Ketogenic Diet

The two great types of diabetes, that due to excessive formation, the other to diminished assimilation of saccharine matter, require, of course, as far as animal dieting is concerned, opposite modes of treatment ; for while in the former class of cases it is a most important — I might almost say an essential — adjunct to the other treatment, in the latter it is either detrimental, or, at best, of no use at all. 

Even in the most favourable cases for restricted diet, we must never allow ourselves to be deluded into the idea that, because we are mitigating the symptoms, and reducing the amount of sugar in the urine, we are necessarily curing the disease, or we shall frequently be doomed to sad disappointment. In keeping a patient on restricted diet, we are merely with-holding from him the straw and mortar out of which the bricks are made — not removing the makers — so that, as soon as the straw and mortar is refurnished to them, they will again be found at work as actively as ever. It is true that it occasionally happens during the withdrawal of the straw and mortar the makers disappear; but this, unfortunately, is by no means invariably or even frequently the case; it is rather, indeed, the exception than therule. We must therefore rely on other means for the removal of the makers. Of these other means I shall presently speak. 

Meanwhile, let me explain that by the term restricted diet we mean not only the avoidance of all sugars, and substances containing saccharine matter, but also of all kinds of food convertible during the process of digestion into sugar. The foods convertible into sugar in the digestive canal are those containing starch (not gums), such as arrowroot, tapioca, sago, flours of all the different kinds of cereals (wheat, barley, oats, peas, beans, etc.), potatoes, carrots, beetroot, parsnips, turnips, and other edible roots. 

Green vegetables, on the other hand, such as spinach, cabbage, turnip tops, Brussels sprouts, and lettuce need not be forbidden, as they contain too small an amount of starch to do much injury. 

As for animal foods, on the other hand, every imaginable kind of fish, fllesh, and fowl may be indulged in, so that even on the most restricted diet the patient has still a large margin for selection — beef, mutton, pork, venison, poultry, game, and wild fowl, oysters, lobster, crabs, prawns, salmon, cod, turbot, etc., Iceland and Irish moss, calf's foot or gelatine jellies, butter sauces, and salad oils. 

The only true hardship, in fact, the patient suffers is the deprivation of ordinary bread, and that appears to be a more severe one than most people imagine. I have known patients in whom the craving became at last almost intolerable, as if nature were crying out for some indispensable element of food. In order to mitigate this hardship, a great number of plans of depriving bread of the forbidden element, starch, have been suggested, and many of them have been in a great measure successful. Thus, we have bran, gluten, almond, and glycerine breads and biscuits constantly kept in stock by many of our London bakers, (a) After a time patients get very tired of these substitutes, so it is as well to know that we may occasionally indulge them with well done toast, or very crisp pulled bread, the extra heat having destroyed a considerable portion of the starch normally contained in the article. 

As regards drinks, all such as contain saccharine matter are to be avoided ; such, for example, as sweet sparkling wines, whether they be champagnes, moselles, or hocks. An embargo is also to be put on all liqueurs and fruity wines, such as young port, RoussUlon, etc. ; sweet ales, stout, and porter are also to be shimned. If the patient is to be indulged in wines at all, let him have dry Lisbon, old Madeira, Manzanilla, or Amontillado sherries, Chablis, Niersteiner, or old Sauteme ; sound clarets may also be indulged in. "When stimilants are deemed requisite, brandy, whisky, rum, or Hollands may be used ; but these ought always to be employed with caution for the reasons previously given, when speaking of the artificial production of diabetes by means of stimulants introduced into the portal circulation. All that has now been said regarding regimen has of course only had reference to that form of diabetes arising from excessive formation. There are no restrictions either as regards food or drink requisite in cases springing from defective assimilation. On the contrary, the duty of the Practitioner is to select for his patient not only that which is most nourishing, but also that most easy of assimilation. He will often find, too, that such cases not only tolerate but even demand the free use of stimulants, in order to support the flagging vital energies, and enable the weakened organs to perform their work. I think if I were asked what is the best remedy for diabetes, I might venture to answer, in the language of Opie, when the student inquired what he mixed his colours with, "Brains, Sir." For to say that any one remedy or particular line of treatment is suitable to all cases of diabetes would be simply charlatanism of the worst sort.

Mr. J. B., 49 years old, merchant, had the English disease (rhachitis) as a child and therefore learned to walk only when he was 5 years old In the 20s hemorrhoids set in.     Towards the end of the 20s ; years he suffered from paralysis of the legs, which is why he was in 2 Somn.ern

I am unable to form a clear picture of the more detailed causes of this paralysis from the patient's statements; he was never syphilitic.  The signs of paralysis were "sporlo" toriiber.  The hemorrhoids developed more strongly over the years, there was prolapse of the rectum with frequent bleeding and the naehtheilige influence on the general condition, which - this suffering KU tends to accompany.  "In a very run-down condition I saw patient yoi; 7 years first.  He could not walk a short distance without the rectum protruding and bleeding.  I therefore did the cuffed operation at that time, which consisted of removing the most protruding nodes forming the prolapse with the ecrasenr. Despite slow progress with the instrument, there was a not insignificant secondary hemorrhage, which was not easy to stop, but finally succeeded.  The patient recovered rapidly and enjoyed good health for about 5 years.  Gradually, however, the disease reappeared, and only recently he was freed from it, and I preferred to use a non-bloody method of treatment, because the patient is very prone to bleeding.  The cure, which in a few weeks brought him to the point that the rectum no longer prolapsed and that he was again able to take gprössero walks, consisted of his inserting stool suppositories of stearin, which were provided with longitudinal fnrchen and coated with subsequent ointment.

Argenti nitr.  ^j.

Acid. tannic. 5jj.

Extr. belladonn.  ^jj.

Extr. opii 9/9.

Ax. porc.  5/S.

F. ungt. moUe.

 I owe the knowledge of this treatment of the rectal incident to a communication from Geheimrath Burow of Königsberg.     It seems to me that it deserves to become generally known.

In January 1866, a scaly, slightly oozing rash first appeared on the back of the patient's head, which he would have paid little attention to if it had not been the cause of his clothes always being covered with fallen scales.     On the hairy head and on the left ear, crusts formed between and next to the scales, which, when removed, quickly formed anew by secreting a yellowish flakiness.     The attending physician prescribed rubbing with ointment, but without success; rather, the disease spread to the head, and in the spring it also affected the chest.    The patient went to a cold-water institution, where he used rain, sitting and wave baths.     This cure had no favorable effect on the rectal prolapse, but a decidedly unfavorable effect on the skin rash.     The secretion of yellowish liquid on the head increased so that it often ran down the patient's face and neck; the head and chest were covered with scales and yellow crusts.     Since in the course of the cold water cure several small boils developed on the head and a larger one on the right hand, the patient gave it up and returned here in August.

The rash had become very extensive.  The hairy head, the ears, some parts of the face, the chest, the abdomen, the genitals, a part of the back and various parts of the legs were affected.     The affected areas of the skin were reddened.

A few weeks of aafentiialt in a mountainous area, daily walks of 6 - 8 hours (the rectal incident had already been eliminated), had a favorable effect on the rejection. It decreased.  Oertlich applied patient compresses covered with wax and fat rubs of sweet almond oil or cold cream, 2 times a week he took a lukewarm bath, in which he stayed for 1 hour.  When he returned from this two-week stay in the mountains and resumed his professional work, the rash soon worsened again.  All too soon it had spread again over a large part of the body, to the patient's great annoyance.  The hairy head, neck, ears, external auditory canal, part of the face, chest, abdomen, genitals, neck were mostly covered with it, as well as the armpits and part of the thighs.

In this condition I prescribed the flesh cure to the patient.  However, it was not used strictly and when after 8 days no substantial improvement had occurred, it was abandoned again and more vegetable food was consumed.  The adverse effect of the latter was so striking that the patient decided to try the meat cure again.  He now avoided bread completely, as well as flour foods, and subsisted almost exclusively on meat, meat broths, eggs and milk, allowing only some green vegetables and cooked fruit. After only 4 days on this diet, the appearance of the rash had changed considerably, the red areas of skin had become more massive, the watery secretion had become almost zero, as well as the formation of scales and crusts.  After 6 weeks the disease was almost completely gone.

A repeated attempt to eat bread again resulted in an aggravation as before; therefore, the patient soon returned to his meat diet, to which he owes his complete recovery.

The history given here might easily give the impression that this is not so much a psoriasis as an eczema.  For this reason I have called it Eczema squamosum, without attaching any importance to this name, but I have chosen it precisely because against the form of the disease described here, call it by whatever name you like, the animal diet was of definite benefit, while the relapse to vegetable food always showed itself by Becidive in the disease.

From Artic Passage Book - Page 135 Physical Hardcover:

Captain Frederick A. Barker of the Japan was one of the few whaling men to cry out against the wholesale destruction of the walrus herds of the Bering Sea. In a letter to the Whalemen's Shipping List and Merchants Transcript he warned New England whaling men that the practice "will surely end in the extermination of this race of natives who rely upon these animals alone for their winter's supply of food." 28 If the butchering of the walrus did not cease, the fate of the Eskimo was inevitable: "Already this cruel persecution has been felt along the entire coast, while a wail like that of the Egyptians goes through the length and breadth of the land. There is a famine and relief comes not." 29 Eskimos had often asked Barker why the white men took away their food and left them to starve, and he had no answer to give them. They told him of their joy when the whalemen first began to come among them, and of their growing despair as the hunters began to decimate the walrus. "I have conversed with many intelligent shipmasters upon this subject," wrote Barker, "since I have seen it in its true light and all have expressed their honest conviction that it was wrong, cruel and heartless and the sure death of this inoffensive race." 30 Captains had told Barker that they would be glad to abandon walrus hunting if the ship owners would approve it, "but until the subject was introduced to public notice, they were powerless to act." 31 It would be hard to give up an enterprise that provided 10,000 barrels of oil each season. My advocacy "may seem preposterous and meet with derision and contempt, but let those who deride it see the misery entailed throughout the country by this unjust wrong." 32 

Captain Barker was not the only shipmaster to appeal for an end to the walrus slaughter, but he knew better than to most what was happening to northern natives. Barker had taken his Japan into the Arctic Ocean in 1870 and had made a good catch. Whales were plentiful and the weather was good, so Barker was reluctant to return south through the Bering Strait. As the days grew colder and the shore ice thickened, Barker was forced to give up the chase and work the Japan toward the strait. Unfortunately, he encountered heavy fog which slowed his progress, then a storm which buffeted the Japan for four days. On October 9, 1870, the Japan was off East Cape, Siberia, and in serious trouble. "The gale blew harder, attended by such blinding snow that we could not see half a ship's length." 33 Although Barker had taken in most of his sails, the Japan was racing at breakneck speed before the gale. "Just then, to add to our horror, a huge wave swept over the ship, taking off all our boats and sweeping the decks clean." 34 

The situation was critical. Barker steered for the beach and hoped for the best. An enormous wave hit the Japan and drove it upon the rocky shore. Miraculously, all the men got ashore safely, but their travails were just beginning. The weather was bitterly cold, and clothing and provisions had to be recovered from the disabled ship. Barker and his men struggled through the surf to the ship and back to the shore again and suffered fearful consequences. All were severely frostbitten, and eight of the thirty-man crew died in the effort. Natives came to the mariners' assistance. Barker was dragged out of the breakers, breathless and nearly frozen, loaded onto a sled, and taken to village. "I thought my teeth would freeze off." 35 Barker scrambled out of the sled and tried to run, hoping the exertion would warm him. Instead he fell down as one paralyzed. The natives picked him up and put him on the sled once more. 

In the village the survivors received tender care. "The chief's wife, in whose hut I was," wrote Barker, "pulled off my boots and stockings and placed my frozen feet against her naked borom to restore warmth and animation," 36. With such care the seamen who had not died on the beach recovered. But for the natives "every soul would have perished on the beach... as there was no means at hand of kindling a fire or of helping ourselves one way or the other." 37 

Barker and his men wintered with the Eskimos, They had no choice in the matter as the entire whaling fleet had returned south before the Japan started for Bering Strait, It was during these months that Barker leaned someching of the Eskimos' way of life and became their advocate. Except for a few casks of bread and flour that had washed ashore, the seamen were entirely dependent upon their hosts. The men ate raw walrus meat and blubber that was generally on the ripe side. The whalemen did not relish their diet, but it sustained them. Prejudices against a novel food inhibited Barker for a time. He fasted for three days. "Hunger at last compelled me and, strange as it may appear, it tasted good to me and before I had been there many weeks, I could eat as much raw meat as anyone, the natives excepted." 38 Barker soon understood that the natives were short of food. "I felt like a guilty culprit while eating their food with them, that I have been taking the bread out of their mouths."39 Barker knew and the Eskimos knew that the whalemen's hunting of walrus had reduced the natives to the point of famine, "still they were ready to share all they had with us." 40 Barker resolved to call for a prohibition of walrus hunting when he returned to New Bedford and further resolved that he would never kill another walrus "for those poor people along the coast have nothing else to live upon." 41 

In the summer of 1871 Barker and his men were rescued when the whaling fleet returned. Some recompense was made to the Eskimos for their charity; they were given provisions and equipment from the ships. The natives plight was observed by other captains too. One wrote a letter to the New Bedford Republican Standard to describe the "cruel occupation" of walrus killing. Most of those killed were females which were lanced as they held their nursing offspring in their flippers "uttering the most heartrending and piteous cries."' 42 Many whalemen felt guilty about this butchery, and they had to have very strong stomachs to carry out the bloody job under such circumstances. "But the worst feature of the business is that the natives of the entire Arctic shores, from Cape Thaddeus and the Anadyr Sea to the farthest point north, a shoreline of more than one thousand miles on the west coast, with the large island of St. Lawrence, the smaller ones of Diomede and King's Island, all thickly inhabited are now almost entirely dependent on the walrus for their food, clothings, boots and dwellings." 43 Earlier there were plenty of whales for them, but the whales had been destroyed and driven north. "This is a sad state of things for them." 

Other captains reported that they had seen natives thiry to forty miles from land on the ice, trying desperately to catch a walrus or find a carcass that had been abandoned by the whalemen. "What must the poor creatures do this cold winter, with no whale or walrus?" 45 Such appeals might have been effective eventually, though whether they would have led to a prohibition of walrus killing in time to spare the northern natives from famine is unlikely. But events took an unexpected turn in 1871: The ships which passed through the Bering Strait that season did so for the last time. The entire fleet was caught in the ice near Point Barrow, as the men including the Japan survivors-hunted walrus and whale. Thanks to the Revenue Marine, the seamen were saved, but the ships were lost. This disaster, coming six years after the Shenandoah's destructive cruise, dealt the whaling industry a blow from which it never recovered. But it may have saved the walrus and the northern natives from extinction. It was clear enough to the Bering Sea natives that they had benefited by the loss of the fleet. As an Eskimo or Chukchi of Plover Bay put it to a whaling captain when word of the loss reached Siberia: "Bad. Very bad for you. Good for us. More walrus now." 46

OBSERVATION XLI. Mr. Félice F., from Cajazzo, 66, owner, almost exclusive amylivore, recognized diabetic for two months, when he presented, in addition to the symptoms of diabetes, signs of mental alienation: he was submitted on April 4 with notable worsening of symptoms for eight months, presented, on April 26, 1872, urine with a specific weight of 1030, and containing 35 gr. of sugar plus half a gram of albumin per liter. The patient undergoing rigorous treatment, his urine was examined again on May 3: it was absolutely free from sugar; the same on May 15 and 30. Since then I have heard of the complete recovery of this patient, although he had long since returned to mixed food. 1872 to the rigorous cure: after four days the sugar had disappeared, and did not reappear, although the patient quickly returned to mixed food. In this case, we never did a quantitative analysis. The patient continued to be free from diabetes until the latest news, which is about four months old. 

OBSERVATION XLII. Doctor Francesco A., doctor of the province of Salerno, 53 years old, great lover of flour, was treated by Professor Primavera, who found, in the first analysis, 105 gr. of sugar per liter: after a week of rigorous treatment accomplished according to my prescriptions, the urine contained only 23 gr. of sugar per liter: the patient admitted that he had continued to eat a little bread: having left it completely, the sugar disappeared entirely, and the patient has enjoyed the best health ever since. 

OBSERVATION XLIII. - Mr. Nicola C., from Pisticci (Basilicata) 25 years old, almost exclusively amylivore, ill for an indefinite time, but suffering for a year from ardor, thirst, sexual debilitation, gastro catarrh -enteric with coprostasis, presented on July 22, 1873, according to the analysis of Professor Primavera, 135 gr. of sugar per liter of urine, and the specific weight of 1042: subjected at this time to the cure; from July 29 the urine was free of sugar; they were still in November 1873, according to what his doctor from Pisticci told me, who wrote to me to ask me for advice about an ischialgia from which this patient was suffering, his urine still remaining absolutely normal: they were also such in the last analysis, made by Professor Primavera on February 21, 1874, although the subject had for some time returned to mixed feeding, and even to mealy foods. I saw this patient again on June 24, 1874; his urine, again analyzed by the same professor, was absolutely free of sugar, although he ate during that time, flour in moderate quantities. 

OBSERVATION XLIV. - Baron Rodolfo A., from Naples, 34, has always made great use of starches; for only two years, he suffers from a great thirst with polyuria, his general condition progressively worsens, as well as weakness and thinness; this is why in October 1872, he had his urine examined; there was evidence of the presence of sugar. What frightened the patient the most, threatening of the lens; the various cures to which he was subjected had only a mediocre success, because he came to see me on March 30, 1873, with 100 gr. of sugar per liter of urine, according to the analysis of Professor Primavera, and the specific weight of 1040. Submitted to my treatment in all its rigor, from April 6 his urine was free of sugar, weighed 1020 and on the 10th April, 1015. Since that time he has been in perfect health. Professor Primavera has it. core examined urine on June 19; they were completely free of sugar, although the patient had, for some time now, neglected the rigorous treatment. He went well, until the last news received. 

OBSERVATION XLV. - Mr. Gennaro M., owner in Santa Maria di Capua Vetere, aged 40; he greatly abused flour and fruit, and also sweet dishes; for some time he had felt an ardor of the mouth, with thirst and polyuria, and in June 1873 he presented all the other symptoms of diabetes, sexual weakness, emaciation, frustration. In October, furunculosis was added to it, and this, by its obs- tession, decided the attending physician, Dr. of 110 gr. of sugar per liter, the specific weight of 1037, a polyuria of 5 to 6 liters per day (which makes 5 to 600 gr. of sugar per 24 hours), and the almost disappearance of urates. Submitted to my treatment in all its rigor, the urine no longer contained, after three days, only 50 gr. of sugar, and, after eight days as 25: after eight more days, sixteen from the start of treatment, the sugar had dropped to 4 gr., and in the fourth week to zero, with abundance of uric acid and urates. - I saw this patient again on December 16; I found him in perfect health, however he complained of a more marked muscular weakness even than before, although he had grown a lot in appearance: later he regained all his strength. - Doctor Fossataro also told me that this patient, when he took a lot of baking soda with lactic acid, had limpid urine with a slight sediment of urates after cooling (note that it was winter) , while taking little or no bicarbonates, it frequently emitted free uric sands. February 3, 1874, almonds, dairy, coffee and wine; his urine was always free of sugar: it remained as it was after the patient had resumed the use of bread and pastries in moderate doses. As to the causes, it should be noted that this patient has always abused farinaceous plants a lot: the occasional causes of diabetes, admitted by the patient, would have been repeated exposure to damp cold, and fear: but by examining the things up close, we see that these acted when the diabetes had started a long time ago: the shock of fear only drew more attention to the patient's state of health; At the most, we can admit after this moral emotion, an aggravation of the disease. - I saw the patient again in July 1874, he was perfectly well (and it was after four months of mixed feeding), flourishing in appearance and ruby ​​in color, with absolutely normal urine (according to Professor Primavera's analysis); it is therefore legitimate to consider this gentleman as perfectly cured. I had further news in September 1874: he was doing the best in the world. 

OBSERVATION XLVI. Canon Vincenzo C., 68 years old, from San Severino Lucano, a man endowed with a strong constitution, and a great hunter, feeding mainly on starch, suffered from renal colic, due to uric stones, such as attests to the report of his doctor, Doctor Santagata. For some time now he had suffered from great thirst with exaggerated appetite, and urinated much more profusely than usual. The urine examined on July 10, 1873, discovered sugar in a dose of 30 gr. per liter, showed the specific weight of 1025, with about 3 liters of urine per day; then subjected to the rigorous cure, from July 21 the urine was free of sugar; since then he has always been doing well. In January 1874 I had more good news from him, and yet he had returned to mixed feeding. 

OBSERVATION XLVII. - M. Filippo F., aged 34, silversmith in Naples, from a very healthy family, and himself of good health and a robust constitution, gradually experienced an increase in the quantity of urine, up to 16 or 20 urinations per day; at the same time, he felt a dry mouth, and a burning stomach. His urine having been examined by Professor Primavera, according to the advice of 100 gr. of sugar per liter: they were abundant up to 6 or 8 liters per day, which made from 6 to 800 gr. of sugar in 24 hours. The patient could absolutely indicate no cause for his illness; he had experienced no sorrow, no trauma, no morbid history: let us note, however, that he ate a lot of starchy foods, and extraordinarily abused sweet jellies. Submitted to my cure, and following it in all its rigor, the urine had, on September 15th, the specific weight of 1021, its quantity was reduced to a liter or a liter and a half, and the sugar had completely disappeared. Another analysis of December 11 gave the same result, but by the fact of Oliguria the specific gravity was 1027. He then began to eat pastures, milk and dairy products, cheese, olives, salads: he drank wine: later he tried a little piece of bread. He continued to be well, having returned to a moderate mixed diet, although he experienced very great sorrow in February 1874, owing to an illness of his father, who died on February 18, and that he was very afraid of "a recurrence" as a result of this great sorrow. At this time his urine was analyzed, for he was deeply struck; however on March 3 they were completely free of sugar, rare in their quantity (800 gr. in 24 hours) and specifically made 1026: they also contained very-numerous crystals of oxalate of lime; thus the oxa-. luria was substituted in this case, as in several others, for the sweet biabetes. This patient still enjoys today hui (September 1874) in the best health. 

OBSERVATION XLVIII.-MTR, of Roccasecca, 40 years old, amylivorous by habit, suffered for about two months, according to the report of his doctor, Doctor Giovinazzi, from an intense thirst with polyuria of 7 to 8 liters per 24 hours, poor hunger, great emaciation and weakness in walking. The chemical examination showed the presence of sugar, which was however not measured. Subjected on April 23, 1873 to the rigorous cure, the sugar, after four days, was reduced to traces: on August 29, urine was sent to Professor Primavera, and the latter, not knowing how it was previously recognized the existence of diabetes, believed in an erroneous diagnosis, so absolute was the absence of any trace of sugar. MTR continued to do well until the last news received, although it has returned to a carefully mixed feed.

OBSERVATION XLIX. The dream. M. A Camilleri, 62 years old, from Nadur del Gozo (Malta), lived to live on mealy and bonbons, a case observed in January 1873, by Dr. P. Sammut, of Gozo, and already published by him. In the grip of progressive weight loss and digestive disturbances for a year, when it was first observed, with a urine emission of 6 to 7 liters per 24 hours, and considerable thirst; these symptoms made Doctor P. Sammut suspect diabetes; urine analysis, with a specific gravity of 1048, confirmed this diagnosis. The mala was so weak at this time that he could not extinguish a candle within eight inches. Subject to my treatment, it improved rapidly: in a few days, the specific weight fell to 1032, after another eight days, to 1026. It was discovered that he secretly ate the sixth part of a biscuit, and this was deleted again: after another twelve days, the urine was completely free of sugar, according to Trommer's test, and weighed 1012 Dr P. Sammut notes that this is the first case of diabetes cured in the island of Gozo, where in the past all diabetics would die without remission (as everywhere else), from the sad consequences of this disease. 

OBSERVATION L. Doctor Salvatore Grima, 32 years old, from Casal Kala del Gozo (Malta), courageous amylivore, recognized as diabetic on March 29, 1873, by doctor P. Sammut, with 8 liters per day of urine, a specific weight of 1045: he had lost extraordinary weight. Subject to my treatment, his condition improved in a few days; from April 12, 1873, the urine was completely free of sugar, and all diabetic symptoms were gone; since then he has been doing well. This observation has already been published by Dr. P. Sammut.

"The patient must be supplied with a diet consisting of nitrogenous food, such as butcher-meat, fish, eggs, and soups. Fat (which does not contribute in the least to the formation of sugar) may be given in all its forms, such as cream, butter, cheese, and oil. 

Spinach, lettuce, and cresses may be freely used, but celery and radishes only sparingly; while potatoes, carrots, parsnips, turnips, peas, French beans, cabbage, Brussels sprouts, cauliflower, brocoli, asparagus, seakale, and fruit of all kinds, both fresh and preserved, should be avoided, with the exception of nuts and almonds."