall LDL less than 10% (LDL less than 60 mg/dl)
    Elevated TGWheat elimination, increased intake good oils/fats, high dose fish oil, Vitamin D3, Vitamin B3 (niacin), etcTG << 60 mg/dl
    Low HDL

    See above, strength training, carbohydrate restriction, dietary oils/fats, etc

    HDL 60 mg/dl or higher
    Lipoprotein(a)Niacin, Vitamin D3, high dose fish oil, Carb restriction, L-carnitine, coQ10, raw nuts, DHEA, Estrogen, Testosterone, adequate good oils/fat, etc

    Normalization: Lp(a) less than 30 mg/dl or large buoyant

    HomocysteineVitamins B6, B12, Folic acid, Wheat elimination, Estrogen, etcNormalization: Homocysteine less than 8.0
    FibrinogenAspirin, fish oil, raw nuts, carb restriction, exercise, smoking cessation, etcNormalization
    Abnl Glucose, Hyperinsulinemia,Type 2 Diabetes, Type 1 DiabetesWheat elimination, Carb restriction, Exercise, IBW, Vitamin D3, high dose fish oil, raw nuts, Magnesium, Estrogen, etcNormalization: Premeal glucose less than 85 mg/dl; Insulin < 4 uIU/L; A1C < 5.0%
    Metabolic syndrome (including Central Obesity, NAFLD, Cardiac Steatosis, PCOS, Acanthosis Nigricans)Same As AboveNormalization: ALT, AST < 20-40 (Normal Echo)
    Estrogen DeficiencyBio-identical HRT, Vitamin D3, etcNormalization
    Testosterone DeficiencyReplacement, Vitamin D3, etcNormalization
    Antioxidant DeficienciesDiet/supplementation of Vitamin K2, C, E, A, D3, etcNormalization
    Thyroid DisorderReplacement, Vitamin D3, Magnesium, Calcium, etcNormalization: TSH 0.2 - 1.0 mIU/L
    Oxidative Stress, InflammationAbove strategies, exercise training, yoga, meditation, Natural Vitamins, improvement of sleep (quantity, quality), mental stress reduction, high dose Vitamin ‘O’, etcNormalization: CRP less than 3.0
    Chronic Kidney DiseaseBP and glucose normalization, Vitamin D3, high dose fish oil, address Lp(a)/Homocysteine, etcNormalization: Cr less than 0.8-1.0 Microalbuminuria less than 10- 20 ug/mg
    Abdominal/Thoracic Aortic Aneurysm, Valvular DiseaseAll the above, BP normalization, Vitamin D3, etcNormalization: Prevention of dissection and expansion
    Other CAD Risk FactorsSee above articleNormal

    Thursday, April 10, 2008

    Be An Inhaler

    How often do you hold your breath?
    Do you ever feel tightness in your neck?
    What level of stress affects you?
    How much vitamin 'O' do take? (Optimism that Dr. Davis speaks of)

    I confess I'm a gym-rat. And yoga's my Vitamin 'O'. It's an essential vitamin.

    Since the new year started off with bright shiny resolutions, the gym has been understandably packed.

    So packed... there is no parking....
    But as they say, the road to hell is paved with good intentions. And right now... that path is paved with a bunch of ya-hoos clogging my favorite yoga class :)

    Hopefully not for long though.

    I'm optimistic. *chuckle*

    It's definitely a different experience. Being hip to hip with strangers. Hearing their groans (and whimpers) as our instructor teaches us how to self-torture, self-massage, and self-relax ourselves. Why am I into deep breathing?

    How does that enhance pharmacology?

    In class it's hard to miss deep audible breathing... in unison...the whole class.... Is it sexy? Being back to back?

    Highly suggestive of... tantric... cool... Sting...

    The class is almost semi-advanced and lead by our shaved-head yoga-stud. It's not a fancy-shmancy class... just gymrat-yoga. What the class is not: bikram, strict/hatha, iyengar, naked yoga (in case you're wondering(!!) sorry to disappoint).

    Special names he gives poses:

    • Airplane (stand on one leg, arms out, other leg horizontal out)
    • Dog
    • Fire hydrant (imagine above, one knee lifted, get it?)
    • Dead bug (on back, grabbing toe; this is actually known as 'happy baby' and he says there's a reason why this isn't called the 'happy grandma' pose -- funny guy -- and all the grandmas in our class laugh when he says this)
    And he's always telling us to b-r-e-a-t-h-e !
    Isn't that involuntary?!

    Aren't you an inhaler??
    (and exhaler?)

    Hooverphonic: INHALER
    (Excellent Elvises...
    Like the one at my best buddy's wedding!)
    Courtesy of

    I tried to count once how many times he incants i-n-h-a-l-e . . .
    A-n-d . . . .
    E-x-h-a-l-e . . .
    F o c u s . . . o n . . . t h e . . . b-r-e-a-t-h . . .
    E - x - t - e - n - d . . . . . . . (but it's hard when you're zoning out)

    Occasionally he'll put these zigger-platitudes out:
    ---he hears complaints all the time people are 'soooo tired'
    ---then he hears complaints (from the same individuals) they 'can't fall asleep' (??!! he never gets it)
    ---he often wonders... 'why do they keep coming up with new gadgets that are supposed to make our lives easier? when truly the latest gadget always makes our lives more miserable than the previous gadget.'

    Class is too hilarious and any position becomes difficult to breathe and hold when you're trying not to laugh.

    How does breathing (and laughing) help our hearts?
    And your BP, heart rate and mood?

    Classic Heartscanblog: Parasympathetic effects

    Deep breathing during yoga, exercise training and relaxation techniques opens the lowest lobes of the lungs which subsequently activate vagal pathways to the brain. The vagal nerve is responsibility for parasympathetic nervous system (PSNS) activities which are related to restoration, rejuvenation and relaxation in the body. These functions are crucial, vital and potent for reduction in systemic inflammation, heart rhythm stabilization and maintenance of a strong immune system. Activation of the PSNS (or autonomic nervous system) via deep breathing is significantly associated with decreasesin heart rate irregularity, less harmful heart remodeling, and reduction of anxiety and stress.

    Deep breathing is a plaque-buster indeed.

    Anything that strengthens the immune system probably also reduces Lp(a), an acute phase reactant of the immune system, which is one of the most challenging heart risk factors we deal with at Track Your Plaque. Yoga feels great, in fact, sometimes it's better than s..e..x.., omg did I just say that? Yes, it's true, n-o-t . . . e-v-e-r-y-d-a-y, but the endorphins released are frequently quite fantastic. Endorphins are natural opioids we make in our own bodies which reduce stress, elevate mood and alleviate tension.

    That is the pharmacology that I'm referring too...

    Have you tried being an inhaler?


    And exhale... deeply... for deep plaque-busting!
    Many athletes engage in yoga for its obvious advantages. Including... my FAVORITES Tiger and Tom.


    Friday, April 4, 2008

    Do you believe in what you see?

    HOPE by Jack Johnson
    Courtesy of

    Do you believe in what you see (Zero 7: IN THE WAITING LINE) ?
    Is the 'flu economy' profitable?

    Is the 'cardiovascular economy' profitable...??

    This is a quote from the Lifepoint Hospitals CFO (courtesy of Wall Street Journal) 'You have a strong flu season and the ancillary business is very profitable.' The link here will probably disappear later...

    Who are the ancillary businesses this hospital director is referring to???

    • Kleenex and Vicks companies
    • Hospitals who see children and adults with the flu, pneumonia, etc. Some ancillary treatments may be considered as Dr. Davis puts it 'disease engineering'
    • Over the counter sales of cold and flu preparations (Walmart reported 'that cold-and-flu sufferers spurred January sales OTC medications')
    • Alcohol hand sanitizers (ie HandsClens featured at Costco)
    • Even automobile insurers (less drivers, thus less accidents)

    Who are the winners???

    • Not: people who come down with the flu... And our household was not immune this year *sigh*
    • Not: our public schools... who don't get paid when children are absent, sick, hospitalized
    • Not: employer insurance groups... who pay for hospitalizations, specialists, diagnostic tests, expensive antibiotics (which btw are useless against viral infections and just create more broadly-resistant super bacterial infections)
    • Not: employers... who lose on employee productivity, workload, etc
    • Not: all businesses... who lose on reduced commerce, transactions

    If you're not certain about the profitability of healthcare in the U.S., suggested readings are 'Overtreated' by S. Brownlee and 'The Secret History of the War on Cancer' by D. Davis (no relation to our Davis *hee he*). All Americans are indirectly paying and subsidizing the the profitability of P.P.O./fee-for-service healthcare. Healthcare outcomes are not improving despite the high costs and resources poured in. We are all in this together. And I wonder, when will the price be too high...


    (For educational, non-commercial, personal use, courtesy of

    Flu Economy Takes Unexpected Turn
    The Illness's Unusual Course This Year Has Mixed Results For Health-Care Companies

    April 3, 2008; Page B1

    The surprising course of the latest flu season -- one of the most unpredictable in years -- has been a headache for companies from tissue makers to hospital owners.
    In recent seasons, the flu has generally hit hard in December and peaked in February before petering out in March. But this year it followed a different pattern, getting off to a tamer start than usual and then roaring back in late February with the strongest surge in years. One reason: Vaccine planners failed to accurately predict the strains of the virus that would emerge this winter, making the flu shots most people got less effective than usual.
    This has created a scramble at companies that count on Americans to sniffle and sneeze. Kimberly-Clark Corp., maker of Kleenex, blamed the cold-and-flu season's initial weakness for a 12% reduction in facial-tissue shipments in the quarter ended Dec. 31, compared with a year earlier.
    In January, Walgreen Co. CEO Jeffrey Rein told a shareholder gathering that December marked the first time in his 25-year career at the company that cough- and cold-medicine sales fell during the month. If attendees of the meeting needed to cough, he joked, they should leave the room and "go to a movie theater or on a bus" to spread their germs. "We're really hoping for a very strong flu season," Mr. Rein told the crowd, according to a transcript of his presentation.
    Procter & Gamble Co. said on a conference call in January that quarterly sales of its Vicks cold medicine had been weak. "Unfortunately, people have not been getting sick at a rate that we would all like yet," P&G CEO A.G. Lafley said on the call, with a chuckle.
    Of course, each year, influenza, with its chills, aches and fever, takes a serious toll, killing about 36,000 Americans and hospitalizing more than 200,000; one government study pegs lost earnings at $16.3 billion a year. For most people, the flu season means having to get through a couple of days of fever, achiness and coughing. Americans bought $4.1 billion worth of cold, flu and allergy remedies last year, according to market-research firm Mintel International.
    However, the flu economy encompasses more than just the makers and sellers of cold medicines. Even car insurers can get a financial boost when more drivers get the flu, because at least some stay off the roads.
    The recent flu outbreak, despite its severity, has led to mixed results for businesses. Sales of Vicks and Kleenex have increased since the weakness their makers reported for the end of 2007, spokesmen for the companies say. Walgreen reported on Wednesday that the number of prescriptions filled in March was down 0.1% from the previous year, partly because it filled fewer flu prescriptions.
    The surge in flu cases that began in February probably saved HandClens, a fledgling hand sanitizer made by Woodward Laboratories Inc., of Aliso Viejo, Calif. It won a big order from Costco Wholesale Corp. last year only to see crowds of healthy shoppers ignore the product in January. "We were absolutely in panic mode," says CEO Kenneth Gerenraich. "We were borrowing from our credit line to pay the bills and keep ourselves afloat."
    As the flu flourished in February, so did sales. "Now we're paying our bills, and the checks are flowing in," Mr. Gerenraich says. "Business is good."
    Hospitals also rode the roller coaster of this flu season. Sicker patients often bring higher reimbursement from insurers or the government, and the flu can cause pneumonia and other complications. "You have a strong flu season, and the ancillary business is very profitable," David Dill, chief financial officer of LifePoint Hospitals Inc., explained to investors at a conference in January. If an elderly flu sufferer in intensive care needs a tracheotomy, "that turns into higher acuity business for us," he said. "Or, on the pediatric side, young kids coming into the hospital, that's a nice margin for us, as well."
    LifePoint, a publicly traded chain based in Brentwood, Tenn., with 49 hospitals in 18 states, reported a 4.2% drop in year-over-year admissions in the fourth quarter of last year, which analysts and the company said was in large part because of the lack of flu cases. A LifePoint spokeswoman said admissions rose as flu cases soared in February and again in late March.
    Meanwhile, at Cross Country Healthcare Inc., which provides temporary nurses to hospitals, orders in early March were up 35% from the end of January, partly because of the late flu season this year, CEO Joseph Boshart told investors.
    There is little that companies can do to plan around the pattern of the flu outbreak, which depends largely on what strain of virus takes hold, or to blunt the economic impact of a slow flu season. When there is a surge, of course, they can work with retailers to make sure the stores are fully stocked. It is still too early to know the final impact that this odd flu season will have on the bottom lines at hospitals and other health-care companies, says Cowen & Co. health-care analyst Kemp Dolliver in Boston.
    By February, every state in the country was reporting widespread flu outbreaks except Florida, which as an exception had been hit earlier in the season. Maine was one of the last states to see an outbreak, but it got walloped in March. One high school in the central part of the state reported in early March that 40% of its some 1,000 students were home sick, and dozens of other schools have reported absence rates of at least 15%. "This definitely is one of the worst seasons ... in my 12 years on the job," says Dora Mills, the state's public-health director.
    Through the second week of March, the flu remained rampant in more than 40 states, according to the Centers for Disease Control and Prevention. It was still widespread in 17 states as of March 22 and persisted in pockets in most other states, according to the latest data available from the CDC.
    A confluence of factors seem to have contributed to this year's flu season. The strains of flu that have predominated in the U.S. in recent years are known as H1N1. Health officials predicted last year that that trend would continue, so pharmaceutical companies pumped out vaccines to target those strains. But H3N2 strains proved more prevalent this year. To make matters worse, H3N2 is a particularly nasty variety of the flu.
    Moreover, flu season is inherently unpredictable, starting as early as October and sometimes peaking only in April. Even the right vaccine doesn't prevent outbreaks altogether, as a relatively small number of people get vaccinated. Manufacturers distributed about 115 million doses last year, so no more than about a third of Americans were vaccinated at all.
    Of course, the flu season can be fickle about whom it rewards. Not long after Wal-Mart Stores Inc. reported that cold-and-flu sufferers spurred January sales of over-the-counter medications, CEO Lee Scott apologized on a conference call for the sound of his voice. He had the flu.

    Correction & Amplification:
    The number of prescriptions filled in Walgreen Co. stores open at least a year fell 0.1% in March from the previous year, partly because of the slow flu season. A previous version of this article incorrectly said the decline was 1.6%.