They went looking for a turnaround team to spruce it up and take it public again. Herbalife hired PricewaterhouseCoopers and said it aimed to have the statements reapproved by the end of the year. That year the company became the subject of a CNN series that highlighted dubious medical claims distributors were making about Herbalife products. Ackman hailed the news as showing that Herbalife had exhausted its mature markets and that its modest efforts to curb fraud were crippling its ability to do business. But if the commission finds that an MLM is a pyramid scheme—which is considered inherently deceptive—it must shut it down.
Acute liver injury associated with the herbal supplement hydroxycut in a soldier deployed to Iraq. Shim M, Saab S. Severe hepatotoxicity due to Hydroxycut: Severe hepatotoxicity following ingestion of Herbalife nutritional supplements contaminated with Bacillus subtilis.
Association between consumption of Herbalife nutritional supplements and acute hepatotoxicity. Herbal does not mean innocuous: Hepatotoxicity associated with the consumption of herbal slimming products.
Med Clin Barc ; Hepatotoxicity associated with supplements containing Chinese green tea Camellia sinensis Ann Intern Med. Fulminant hepatitis during self-medication with hydroalcoholic extract of green tea. Eur J Gastroenterol Hepatol. Green tea extracts and acute liver failure: Bjornsson E, Olsson R. Serious adverse liver reactions associated with herbal weight-loss supplements. Acute liver failure induced by green tea extracts: Acute hepatitis due to Exolise, a Camellia sinensis dried ethanolic extract [letter] Med Clin Barc ; Acute hepatitis associated with Camellia thea and Orthosiphon stamineus ingestion [letter] Gastroenterol Hepatol.
Hepatotoxicity associated with green tea extracts [electronic letter]. Toxicity of green tea extracts and their constituents in rat hepatocytes in primary culture. Bacillus cereus and other Bacillus species.
Bacillus subtilis as a cause of cholangitis in polycystic kidney and liver disease. N Engl J Med. Slimming at all costs: Supplemental products used for weight loss. J Am Pharm Assoc ; Published online February This article has been cited by other articles in PMC. Aloe has been widely used in phytomedicine. Phytomedicine describes aloe as a herb which has anti-inflammatory, anti-proliferative, anti-aging effects.
In recent years several cases of aloe-induced hepatotoxicity were reported. But its pharmacokinetics and toxicity are poorly described in the literature. Here we report three cases with aloe-induced toxic hepatitis.
A yr-old woman, a yr-old woman and a yr-old woman were admitted to the hospital for acute hepatitis. They had taken aloe preparation for months.
Their clinical manifestation, laboratory findings and histologic findings met diagnostic criteria RUCAM scale of toxic hepatitis. Upon discontinuation of the oral aloe preparations, liver enzymes returned to normal level. Aloe should be considered as a causative agent in hepatotoxicity.
The demand for dietary supplements has continually increased in recent years as the concept of 'well being' widely spread in Korea. The market value for dietary supplements in Korea was approximately billion won million USD in year 1 , and personal spending was approximately , won USD per year in 2. One of the leading products in Korea's dietary supplements market is aloe. Aloe has been purported to have positive effects on wound healing, recovery from burn injury, cell growth, and immune modulation.
However, cases of aloe-induced toxic hepatitis have been reported since We report 3 cases of aloe-induced toxic hepatitis in Korea. Case 1 A yr-old female patient with a 2 month history of dyspepsia was presented to our department. Past medical history and family history did not reveal any significant disease. She also used drugs for arthralgia intermittently for several years.
She did not take any alcohol. She had taken aloe tablets containing mg of an extract of Aloe arborescens and On admission, the patient's physical examination was normal. Preparation of aloe which the patient had taken. A Container bottle and tablets. B Packs of aloe extract. Anti-HBs IgG was positive. Autoimmune markers were all negative. Abdominal ultrasonography showed reduced echogenicity of liver. Dilatation of intra- or extrahepatic bile ducts was absent.
Liver biopsy revealed moderate portal infiltrates consisting of eosinophilis, neutrophils, and monocytes. There were inflammatory cell infiltration and acidophil body on the hepatic lobule. There was no bile stasis Fig. Histopathological findings of the liver.
Aloe tablets was immediately discontinued. ALT as well as total bilirubin gradually returned to normal level over several weeks Fig.
Upon discontinuation of the oral aloe preparation, liver enzymes returned to normal level. Case 2 A yr-old female patient was presented to our department with a week history of fatigue. The patient did not take any alcohol or durgs.
She had taken aloe powder containing mg of an extract of Aloe vera Fig. Physical examination revealed jaundice on her sclera. She was the sales person of the aloe product she was taking. Abdominal ultrasonography was normal. Liver biopsy revealed severe portal and lobular infiltrates consisting of neutrophils and monocytes.
There were several acidophilic bodies and ballooning cell change in hepatic lobule. There were bile-stasis and bile stained Kupffer cells Fig. Aloe extract was immediately discontinued. We explained to her about the aloe-induced hepatotoxity and advised not to take it anymore.
However, the patient started taking the same aloe extract again 1 month after her discharge from the hospital. Since a hepatitis recurred after re-challenge of aloe extract, we could confirm her diagnosis as aloe-induced toxic hepatitis. The type of liver injury was determined as 'hepatocellular' since R ratio was After re-challenge arrow , liver enzymes go up again.
Six months later, the patient was presented to our department with a 2 week history of jaundice. We recommended admission, but she refused to be admitted and she never visited our hospital again. Case 3 A yr-old female patient was presented to our department with a 3 month history of epigastric discomfort. The patient did not take any alcohol or drugs. She had taken aloe extracts Fig. On admission, the patient's physical examination was normal except mild tenderness on epigastric area.
Autoimmune markers were negative. Abdominal ultrasonography showed increased echogenicity of liver. After 4 days, she visited our department for follow-up. The major driving force for the growth of the dietary supplements market is the perception that 'they are safe because they are natural'.
However, the recently reported cases of hepatotoxicity induced by natural substances 8 indicate that natural substances may not be entirely safe. There are about species of aloe. Among them, particularly aloe vera has been used in phytomedicine. There have been positive reports on aloe vera as anti-inflammatory, anticancer, analgesic, anti-aging as well as liver protective.
But, clinical effectiveness of aloe vera was not sufficiently defined because there were no large and randomized studies 9. In , Korea's National Institute of Safety Research conducted an experiment on the efficacy and toxicity of aloe There was no difference of natural killer cell activity between the aloe vera gel treated and control animals. To observe the toxicity of aloe gel, rats were given the high dose aloe orally.
Any adverse effects were not detected in hematological test, serum biochemistry, and histopathological examination. There are no specific tests or diagnostic criteria for herbinduced hepatic injury. Careful history taking, laboratory finding, and histopathology are used to diagnose it.
The best way to determine causing agent is re-challenging. But it is not ethical and not applicable. Since patients usually do not regard dietary supplements as 'real' medicine, they may fail to mention it when physicians query medication history. Physicians should keep in mind that dietary supplements can be the cause of hepatotoxicity when querying medication history, and should educate the lay public.
There are three types of acute liver injury by drug or herb Our cases are characterized as hepatocellular; there is a predominant initial elevation of the ALT level. There are two proposed pathogeneses of drug induced liver disease It is more likely that an idiosyncratic immunological mechanism hypersensitivity is responsible for the cases. A role for hypersensitivity is further supported by the presence of eosinophilic granulocytes in the periportal fields seen in the biopsy.
Hypersensitivity to aloe has been described in humans 14 , and the patch test or allergic skin test showed positive results Herb induced liver injury is an important problem in clinical setting, because it can be an etiology of undiagnosed acute hepatitis. However, there are few available data about the incidence and clinical manifestation of dietary supplements such as aloe.
Our cases emphasize that physicians should consider various dietary supplements as causative agents for hepatotoxicity. Food and Drug Statistical Yearbook. Korea Food and Drug Administration. Aug, [accessed 0ct 27]. The survey for the actual condition of drug medication and development of health care cost associated with toxic liver injury in Korean: Acute hepatitis induced by an aloe vera preparation: Aloe vera-induced acute toxic hepatitis in a healthy young man.
Eur J Intern Med. Oral aloe vera-induced hepatitis. Criteria of drug-induced liver disorders. Report of an international consensus meeting. Vogler BK, Ernst E. Br J Gen Pract. Studies of the effectiveness and toxicity of aloe vera gel. The report of National Institute of Safety Research. Clinical features and diagnosis of drug induced liver injury. Pathologic features of toxic and drug induced liver injury. A case of hypersensitivity associated with oral aloe agent.
J Asthma Allergy Clin Immunol. Herbalife, Liver, Hepatotoxicity, Weight loss products, Dietary supplements. Case 1 involved a patient who did not consume Herbalife products, while Cases 2 and 3 each reportedly consumed various Herbalife products.
Herbalife fundamentally disagrees with the conclusions made by the authors with regard to any cause and effect relationship related to the intake of Herbalife products. First, Herbalife is not a single product and no unique suspect product or ingredient has been implicated in this paper amongst the reported cases.
In addition, the authors arbitrarily compared cases involving the use of a single product Hydroxycut with patients who consumed a group of totally unrelated products produced by the company Herbalife.
To bundle a brand of products such as Herbalife with another company that sells different products simply because they are all dietary supplements is not valid. Finally, there are specific considerations, in regard to the two patients who consumed Herbalife products, that would render many of the observations and conclusions discussed by the authors as speculative and unsubstantiated.
The specific and factual points supporting these views are further detailed below. Case 2 describes a year-old female who developed symptoms of abdominal pain, mild nausea, and painless jaundice 1 mo prior to presenting at the hospital[ 1 ].
Several pertinent negatives were disclosed by the authors, including autoimmune markers and viral serology. According to the authors, the patient did not report any pre-existing medical conditions for which the onset had preceded the use of Herbalife products. This opinion contradicts repeated statements by the authors that acute liver injury in each case report was due to the use of herbal weight loss products.
In addition, the etiology of the pre-existing condition was not identified by the authors, and there was no discussion regarding the role of the condition in the acute onset of her symptoms. Furthermore, the dosage and frequency at which this patient consumed Herbalife products is unknown. In the absence of the aforementioned data, the exclusion of possible differential diagnoses is not well-supported.
Case 3 describes a year-old female who developed symptoms of painless jaundice and pruritus 3 wk prior to presenting at the hospital[ 1 ]. The authors further stated that the patient had not been prescribed any new medications, which implies that she may have been taking other agents concomitantly. However, information regarding the use of concomitant medications, or the conditions for which she may have been receiving treatment, was not disclosed.
In addition to the absence of the aforementioned pertinent patient data, there are various refutable facts that remain in regard to the comments and conclusions made by the authors. In their WJH article, the authors concluded that it was difficult to isolate a single ingredient or mechanism associated with acute liver injury for either patient consuming Herbalife products[ 1 ]. In an effort to discuss potential causative agents for the reported conditions in these patients, the authors extraneously reference previously published case reports involving Herbalife products, including those of two consumers who reportedly developed hepatotoxicity following exposure to Bacillus subtilis B.
In review of this reference, it has been noted that there were various critical deficiencies in the scientific methodology used to isolate B. Neither patient reported symptoms consistent with classical B. Furthermore, the investigators did not enumerate the levels of B.
This was a crucial step missing in the reported investigation as all previous documented reports find that high levels of the organism must be consumed to cause illness. Herbalife products, consumed by the patients described in the WJH article, to date show no evidence of B. This bacterium is actually ubiquitous in nature and generally recognized as safe with a history of safe use in food, and is considered to be safe for the production of enzymes or ingredients for use in food[ 3 ].
There have been reported cases of B. Therefore, it is highly unlikely that B. The WJH authors also suggest intentional or incidental contamination of Herbalife ingredients and identify various potential sources, including unrefined raw herbal extracts, heavy metals, pesticides, and additives[ 1 ].
However, some of the additives mentioned as potential contaminants by the authors e. In addition, authors also reference an article from that reviews possible contamination sources inherent to herbal remedies marketed without proper quality control measures in place[ 5 ]. Herbalife is not specifically implicated in the referenced article, yet the authors imply that Herbalife product contamination and lack of quality control contributed to the liver injury.
Herbalife has rigorous processes in place concerning quality control, including extensive safety reviews based on existing literature for product ingredients, testing to confirm that labeled ingredients are present in finished goods, and to assure all tested ingredients meet product specifications on an ongoing basis.
In addition to complying with cGMP regulations, Herbalife acts in accordance with other generally recognized industry standards or requirements by sourcing and testing raw materials to further ensure that the final product complies with specifications for identity, purity, potency and contaminants. The authors also try to implicate the Camellia sinensis C. The most important safety consideration for green tea is the extraction method.
The historical data supporting the safety of green tea is based on the consumption of an aqueous extract over thousands of years, specifically, the typical three cups per day that are commonly consumed in Asian countries.
Aqueous extracts of green tea are quite different from solvent extractions, which are commonly used to concentrate select fractions of green tea, such as EGCG or caffeine. Again, the WJH authors have not considered the clinical significance of potential differences in raw material processing amongst manufacturers, controls for contamination and identification of raw materials, and the implication of these differences when reviewing published case reports of liver injury. In addition, the authors state that Herbalife has refused to provide detailed analyses of ingredients and formulations, although no attempt was made by these authors to contact Herbalife to obtain further information regarding Herbalife products or ingredients.
Herbalife has, to date, remained compliant with all formal regulatory requests and requirements for product information. The authors state that significant liver injury induced by herbal supplements is a rare event[ 1 ]. This statement is true as approximately 20 to 50 percent of all cases presenting as hepatotoxicity are cryptogenic leading to the incidental association of liver disease with a group of products in the absence of specific evidence[ 5 ].
While this disease is the most common cause of drug withdrawal during post-marketing surveillance, it is an uncommon cause of liver disease. The background incidence of hepatotoxicity in populations is clearly comparable to the reported incidence of immunoallergic and individualistic reactions to allergens in foods, supplements, or the environment. While the spectrum of liver diseases may well have changed since when this survey was done, idiopathic liver disease remains a significant percentage of all cases.
Therefore, it is particularly important in making such associations to have incontrovertible evidence such as is often available for prescription drugs where, under controlled conditions, a cause-effect relationship can be established. The Department of Justice of Canada filed criminal charges against the company in November for misleading medical claims in advertisements.
By , the company was considered the fastest-growing private company in America by Inc. The company suffered as a result of the lawsuit and was forced to lay off nearly employees by May In , the company underwent a secondary offering of five million shares. In , the company had expanded its reach to 32 countries, with international sales accounting for more than half of total sales.
The company was sued in civil court by two former distributors in for withholding earned income. In , Hughes attempted to take the company private after asserting that Wall Street was undervaluing the company.
While the board approved the buyout offer, shareholders of the company filed a suit against the firm because they believed the share price they were offered was unfair. Hughes eventually abandoned his attempt to buy the company and settled the suit with shareholders. On April 9, , the company's long-time auditor, KPMG , resigned after the KPMG executive who oversaw Herbalife audits admitted to providing insider information to a golfing friend about several companies, including Herbalife and Skechers.
In March , Herbalife came under investigation by the U. Federal Trade Commission and the state of Illinois. The company also announced that its shareholders had approved a two-for-one stock split. Herbalife's "nutrition" products include weight-loss and protein shakes. Other products include products for heart health , digestive health , skin care, and the 24 sports line.
Some products are vegetarian, kosher , allergen free,  or halal. Herbalife's products are produced at the company's five manufacturing facilities in the U. As of , 58 percent of the company's nutrition products were manufactured at Herbalife owned facilities. In China, the company's manufacturing sites are located in Suzhou , Nanjing. Herbalife's claims of health benefits from its products have met scrutiny from the medical community, consumers, and government agencies.
In May , an organization known as the Fraud Discovery Institute reported that laboratory test results of Herbalife products showed lead levels in excess of limits established by law in California under Proposition Multiple independent labs reported finding lead in Herbalife products.
On May 10, , a civil lawsuit was filed on behalf of a woman who developed lead-related liver complaints that she claimed were a reaction to a combination of Herbalife products. In , Israel's Health Minister began an investigation into Herbalife's products after four persons using Herbalife's products were found to have liver problems. Herbalife was accused of selling products containing toxic ingredients such as Qua-qua, Kompri, and Kraska. D , to a private U.
A study of the cases funded by the Israeli Ministry of Health concluded that a causative relationship  is suggested by the evidence, which included the temporal association between exposure to Herbalife products and the development of liver injury, the negative evaluation of other potential causes of liver injury, the normalization of liver function when Herbalife products were discontinued, and the return of liver injury symptoms in three patients who resumed using Herbalife products after recovery.
Herbalife withdrew one product, which was only marketed in Israel, but not all of the Israeli patients had consumed this specific Herbalife product.
The Israeli Ministry of Health advises individuals with compromised liver function to avoid dietary supplements. Scientific studies in by doctors at the University Hospital of Bern in Switzerland and the Liver Unit of the Hadassah-Hebrew University Medical Center in Israel found an association between consumption of Herbalife products and hepatitis. Hospitals in Israel, Spain, Switzerland, Iceland, Argentina, and the United States had reported liver damage in a number of patients, some of whom had used Herbalife products.
After reviewing cases implicating Herbalife products in Spain, Switzerland, Israel, Finland, France, Italy, Iceland and Portugal, the member scientific panel issued a report concluding: The panel attributed the cases to metabolic changes from overzealous and unsupervised dieting.
A July peer-reviewed study published in the World Journal of Hepatology reexamined known cases of hepatoxicity that had previously been linked to consumption of Herbalife products and concluded that using "the liver specific Council for International Organizations of Medical Sciences scale, causality was probable in 1 case, unlikely and excluded in the other cases.
Thus, causality levels were much lower than hitherto proposed. Herbalife is a multi-level marketing company. As a result of the FTC settlement, the company is required to prove that at least 80 percent of its sales are made to individuals outside of its distributor network. Distributors are responsible for providing receipts for sales and proving they have legitimate customers. In the past, company management considered the number and retention of distributors a key parameter and tracked it closely in financial reports.
By January of each year, sales leaders are required to requalify. In February of each year, individuals who did not satisfy the sales leader qualification requirements during the preceding 12 months are removed from that rank. For the latest month requalification period ending January , approximately In a California class action suit Minton v.
Herbalife International, et al. In a West Virginia class action suit Mey v. More specifically, the plaintiffs' complaint alleges that several of Herbalife International's distributors used pre-recorded telephone messages and autodialers to contact prospective customers in violation of the TCPA's prohibition of such practices. Herbalife management insisted they have meritorious defenses in both cases and that, in the West Virginia case, any such distributor actions also went against Herbalife's own policies.
In July, Johnson, now 61, completed his third Tour TransAlp, the legendarily grueling, seven-day, mile stage race through the Alps during which cyclists traverse ascents totaling more than 60, feet. That business took off, and he rode it up the ranks until he was heading the international operations of the whole company. Along comes a guy with half-facts and half-truths and a jaded point of view and starts not just shorting your stock but trying to totally demonize me and demolish the company.
Who the hell does he think he is? Six-foot-three, lean, fit, with salt-and-pepper hair, Ackman cuts an intimidating presence. He spits out words with machine-gun rapidity, and often with flesh-tearing trenchancy. We spoke at his offices on the 42nd floor of a midtown building that offers panoramic views of Central Park. In the corner of the conference room stands a striking memento: It evokes a crucial skill for a hedge fund manager: Yet he is fallible.
His first fund, Gotham Partners, had to be suddenly wound down in late after some illiquid investments left him unable to rebound from a handful of redemptions.
He also lost big on stakes in Borders, J. Risk management is not his strong suit. Ackman is astoundingly competitive. His father wisely let him off the hook the night before, and he scored a And then there was a Hamptons bike ride of , described by William Cohan in Vanity Fair, in which Ackman joined several hedge fund guys and serious cyclists on a mile pleasure ride.
Though out of practice, Ackman rushed out in front at an unsustainable pace, became dehydrated, and had to be helped back, barely able to pedal due to excruciating cramping. The battle has taken a toll. Yet he professes no regrets. But if the commission finds that an MLM is a pyramid scheme—which is considered inherently deceptive—it must shut it down. The best definition of pyramid scheme emerged from a case in which the FTC shuttered a cosmetics marketer called Koscot Interplanetary.
Few MLMs are so foolish as to do that. Instead, they typically pay a distributor—as Herbalife does—based on the products he orders, and on the products ordered by his first three levels of recruits, i. Further complicating the analysis is another striking feature of virtually all MLMs, including Herbalife. Whereas conventional businesses pay salespeople based on their sales, MLMs pay them based on their purchases and those of their downlines.
The year-old Johnson, training near his home in Malibu, recently completed his third Tour TransAlp, a mile, seven-day race across the Alps. While judges and economists have proposed other definitions, most boil down to this: With a pyramid scheme, the product is little more than a fig leaf camouflaging what is, at its core, an elaborate chain letter.
When the FTC ruled that Amway was legitimate in , all other MLMs took steps to make themselves look like Amway—at least on paper—and an industry exploded. In recent years, however, with consumer advocates protesting that the industry is rife with pyramid schemes, several market leaders have sought to disassociate themselves from the pack. Tupperware quit the Direct Sellers Association in , and Avon dropped out in Both declined to be interviewed for this article.
But Johnson has made key changes to Herbalife during his 12 years there. The question is whether the great white whale Ackman is so doggedly pursuing still exists. In the beginning Hughes, a ninth-grade dropout, sold weight-loss products from the trunk of his car, according to company lore. His main product was Formula 1, which then came in one flavor: That year the company became the subject of a CNN series that highlighted dubious medical claims distributors were making about Herbalife products.
The California attorney general sued the company, and a Senate subcommittee held a hearing. His scrappy performance energized his loyal distributors. Hughes wrote for Herbalife a comically complex, page compensation plan. Such impenetrability is typical of MLM remuneration schemes. Critics say these are intended to perplex the recruit, leaving him no choice but to trust what the recruiter tells him. Defenders of the Herbalife plan say its complexity arises from efforts to reward diligence, punish laziness, and ensure fairness.
The plan created nine main levels of distributor. Ackman will later reject this notion, insisting that these distributors are pursuing the business but failing. At level seven they begin accruing additional bonuses. Only a tiny percentage of distributors reach this level, though precisely how tiny is a matter of dispute. In in the U. Top-tier distributors are also eligible for the subjective and lucrative Mark Hughes bonus. It has always been hard to make money as an Herbalife distributor.
That number excludes income distributors may make from retailing, but also fails to take into account any business expenses they may incur. Ackman will later argue that a system so slanted toward rewarding the highest tiers—attainable only through recruiting—must be a pyramid scheme. In May , Mark Hughes, 44, was found dead in his bedroom. In two private equity firms—W. They went looking for a turnaround team to spruce it up and take it public again.
A headhunter approached Michael Johnson, then in his 17th year at Disney. But the private equity guys promised him he would be in control, stressed that it was about nutrition, and offered him a slice of the company.
In April , Johnson made the move. Johnson tried to quickly launch a new product without consulting the distributors. And they deeply mistrusted him. What does he know? A lot of them felt that when the company went public I would exit. The company could annul their distributorship, but that meant forfeiting a business the distributor had built over years. If expelled, the distributor might take his whole downline—sometimes thousands of people—to another MLM.
Top Herbalife distributors ran several dozen such side businesses at the time. They worked like this. They, in turn, would contact the prospective recruits and send them a video that showed testimonials of top distributors describing astounding wealth they had purportedly amassed in very little time and with no discernible skills.
Herbalife shut down Newest Way to Wealth in , before CEO Johnson was hired, and reached a tentative settlement of the suit a few months after he got there. That fall, he considered quitting. He went to see his mentor, Jerry Perenchio, who was then chairman of Univision. Perenchio asked him a series of rhetorical questions, Johnson recalls: You can stick your tail between your legs and go back to Disney, or you can go in there and exercise your desires and will.
The plan was about product, brand, image, and the business opportunity. The company needed its own upgraded manufacturing facilities, he felt, plus labs to ensure that the products really contained the herbs the labels claimed they did.
To tout the brand, Johnson wanted to sponsor sporting events, teams, and star athletes. It now sponsors more than of them, including Cristiano Ronaldo, the Portuguese soccer star. Finally, and most important, Johnson wanted changes in the way the business opportunity was pursued. That meant curbing some practices while also embracing positive ideas being urged by other distributors, he says. At a videotaped global management retreat in June , viewed by Fortune , Johnson appeared to walk a tightrope, discussing the need for these changes while trying not to alienate powerful distributors.
It puts distributors in debt up to their ears. Johnson also wanted to embrace changes being urged by two top distributors, which were designed to reduce the high rates of turnover then being experienced among level-five distributors—those beginning to pursue the business.
The company phased in changes. It rolled out its own online software tools, supplanting those sold by distributors. Herbalife charged less and could exercise control over content. Over time, most top distributors exited that business. The rule changes easing the qualification hurdles for level-five distributors were introduced on a test basis in Russia in , and then globally in As a result, according to statistics provided by Walsh, the percentage of U.
Purchasing patterns also changed, these statistics show.