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"NO" stands for...Nitric Oxide
Steve Irsfeld RPh • November 20, 2024
Did you think I was telling you "NO"?
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In last week’s article, I discussed the state of health in our country and how inflammation, if left unchecked, can be a driver of disease and illness. T oday’s article is going to piggyback off that same concept only coming at it from the stance of cellular or mitochondrial dysfunction . If the cells in our bodies are not functioning optimally, this can be another driver of disease and illness. How many of you reading this article suffer from low energy? I think if we took a poll the number would be quite high. Mitochondrial dysfunction could easily be the cause of low energy. Dysfunction is not a new term in society today, but mitochondria may be a new topic to you. Having mitochondrial dysfunction is a big deal, and I will explain why in the context of this article. First off, let me explain what mitochondria are and what they do in our bodies. Mitochondria are in every cell in your body, but most know very little about them or how to take care of them. Mitochondria are responsible for creating more than 90% of our body's energy needs. The Mitochondria make adenosine triphosphate (ATP), which, when broken down, releases energy. If we don't have energy, we are unable to grow and sustain life. The body's primary energy consumers are muscles, brain, liver, heart, lungs, and GI tract. When mitochondria are not working to their full potential, the systems listed can suffer. This process is referred to as mitochondrial dysfunction, often due to genetic or environmental factors, which can ultimately then lead to cell injury and premature cell death. Think of mitochondria dysfunction like a blackout is to a city. Once the power goes out, nothing seems to work as it should. Aside from being energy factories, more than 95% of the genes that make up the mitochondria are involved with other cell functions. Thus, mitochondrial dysfunction can affect issues related to extreme fatigue, cardiovascular disease, diabetes, Parkinson's disease, depression, chronic fatigue syndrome, Alzheimer's disease, asthma, and diseases of the liver, skeletal muscles, kidney, and hormonal systems. When the mitochondria fail to meet the body's energy needs, symptoms of this energy shortage start to show. These symptoms can include heart and kidney issues, digestion seizures, strokes, developmental delays, speech, and sight problems, and simply walking can be a problem. As you can see from the list, many of these symptoms can overlap with other disease states making it difficult to differentiate between them. Lifestyle assaults like tobacco and excessive alcohol, environmental toxins, poor diets, which generate free radicals, and mismanaged stress can negatively affect the mitochondria. Drug-induced mitochondrial toxicity can create toxicity in the liver, skeletal muscles, kidney, and central nervous system. Medications affect our mitochondria by directly affecting the mitochondria or depleting co-factors that go into the production of ATP. The most common drugs that can cause these include pain medications, omeprazole, and statin medications which many patients routinely take. Statin drugs used to lower cholesterol have been shown to induce mitochondrial dysfunction through the depletion of Coenzyme Q10 (CoQ10). Omeprazole appears to inhibit carnitine absorption. Pain medications like naproxen and acetaminophen directly affect the function of the mitochondria . Avenues to pursue if you think you may have a mitochondrial issue would be an organic acid test, a urine test that looks at metabolites of metabolic pathways. If these pathways are not functioning correctly, the metabolites can overflow into the urine and can be easily measured to correlate to the faulty pathway. Another option is to have genetic testing done. Once you have the test done, you have the results for life, which makes this test an excellent value. Genetic tests can pick up faulty pathways. The most important thing you can do is to improve your lifestyle. Adhering to the tenants of the Magnificent 7 which I mentioned last week, is a perfect way to work on your lifestyle. Eating right and moving right are a great start, especially now that it is nice outside. Quit smoking, limit alcohol consumption, exercise 5 days per week, and eat food loaded with nutrients. When considering supplementation to support your mitochondria, utilizing supplements that help protect the mitochondria would be the goal, and CoQ10 is at the top of the list. If you read this column regularly, then the chances are that you have heard about CoEnzyme Q10 (CoQ10) and its many benefits. The fact that it is the third most popular supplement sold in the United States is a testament to its use. CoQ10 is also one of the most well-studied supplements, and a quality CoQ10 will offer you benefits ranging from mitochondrial support, antioxidant protection, tissue repair, as well as cognitive and cardiovascular support. Choosing a CoQ10 product can be quite a task, as there are many forms and delivery systems. Keep in mind a couple of factors. A dry powder formulation is not easily absorbed through the GI tract since the CoQ10 crystals never fully dissolve. The second confusing issue is whether to buy ubiquinol vs. a ubiquinone formulation. We recommend a Ubiquinone formulation with the crystals fully dissolved, allowing for better absorption, often up to 8 times better than other products on the market. The second product I recommend is designed to increase cellular energy. It is a combination of acetyl L-carnitine, NAC, alpha-lipoic acid, grape seed extract, magnesium, and manganese. These ingredients help are support the healthy functioning of mitochondria and overall cell activity. The product is called Mito-Recharge. In addition to helping our mitochondria increase ATP production, this combination of ingredients helps support the following systems: energy production, cardiovascular function, blood flow, and nitric oxide production, antioxidant support, and body tissue, including epithelial, muscle, connective, and nervous tissues. All this talk about inflammation and mitochondrial dysfunction may sound a bit like chicken little and the sky is falling but it is more of a call to action. You are now armed with information and proven protocols to take back your health. Start now and start small, building off the small steps that you take will yield results over time. Spring is here and there is no better time to use it to dive into a healthy summer. Call or stop by the pharmacy if you want to schedule a consult to help navigate your journey to attacking inflammation and mitochondrial dysfunction. Please visit my website at www.irsfeldpharmacy.com to view this and other health-related articles in the blog section. Until next time, be vigilant about your health!!
The current state of health in our nation is on a bad path. Some of the statistics will literally make you sick (no pun intended). The US spends more money on healthcare per capita than any other country in the world, $12474 in 2022, almost $4000 more than the next country on the list, unfortunately with all the spending we are not living longer when compared to other countries. Let me summarize that, we spend the most money and get poor results. How does that even happen? I’m not sure it can be answered in this article, but I do have some ideas to improve your health. If you have read this article going way back, you may remember me referencing the Magnificent 7 which is eat right, drink right, think right, talk right, move right, sleep right and poop right. If you are doing all these things “right”, your ability to maintain optimal health should be greatly improved. Dr. Robert Rakowski is the person who came up with the Magnificent 7 and it really cuts to the chase when thinking about how to improve or maintain our health. What happens when we don’t utilize these tenants? One thing for sure is the title of this article, inflammation, a driver to disease and chronic illness. Inflammation is something most of us are familiar with, unfortunately, it can have some of the same characteristics as high blood pressure. You may be wondering how that comparison is possible. Blood pressure is known as the “silent killer”, due to the fact it often has no symptoms. as a person may not know that it is affecting their body adversely until it is too late. However, in severe cases, it causes headaches, shortness of breath, and nosebleeds. Unfortunately, when BP remains elevated for too long, it starts to wreak havoc on certain organ systems like the eyes and kidneys. We don’t really think of inflammation in the sense that it is silent but when it first presents itself, in its infancy, it isn’t something that hits you over the head like a hammer. We have different types of inflammation, one kind is the natural immune response that occurs when we have an injury, or infection. We need this type of inflammation as it is necessary for survival. This type of response is usually a big response that is quite evident. Think of a sprained ankle and what that process looks like. After the sprain, we get immediate inflammation at the site, which is a natural casting mechanism, immobilizing the ankle so that we can’t do further damage to the site. Over time, the ankle heals, and the inflammation dissipates, and the tissue returns to normal. This is a normal and needed inflammatory response. Another form of inflammation is chronic inflammation that is a low level, under the surface, like a smoldering fire. The first type of inflammation is a five-alarm fire, while this is more like the coals left over from a campfire, the bad part is that if it isn’t addressed, it will smolder on for a long period of time. This type of inflammation does not serve a purpose and if it is left unchecked, it can degrade tissue over time. The best example of this is rheumatoid arthritis and what it does to our joints. I was just working with a 28-year-old patient who had a ton of inflammation and one issue that I am pretty passionate about, degenerative disk disease or DDD, because I too have that going on in my body. DDD is the crumbling of your disks in the lower back, kind of like a crumbling foundation of your house, not a good thing. My plight with DDD started around 2000 when my good friend Dr Mike Wolf told me I had the back of a 65yo when I was only 35 at the time, thanks Dr Wolf. Over time, I started to develop some numbness in my left foot, which eventually led me to having an MRI of my back in 2011and seeing a neurosurgeon who told me he would gladly do surgery on me but one of the side effects could be numbness. That surgery never happened. This was a point where I met the fork in the road . Do I keep doing the same thing and expect a different result, the definition of insanity, or do I make some changes to better my situation? I am a bit stubborn in certain areas of my life and this was going to be one of those areas, so I started to get busy working on ways to decrease inflammation and to stabilize my low back. Some of the things I started and continue to do , eating clean food, when possible, organic fruits and vegetables which can be a challenge in western ND, non-seed oils for cooking, clean proteins with organic beef from Odermann Cattle Company, fish and chicken. I try to exercise 3-4 times per week. We do our best to limit toxin exposure. My wife and I have been gluten free for 13 or more years and that has been super helpful for lowering inflammation especially in my knees. If I happen to get into some gluten, my knees will act up about 2 days after and then it takes a couple of day for them to tame down. I take many supplements including Curcumin, Omega 3 fish oil, ProResolving Mediators or PRMs, joint complex with collagen, and D3 + K2 and one prescription called low dose naltrexone. Seven years after my initial MRI, I wanted to have a repeat MRI because my foot still has some numbness however no pain. I specifically asked the neurosurgeon how the new MRI compared with the previous one and he said there was no change from the two MRI’s and to keep doing what I was doing because it was working. The fruits of my labors paid off and continue to do so. If this sounds remotely like what you might going through or maybe yours started with a knee replacement, and then another, and then a shoulder, I challenge you to stop the inflammation . Replacing body parts should be the last resort, changing lifestyle is a solution to stopping the inflammatory progression that might be going through your body. If the inflammation is not stopped, it will continue to smolder under the surface damaging your tissue. You have the ability and now a road map to change. There is no better time than now to get busy and make the necessary changes to turn your situation around because, if nobody has given you tools before, you now have a roadmap. Call or stop by the pharmacy if you want to schedule a consult to help navigate your journey to attacking inflammation. Please visit my website at www.irsfeldpharmacy.com to view this and other health-related articles in the blog section. Until next time, be vigilant about your health!!
The process of working towards better or optimal health, in my opinion, requires small steps or changes that over time , turn into big results. An example would be changing your diet, which can be as simple as removing processed foods or trying to decrease the amount of fast food that you consume. The next step in the process may be to incorporate more fresh fruits and vegetables into your diet. You can see that over time, these little steps continue to grow and change occurs. The problem can often occur with simply starting the process. A common question at the pharmacy is, “I don’t take any vitamins, so where should I start?” That is an excellent question for a couple of reasons. First, it indicates that the patient is interested in bettering their health; secondly, they see value in supplements helping in that change. The answer to their great question is quite simple, and we refer to it as the core 4. We call it “foundational nutrition” because it is the foundation of health; without a strong foundation, the structure or body can easily crumble. The four supplements that comprise the Core 4 are Multivitamins/minerals, Vitamin D, omega-3 Fatty Acids, and Probiotics. Multivitamin: A multivitamin fills in the gaps our diets don’t meet. Documentation shows that our food supply does not contain the same nutrients as 40-50 years ago. By taking a multivitamin, we exceed levels that prevent disease and illness. The goal is optimal health, and providing nutrients is essential for making that happen. A micronutrient test to determine if you are deficient in nutrients can be done for $400. Vitamin D : Vitamin D is formed when your skin is exposed to sunlight. Unfortunately, we live too far from the equator to allow the sun to make this happen year-round. If it’s warm enough in April, the sun is potent enough, and getting 10-15 minutes of exposure should cover us until about mid-September. That means that in our neck of the woods, we won’t get our daily dose of Vitamin D for 6-7 months out of the year. It only makes sense for us to supplement, and if you are like me, my tan usually comes from the fluorescent lights of the pharmacy. I recommend 5000IU/day with K2 for adults to aid absorption. Testing can be done for as little as $50. Omega 3 Fatty Acids or Fish Oil : Unless you eat fish twice a week, you probably are not getting the necessary omega 3’s to help support cell structure. It is anti-inflammatory, essential for the brain, skin, and eyes, and has cardiovascular benefits. Omega 3’s are one of the few supplements that cost less to buy a supplement than if you were going to get it from a food source. Depending on the treatment plan, the dosage ranges from 1000 to 4000mg per day of EPA + DHA. You must read the label to make sure you are getting the proper dose, as some companies label their product as 1000mg of fish oil, yet the actual amount of EPA + DHA is 25-30% of that figure. If you burp up fish, your product is either rancid or poor quality. Testing your levels is an option and can be done for as little as $75. Probiotics: It seems a little weird that we would add bacteria to our systems, and good would come from it, but yes, that is the case. Healthy (and unhealthy) gut flora affects so many things. The immune system, skin conditions, aging, digestive disorders, mood and brain function, weight gain, fatigue, and more. It is almost impossible to help anyone not feeling optimal if they have unaddressed dysbiosis. Believe it or not, you can have a stool test done to find the makeup of bacteria in your feces, providing information about what might be happening in your colon As stated above, the Core 4 is foundational nutrition, and building a regimen on that is where a personalized protocol comes into play. That protocol could include joint health, gut health, inflammation, stress, or immune health, to name a few. Treating each patient as an individual needs to happen because we are unique. One of the challenges is trying to meet the patient where they are. Here are a few examples of that: • What kind of change are they willing to make? Can they change their diet or exercise for 30 minutes at least three times a week? • How often can they take their supplement? I can usually convince them that if they brush their teeth twice a day, they can take supplements twice a day, and I know this because I fall into this category. • What can they afford to spend on a regimen? Trying to work within the confines of this because if you bombard them with too much product, they can’t afford, they can shut down and quit. • And lastly, what are the patient’s expectations? Today, we expect you to make that happen by taking a magic pill. I hope I don’t burst anyone’s bubble, but changing the trajectory of your health will not happen by simply taking a pill. It requires hard work and commitment, something very different than a magic pill, and it may cost you more than that perceived magic pill, but, in the end, you will be better off for it. If you are considering starting the process, implementing the Core 4 foundational nutrition is a great way to start. I would challenge anyone who is not currently taking vitamins to try this for 30 days and see if this regimen makes a difference. You may find yourself with more energy and mental clarity, both are things most of us would appreciate. Stop by the pharmacy if you need help navigating the Core 4 or are looking for help designing a protocol to meet your needs. Please visit my website at www.irsfeldpharmacy.com to view this and other health-related articles in the blog section. Until next time, be vigilant about your health!!
Questions regarding the use of peptides for multiple health issues, seem to be more frequent as information about them continues to grow. The most common peptide, insulin, has been around for a long time however the ones getting the most attention these days are the GLP1s, prescription medications like Ozympic and Wygovy to name two of them. I am quite certain we will be seeing more of these as time goes on. Imagine tiny building blocks in your body that help you stay strong, heal faster, and even look younger. These little wonders are called peptides, and they’re making waves in the world of pharmacy and health. But what exactly are peptides? What do they do for us? And which ones are the most popular in medicine today? Let’s dive into this exciting topic and find out! Peptides are short chains ranging from 2 to 50 amino acids. Proteins are also chains of amino acids with 50 or more but their structures are more complex than a peptide. Think of peptides as mini-proteins—smaller and simpler, but still super powerful. Your body naturally makes peptides to do all sorts of jobs, like sending signals between cells, repairing tissues, or fighting off germs. Scientists have figured out how to make synthetic (lab-made) peptides too, and these are now used in medicines, supplements, and even skincare products. Unlike proteins, which can be huge and complicated, peptides are small enough to slip into places where bigger molecules can’t go. This makes them perfect for targeting specific problems in the body, like inflammation or muscle loss. They’re like the special forces of the molecular world—small, fast, and precise! So, why are peptides such a big deal? Fortunately for us, they come with a bunch of benefits that can help people live healthier lives. Here are some of the coolest things peptides can do: Muscle Growth and Repair : If you’ve ever hit the gym, you know how sore your muscles can get. Peptides like growth hormone-releasing peptides can help your muscles recover faster and grow stronger by boosting the production of growth hormone in your body. Anti-Aging : Want to keep your skin looking fresh? Peptides like collagen peptides can improve skin elasticity, reduce wrinkles, and even strengthen your hair and nails. They’re a secret weapon in many anti-aging creams! Weight Loss: Some peptides can help control appetite or speed up your metabolism, making it easier to shed extra pounds. This is a game-changer for people struggling with obesity. Healing and Recovery: Peptides can speed up wound healing and repair damaged tissues. This is why they’re popular with athletes or people recovering from injuries or surgeries. Boosting Immunity : Certain peptides can help your immune system fight off infections by acting like tiny guards that protect your body from bacteria and viruses. Because peptides are so versatile, pharmacists and doctors are finding new ways to use them all the time. They’re safe, effective, and can be tailored to tackle specific health issues. Now that we know how awesome peptides are, let’s meet some of the superstars you might find at the pharmacy or hear about from your doctor. These are the most popular ones making a difference in people’s lives. Insulin: You’ve probably heard of insulin if you know someone with diabetes. Technically, insulin is a peptide hormone made of 51 amino acids. It helps control blood sugar by letting your cells take in glucose (sugar) for energy. Without insulin, people with type 1 diabetes couldn’t survive, and many with type 2 diabetes rely on it too. It’s one of the most famous peptides in medicine! BPC-157 : This peptide is a rising star, especially for healing. BPC stands for “Body Protection Compound,” and it’s known for repairing muscles, tendons, and even your gut. Athletes love it for recovery, and some studies suggest it might help with conditions like ulcers or joint pain. Collagen Peptides: Walk into any drugstore, and you’ll see collagen supplements everywhere. These peptides come from breaking down collagen proteins (found in skin, bones, and cartilage) into smaller pieces. They’re a hit for improving skin health, strengthening joints, and keeping bones sturdy as you age. Semaglutide: This peptide is a lifesaver for people with type 2 diabetes and is also being used for weight loss. Semaglutide mimics a hormone that controls blood sugar and appetite. Semaglutide works best when it is combined with a diet that contains protein and regular exercise program. The key is to lose weight in the form of fat and not muscle. Peptides are changing the game in pharmacy because they’re so adaptable. Scientists can tweak them to do exactly what’s needed, whether that’s fighting a disease or helping someone feel better. Plus, they usually have fewer side effects than traditional drugs since they work with your body’s natural systems. These products are found in oral, topical and injectable forms. They can be purchased in locally or over the internet. A note of caution when sourcing these great products, make certain you are buying from a reputable source as the internet can often be the wild west and the last thing you want to do is buy something that may actually make things worse. In short, peptides are tiny but mighty. They’re helping people build muscle, heal faster, look younger, and stay healthy—all while showing us just how incredible science can be. So next time you hear about peptides, you’ll know they’re the unsung heroes working behind the scenes to keep us feeling our best! If you have any questions about peptides, feel free to stop in or give us a call to schedule a consultation. Please visit my website at www.irsfeldpharmacy.com to find this and other archived articles in the blog section. Until next time, be vigilant about your health!!
It seems like we are helping more and more patients who suffer from Hashimoto’s Thyroiditis or HT. I have written about this in the past, but it is such an important subject that it needed to be reviewed again. This article will review ways to address HT and the supplements to support this illness. HT is an auto-immune thyroid condition that affects up to 2% of the population . As with all auto-immune states, the body attacks itself through inflammatory processes. In HT, if the inflammatory process goes unaddressed, the thyroid gland will eventually quit working, leading to full blown hypothyroidism. An important statistic is that 25% of patients with an auto-immune condition have a second AI condition. There is also the possibility of multiple auto-immune diseases characterized by patients having three or more AI conditions. These statistics reinforces the need for stopping the inflammation in its tracks and it should be the primary goal. When searching for treatment options for Hashimoto’s in conventional medicine, you won’t find information on treating this condition differently than treating hypothyroidism. The current treatment or standard of care for HT is levothyroxine. If we look at other auto-immune disorders, they all seem to have a treatment option, but not with HT. I find this to be rather intriguing, and I wouldn’t be surprised if they come up with a drug soon that is the cure for HT but carries a ginormous price tag. In my experience, It is not uncommon for patients with HT to express frustration with the treatment options presented. The most common statement is, “my thyroid labs are all normal, but I experience fatigue, and I don’t feel normal.” Often these patients are left with the options to “buck up” and “deal with it.” I think we as a medical community can do better in helping these patients struggling with HT. If you suspect you have a thyroid condition based on how you feel, some symptoms are low energy, dry skin, cold hands and feet, weight gain, brain fog, constipation, infertility, GERD, and hair loss, you can take a no-cost questionnaire at the pharmacy to see if a person should have thyroid levels tested. The standard thyroid test is TSH, and additional testing can include Free T3 and Free T4. These three tests are great if you have hypothyroidism but to find out if you have HT, you will need to test thyroid peroxidase anti-body and TPO Antibody. These two tests will give you an idea if your body is mounting an inflammatory response to the thyroid gland. With any auto-immune condition, t he easiest and most common test to check and track inflammation is C-reactive protein , an inflammatory marker tested in your blood and monitored. If this is something you haven’t done and you are being treated for a chronic condition, I would request it at your next office visit. You can have this done for as little as $60 with a fingerstick test if you are curious about your level. Another test you could look at will be an IgG food sensitivity test to see if you have foods that may be causing inflammation in your system. If you do this and have multiple food sensitivities, avoiding the foods you are reactive to will decrease your inflammatory burden. Besides avoidance, healing a leaky gut so that the food proteins are not absorbed would help reduce the inflammation created by these proteins. You have done your testing and have been diagnosed with HT; now, what do you do ? Keep in mind that HT is an auto-immune process resulting from inflammation that is out of control. The thoughts and ideas presented are an effort to halt the process, decreasing overall inflammation. Start with simple lifestyle modifications , which include cleaning up your diet. Consider a gluten-free diet that may sound like a mountain too big to climb, but it is a small hill today vs. years ago. Consumer demand has created many good options for people looking to keep gluten out of their diet. Other dietary considerations include eliminating sugar, quitting processed foods, and avoidance of fast food. The second thing, as mentioned above, would be to work on healing the gut . This healing can be accomplished by eating a gut-healthy diet and incorporating supplements to help the healing process. The following are gut-healthy supplements; glutamine, zinc carnosine, bovine colostrum, aloe vera, and other sticky, mucus-like nutrients. Along with dietary modifications and gut healing, several supplements can be helpful to take. Omega 3 fatty acids , also known as fish oil, can help reduce inflammation and are essential building blocks for cell structure and gut healing. Taking 2000mg of EPA + DHA is a good starting dose. Curcumin , the most studied active ingredient in turmeric, has been shown to have anti-inflammatory, antioxidant, antibacterial, and antiviral activity, all of which can provide benefits to those suffering from Hashimoto’s-related symptoms. Selenium (combo product pictured) in the form of selenomethionine at 200mcg per day is a necessary nutrient for the conversion of T4 to T3. This conversion is facilitated by the de-iodinase enzyme, which requires selenium to make this conversion happen. Vitamin B12 and all of the B vitamins are important for energy production and cellular and metabolic functions. Taking a quality multivitamin with high amounts of B vitamins is essential. The last nutrient is a part of foundational nutrition, Vitamin D. It is an essential nutrient to support your immune system, and the optimal level would be 50-80ng/ml. Getting this level is not difficult in the summer as Vitamin D is synthesized in the skin with UV light. As little as 15-20 minutes in the sun without sunscreen between the hours 10 am and 2 pm is all it takes. Winter is the opposite, and supplementing with 1000-5000IU’s is necessary to maintain these optimal levels. Many of our practitioners who work with HT utilize a prescription medication called low-dose naltrexone (LDN) to help with this condition. There is no indication for its use in HT, but LDN works on the immune system to lower inflammation. The mechanism of action that increases endorphins seems beneficial to improve overall energy in patients, a symptom that plagues patients with HT. It is crucial to keep in mind that auto-immune conditions, like HT, are not healed in a short time, and it is often necessary to continue following a healing regimen throughout your life span. The byproduct of a plan that decreases overall inflammation is the potential for disease prevention and a better quality of life. My staff and I would like to help you with questions regarding Hashimoto thyroid issues that you might be having, so call or stop in to schedule a consultation. Please visit my website at www.irsfeldpharmacy.com to find this and other archived articles in the blog section. Until next time, be vigilant about your health!!
Last week's article drew some attention on social media from both individuals open to the information presented and others who were not in favor of it. If the information gave you heartburn, my apologies, as that was never the intention. In writing these articles, I aim to provide not mainstream information but more outside-the-box information. Thinking outside the box is to think differently, unconventionally, or from a new perspective and to explore creative and unusual ideas. If you were to come to my pharmacy and had a consultation about whatever issue or condition you are looking for help with, you will likely walk away with potential solutions to your problem that are often outside the box ideas. We like to think of ourselves as problem solvers. The good news is, patients who choose to seek out our services are exposed to multiple tools, including conventional medications, compounded medications, and dietary supplements. Conventional medications are FDA-approved drugs that have passed the FDA's approval process, rendering them safe and effective for their intended uses. Compounded medications are FDA-approved drugs prescribed for off-label use. Off-label use refers to prescribing a medication for a different purpose than those formally approved by the FDA and found in the drug's package labeling. Providers might prescribe medications off-label for a medical condition because the use is well-known and has been done for many years without concerns, or there is a lack of safe or effective alternatives. An example of off-labeled prescribing is the drug Trazodone, an FDA-approved anti-depressant that has a side effect of drowsiness. Trazodone is often prescribed off-label for insomnia. In the compounding world, the majority of medications that we make fall into the off-label use category. An example of a compounded medication is taking a commercially available tablet like carvedilol a cardiovascular drug, crushing the tablets, and making a liquid suspension for a small child. The drug is only available in tablet form, yet the provider would like the child to have the drug in a much lower pediatric dosage. The child cannot swallow a tablet, so a suspension is formulated based on the provider's prescription. One off-labeled medication that has evolved since we first started investigating its use is naltrexone. Fifteen years ago, a handful of studies looked at the benefits of using low doses of naltrexone to treat pain. Research has mapped out naltrexone's effect on different receptors in the body, which have multiple mechanisms of action. When looking at different disease states, you can see which receptors are associated with the disease state and then work backward to consider prescribing the medication for a specific specific condition. There are no large-scale studies to prove effectiveness of naltrexone for specific conditions, but theoretically, the medications could benefit a multitude of conditions. For some who prescribe compounded medications, this may be a sticking point or an area they may not feel comfortable venturing into, and we respect that opinion. When compounding a specific medication, we ensure that the product is safe at the prescribed doses. The tenant of "first do no harm" is an important part of the process that goes into a compounded medication. If we are uncomfortable with a dose of a particular medication, we will visit with the prescriber to ensure dosage is appropriate. On some occasions, new information has come out to warrant a dose we may not have seen previously. Learning is a big part of what we do as we try to provide the best therapies for our patients. Once we have received a prescription for a compounded medication, if it is something we have not made previously, we begin the formulation process. In the case of carvedilol that was previously referenced, how will we best make a liquid suspension for a child? Choosing the right liquid base has us looking at studies and formulas for the best preparation. After formulation, the medication needs to be compounded, which requires another set of education and equipment to make that happen. Both FDA-approved and compounded medications need to be prescribed by a licensed provider for an individual patient . The exceptions to this rule are when pharmacists have limited prescriptive authority, such as with naloxone, an opioid antagonist, vaccines, and smoking cessation medications. The third tool, dietary supplements , fall into a different category of regulation by the FDA. The FDA has established good manufacturing practices (GMPs) that companies must follow to help ensure their dietary supplements' identity, purity, strength, and composition, and they periodically inspect manufacturing facilities. Supplement companies are responsible for having evidence that their products are safe and that the label claims are truthful and not misleading. The FDA does not determine whether dietary supplements are effective before marketing. The title of this article is Living Outside the Box . I t is truly the direction my team and I have chosen to help our patients differently. We are helping both patients and prescribers in our community and beyond, with difficult medication problems. There are many great pharmacists in our community who can fill your prescriptions and provide consultative services to help you with conventional medications, however not many have the tools we have to offer. Irsfeld Pharmacy is on the path least traveled, and at times, that can be a rocky path that many don't want to venture on. It is a path that has been helpful to so many in our community while being professionally rewarding. My hope is that most of you won't need to utilize our services but know that if you do, our team is committed to helping you on your journey to optimal health. If you want help with outside-the-box options in your health journey, please call the pharmacy @ 701-483-4858 or stop in to schedule a consultation. Please visit my website at www.irsfeldpharmacy.com to find this and other archived articles in the blog section. Until next time, be vigilant about your health!!!
Ivermectin Most people had not heard of Ivermectin until the fall of 2021, however, as you will read, it has been around for a very long time. Many patients chose to utilize this treatment option for Covid due to its anti-viral benefits and many providers are prescribing it for Long Covid in a widely prescribed treatment protocol. Lately we have been getting many questions at the pharmacy about the utilization of Ivermectin for cancer due to two recently published studies on this topic. Today we will look at those studies and the basis behind its potential benefit for cancer treatment. Ivermectin is a drug that has been widely used for decades to treat parasitic infections in humans and animals. Originally developed to fight diseases like river blindness and scabies, ivermectin has recently gained attention for its potential role in cancer treatment. This interest is based on research, including the studies "Antitumor Effects of Ivermectin at Clinically Feasible Concentrations Support Its Clinical Development as a Repositioned Cancer Drug" and "Targeting the Mitochondrial-Stem Cell Connection in Cancer Treatment: A Hybrid Orthomolecular Protocol." These studies suggest that ivermectin could be repurposed as a cancer drug due to its unique properties. Ivermectin is an anti-parasitic medication discovered in the 1970s . It works by paralyzing and killing parasites, making it an effective treatment for infections caused by worms and certain skin conditions. I t has been considered safe when used properly and has even been listed as an essential medicine by the World Health Organization (WHO). Recent studies have shown that ivermectin may have antitumor effects, meaning it can help stop the growth of cancer cells. The 2020 study "Antitumor Effects of Ivermectin at Clinically Feasible Concentrations Support Its Clinical Development as a Repositioned Cancer Drug" explains how ivermectin can target cancer cells in several ways: Disrupting Cell Division: Cancer cells grow uncontrollably because they divide rapidly. Ivermectin interferes with the proteins that help cells divide, which slows down or stops the growth of tumors. Inducing Apoptosis: Apoptosis is a process where damaged or unneeded cells "self-destruct." Many cancer cells avoid this process, which helps them survive longer than normal cells. Ivermectin can trigger apoptosis in cancer cells, leading to their death. Inhibiting Cancer Stem Cells : Cancer stem cells are a small group of cells within tumors that can start new growth and cause cancer to spread. Ivermectin has shown promise in targeting these stem cells, reducing the chances of cancer returning after treatment. Blocking Energy Production: Cancer cells need a lot of energy to grow and spread. Ivermectin can interfere with the mitochondria, the "powerhouses" of cells, reducing the energy supply that cancer cells need to survive. The second study from 2024, "Targeting the Mitochondrial-Stem Cell Connection in Cancer Treatment: A Hybrid Orthomolecular Protocol," focuses on how cancer stem cells rely heavily on mitochondria for energy. Mitochondria are tiny structures inside cells that produce energy from nutrients. In cancer stem cells, these mitochondria are often more active than in normal cells. Ivermectin disrupts this mitochondrial function, making it harder for cancer stem cells to survive . This is important because cancer stem cells are usually resistant to traditional treatments like chemotherapy and radiation. By targeting the mitochondria, ivermectin can weaken these cells, making them more vulnerable to other cancer therapies. One of the exciting possibilities discussed in these studies is combining ivermectin with other cancer treatments. This approach is known as a "hybrid orthomolecular protocol." It involves using natural substances and drugs together to improve treatment outcomes. Ivermectin, when used alongside chemotherapy, radiation, or other drugs, may enhance their effectiveness. This is because it weakens cancer cells, making them more sensitive to traditional treatments. Additionally, by targeting cancer stem cells, ivermectin could help prevent cancer from coming back after initial treatment. While these studies show promising results, it is important to remember that most of the research has been done in laboratory settings or on animals. Clinical trials in humans are necessary to confirm the safety and effectiveness of ivermectin as a cancer treatment. T he dosing of Ivermectin is often based on an individual’s weight and therefore having a healthcare provider involved in this process is highly recommended. Ivermectin is generally safe when used correctly for parasitic infections, but high doses or improper use can cause side effects. These can include dizziness, nausea, skin rashes, and, in rare cases, more serious problems like seizures. Therefore, it should never be used for cancer treatment without the supervision of a qualified healthcare professional. The potential for ivermectin as a cancer drug is an exciting area of research. Its ability to target cancer cells, disrupt energy production, and enhance the effects of other treatments makes it a promising candidate for future cancer therapies. However, more studies and clinical trials are needed to fully understand how it works and to ensure it is safe and effective for cancer patients. While ivermectin was originally designed to treat parasitic infections, new research suggests it could play a role in cancer treatment. By targeting the unique characteristics of cancer cells and stem cells, ivermectin might help improve outcomes for patients in the future. As with any potential new treatment, it is essential to rely on scientific evidence and consult healthcare professionals before considering its use. If you would like more information about Ivermectin, please call the pharmacy @ 701-483-4858 or stop in to schedule a consultation. Please visit my website at www.irsfeldpharmacy.com to find this and other archived articles in the blog section. Until next time, be vigilant about your health!!!
As promised, today’s article will focus on inflammation in the GI tract also known as Gastritis . Inflammation is often the root cause of many diseases, and that concept is no different in the GI tract. The two areas most affected by inflammation are the stomach, where we can have gastritis, and the colon, where inflammatory bowel disease can occur. Today’s article will focus on inflammation of the stomach today. Have you ever had an endoscopy? An endoscopy is where the doctor puts a camera down your throat and looks at your esophagus, stomach, and sometimes your small intestine or duodenum. They are looking for damage or inflammation of the stomach lining or mucosa. Gastritis is when the stomach lining or mucosa is inflamed. Think of gastritis as a sunburn on the lining of the stomach. The stomach lining contains special cells that produce acid and enzymes, which help break down food for digestion, and mucus, which protects the stomach lining from acid. When the stomach lining is inflamed, it produces less acid, enzymes, and mucus. Gastritis is sometimes mistakenly used to describe any symptoms of pain or discomfort in the upper abdomen. Many diseases and disorders can cause these symptoms, and most people who have upper abdominal symptoms do not have gastritis. Gastritis may be acute or chronic. Sudden, severe inflammation of the stomach lining is called acute gastritis. Inflammation that lasts for a long time is called chronic gastritis. Chronic gastritis may last for years or even a lifetime if it is left untreated. Two of the more common types of gastritis are non-erosive and erosive. The most common cause of non-erosive gastritis is H. pylori infections. H. pylori is an opportunistic infection in the stomach that I discussed in last week’s article and has a link to low stomach acid. Other causes include autoimmune disorders affecting the stomach lining, Crohn’s disease, pernicious anemia, and some pathogens, bacteria, virus, fungi, and parasites. Erosive gastritis is a type of gastritis that can wear away the stomach lining without causing significant inflammation. Bleeding, erosions, and ulcers are the results of erosive gastritis. The chronic overuse of NSAIDs can cause erosive gastritis. NSAIDs are products like ibuprofen and naproxen that at one time were only available by prescription but now can be purchased over the counter. It is not uncommon for people with pain and inflammation to take NSAIDs routinely, unaware of the potential side effects that can occur over time. There is some irony to the fact that you consume something to help with pain and inflammation, yet it can cause inflammation to the lining of your stomach . Additional causes of erosive gastritis include alcohol, cocaine, and radiation. One of the crazy things about gastritis is that the symptoms don’t always make sense. Some patients experience pain and discomfort, while others don’t have any symptoms. The most common symptoms include upper abdominal discomfort or pain, nausea, and vomiting. Erosive gastritis is a little more violent as the lining of the stomach can bleed, causing bloody vomit, black and tarry stools, and blood in the stools. Conventional treatments for gastritis are relatively limited, focusing on eradicating H. pylori if it is present and making the pH of the stomach less acidic by taking antiacids, H2 blockers (famotidine), and Proton Pump Inhibitors (omeprazole). When the pH of the stomach is less acidic, it will not be an irritant to the inflamed tissue or sunburn, and the hope is that healing will take place. When it comes to non-conventional treatments, one of the most common is zinc carnosine, which is well-documented in scientific research to support GI integrity and intestinal permeability. Zinc carnosine has been studied in Japan for years and has studies showing that it can improve the integrity of the stomach lining and offset the side effects of NSAIDs. We are familiar with the properties of zinc and that it is an essential mineral that plays vital roles in the GI tract, gene expression, stabilizing cell membranes, immune function, reproduction, sexual maturation, and other biological processes. When zinc is attached to carnosine, the resulting complex supports gut ecology, permeability, and the mucosa. Research suggests zinc-carnosine stimulates healthy gut reactions and helps a healthy gut response to everyday life. Carnosine is a dipeptide (made up of the amino acids beta-alanine and L-histidine) in muscle cells and nerve cells. It is suspected that carnosine supports tight intercellular junctions and cell-mediated immunity. L-glutamine is a crucial amino acid for supporting a healthy GI tract, notably by maintaining the integrity of the intestinal wall. L-glutamine is the most important fuel for intestinal tissue, with research showing it is imperative for gastrointestinal integrity and a healthy immune response. Glucosamine HCl is an amino sugar precursor to many glycosylated proteins and lipids throughout the body. A recent study suggests that supplemental glucosamine HCl modulates the inflammatory response in the gastrointestinal tract, which may promote a healthy gut environment. Licorice root is abundant with novel phytochemicals that help soothe the gastrointestinal tract by supporting the mucosal lining of the intestines and stomach. Deglycyrrhizinated (DGL) licorice, free from substantial parts of glycyrrhizin that can affect blood pressure, is a safer option for long-term use. Additional natural ingredients that help to soothe the GI tract are apple pectin, aloe vera leaf extract, slippery elm, and mucin. These plant-derived biologically active constituents support and comfort the gastrointestinal tract. The benefit comes from the ingredients contained in each nutrient, such as vitamins, enzymes, minerals, mucopolysaccharides, fiber, lignin, saponins, and amino acids. There is a combination product that we use for this. I hope this article sheds some light on gastritis and what might be going on you're your gut if you have been diagnosed with that condition. While conventional products address the symptoms, natural products may be a better option to help deal with inflammation in the GI tract and they have excellent data to support their recommendations. If you are not getting the results you would like with conventional treatments, these are options in your healthcare journey. For more information on gastritis and gut health, call the pharmacy @ 701-483-4858 or stop in to schedule a consultation. Please visit my website at www.irsfeldpharmacy.com to find this and other archived articles in the blog section. Until next time be vigilant about your health!
It has been a while since I wrote about stomach acid a huge component into having an optimal gastrointestinal tract. You may find this tidbit of information interesting, the very first article that the pharmacy did for the Dickinson Press was back in 2013 with the title “The Crimes We Commit Against Our Stomachs”. It was written by Scott Frank PharmD who worked at the pharmacy at that time. The article was a dive into stomach acid which will be discussed in today’s article. How many of you are bombarded by information about having too much stomach acid? Many ads promote products designed to lower the amount of stomach acid and they include products like proton pump inhibitors, H2 blockers and antiacids. How do we know if we have too much stomach acid? Hippocrates, the father of medicine, once said that “all disease begins in the gut.” If he knew about this problem thousands of years ago, we should probably take notice and take care of our guts. When we think about the start of digestion, it starts in our minds and noses. Thinking about and smelling food starts the process of saliva production. One of my favorite things is to walk in the door after a long day at work and to be greeted with the smell of food, which always gets my digestive juices flowing. Saliva, acid, and enzymes are ramped up by these sensory stimuli so that when we put food in our mouths, the food can be broken down easily. The act of chewing is such an important part of digestion and chewing your food 20-30 times with each bite is optimal, but it takes time and effort . Unfortunately, most of us don’t take the time to chew our food adequately. Chewing also produces the digestive enzyme amylase, which helps to break down carbohydrates in our mouth. If you have ever tried chewing on a cracker and keeping it in your mouth for as long as possible, it will eventually taste sweet. This is the enzyme amylase at work turning starch into sugar. Once the chewed food is ready to be swallowed, it goes thru the upper esophageal sphincter down the esophagus, thru the lower esophageal sphincter (LES), and into the stomach. We have two sphincters or valves attached to the stomach, the LES, connecting the esophagus to the stomach, and the pyloric sphincter (PS), which connects the stomach to the duodenum or small intestine. The LES and PS valves are pH or acid dependent. The information on how these valves are affected by the pH of the stomach contents is hidden away in research dating back to the 1960s; more on that later. Thinking about, smelling food, and now chewing all stimulate acid production in the stomach. The optimal pH of the stomach when it empty is 1.2 to 1.4, the acidity of battery acid. Having an acidic stomach is important and has benefits outside of simply breaking down your food. Stomach acid is on the front line of our immune system killing bacteria, fungi, and viruses in our stomachs. If these microbes get past the stomach unharmed, they can wreak havoc on our GI tract and possibly invade our bodies. A condition where you have inflammation lining of the esophagus and stomach is called gastritis, which I will discuss in depth next week. I want you to think of having gastritis is like having a sunburn on the lining of your stomach. We often hear from patients that they have gastritis being prescribed a proton-pump inhibitor (PPI- omeprazole or Prilosec) or histamine-2 blocker (Pepcid or famotidine), which decreases the production of stomach acid leading to an elevated pH of 4 or greater, which is the acidity of beer. It is now when I ask the patient, “what do you think will digest your food better, battery acid or beer?” No one has ever gotten the question wrong, as battery acid will do a better job. Why do medications that are recommended work so well in reducing discomfort from gastritis? Because now the contents of the stomach are not irritating the inflamed or sunburned tissue. Driving the pH up and making the stomach less acidic is not a fix but a band aide to the problem. Once the band aide is ripped off, we are back to splashing acid on the inflamed tissue creating pain and reinforcing the need to continue treatment, and the vicious cycle continues. If you read the label or look at the package insert, PPIs are indicated for short courses of treatment, typically 4-8 weeks, unless a patient has a specific condition that requires long-term treatment. One of those conditions is called Barrett’s Esophagitis which occurs in about 1-2% of the population in the US. The CDC shows that 16.9% of adults take a prescription PPI, but that doesn’t include patients taking the OTC versions. These numbers don’t add up and way too many patients are taking these medication for longer than they should. Long-term use of PPIs is setting patients up for potential chronic problems, including an increased risk of candida (yeast) infections, H. Pylori (stomach infection), and SIBO (overgrowth of bacteria in the small intestine), all are microbial overgrowth due to a less acidic environment in the stomach. Other concerns come from the lack of nutrients being absorbed due to the less acidic environment, including the inability to absorb vitamin B12, gas, bloating, heartburn, acid reflux, and trouble digesting proteins. One of the problems with low stomach acid, also known as hypochlorhydria, is that we are not checking to see if you have too much or too little acid. The general assumption is that if you have stomach issues, you have too much acid in your gut. Unfortunately, that isn’t always the case, and making the stomach less acidic with medications only fuels the fire. Checking the pH of the stomach with conventional methods can be expensive and I think that is why it is seldomly accessed. Why don’t we know more about the issues surrounding low stomach acid? This question could be pondered or speculated about for a long time. It seems like this information has been hidden since big pharma couldn’t make money by increasing stomach acid or fixing gastritis. The only way to profit from the stomach issues is to say all stomach issues are due to elevated stomach acid and they happen to have a product that will block a receptor or system shutting down the acid production. The good news is that we have tools to get to the bottom of the acid question and protocols to get you feeling better. These tools are cheap ways to access stomach acid and, if needed, support the acid with dietary supplements. If you want help accessing your stomach acid or digestive issues, call the pharmacy @ 701-483-4858 or stop in to schedule a consultation. Please visit my website at www.irsfeldpharmacy.com to find this and other archived articles in the blog section. Until next time, be vigilant about your health!!!
Before diving into today’s article, I want to follow-up on last week’s article covering hydroxyapatite, specifically for dental health. We had many questions about which toothpastes would have hydroxyapatite. The two toothpastes that were recommended by my dental hygienist were Boka and Dr Jen’s, both available online. I am currently using Boka and like how it feels in my mouth, and it has a refreshing mint taste. It is not often that a topic for these weekly articles just drops in your lap, fortunately today’s topic happens to be one of those times. Up until 2 weeks ago, I had never heard of the supplement moringa, but in separate conversations in those 14 days, three people commented that they were currently taking moringa as a part of their supplement regimen. The moringa tree, often referred to as the "miracle tree," is a plant that has been celebrated for centuries for its incredible nutritional and medicinal properties. Native to parts of Africa and Asia, moringa has gained global recognition in recent years as a superfood with the potential to combat malnutrition, support health, and promote sustainability. This article will review the fascinating background of the moringa tree and highlights the numerous health benefits of incorporating moringa into one’s diet. Moringa oleifera, the most widely cultivated species of the moringa tree, originates from the foothills of the Himalayan mountains in northern India. Over time, it spread to Africa, Southeast Asia, and other tropical and subtropical regions. Today, it grows in many parts of the world due to its ability to thrive in harsh climates, including areas with poor soil and limited rainfall. Historically, moringa has been used in traditional medicine and as a food source. Ancient texts from India, such as the Ayurvedic writings, mention moringa’s healing properties. The plant’s various parts—leaves, seeds, pods, flowers, bark, and roots—have been utilized for their diverse applications. In Africa and Asia, moringa is often referred to as the "drumstick tree" because of the long, slender seed pods it produces. One of the reasons moringa is so remarkable is its resilience and rapid growth. It is a drought-resistant tree that can grow up to 10 feet in its first year. This adaptability makes it a valuable resource in regions prone to food scarcity, where it is cultivated as both a nutritional supplement and a source of income. Moringa is packed with an impressive range of nutrients, earning its status as a superfood. Its leaves are especially nutritious, containing high levels of vitamins, minerals, and antioxidants. Here are some of the key components found in moringa: • Vitamins: Moringa leaves are rich in vitamin A, vitamin C, and several B vitamins, which are essential for maintaining healthy skin, immune function, and energy production. • Minerals: It contains significant amounts of calcium, potassium, magnesium, and iron, all of which are important for bone health, muscle function, and oxygen transport in the blood. • Protein: Moringa leaves provide a good source of plant-based protein, containing all nine essential amino acids. This makes it particularly beneficial for vegetarians and vegans. • Antioxidants: Compounds like quercetin and chlorogenic acid in moringa help neutralize harmful free radicals in the body, reducing oxidative stress. Moringa is a powerhouse of nutrients that can help address malnutrition, especially in developing countries. Its leaves can be dried and ground into a powder that is easily stored and added to food. This powder is used to supplement diets lacking essential vitamins and minerals, particularly for children and pregnant women. The high levels of vitamin C and other antioxidants in moringa enhance the body’s immune response. These nutrients help protect against infections, promote faster recovery from illnesses, and maintain overall health. Moringa contains fiber, which aids in digestion and prevents constipation. Additionally, it has natural antibacterial properties that can help combat harmful bacteria in the gut, contributing to a balanced digestive system. Research suggests that moringa can help regulate blood sugar levels, making it beneficial for people with diabetes. Compounds in moringa, such as isothiocyanates, have been shown to reduce insulin resistance and lower blood sugar levels after meals. Moringa’s antioxidants, combined with its ability to lower cholesterol and reduce inflammation, support cardiovascular health. Regular consumption may help lower the risk of heart disease and improve overall heart function. The vitamins and antioxidants in moringa nourish the skin and hair, promoting a healthy complexion and stronger hair. Its oil, extracted from the seeds, is commonly used in skincare products for its moisturizing and healing properties. Moringa is believed to improve brain function and mental clarity due to its high content of antioxidants and essential nutrients. It may also help protect against neurodegenerative diseases by reducing inflammation in the brain. The patients I referenced who were using moringa as part of their supplement regimens were using the product as part of a cancer treatment protocol. There are several studies looking at the use of moringa for both cancer prevention and treatment. Moringa is incredibly versatile and can be consumed in various forms. Fresh moringa leaves can be cooked like spinach or added to soups and salads. Moringa powder, made from dried leaves, is a convenient option for smoothies, teas, or baked goods. The seeds can be eaten roasted or pressed to extract oil, which is used in cooking and cosmetics. Sourcing fresh moringa might be a difficult task, however it is easily obtained in powder form. When incorporating moringa into your diet, start with small amounts to allow your body to adjust, especially if you’re using the powder. While moringa is generally safe, consuming large quantities may cause mild side effects such as digestive discomfort. Beyond its health benefits, moringa has significant environmental and economic advantages. Its fast growth and ability to thrive in challenging conditions make it a sustainable crop. The tree also helps improve soil quality and provides shade for other plants. For many communities, cultivating and selling moringa products offer a vital source of income, empowering farmers and boosting local economies. The moringa tree is a remarkable gift from nature, offering a wealth of nutrients and health benefits. From boosting nutrition and supporting immunity to promoting sustainability, it’s no wonder moringa has earned the title of "miracle tree." By adding moringa to your diet, you can take a step toward better health while supporting a sustainable and impactful plant that benefits communities worldwide. Sourcing products that are not readily obtainable is something we do for many of our patients and moringa may be one of those. Please reach out to my staff at the pharmacy, as they would be more than willing to help you out at 701-483-4858. All my articles can be found online at our website, www.irsfeldpharmacy.com. My podcast, "The Irsfeld Pharmacy Optimal You Podcast," can also be accessed through the website. Until next time, be vigilant about your health!!
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