Good Food is Great Medicine: Which Diet and Lifestyle Choices

Really Matter? Miles Hassell, MD

Providence Cancer Center Integrative Medicine Department

providence.org/integrativemedicine

Comprehensive Risk Reduction Clinic Providence St. Vincent Medical Center

goodfoodgreatmedicine.com

Co-author: Good Food, Great Medicine, 3rd Edition

Z:\Share Docs\Current Talks\Heart.BP.Stroke\IHD Overview Powells 10.03.2014

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Getting started

• Important elements for lifestyle change – Create clear cut goals – Identify consistently credible sources of information

• Without these two pieces in place its easy to ping pong between wildly divergent views and give up

• The good news – Good Food, Great Medicine is designed to help you get started

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Why talk about lifestyle choices?

• Goal: identify those choices that matter, choices associated with improvement in meaningful health outcomes – Benefits should ideally be evident across a

broad range of diseases: • cancer, heart disease, stroke, diabetes, dementia,

depression, excess weight and waistline, high blood pressure, abnormal cholesterol…and so on.

– Better long term health and independence

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Combined lifestyle choices mortality outcomes in women

• Good diet (veg >5s/d, fruit >4/d, nuts or soy daily, fish/poultry>red meat, cereal fiber >15g/d, rare hydrogenated oils, PS:S >1.0)

• BMI <25: Get or maintain a healthy waistline • 30min/day brisk walking or equivalent • Light alcohol intake (Consumption of up to 1 drink /day, excluding

non-drinkers) • 31% of cancer, 12% of CAD, 23% of all cause mortality

– Also identified with about 90% less diabetes incidence

Compared to being sedentary, overweight smoker with poor diet. Non-smokers, 24 year follow up, 78k, Nurses Health Study van Dam, R. BMJ 2008;337:a1440doi:10.1136/bmj.a1440

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Lifestyle change could put some doctors out of business

• 6,229 people followed for average of 7.6 years • If you were not obese, non-smoker, ate

Mediterranean (including alcohol), exercised 75-150 minutes/week – 81% lower risk of premature death Multi-Ethnic Study of Atherosclerosis

(MESA) Ahmed, H et al. Am J Epid 2013;doi:10.1093

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A real hero: S.B.

Before After

11 months elapsed between pictures 6

S.B. took advice seriously! Able to stop insulin, fibrate, statin, metformin. Only medicine is ASA

• Initial findings – Weight 212 – Blood pressure 137/107 – Total cholesterol 217 – HDL 13 – Triglycerides 6701/1570 – LDL ? – TC:HDL ratio 17 – Random glucose 939 – HbA1c 11.5%

• 11 months later: – Weight 155 – Blood pressure 110/70 – Total cholesterol 152 – HDL 39 – Triglycerides 75 – LDL 98 – TC:HDL ratio 3.9 – Fasting glucose 102 – HbA1c 4.9%

3 years later: HbA1c 5.1%, HDL 47, no meds

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What lines of evidence do we use? • What have people eaten, when given the choice,

over recorded history: “historical precedent”? • What do we learn from high quality medical

studies? • What have we learned from our patients over the

last 20 years? – Which ideas are the most sustainable? – Which ideas are easily adaptable over a broad range

of demographics?

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Why be omnivorous?

• Omnivores eat just about everything, as most populations have been doing throughout recorded history.

• Certain patterns of omnivorous diets appear to be healthier, like the Mediterranean model which we will be discussing today. – We’ll also talk about a few foods to avoid.

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A whole food Mediterranean diet #1 • Aim for 9 servings of vegetables and whole fruits daily. Potatoes

don’t count! Avoid juice and eat whole fruit or vegetables instead.

• Eat plenty of beans/legumes, and include raw nuts and seeds. • Eat intact or minimally-processed whole grains like oat groats,

barley (whole/hullesss not pearled), whole rye berries, millet, quinoa, brown rice, steel cut oats, old-fashioned rolled oats, etc.

• Eat good fat with each meal and snack (avocados, raw nuts, raw seeds, etc) and use extra-virgin olive oil as main kitchen oil.

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A whole food Mediterranean diet #2

• Animal proteins: Fish, especially oily fish like salmon, tuna, and sardines; unprocessed (uncured) meat and poultry, dairy, and real whole eggs.

• Cultured dairy foods like unsweetened yogurt and kefir, and aged cheese.

• Includes moderate alcohol • This diet is typically not low in fat, saturated fat, or

cholesterol.

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Mediterranean diet benefits: Prospective Cohort Studies

• Over 2 million people followed for up to 20 years: – for every 2 points greater adherence on a 10 point scale

• Total mortality: 8% less • Heart attack and stroke: 10% less • Dementia, Parkinson’s: 13% less • Risk of cancer, or cancer death: 6%-12% less Sofi, F. AJCN 2010;92:1189-96; Greek EPIC

Benetou, V. B J Cancer 2008;99:191-95

• Risk of type 2 diabetes: Up to 80% less • Depression: 30-50% less • Less disability in the elderly • Better weight loss and metabolic improvement

compared to other diets in head-to-head studies

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A summary of Mediterranean diet benefits

RANDOMIZED CONTROLLED TRIALS (RCT) PROSPECTIVE OBSERVATIONAL STUDIES

Lower death rates1

Less heart disease, stroke2

Improvement in heart disease risk factors3

Less type 2 diabetes4

Better blood sugar control5

Sustainable weight loss6

Less cancer7

Improved brain function8

Lower death rates9

Less heart disease, stroke,10 and peripheral artery disease11

Less type 2 diabetes12

Less cancer13

Less mild cognitive impairment and progression to dementia14

Less dementia, Parkinson’s disease15

Less depression16

Less menopausal symptoms, hot flashes and night sweats17

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1 Lorgeril M. et al. Circulation 1999;99:779-85 2 Estruch, R. et al. NEJM 2013;368:1279-90 3 Nordmann, A. et al. Am J Med 2011;124:841-51 (Meta-analysis: 6 Randomized Controlled Trials) 4 Salas-Salvado, J. et al. Diabetes Care 2011;34:14-9 5 Ajala, O. et al. AJCN 2013; 97:505-16 (Meta-analysis: 20 Randomized Controlled Trials) 6 McManus, K. et al. Int J Obes Relat Metab Disord 2001;25:1503-11, Shai, I. et al. NEJM 2008;359:229-41 7 Lorgeril, M. et al. Arch Intern Med 1998:158:1181-1187 8 Martinez-Lapiscina, E.H. et al. J Neurol Neurosurg Psychiatry 2013, May 13 9 Sofi, F. et al. AJCN 2010;92:1189-96 (Meta-analysis of 7 prospective studies) •10 Sofi, F. et al. AJCN 2010;92:1189-96 (Meta-analysis of 7 prospective studies), Psaltopoulou, T. et al. Annals Neurology 2013 doi: 10.1002/ana.23944, (Meta-analysis of 11 stroke studies) •11 Ruiz-Canela, M. et al. JAMA 2014; 311(4):415-7 •12 Kastorini, C.M. J Am Coll Cardiol 2011;57:1299-313 (Meta-analysis: 35 Clinical trials, 2 Prospective, and 13 Cross-sectional) •13 Sofi, F. et al. AJCN 2010;92:1189-96, Trichoupoulou, A. AJCN 2010;92:620-25, Bamia, C. et al. Eur J Epidemiol 2013;28(4):317-28 •14 Feart, C. et al. Curr Opin Clin Nutr Metab Care 2010;13:14-8 •15 Psaltopoulou, T. et al. Ann Neurol 2013 doi: 10.1002/ana.23944, Alcalay, R.N. et al. Mov Disord 2012;27:771-4 •16 Psaltopoulou, T. et al. Ann Neurol 2013 doi: 10.1002/ana.23944, Akbaraly, T. et al. Br J Psych 2009;195:408-13 •17 Herber-Gast, G. and Mishra, G. AJCN 2013;97:1092-9 14

Mediterranean Diet: Lyon Diet Heart Study A randomized controlled trial for secondary prevention of heart disease

• “Prudent Western Diet” vs. Mediterranean Diet after Myocardial Infarction (MI) – 72% reduction cardiac events, – 56% reduction in all cause mortality, – 61% reduction in all cancers – Independent of cholesterol, blood pressure, aspirin,

alcohol use RCT, 4y, n= 604 de Lorgeril, M et al. Circulation 1999;99:779-85

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Mediterranean diet vs. low-fat diet for heart risk factors, weight loss, diabetes

• Meta-analysis of high-quality studies comparing the Mediterranean diet to low fat diets for overweight and obese people – Mediterranean diet superior to low-fat diets for:

weight loss, BMI, blood pressure, blood glucose, cholesterol, hsCRP Trends towards better HDL, LDL; Nordmann, A. Am J Med 2011;124:841-51

– better for diabetes management Ajala, O et al. AJCN 2013;97:505-16

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Extra-virgin olive oil • Associated with the Mediterranean diet and:

– Improved endothelial function, blood pressure Morena-Luna, R. et al. Am J Hypertens 2012;1299-304 Ferrara. Arch Int Med. 2000;160:837-42,

– Improves fibrinolysis, reduces platelet aggregation Lopez-Miranda, J. Mol Nut Food Res 2007;51:1249-59

– Reduces post-prandial: activation of Factor VII, p inflammation, increases antioxidants Bogani, P. Atherosclerosis 2007;190:181-6

– Less stroke Samieri, C. et al. Neurology 2011;77:418-25

– Improved mood, physical activity, resting energy expenditure Kien, CL et al. Am J Clin Nutr 2013;97:689-97

– Modest lipid benefits • Many of the benefits appear to be phenol-mediated, so

watch out for extra processing

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Fats and health outcomes • Beneficial:

– Olive oil, especially extra-virgin – Raw nuts, oilseeds (sunflower, sesame, pumpkin, flax, etc) – Oily fish: sardines, salmon, herring, mackerel, tuna – Avocado, probably coconut oil and dairy fats (!)

• Harmful: – trans fats, typically found in partially hydrogenated oils and many

packaged foods like baked goods, crackers, and cake mixes • Used with caution:

– Most non-olive vegetable oils: typically very highly processed, little nutrition, often high in omega-6 fatty acids, possible associations with poor health outcomes.

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Vegetables and whole fruit • Broad range of benefits: Less death, heart disease and

stroke, cancer, diabetes, dementia… • How much to eat? 5 – 9 servings/day:

– Serving: 1 medium piece of fruit, 1/2 cup chopped fruit, 1/2 cup chopped vegetables, 1 cup raw leafy vegetables

– Have at least one serving with every meal – Consider starting your meal with vegetables

• Fresh (raw or cooked) & frozen better than dried or canned. Read ingredient labels!

• Minimize fruit juices: more calories, less fiber, less total nutritional content, increase risk of weight gain and diabetes. NHS, DM risk +18% with 1 serving fruit juice/day Bazzano, L Diabetes Care 2008;31:1311-17

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Whole grains, beans and legumes • Whole grains, including “modern” wheat, is associated with lower

risk of breast and colon cancer, stroke, heart disease and type 2 diabetes – Lower total mortality 20%, esp. from cardiovascular, infectious and

respiratory illness 25-30g/d vs. 10-12g/d. Park, Y. Arch Intern Med 2011;doi2011.18; Kim Y. et al Am J Epid 2014;180:565-73

• Intact whole grains contain more minerals, vitamins, antioxidants, oils, fiber than refined grains – Avoid refined grains: this includes anything made with white flour (also

called wheat flour, enriched flour, and unbleached white flour) or any other form of highly-refined grains.

• ‘cold’ breakfast cereals, crackers, white rice, most pasta, bagels, breads, etc. – However, consider avoiding ALL grain foods if you are significantly

overweight or have diabetes

• Legumes/beans have similar benefits as whole grains, create additional opportunities for inexpensive protein

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P.E. 60 yr old male: able to stop 2 prescriptions, now on no medications

• Initial findings on 2 blood pressure drugs:

– Weight 189 – BP 152/90 – Total cholesterol 161 – HDL 28 – Triglycerides 1332 – LDL not measured – TC:HDL ratio 5.8 • Counseled on exercise,

Mediterranean diet, healthy fats, reduced carbohydrates.

• 6 months later, no Rx’s: – Weight 175 – BP 138/76 – Total cholesterol 157 – HDL 45 – Triglycerides 70 – LDL 98 – TC:HDL ratio 3.5

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Chocolate and heart disease Use 70% or higher for therapeutic effect:

(Tea, extra-virgin olive oil have similar compounds)

• Increases HDL cholesterol 11-14% 20-40% lower risk. 75g dark chocolate, 3 weeks Mursu FRBM 2004;37:1351-9

• Reduces platelet adhesion Pearson Clin Dev Immunol 2005;12:1-9

• Reduces LDL oxidation Wan. Am J Clin Nutr 2001;74:576-602 Mathur J Nutr 2002;3663-67

• Improves endothelial function Vlachopoulos Am J Hypertens 2005;18:785-91 Also in smokers. Heiss JACC 2005;46:1276-83

• Appears to reduce heart disease risk by 37%, stroke by 29% Meta-analysis, Buitrago-Lopez, A et al. BMJ 2011;343:d4488

– Optimal dose uncertain, likely < 1oz/day of 70% Circ Heart Failure 2010;5:612-16

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Alcohol and health • Up to 2 alcoholic drinks/men, 1/women daily associated with

– 15-42% less CAD or risk of dying of any cause. Circulation 2010;121:1589-97. Costanzo, S. et al. JACC 2010;55:1339-47 (meta-analysis)

– 50% less heart failure JAMA 2001;285:1971-77

– 45% less mortality following MI JAMA 2001;285:1965-70

– Less dementia Garcia, et al. J Alz Dis 2010;20:577-586

– Lower risk of type 2 diabetes, Rasouli, B. et al. Diabet Med 2013;30:56-64

– Raises HDL, reduces platelet aggregation, increases fibrinolysis, increases NO, stabilizes plaque Review: Kloner, R. Circulation 2007;116:1306-1317

– All alcoholic drinks associated with reduced risk Rimm et al. BMJ 1996;312(7033):731-6

– Promotes arteriogenesis in ischemic myocardium Pig model. Lassaletta, A et al. Circulation 2013;128S1:S136-43

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Caffeine in coffee and tea • Coffee generally associated with lower death rates, heart

disease, stroke, diabetes, gallbladder disease, dementia Freedman, N. NEJM 2012;366:1891-904, and others

• Choose unenhanced coffee and tea. Avoid “coffee” and “tea” drinks with added sweetening and flavors, like caramel lattes, mochas, and sweetened tea drinks.

• Tea associated with less heart disease, osteoporosis, maybe less cancer

• Caffeine may be part of the mechanism for benefit from coffee, tea

• Caffeine is not a substitute for good food

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Foods to avoid or minimize • Refined carbohydrates, such as refined sugars, white

or “wheat” flour, white rice, ready to eat breakfast cereals

• Non-nutritive (artificial) sweeteners • Highly refined fats, such as highly refined vegetables

oils, hydrogenated oils, trans fats • Preserved meats • Foods subject to industrial processing methods:

particle size, heat and pressure, added chemicals are all issues.

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Is this sugar better than that sugar? • Highly refined sugars such as cane sugar, agave, high

fructose corn syrup are all pure calories, and toxic in excess – White flour and white rice are essentially sugars

• Use small amounts of naturally occurring or less processed sugars such as raw honey, pure maple syrup and molasses: these have broad nutritional qualities and are less likely to be used in excess.

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Problems associated with added sugars and starches

• Obesity • Ischemic heart disease and stroke • Insulin resistance, metabolic syndrome and type 2

diabetes • Hypertension • Dementia • Cancer

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Sugars, refined grains, and the heart

• Highest intake of added sugars associated with 3-4x greater risk of dying of heart disease and stroke; 33% more for one 12 ounce soda a day. n=43k, 14.6. Yang, Q et al. JAMA Internal Med 2014;174:516-24

• Highest intake of refined grains (mostly white rice, some wheat flour) had 3x more heart disease. n=117,366, 5.4-9.8y. Yu, D. et al. Am J Epid 2013;178:1542-9

•

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C.M. slim, 56 yr old female: swims daily, great diet! BP154/98, started antihypertensives, father died MI at age 46

• Initial findings, on meds

– Weight 132 – BP 125/95 on Rx – Total cholesterol 235 – HDL 61 – Triglycerides 216 – LDL 131 – TC:HDL ratio 3.9

• Discussed carbohydrate restriction, less bread, more vegetables and achieving ideal weight.

• Follow up: – Weight 122.6 – BP 112/70, no Rx – Total cholesterol 287 – HDL 108 – Triglycerides 68 – LDL 165 – TC:HDL ratio 2.7

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Example to follow! D.A.’s 15k fun-run at age 88

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Benefit of moderate exercise

• Lower total mortality: As good or better than meds for stroke, heart, diabetes BMJ 2013;347:f5577

• Less heart disease (60%), stroke

• Favorable macro-and microvascular adaptation

• Improved endothelial function

• Less depression

•

• 30-80% lower risk of Type 2 Diabetes

• Better cholesterol, triglycerides

• Less fatty liver • Fewer infections, • Less cancer, better cancer

survival • Less disability in old age • Less dementia

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This bar graph displays the years of life gained when participants met various percentages of HHS guidelines for physical activity. 50% = 1.8 years. 100% = 3.4 years. 200% = 4.2 years. 300% = 4.5 years.

Reference: Moore SC, et al. Leisure Time Physical Activity of Moderate to Vigorous Intensity and Mortality: A Large Pooled Cohort Analysis. PLoS Medicine. November 6, 2012. doi: 10.1371/journal.pmed.1001335.

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Get adequate sleep • Goal: 7-9 hours sleep daily

• Increased risks associated with inadequate sleep (less than 7 hours) –Heart disease and stroke Hoevenaar-Blom, M.P. et al. Eur J Prev Cardiol

2013;doi:10.1177/204748731 (MORGEN study)

–Higher death rates Tamakoshi, A. and Ohno, Y. Sleep 2004;27:51-4

–Some cancers –Obesity Carter, P.J. et al. BMJ 2011;342:d2712 (FLAME study)

–Insulin resistance and diabetes Liu, A. et al. Metabolism 2013;doi:10.1016/j.metabol.2013.06.003

–Higher blood pressure –Vulnerability to infection Cohen, S. et al. Arch Intern Med 2009;169:62-7

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Make GREAT health choices! • For effective lifestyle change:

– Identify clear cut goals and consistently credible sources of information. Without these pieces in place its easy to ping pong between divergent views, and even give up

• Good Food, Great Medicine is designed to help you get started: Evidence based information, not just opinion

• 14 Point Action Plan and meal planning sections to make your job easier – For weight loss, type 2 diabetes reversal, heart and stroke

risk reduction, cancer survivorship

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Which diet and lifestyle choices really matter? • Eat a whole food Mediterranean-style diet • Minimize refined grains, sugars, and hydrogenated oils • Read ingredient lists • Prepare your own foods, bring your own lunch, and

plan ahead! • Choose protein + good fat + fiber combinations for

every meal and snack • Exercise daily and don’t be sedentary • Get and maintain a healthy waistline • Schedule 7-9 hours of sleep

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288 easy-to-read pages packed with evidence-based recommendations for the ‘why’ and ‘how’ of implementing a whole food Mediterranean diet. Includes 185 simple-to-follow recipes made with everyday ingredients.

Many thanks to Powell’s Books for providing this forum for discussion. Miles Hassell MD and Mea Hassell goodfoodgreatmedicine.com

Providence St. Vincent Medical Center 9155 SW Barnes Rd, Suite 302 Portland, OR 97225 503-291-1777

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Gluten • A naturally occurring protein in wheat, rye and barley,

that has been part of healthy diets for millenia. – And these grains are associated with dramatically better health

outcomes even in their modern forms – As with almost any food, some people don’t tolerate gluten.

• Avoid added refined (or added) gluten: Read labels! This step may eliminate “gluten intolerance” in many people.

• If you suspect gluten intolerance, medical tests may be of value. If these are normal, remember that no tests are perfect: Try strictly avoiding gluten for a month, then add back whole foods with naturally occurring gluten and see if you notice a difference.

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Saturated fat is OK

• Both epidemiological and randomized prospective studies of dietary saturated fat have had inconsistent results

• Meta-analysis of prospective studies show no significant association between saturated fat and heart disease Dietary: Siri-Tarino PW et al. Am J Clin Nutr 2010;91:502-09; Circulating: Chowdhury, R et al. Ann Intern Med 2014;160:398-406

• Intake of refined carbohydrates is a much greater concern Siri-Tarino PW Am J Clin Nutr Am J Clin Nutr 2010;91:535-46 Also Hu, F. AJCN 2010;91:1541-2

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Red meat: don’t overlook best single source of B12, iron, zinc and protein, but avoid preserved meat

• Studies of meat and risk of heart disease, stroke and diabetes – 20 studies, 1 million people, 10 countries

• No association between red meat 3-4 oz/day and heart disease, stroke or diabetes – 1 ½ lbs (raw) red meat per week safe for cancer risk (AICR 2007) and heart disease

(Bernstein, A. Circulation 2010;122:876-883)

• Preserved (‘cured’) meats associated with more heart disease and diabetes – Sausages, ham, bacon, lunchmeats – Each 50g = 42% more heart disease, 19% more diabetes Micha R Circulation 2010

doi:10.1161

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Eggs (real) • Outcomes data for eggs are inconsistent: evidence of

both benefit and harm in observational studies, but confounded by other factors: e.g. bacon, smoking

• Total egg consumption – Not associated with Type 2 diabetes Cardiovasc Health Study Djousse, L. Am J Clin N

2010;92:422-7

– Has no adverse effect on blood cholesterol or endothelial function 2 eggs/d x 6w. Njike, V. Nutr J 2010;9:28

• Egg breakfast associated with eating fewer calories overall, better blood glucose and insulin Suppressed gherlin. Leite, R. Nutr Research 2010;30:96-103

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Why I eat whole-fat dairy • Dairy foods and dairy calcium inconsistently associated

with weight loss: – Greatest weight loss association appears to be with whole

milk, cheese, and cultured milk (yogurt, kefir) 9y, n= 19352 women Rosell, M. Am J Clin Nutr 2006;84:1481-8

• Butter, milk, other dairy not associated with mortality in systematic review 1952-2012; Sulllivan T et al Am J Public Health 2013;103:e31-42

• Dairy foods associated with: – Increased insulin sensitivity Hirschler, V. J Ped 2009;154:101-5

– More weight loss in diabetics Shahar, D. Diabetes Care 2007;30:485-9

– Lower inflammatory markers Labonte, M et al. AJCN 2013;doi:10.3945

– Less heart disease in some studies Milk fat , Warensjo, E. AJCN 2010;92:194-202

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GMO and organic foods

• Sources of good information: – Organic debate:

• Smith-Spangler, C. et al. Annals of Internal Med 2012;157:348-66 • Baranski, M. et al. British Journal of Nutrition 2014;doi:10.1017

– GMO debate: • Scientific American, September 2013

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Vegetarian/vegan diets • Peer-reviewed vegetarian or vegan diet studies, including

Adventist and EPIC-Oxford, do not show the same degree of health benefit as observed with the Mediterranean diet, and are associated with risks of nutritional deficiencies

• Omnivorous diets have demonstrated sustainability for thousands of years, most people like them better, and don’t require vitamin or mineral supplements

• For detailed China Study and Forks Over Knives critique, see: – http://rawfoodsos.com/2011/09/22/forks-over-knives-is-the-science-legit-a-

review-and-critique/#more-1487

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Paleolithic diets • A diet attributed to hunter-gatherers: lean meats,

non-starchy fruits and vegetables, nuts. – We are unable to identify whether these people were

particularly healthy, how long they lived, their height... – It excludes many demonstrably healthy and enjoyable

foods, is hard to maintain, has not demonstrated significant health benefits

• Any diet that excludes refined sugars and starches is probably helpful, if not optimal.

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Do we all benefit from a low salt diet? No

• Few follow a low salt (<2,300mg/day) diet: it doesn’t taste good, and may be harmful IOM . Bibbins-Domingo, K. et al. JAMA Intern Med 2014;174:136-7

– You don’t live longer – it just feels that way – Lowest mortality seems to be in those eating ‘moderate

sodium’ 2,600-5,000mg/day Meta-analysis, 25 studies, n=274,683. Graudal, N et al. Am J Hypertension 2014;doi:10.1093, also see PURE O’Donnell, MJ et al. NEJM 2014;371:612-23

– Avoid prepackaged foods, especially breads and cereals: about 75% of total salt supply

– Use your saltshaker cheerfully (11% of salt supply) on homemade high-potassium whole foods

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288 easy-to-read pages packed with evidence-based recommendations for the ‘why’ and ‘how’ of implementing a whole food Mediterranean diet. Includes 185 simple-to-follow recipes made with everyday ingredients.

Many thanks to Powell’s Books for providing this forum for discussion. Miles Hassell M.D. , Mea Hassell goodfoodgreatmedicine.com

Providence St Vincent Medical Center 9155 SW Barnes Rd, Suite 302 Portland, OR 97225 503-291-1777

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