Three Ways to Minimize Chronic Pain at Home

Jackie Waters

For people living with chronic pain, it can feel as if life is one long quest in search of relief.

From visualization therapy (a technique used in psychology) to various combinations of painkillers, medical professionals work with you to minimize pain and make life more manageable.

But, if you have yet to find the relief you seek, you may be surprised to learn that some answers very well could be within your home. Many people living with chronic pain find that with a few adjustments to their homes and their lifestyle, they reduce their overall pain levels.

Here are three strategies for minimizing chronic pain at home.

1. Get Help at Home

Being sedentary is not helpful for anyone with chronic pain. That being said, there are some tasks that you perform at home that most likely exacerbate your pain. For example, many people with chronic pain find that chores such as bending and stretching to open and wash heavy windows, scrubbing down the walls of the shower and bathtub, and carrying overloaded clothes baskets up and down the stairs make their pain worse and that symptoms last for a few days. If you find that this is the case for you, you should hire a housekeeper to do the cleaning tasks that exacerbate your pain.

When you interview applicants, explain your situation and determine whether they are willing to do the cleaning tasks that you cannot. You may not need a housekeeper to clean your entire house from top to bottom once a week, but you probably do need someone to help lighten the laundry load and do the heavy-duty cleaning that increases your level of pain. You may continue to do your dishes, run the vacuum, and dust lightly, but a housekeeper may be the better option for the tasks that require more movement and result in more pain for you.

2. Start Eating Healthier Meals

Doctors agree that one lifestyle change that can minimize chronic pain is eating healthier meals. First, a diet that is high in fat and sugar leads to weight gain. Being overweight puts more strain on your joints and back and contributes to chronic pain. Even if you are not overweight, eating healthier meals and avoiding certain foods reduces the amount of inflammation you have, which in turn reduces the amount of pain you have.

When planning meals, incorporate as many foods that fight pain as possible. Add ginger and turmeric to your dishes or start drinking ginger tea because these ingredients ease inflammation and ease discomfort. Incorporate extra-virgin olive oil in your cooking to reduce inflammation. Eat foods that are rich in omega-3 fatty acids such as salmon. Snack on red grapes, berries, and peanuts because these foods contain resveratrol.

If you struggle with planning meals and getting to the grocery store because of your pain, consider subscribing to a meal delivery service that brings fresh produce, meat, and other ingredients directly to your door and guides you through the process of cooking healthy meals from scratch. Cooking at home provides a much-needed distraction from pain and gives you the chance to learn how to prepare healthy meals that can minimize your pain.

3. Start Exercising at Home

People with chronic pain often do not sign up for gym memberships or join fitness classes because the workouts are too intense for their level of pain. But, being sedentary increases chronic pain. Rather than get caught in a catch-22, you should begin exercising at home by doing workouts that soothe your pain. Begin walking on a treadmill, around your home or property, or around your neighborhood.

You may want to start with a 10-minute walk and build up to 30 minutes of walking each day. Walking is a low-impact aerobic activity that delivers oxygen to muscles and decreases pain and stiffness. Other exercises to do at home to relieve pain include water aerobics in a heated home pool, stretching, yoga, and light weightlifting.

If you live with chronic pain and are looking for more ways to minimize your pain, try hiring a housekeeper to help with chores that contribute to your pain, eating healthier meals, and exercising at home.

Jackie Waters is a mother of four boys, and lives on a farm in Oregon. She is passionate about providing a healthy and happy home for her family, and aims to provide advice for others on how to do the same with her site Hyper-Tidy.com.

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The Microbiome and How It Affects Your Health

Sandy Cardy (CPA, CA, CFP)

The microbiome is defined as the microorganisms in a particular environment (including the body or a part of the body). We depend on a vast army of microbes to stay alive — a microbiome that protects us against germs, breaks down food to release energy, and produces vitamins.

Coined in 2001 by molecular biologist Joshua Lederberg, the term “microbiome” has begun to get attention just recently in reference to gastrointestinal or “gut” health. Besides our microbes’ essential functions such as digesting food and synthesizing vitamins, studies have linked the microbiome to gut health as well as human mood and behavior, human development, and metabolic disorders.

It is becoming increasingly clear that assaulting our gut systems with pharmaceutical drugs, harsh environmental chemicals, and toxic food is a primary factor in rising disease rates. Because 60-to-80% of our immune system is located in our gut, gastrointestinal (GI) imbalances have been linked to skyrocketing rates of obesity, autism, and the intestinal diseases of Crohn’s, ileitis, and colitis. Hormonal imbalances (thyroid, adrenals) usually can be related directly to, among other things, a Western diet high in sugars and carbohydrates. Such bad eating habits can throw the delicate balance of intestinal bacteria out of whack. When your gut is unhealthy, it can cause more woes than just stomach pain, gas, bloating or diarrhea.

Recent research suggests intestinal inflammation may play a critical role in the development of certain cancers and immune system diseases. Until we begin to communicate clearly about this complex relationship, we will not be able to prevent or intervene effectively in many of the diseases that are devastating people’s lives today.

Research is also finding that a healthy microbiome with beneficial probiotic bacteria may play “a huge major role in reducing inflammation in the gut, a risk factor involved in illnesses ranging from colds to cancer, heart disease, arthritis, anxiety, depression, and cognitive decline,” according to Katherine Tallmadge, RD, author of Diet Simple. In addition, the bacteria may help burn body fat and reduce insulin resistance. So to stay slim and healthy, she suggests you consider adding more probiotic foods to your diet.

In order for true healing and meaningful prevention to occur, you must continuously send your body messages that it is safe, that it is not under attack, and that it is well-nourished, supported, and calm. Your own research regarding diet, supplements, and calming support programs such as meditation, yoga, and other holistic applications will help you on the path to better health. Many nutritionists and naturopathic doctors can be a huge help in educating you about keeping your gut happy and healthy, thereby ensuring your mental and physical well-being at the same time!

Microbiome testing, such as a stool analysis, can be arranged through your local naturopathic doctor or possibly your M.D. It may be costly but well worth it as the unique problems that may be challenging your immune system will be uncovered. You and your health care provider will then be able to design the perfect dietary and supplementary program for your healthy future.

Sandy Cardy (CPA, CA, CFP) is a leading authority on tax and estate planning, and for many years Sandy helped individuals grow their net worth. But after her own battle with cancer and subsequent full recovery, she immersed herself in researching how to protect your health as well as your wealth. Today, she shares her practical and inspiring knowledge of how to build a lasting legacy, in every sense of the word. To read more from Sandy, please visit her website www.sandycardy.com. You can follow Sandy on Twitter and Like her on Facebook.

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Do You Need an Iron Supplement?


Many of us have heard the advice to use a multivitamin supplement with iron to ensure good health. Older individuals, in particular, grew up in an era in which the sadly portrayed results of “iron-poor, tired blood” which was advertised to millions of television viewers (and targeted to a geriatric audience).

Should all multivitamins contain iron?

In modern times, many people strive to obtain all the nutrients they need from food alone. Unfortunately, we know that is very challenging to achieve due to soil conditions and other factors.

However, it may be possible for iron, at least for some people. Nevertheless, many infants, children, teenagers, and women during their reproductive years fail to obtain the iron they need, and for these people or others diagnosed with iron deficiency anemia, an iron supplement is essential.

While the Recommended Daily Allowances for most nutrients are woefully inadequate, for iron, they may be reasonable. A Western diet that is high in meat, which is a rich source of iron, especially combined with iron supplementation, can frequently elevate iron stores to levels beyond that which is needed.

Iron deficiency

Iron deficiency anemia can often go undetected without blood testing. Signs include fatigue, weakness, shortness of breath, poor circulation, rapid heartbeat and more. According to the World Health Organization’s definition of anemia (hemoglobin level of less than 13 g/dL in men and less than 12 g/dL in women), its presence more than doubles the risk of premature mortality, however, excessively high hemoglobin levels have also been associated with increased premature mortality.1

A study of long-term care facility patients found a 63% higher risk of mortality from any cause among those whose iron deficiency was mild and a 96% higher risk among those with severe deficiency over a five-year period.2 In a study of 17,030 subjects aged 66 years and older, anemia was associated with a greater than four-fold increase in the risk of death over three years of follow up, however, once more, when hemoglobin levels became high, an increase in death from any cause became evident.3

Numerous other studies exist that document an association between iron deficiency or anemia and mortality in different populations.

What are some of the consequences of too much iron?

Iron is, by mass, the most common element on Earth. The mineral is needed for the formation of hemoglobin, the oxygen-carrying protein in red blood cells, and is, therefore, essential to human and other animal life. It’s also needed by the muscles and organs of the body. However, iron generates free radicals—byproducts of metabolism that can damage the body’s tissues, resulting in premature aging.

In the hereditary disease known as hemochromatosis, elevated iron levels result in deposits of the mineral in skin, glands, pancreas, heart and liver. Too much iron in the pancreas can dangerously lower insulin production, leading to elevated glucose levels. In the heart, iron deposits can lead to cardiac arrhythmias and heart failure. In the liver, it can cause cirrhosis and increase the risk of liver cancer.

While most people don’t have hemochromatosis, many get more iron than they need. Iron has been linked to increased risk or complications of numerous diseases.

Higher iron levels have been linked with diabetes. Diabetic women in one study were found to have serum ferritin levels that were three times greater than those of a control group.4 A review of epidemiologic studies examining the associations between iron and cardiovascular disease and diabetes concluded that the evidence was strong in support of the association between iron status and an increased risk of either disease.5

In human liver cells exposed to iron overload, significant inflammation occurred via nuclear factor-kappa beta (NF-kB) signaling.6

Cancer cells use iron to proliferate, and the cells’ uptake of the mineral can result in anemia in those afflicted with the disease.7 Oxidative stress generated by iron accumulation activates signaling pathways needed for tumor growth and induces epigenetic changes associated with metastasis.

Higher brain iron levels are associated with an increase in neurodegenerative diseases, including Huntington’s, Parkinson’s and Alzheimer’s disease, compared to the brains of healthy men and women.7 According to an article published in 2016 in Brain, “Iron accumulation is a cardinal feature of degenerating regions in the Parkinson's disease brain. As a potent pro-oxidant, redox-active iron may be a key player in upstream mechanisms that precipitate cell death in this disorder. Although an elevation in brain iron levels is a normal feature of ageing, the increase is greater in Parkinson's disease […] neurodegeneration in the affected regions may result from the potent redox couple formed by iron and dopamine itself […]”8

Hypotheses

The most recent review concerning iron-mediated toxicity observed that the poor solubility of iron renders it a valuable commodity and that humans have evolved mechanisms to absorb, recycle and store iron while minimizing toxicity.9 The authors assert that “existing regulatory processes are more than adequate to limit the toxicity of iron even in response to iron overload. Only under pathological or artificially harsh situations of exposure to excess iron does it become problematic.”

However, in 2016, an article in Liver International noted that “Excess iron in the blood, in the absence of increased erythropoietic [red blood cell-producing] needs, can saturate the buffering capacity of serum transferrin and result in non-transferrin-bound highly reactive forms of iron that can cause damage, as well as promote fibrogenesis and carcinogenesis in the parenchymatous organs.”10

The Bottom Line

How does one know if one needs to supplement with iron? Routine blood work that includes serum ferritin and hemoglobin levels can provide the information your physician needs to diagnose iron deficiency anemia. Only those who are truly deficient should supplement with iron. Iron protein succinylate is a good choice if supplementation is necessary due to its superior absorption and decreased likeliness of gastrointestinal irritation.

References

  1. Martinsson A et al. Eur J Epidemiol. 2014 Jul;29(7):489-98.
  2. Hsu HS et al. Nutrition. 2013 May;29(5):737-43. 2013 May;29(5):737-43.
  3. Culleton BF et al. Blood. 2006 May 15;107(10):3841-6.
  4. Skalnaya MG et al. J Trace Elem Med Biol. 2016 Nov 16.
  5. Basuli D et al. Front Pharmacol. 2014 May 20;5:117.
  6. Li X et al. Molecules. 2016 Mar 17;21(3):322.
  7. Gozzelino R et al. Int J Mol Sci. 2016 Jan 20;17(1).
  8. Hare DJ et al. Brain. 2016 Apr;139(Pt 4):1026-35.
  9. Eid R et al. Biochim Biophys Acta. 2016 Dec 6;1864(2):399-430.
  10. Pietrangelo A. Liver Int. 2016 Jan;36 Suppl 1:116-23.

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Tips From a Cancer Survivor: Invest in Your Future, Invest in Your Health

Sandy Cardy (CPA, CA, CFP)

On Valentine’s Day in 2012 I was diagnosed with ovarian cancer.

As a leading authority on financial, tax, and estate planning, I’ve spent many years helping people grow their net worth and preserve the value of their estates. My mantra to clients has always been, “Wealth is built with returns over time.” Sound, life-long investment strategies have the greatest impact on your financial future, especially when you’re planning for the later years. It was that Valentine’s Day, after I received the phone call, that I realized that the definition of ”wealth” I’d been operating under was flawed. Because what good is all that financial planning if you aren’t around to enjoy the rewards?

I ate well, exercised, and had a fulfilling career and a great family life. But I hadn’t paid enough attention to investing in my health. This life-changing event forced me to re-examine my health: both in lifestyle & diet. The more I researched, the more it became obvious to me that there was so much more I could have been doing in terms of preventive healthcare.

I had surgery in 2012 and spent three weeks in Reno, Nevada having immune boosting IVs as well as a few sessions of low-dose chemo with IPT. Cancer is a multi-factorial disease, and I now focus on my whole body — mental, emotional, and physical. Embarking on a quest to find ways to get my body back in balance, I spent two years researching and investigating all things health-related, using my body as a test lab. Over a series of blogs I’ve written for Life Extension, I will share with you what worked to get my body back in balance on my journey to optimal health and wellness. My first step was finding the right healthcare provider.

Finding The Right Healthcare Provider

Today, many people are becoming more health conscious, giving way to a new era of personalized medicine and a growing awareness of our body’s ability to repair itself. I predict that in the next decade or so, there will be greater acceptance of the notion that the body is incredibly resilient and a shift in support for preventive medicine and the importance of a healthy mindset.

When it comes to our health, we can't simply rely on medical professionals to take care of us. The smartest approach to healthcare is self-care — that is, self-initiated and deliberate care for one's self.

Whether you begin looking for a healthcare provider because of a health crisis or because you’re looking into preventive health, you need the team you build to provide precisely the right kind of support. The practitioners you choose may be from western or eastern medicine, conventional or alternative — it is your choice. But whoever they are, it is key to find healers who truly empower your outlook. It's about working alongside your team of doctors (involved in decisions, and also taking charge) in a way that makes you feel empowered, because when you are feeling empowered you will heal, provided you give your body the right tools.

Invest In Yourself

Here are three simple steps (or tools as I like to call them) for investing in your health to get started…

1. Add Daily Fiber

Fiber equates to “regularity”, right. “Well, ye-ah, so what?” I used to scoff. Well, fiber is a lot more beneficial than for just keeping you regular. Fiber helps the body eliminate toxins.

Normally, used-up estrogens are excreted (in stool and bile). But if you have a stressed-out liver (and many do) you may not be excreting estrogens as well as you might.

The standard North American diet is prone to raising estrogen levels, because the wrong kind of diet can alter gut bacteria causing used-up estrogens to be re-absorbed into the bloodstream.

Over time, accumulating estrogens can be a contributing factor to breast and gynecological cancers in women, and prostate cancer in men.

One way to shuttle out estrogens is through fiber. To boost fiber intake, grab seeds (like flax) and up your fruit and vegetable intake.

Experts recommend at least 30 grams of fiber per day. If you don’t feel you can get that from food, medicinal fiber from supplements can help.

2. Change Your Breakfast Routine — Just A Little

What you eat at breakfast sets the tone for the day, and improvements can begin with two simple moves.

First, drink a glass of warm water, with the juice of half a lemon, 15-30 minutes before eating. If half a lemon is too harsh, start with just a few drops and slowly build up to half a lemon. This will get your gut’s HCl (hydrochloric acid) stimulated. And you want that because HCL is bad for bugs and good for you! HCl is our first line of defense against bacteria and pathogens – HCl kills bugs that can make you sick. Also, healthy levels of HCl stimulate the enzymes that break down food and optimize extraction of food’s nutritional value.

Second, eat a balance of protein, fat, and fiber at breakfast, to give you balanced energy reserves throughout the day.

3. Support Your Liver

The liver is the largest internal organ in your body and performs about 500 functions, including blood detoxification.

Our livers are more overtaxed than ever. Also, many people have sluggish livers. Signs the liver is overburdened manifest as things like digestive issues, skin problems, lethargy, blood sugar fluctuations, hormonal imbalances, and intolerance to coffee and alcohol.

The standard liver enzyme tests may well result in your doctor telling you your liver is fine. The reality is that liver abnormalities will only register in standard blood work after years of abuse.

While our livers are designed to excrete toxins (such as harmful estrogen metabolites) naturally there are a couple of contemporary problems that obstruct optimal functioning. First, in today’s world, toxic load exceeds the capacity of the channels of elimination. Secondly, some people are genetically better able to detoxify their livers than others. By eating the following several times a week you can support your liver’s detoxification:

Brassicas (like cabbage, cauliflower, and broccoli): Good not just for eliminating toxins, but also for their high nutrient count and for facilitating the excretion of harmful estrogens.

Alliums (onions and garlic): These contain nutrients from the sulfur family and support the liver’s detox pathways.

Turmeric: This spice contains curcumin, which both eases inflammation and supports liver detox.

I’ve learned, from personal experience, true wealth is about more than balance sheets and income statements — health is vital to the equation too.

How are you investing in yourself?

Sandy Cardy (CPA, CA, CFP) is a leading authority on tax and estate planning, and for many years Sandy helped individuals grow their net worth. Diagnosed with cancer in 2012 and now cancer-free and thriving, she speaks and teaches widely on how to make sound personal and financial decisions, embrace radiant health, and how to build a lasting legacy in all senses of the word. You can sign up for Sandy’s newsletter and download her eBook (7 Steps for Finding the Right Financial Advisor and 7 Steps forFinding the Right Healthcare Provider) on her website. You can also find her on Facebook, Twitter, and Instagram.

Sources:

  1. https://www.ncbi.nlm.nih.gov/pubmed/20138982
  2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3731019/
  3. https://www.ncbi.nlm.nih.gov/pubmed/17691916
  4. https://www.ncbi.nlm.nih.gov/pubmed/17028159
  5. https://www.ncbi.nlm.nih.gov/pubmed/20229497
  6. https://www.ncbi.nlm.nih.gov/pubmed/9630736

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3 Reasons Why Pomegranate is a Superfruit


The name "pomegranate" (Punica granatum L.) derives from the Latin pomum and granatum, meaning apple-seeded. The fruit's numerous seeds have made it a symbol of female fertility. The ancient Greeks believed it to be a symbol of life, marriage, and rebirth.

The Composition of Pomegranates


Pomegranate contains the phenol ellagic acid, which in recent research has been associated with protective effects against cancer. The fruit is a good source of vitamin C, tannins, and flavonoids. Major anthocyanidins include delphinidin, cyanidin, and pelargonidin, which contribute to the pomegranate's antioxidant activity.1 An examination of the pomegranate fermented juice and seed oil's antioxidant properties found activity similar to that of green tea, red wine, and and may even act as a preservative.2 Flavonoids extracted from the juice and seed oil demonstrated an ability to inhibit lipoxygenase — an enzyme that converts favorable unsaturated fatty acids to damaging peroxides.

Punicalagin, an ellagitannin contained in pomegranate, has been identified as a major source of the fruit's antioxidant activity.3 A trial in which 14 healthy participants consumed pomegranate juice daily for 15 days found a decrease in plasma malondialdehyde (MDA, a marker of oxidative stress), and an increase in red blood cell levels of the antioxidant glutathione.4 Some of the benefits of pomegranate juice persisted a week after discontinuing the beverage.

While pomegranate seeds and their fleshy covering known as aryls are the parts of the fruit normally consumed, significant free radical scavenging ability has been found in the peel as well.5 For example, a trial of humans with ulcerative colitis found that the peel improved symptoms in comparison with a placebo after four weeks.6

Pomegranates Have Cardiovascular Benefits

In a trial of patients with high cholesterol levels, the addition of pomegranate to the drug simvastatin lowered low density lipoprotein (LDL) cholesterol levels more than simvastatin alone and improved oxidative stress levels in addition to other benefits.7 In another human study, pomegranate juice decreased susceptibility of LDL to aggregation and retention, and increased serum paraoxonase activity, which helps protect against lipid oxidation.8 In other research, pomegranate juice given daily for two weeks lowered systolic blood pressure by 5% and serum angiotensin converting enzyme (ACE, which controls blood pressure by regulating fluid volume) by 36% in a trial of hypertensive individuals.9

When consumed for up to three years by carotid artery stenosis patients, pomegranate juice was associated with a significant decrease in carotid intima media thickness (a measure of atherosclerosis) and systolic blood pressure.10

Pomegranates Have Antimicrobial Effects

A study involving extracts of pomegranate aril and peel found antimicrobial activity against Staphyloccus aureus and Escherichia coli, two common pathogens that are frequently implicated in foodborne illnesses.11 In laboratory studies, pomegranate peel extract as well as some of the fruit's individual polyphenols have demonstrated activity against Mycobacterium tuberculosis and Klebsiella pneumoniae.12Another study found antimicrobial activity for pomegranate extractagainst Clostridium difficile.13

Pomegranates Have Anticancer Effects

A review of pomegranate polyphenols in cancer prevention and treatment noted that "Pomegranate evokes antiproliferative, anti-invasive, and antimetastatic effects, induces apoptosis […]. Furthermore, pomegranate blocks the activation of inflammatory pathways including, but not limited to, the NF-κB (nuclear factor kappa-light-chain-enhancer of activated B cells) pathway."14

In estrogen-dependent and independent human breast cancer cells, fermented pomegranate juice polyphenols exhibited an antiproliferative effect that was approximately double that of fresh juice polyphenols.15 Additionally, pomegranate seed oil was effective at inhibiting proliferation and invasion in estrogen-receptor positive cells and inducing apoptosis in estrogen receptor negative metastatic cells.

A review of the pomegranate's effects against breast cancer notes that "Punica (pomegranate) extracts and its components, individually or in combination, can modulate and target key proteins and genes involved in breast cancer" and that other mechanisms attributed to pomegranate act "at various steps of carcinogenesis including proliferation, invasion, migration, metastasis, angiogenesis, and inflammation." 16

In a trial involving men with prostate cancer and rising prostate-specific antigen (PSA) levels, participants who received pomegranate extract experienced a six month or greater increase in PSA doubling time, which indicates slowing of disease.17

Superfruit, Not Superstar

So why aren't pomegranates more popular? While appearing with greater frequency in the produce section of supermarkets since achieving "superfruit" status, they aren't a top seller.

Combined with their unfamiliarity to some individuals and the absence of year-round availability is the lack of ease of consumption. Pomegranates must be cut open and the juicy, messy aryls removed and consumed raw. Not exactly like biting into an apple.

Fortunately, concentrated pomegranate juice and pomegranate extract capsules are available for those individuals who find whole pomegranate fruit too messy or time-consuming to eat on a regular basis. For those watching their sugar intake, consider the capsules as an alternative to the juice, which contains sugar.

References

  1. Noda Y et al. J Agric Food Chem. 2002 Jan 2;50(1):166-71.
  2. Schubert SY et al. J Ethnopharmacol. 1999 Jul;66(1):11-7.
  3. Cerdá B et al. Eur J Nutr. 2003 Jan;42(1):18-28.
  4. Matthaiou CM et al. Food Chem Toxicol. 2014 Nov;73:1-6.
  5. Singh RP et al. J Agric Food Chem. 2002 Jan 2;50(1):81-6.
  6. Kamali M et al. Complement Ther Clin Pract. 2015 Aug;21(3):141-6.
  7. Hamoud S et al. Atherosclerosis. 2014 Jan;232(1):204-10.
  8. Aviram M et al. Am J Clin Nutr. 2000 May;71(5):1062-76.
  9. Aviram M et al. Atherosclerosis. 2001 Sep;158(1):195-8.
  10. Aviram M et al. Clin Nutr. 2004 Jun;23(3):423-33.
  11. Pagliarulo C et al. Food Chem. 2016 Jan 1;190:824-31.
  12. Dey D et al. Pharm Biol. 2015;53(10):1474-80.
  13. Finegold SM et al. Nutrition. 2014 Oct;30(10):1210-2.
  14. Turrini E et al. Oxid Med Cell Longev. 2015;2015:938475.
  15. Kim ND et al. Breast Cancer Res Treat. 2002 Feb;71(3):203-17.
  16. Vini R et al. Biofactors. 2015 Mar-Apr;41(2):78-89.
  17. Paller CJ et al. Prostate Cancer Prostatic Dis. 2013 Mar;16(1):50-5.

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