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Hampered detoxification processes can result in a condition labeled by many naturopathic and nutrition-oriented physicians as the "congested" or "sluggish" liver, or the more recently coined "impaired hepatic detoxification". Standard liver enzyme blood tests may or may not be elevated in such cases.
The capacity of the liver to detoxify any given compound is determined not only by the inherent toxicity of the compound but also by the available supply of nutrients and endogenous molecules required for Phase I and II reactions, by any pre-existing liver disease which may be present and by the total load of all toxins to which it is exposed.
Causes & Development
Impaired liver function can result from intrahepatic problems caused by exposure to food additives, solvents (cleaning materials, formaldehyde, toluene, benzene, etc.), pesticides, herbicides, heavy metals (lead, mercury, cadmium, arsenic, nickel, and aluminum), and other toxins. Other causes include viral infections of the liver, some inherited disorders such as Gilbert's syndrome, alcohol-induced fatty deposits, the use of anabolic steroids/estrogens/oral contraceptives and hyperthyroidism. Bile flow can be restricted also by extrahepatic means such as gallstones, pregnancy, or other physical causes such as tumors.
The congested or sluggish liver is characterized by a diminished bile flow, a condition known in medical terms as cholestasis, while impaired hepatic detoxification refers to decreased phase I and/or phase II enzyme activity. Phase I detoxification rates that are in excess of Phase II activity will also cause toxicity problems due to excessive accumulation of activated intermediates.
The activity of Phase I detoxification enzymes decreases in old age. Aging also decreases blood flow through the liver, further aggravating the problem. Lack of the physical activity necessary for good circulation, combined with the poor nutrition commonly seen in the elderly, add up to a significant impairment of detoxification capacity, which is typically found in aging individuals. This helps to explain why toxic reactions to drugs are seen so commonly in the elderly.
Signs & Symptoms
The presence of chronic fatigue is a frequent symptom. Among the other symptoms, people with a sluggish liver may complain of depression, general malaise, headaches, digestive disturbances, allergies and chemical sensitivities, premenstrual syndrome, and constipation. Not surprisingly, these are the same types of symptoms people exposed to toxic chemicals often complain of. Many toxic chemicals (especially solvents) and heavy metals have an affinity for nervous tissue, giving rise to a variety of psychological and neurological symptoms such as depression, headaches, mental confusion, mental illness, tingling in extremities, abnormal nerve reflexes, and other signs of impaired nervous system function.
Diagnosis & Tests
Although there are more sensitive tests to determine the functional activity of the liver, such as a serum bile acid assay and various clearance tests, clinical judgment based on medical history remains the major diagnostic tool for the sluggish liver.
Clearance tests using saliva, urine, and/or blood after chemical challenge by caffeine, aspirin, and acetaminophen can be useful in detecting Phase I and II imbalances.
Treatment & Prevention
General treatments include:- Protection against toxic substances
- Artichoke leaf extract
- Milk thistle (Silymarin)
- Bile creation enhancement (cholerectics) often lowers cholesterol
- Dandelion
- Artichoke leaf extract (cynara which becomes caffeic acid in stomach)
- Curcumin
- Bile movement enhancement (cholagogues)
- Fatty Infiltration reduction
- Alcohol avoidance
- Low fat diet
- High water-insoluble fiber consumption
- Carnitine supplementation (other lipotropics less effective)
- Protection from free radical damage
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Signs, symptoms & indicators of Liver Detoxification / Support Requirement:
Conditions that suggest Liver Detoxification / Support Requirement: | | | | | Circulation |  Varicose Veins
Bruising Susceptibility |
Digestion |
Hemorrhoids |
Hormones |
 Progesterone Low or Estrogen Dominance |
Immunity |
 Chronic Fatigue / Fibromyalgia Syndrome | In one evaluation of 200 Chronic Fatigue and Fibromyalgia patients it was found that 80% had a significant impairment of liver detoxification function.
Patients suffering from toxic burdens may experience a wide range of symptoms, among them fatigue and poor tolerance for exercise. These processes have been postulated to be a central factor in the development of CFS. Oxidative damage to mitochondria and the detoxification process itself is being considered as a fundamental mechanism in the development of CFS. [1 Bland JS, HealthComm Inc., 1997; Int Clin Nutr Rev 1988;8(4): pp.173-5] |
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Infections |
Yeast / Candida Infection |
Metabolic |
Migraine/Tension Headaches| | A 'sluggish liver' often contributes to headaches. |
Susceptibility to Hangovers| | Acetaldehyde is a toxic substance produced in the body from alcohol and is one of the impurities found in cheap wine and 'moonshine' spirits. Some researchers believe that an acetaldehyde buildup is the cause of hangovers. If the liver's detoxification pathways are impaired, aldehydes can, instead of being converted to the next intermediate product, build up to harmful levels and cause damage since they are often more toxic than the original substances from which they are derived.
It is probably the metabolism of methanol to formaldehyde and formic acid that caused the symptoms of the hangover. Quick methanol metabolizers suffer more. This is reinforced by the fact that the types of drinks associated with more severe hangovers contain higher levels of methanol. [Hangovers: Not The Ethanol, Perhaps The Methanol, British Medical Journal, January 4, 1997;14: pp.2-3]
All types of alcoholic drinks contain some methanol, a substance blamed for the worst hangovers. Whiskey, cheap red wine, fruit brandy and other dark spirits contain the most methanol, sometimes as much as 2% by volume. Vodka and other clear drinks contain the least. In the liver, methanol takes 10 times longer than ethanol to break down. |
Jaundice
Intoxication Susceptibility
Edema (Water Retention)
Bulimic Tendency |
Nutrients |
Magnesium Requirement |
Organ Health |
Night Blindness| | Reduced night vision can be linked to a variety of conditions caused by impaired liver function which in turn reduces vitamin A metabolism. |
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Skin-Hair-Nails |
Psoriasis| | Correcting abnormal liver function is of great benefit in the treatment of psoriasis. The connection between the liver and psoriasis relates to one of the liver's basic tasks (filtering and detoxifying the blood). Psoriasis has been linked to the presence of several microbial byproducts in the blood. If the liver is overwhelmed by excessive levels of these toxins in the bowel, or if there is a decrease in the liver's detoxification ability, the toxin level in the blood will increase and the psoriasis will get worse. |
Body Odor
Dandruff
Night Sweats |
Symptoms - Liver / Gall Bladder |
Gallbladder attacks |
Symptoms - Muscular |
History of/having a fibromyalgia diagnosis |
Tumors, Benign |
Ovarian Cysts |
Uro-Genital |
Fibrocystic Breast Disease| | Impaired liver function can result in excess circulating estrogens and a worsening of breast tenderness. |
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Risk factors for Liver Detoxification / Support Requirement:
Liver Detoxification / Support Requirement suggests the following may be present:
Liver Detoxification / Support Requirement can lead to: | | | | | Immunity | Chronic Fatigue / Fibromyalgia Syndrome| | In one evaluation of 200 Chronic Fatigue and Fibromyalgia patients it was found that 80% had a significant impairment of liver detoxification function.
Patients suffering from toxic burdens may experience a wide range of symptoms, among them fatigue and poor tolerance for exercise. These processes have been postulated to be a central factor in the development of CFS. Oxidative damage to mitochondria and the detoxification process itself is being considered as a fundamental mechanism in the development of CFS. [1 Bland JS, HealthComm Inc., 1997; Int Clin Nutr Rev 1988;8(4): pp.173-5] |
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Skin-Hair-Nails |
Body Odor
Psoriasis| | Correcting abnormal liver function is of great benefit in the treatment of psoriasis. The connection between the liver and psoriasis relates to one of the liver's basic tasks (filtering and detoxifying the blood). Psoriasis has been linked to the presence of several microbial byproducts in the blood. If the liver is overwhelmed by excessive levels of these toxins in the bowel, or if there is a decrease in the liver's detoxification ability, the toxin level in the blood will increase and the psoriasis will get worse. |
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Recommendations and treatments for Liver Detoxification / Support Requirement: | | | | | Botanical |  Silymarin / Milk Thistle
Dandelion
 Garlic
Castor Oil| | Castor oil packs are commonly placed over the liver. |
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Detoxification |
Coffee Enema| | The coffee enema causes the liver to produce more bile (which contains processed toxins) and moves bile out towards the small intestine for elimination. This frees up the liver to process more incoming toxic materials that have accumulated in the organs, tissues and bloodstream. Coffee contains some alkaloids that also stimulate the production of glutathione-S-transferase, an enzyme used by the liver to make the detox pathways run. It is pivotal in the formation of more glutathione, one of the main conjugation chemicals, enabling toxins to be eliminated via bile into the small intestine. So in other words, a coffee enema speeds up the detoxification process and minimizes the backlog of yet-to-be-detoxified substances. |
Liver/Gall Bladder Flush
Liver Detoxification Phase II Support |
Diet |
Therapeutic Fasting| | Fasting has a powerful effect on improving liver function, an effect which continues after the fast. However, fasting should be avoided in cases of severe liver disease or failure. |
Alcohol Avoidance| | Acetaldehyde, a metabolic breakdown product of alcohol, is said to destroy vitamins B1, B6 and C. Even though supplements of these nutrients, together with the amino acid cysteine, may help the liver detoxify acetaldehyde, it would be wiser to avoid alcohol, it's primary source. |
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Environmental |
 Particulate Matter Avoidance |
Lab Tests/Rule-Outs |
Test/Monitor Liver Function
Liver Detoxification Profile |
Nutrient |
TMG (Tri-methyl-glycine)
Alpha Lipoic Acid| | Alpha-lipoic acid has been used very successfully as a therapeutic agent in a number of conditions relating to liver disease, including alcohol-induced damage, mushroom poisoning, metal intoxification and carbon tetrachloride poisoning. |
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KEY | | Weak or unproven link | | | Strong or generally accepted link | | | Proven definite or direct link |  | | Strongly counter-indicative | | | May do some good | | | Likely to help | | | Highly recommended |
GLOSSARY
Allergy (Allergies)
Hypersensitivity caused by exposure to a particular antigen (allergen), resulting in an increased reactivity to that antigen on subsequent exposure, sometimes with harmful immunologic consequences.
Amino Acid (Amino Acids)
An organic acid containing nitrogen chemical building blocks that aid in the production of protein in the body. Eight of the twenty-two known amino acids are considered "essential," and must be obtained from dietary sources because the body can not synthesize them.
Anabolic (Anabolism)
Promoting anabolism: Allow the conversion of nutritive material into complex living matter in the constructive metabolism. Specifically, an agent or function that stimulates the organization of smaller substances into larger ones. Examples: making a starch out of sugars, a protein out of amino acids, or making triglycerides out of fatty acids are anabolic functions. Anabolic steroids are internal or external substances that will induce increased body size or mass. The opposite of catabolic.
Bile
A bitter, yellow-green secretion of the liver. Bile is stored in the gallbladder and is released when fat enters the first part of the small intestine (duodenum) in order to aid digestion.
Carnitine
A compound found in skeletal and cardiac muscle and certain other tissues that functions as a carrier of fatty acids across the membranes of the mitochondria. Carnitine has been used therapeutically in treating angina and certain deficiency diseases.
Cholestasis
Cessation or suppression of bile flow.
Cholesterol
A waxy, fat-like substance manufactured in the liver and found in all tissues, it facilitates the transport and absorption of fatty acids. In foods, only animal products contain cholesterol. An excess of cholesterol in the bloodstream can contribute to the development of atherosclerosis.
Chronic Fatigue Syndrome (CFS, Chronic Fatigue)
A disorder of unknown cause that lasts for prolonged periods and causes extreme and debilitating exhaustion as well as a wide range of other symptoms such as fever, headache, muscle ache and joint pain, often resembling flu and other viral infections. Also known as Chronic Fatigue and Immune Dysfunction Syndrome (CFIDS), Chronic Epstein-Barr Virus (CEBV), Myalgic Encephalomyelitis (ME), "Yuppy Flu" and other names, it is frequently misdiagnosed as hypochondria, psychosomatic illness, or depression, because routine medical tests do not detect any problems.
Constipation (Constipated)
Difficult, incomplete, or infrequent evacuation of dry, hardened feces from the bowels.
Cysteine
A nonessential amino acid but may be essential for individuals with certain diseases or nutritional concerns. Cysteine is a sulfur-bearing amino acid with antioxidant properties. It is important for keratin synthesis, a protein found in skin, hair and nails and is a component of coenzyme A and glutathione.
Diabetes Mellitus (Diabetes, Diabetic, Diabetics)
A disease with increased blood glucose levels due to lack or ineffectiveness of insulin. Diabetes is found in two forms; insulin-dependent diabetes (juvenile-onset) and non-insulin-dependent (adult-onset). Symptoms include increased thirst; increased urination; weight loss in spite of increased appetite; fatigue; nausea; vomiting; frequent infections including bladder, vaginal, and skin; blurred vision; impotence in men; bad breath; cessation of menses; diminished skin fullness. Other symptoms include bleeding gums; ear noise/buzzing; diarrhea; depression; confusion.
Endogenous
From within the body, either a native function or the product of the extended colony. Normal flora in the colon are considered endogenous.
Enzymes (Enzyme)
Specific protein catalysts produced by the cells that are crucial in chemical reactions and in building up or synthesizing most compounds in the body. Each enzyme performs a specific function without itself being consumed. For example, the digestive enzyme amylase acts on carbohydrates in foods to break them down.
Fibromyalgia (FMS)
Originally named fibrositis, it is a mysteriously debilitating syndrome that attacks women more often than men. It is not physically damaging to the body in any way, but is characterized by the constant presence of widespread pain that often moves about the body. Fibromyalgia can be so severe that it is often incapacitating.
Free Radical (Free Radicals)
A free radical is an atom or group of atoms that has at least one unpaired electron. Because another element can easily pick up this free electron and cause a chemical reaction, these free radicals can effect dramatic and destructive changes in the body. Free radicals are activated in heated and rancid oils and by radiation in the atmosphere, among other things.
Gallbladder (Gall Bladder)
A small, digestive organ positioned under the liver, which concentrates and stores bile. Problems with the gallbladder often lead to gallbladder attacks, which usually occur after a fatty meal and at night. The following are the most common symptoms: steady, severe pain in the middle-upper abdomen or below the ribs on the right; pain in the back between the shoulder blades; pain under the right shoulder; nausea; vomiting; fever; chills; jaundice; abdominal bloating; intolerance of fatty foods; belching or gas; indigestion.
Gallstone (Biliary Calculus, Gall Stone, Gall Stones, Gallbladder Attack, Gallbladder Attacks, Gallstones)
Stone-like objects in either the gallbladder or bile ducts, composed mainly of cholesterol and occasionally mixed with calcium. Most gallstones do not cause problems until they become larger or they begin obstructing bile ducts, at which point gallbladder "attacks" begin to occur. Symptoms usually occur after a fatty meal and at night. The following are the most common ones: steady, severe pain in the middle-upper abdomen or below the ribs on the right; pain in the back between the shoulder blades; pain under the right shoulder; nausea; vomiting; fever; chills; jaundice; abdominal bloating; intolerance of fatty foods; belching or gas; indigestion.
Glutathione
A natural sulfur-bearing peptide formed from the linking of three amino acids: glutamic acid, cysteine and glycine. Glutathione acts as an antioxidant and detoxicant and is involved with the selenium-containing enzyme glutathione peroxidase. Glutathione is also involved in amino acid transport across cell membranes and is a powerful free radical scavenger and antioxidant that removes unwanted substances from the body.
Hangover (Hangovers)
A commonly used nonmedical term for the disagreeable physical effects following excessive consumption of alcohol (or the use of other drugs).
Hepatitis
Inflammation of the liver usually resulting in jaundice (yellowing of the skin), loss of appetite, stomach discomfort, abnormal liver function, clay-colored stools, and dark urine. May be caused by a bacterial or viral infection, parasitic infestation, alcohol, drugs, toxins or transfusion of incompatible blood. Can be life-threatening. Severe hepatitis may lead to cirrhosis and chronic liver dysfunction.
Hyperthyroidism (Hyperthyroid)
An abnormal condition of the thyroid gland resulting in excessive secretion of thyroid hormones characterized by an increased metabolism and weight loss.
Jaundice
Yellow discoloration of the skin, whites of the eyes and excreta as a result of an excess of the pigment bilirubin in the bloodstream.
Kidneys (Kidney, Renal)
Bean-shaped organs, each about the size of a fist. They are located near the middle of the back, just below the rib cage. The kidneys are sophisticated reprocessing machines, each day handling about 50 gallons of blood to sift out about half a gallon of waste products and extra water. The waste and extra water become urine, which flows to the bladder through tubes called ureters. The actual filtering occurs in tiny units inside the kidneys called nephrons. Every kidney has about a million nephrons. In a nephron, a glomerulus -- which is a tiny blood vessel, or capillary -- intertwines with a tiny urine-collecting tube called a tubule. A complicated chemical exchange takes place, as waste materials and water leave your blood and enter your urinary system. The kidneys recycle chemicals such as sodium, phosphorus, and potassium and thus regulate their levels. Renal: Pertaining to the kidneys.
Lipoic acid
(Thioctic Acid) A sulfur-containing coenzyme used in the energy process which is also an extremely powerful antioxidant capable of trapping many different types of free radicals in the body. Has been used therapeutically in the treatment of AIDS and diabetes because of the synergy between alpha-lipoic acid and vitamin E and the interlocking cycles which lead to better optimization of antioxidant nutrients. It is also able of chelating (pulling out) heavy metals such as lead, cadmium and mercury.
Liver (Hepatic)
The largest and one of the most complex organs of the body, the liver is responsible for much of the metabolism of fats, proteins and carbohydrates. It is the site of much of the body's detoxification. It is connected very closely with digestion and the regulation of blood sugar, among many other functions. Found behind the ribs on the right side of the abdomen, it has many important functions such as removing harmful material from the blood, making enzymes and bile that help digest food, and converting food into substances needed for life and growth. Hepatic: Pertaining to the liver.
Magnesium
An essential mineral. The chief function of magnesium is to activate certain enzymes, especially those related to carbohydrate metabolism. Another role is to maintain the electrical potential across nerve and muscle membranes. It is essential for proper heartbeat and nerve transmission. Magnesium controls many cellular functions. It is involved in protein formation, DNA production and function and in the storage and release of energy in ATP. Magnesium is closely related to calcium and phosphorus in body function. The average adult body contains approximately one ounce of magnesium. It is the fifth mineral in abundance within the body--behind calcium, phosphorus, potassium and sodium. Although about 70 percent of the body's magnesium is contained in the teeth and bones, its most important functions are carried out by the remainder which is present in the cells of the soft tissues and in the fluid surrounding those cells.
Malabsorption
Improper utilization of needed and available nutrients, either from impaired digestive function (such as B12 being unabsorbed because of gastritis), impaired absorption (poor Vitamin E absorption because of an inflamed ileum) or impaired transport (the diminished blood proteins of the advanced alcoholic). There are other causes as well.
Malaise
A vague feeling of bodily discomfort, as at the beginning of an illness. A general sense of depression or unease.
Metabolism (Metabolic, Metabolize, Metabolizes, Metabolizing)
The chemical processes of living cells in which energy is produced in order to replace and repair tissues and maintain a healthy body. Responsible for the production of energy, biosynthesis of important substances, and degradation of various compounds. Also defined as the sum total of changes in an organism in order to achieve a balance (homeostasis): Catabolic burns up, anabolic stores and builds up; the sum of their work is metabolism.
Mitochondrion (Mitochondria)
Structure inside a cell that is the location of the cell's energy production machinery. (Plural: Mitochondria)
Naturopathy (Naturopath, Naturopathic, Naturopaths)
Medical practice using herbs and other various methods to produce a healthy body state by stimulating innate defenses without the use of drugs.
Nervous System
A system in the body that is comprised of the brain, spinal cord, nerves, ganglia and parts of the receptor organs that receive and interpret stimuli and transmit impulses to effector organs.
Premenstrual Syndrome (PMS)
PMS consists of various physical and/or emotional symptoms that occur in the second half of the menstrual cycle, after ovulation. The symptoms begin about midcycle, are generally the most intense during the last seven days before menstruation and include: acne; backache; bloating; fatigue; headache; sore breasts; changes in sexual desire; depression; difficulty concentrating; difficulty handling stress; irritability; tearfulness.
Protein (Proteins)
Compounds composed of hydrogen, oxygen, and nitrogen present in the body and in foods that form complex combinations of amino acids. Protein is essential for life and is used for growth and repair. Foods that supply the body with protein include animal products, grains, legumes, and vegetables. Proteins from animal sources contain the essential amino acids. Proteins are changed to amino acids in the body.
Psoriasis
An inherited skin disorder in which there are red patches with thick, dry silvery scales. It is caused by the body making too-many skin cells. Sores may be anywhere on the body but are more common on the arms, scalp, ears, and the pubic area. A swelling of small joints may go along with the skin disease.
Saliva (Salivary)
The watery mixture of secretions from the salivary and oral mucous glands that lubricates chewed food and moistens the oral walls.
Selenium
An essential element involved primarily in enzymes that are antioxidants. Three selenium- containing enzymes are antioxidant peroxidases and a fourth selenium-containing enzyme is involved in thyroid hormone production. The prostate contains a selenium-containing protein and semen contains relatively large amounts of selenium. Clinical studies show that selenium is important in lowering the risk of several types of cancers. In combination with Vitamin E, selenium aids the production of antibodies and helps maintain a healthy heart. It also aids in the function of the pancreas, provides elasticity to tissues and helps cells defend themselves against damage from oxidation.
Serum
The cell-free fluid of the bloodstream. It appears in a test tube after the blood clots and is often used in expressions relating to the levels of certain compounds in the blood stream.
Small Intestine (Small Bowel)
The small intestine lies between the stomach and the large intestine. It is about 6 meters (20 feet) long and its primary function is to digest (break down) food and absorb nutrients (vitamins, minerals, proteins, carbohydrates, and fats). The small intestine makes up more than 70% of the length and 90% of the surface area of the gastrointestinal (GI) tract.
Steroid (Steroids)
Any of a large number of hormonal substances with a similar basic chemical structure containing a 17-carbon 14-ring system and including the sterols and various hormones and glycosides.
Stomach
A hollow, muscular, J-shaped pouch located in the upper part of the abdomen to the left of the midline. The upper end (fundus) is large and dome-shaped; the area just below the fundus is called the body of the stomach. The fundus and the body are often referred to as the cardiac portion of the stomach. The lower (pyloric) portion curves downward and to the right and includes the antrum and the pylorus. The function of the stomach is to begin digestion by physically breaking down food received from the esophagus. The tissues of the stomach wall are composed of three types of muscle fibers: circular, longitudinal and oblique. These fibers create structural elasticity and contractibility, both of which are needed for digestion. The stomach mucosa contains cells which secrete hydrochloric acid and this in turn activates the other gastric enzymes pepsin and rennin. To protect itself from being destroyed by its own enzymes, the stomach’s mucous lining must constantly regenerate itself.
Syndrome
A medical condition characterized by a collection of related symptoms (what the patient feels) and signs (what a doctor can observe or measure).
Taurine
A nonessential amino acid but may be essential for individuals with certain diseases or nutritional concerns. May be needed for the proper development and maintenance of the central nervous system. Taurine's role in bile formation is important for fat metabolism and blood cholesterol control.
Thiamine (B1, B-1, Thiamin, Vitamin B1)
A B-complex vitamin that acts as a coenzyme necessary for the conversion of carbohydrates into glucose, which is burned in the body for energy. It is essential for the functioning of the nervous system.
Tumor (Tumors, Tumour, Tumours)
An abnormal growth of tissue resulting from uncontrolled, progressive multiplication of cells and serving no physiological function; a neoplasm. Literally, a swelling; in the past the term has been used in reference to any swelling of the body, no matter what the cause. However, the word is now being used almost exclusively to refer to a neoplastic mass, and the more general usage is being discarded.
Vitamin A
A fat-soluble vitamin essential to one's health. Plays an important part in the growth and repair of body tissue, protects epithelial tissue, helps maintain the skin and is necessary for night vision. It is also necessary for normal growth and formation of bones and teeth. For Vitamin A only, 1mg translates to 833 IU.
Vitamin B6 (B6, B-6)
Influences many body functions including regulating blood glucose levels, manufacturing hemoglobin and aiding the utilization of protein, carbohydrates and fats. It also aids in the function of the nervous system.
Zinc
An essential trace mineral. The functions of zinc are enzymatic. There are over 70 metalloenzymes known to require zinc for their functions. The main biochemicals in which zinc has been found to be necessary include: enzymes and enzymatic function, protein synthesis and carbohydrate metabolism. Zinc is a constituent of insulin and male reproductive fluid. Zinc is necessary for the proper metabolism of alcohol, to get rid of the lactic acid that builds up in working muscles and to transfer it to the lungs. Zinc is involved in the health of the immune system, assists vitamin A utilization and is involved in the formation of bone and teeth.
Last updated: Nov 14, 2009
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