Vitamins and Prostate Cancer

May 16th, 2007

I am amazed by the number of poorly conducted studies that get published. Today I am aware of another study whose design would fail a Fourth Grade Science Fair. The Journal of the National Cancer Institute has just published a study that supposedly links consistent higher dose multivitamin use in AARP men at a medin age of 63 years-old to an increased rate of prostate cancer over 5 years. Nearly 30 thousand men participated in this survey driven study. Nearly 1/3 of the participants supposedly “developed” prostate cancer over the five years. I say supposedly, since the criteria for “prostate cancer free” was based on reported “normal” PSA and digital rectal exam within the last 3 years by the subject. As this study is released, another study is published by the Journal of Urology that shows that prostate cancer is under-diagnosed in up to 36% of men with PSA values from 2-10 ng/ml. This nearly equals the number of prostate cancers later detected in the multivitamin study. So the assumption that their subjects were cancer-free is inappropriate. This weakness in their study may have been minimized by having prostate ultrasounds, and biopsies if indicated.

The next weakness in this study, that the authors also failed to mention, is that WE ARE WHAT WE ABSORB AND METABOLIZE, not what we eat. Some people can eat many vitamins, foods, and still be under nourished and vitamin deficient. The study coordinators did not assess vitamin metabolism or prostate tissue or immune system nutriture. My patients benefit from individualized health assessments that include Spectracell’s comprehensive leukocyte nutriture testing. In this way they have a much better idea about the vitamin deficiencies in their immune system. The subjects of this study did not have this included in the survey. This study was filled with assumptions.

They noted a correlation with prostate cancer aggressiveness with increased zinc intake. Again, the authors missed important concepts in nutrition. Zinc and vitamin A have a balance. High levels of zinc can deplete vitamin A. Furthermore, low serum levels of zinc and vitamin A have both been noted in patients with prostate cancer. So the survey-oriented study did not address this adequately either. Did the zinc get metabolized and deplete another necessary nutrient, vitamin A? Were these subjects still low in zinc despite ingestion? Did the zinc act as an aromatase inhibitor that indirectly increased 5 alpha reductase activity and elevated dihydrotestosterone levels? (That’s another important factor that went completely unaddressed!)

I am disappointed in the NIH for financing such a poorly constructed study. This study has not shown us that vitamin use is a problem, but rather that the health care system needs to assess nutriture status through tissue testing, metabolic analysis and that prostate cancer risk assessments need to include better diagnostic methods like prostate ultrasound, nutrition and hormone testing.


Lawson K, Wright M, Subar A, Mouw T, Hollenbeck A, Schatzkin A, Leitzmann M. Multivitamin use and risk of prostate cancer in the National Institutes of Health-AARP Diet and Health Study. Journal of the National Cancer Institute. Vol 99, No. 10. pp754-764.

Pelzer AE, Bektic J, Akkad T, Ongarello S, Schaefer G, Schwentner C, Frausher F, Bartsch G, Horninger W. Under diagnosis and over diagnosis of prostate cancer in a screening population with serum PSA 2 to 10 ng/ml. Journal of Urology 2007 May 10. (Epub ahead of print).

Ozmen H, Erulas FA, Karata F, Cukurovali A, Yalcin O. Comparison of the concentration of trace metals (Ni, Zn, Co, Cu ans Se), Fe, vitamin A, C and E, and lipid peroxidation in patients with prostate cancer. Cin Chem Lab Med 2006;44(2):175-9.

A possible decline in breast-cancer incidence in 2003

April 19th, 2007

These are confusing times. The media quickly alerts us to potential health disasters and keep us ever-weary of the risks for cancer. Yet in all the hype and excitement, the value of bio-identical hormone replenishment is often discounted or overlooked. The New England Journal of Medicine April 19, 2007 issue releases a report about “The Decrease in Breast-Cancer Incidence in 2003 in the United States.” Assuming that the statistics are correct, then much can be speculated about the causes of this overall decline in the disease. And the authors certainly do speculate about this, without much information to truly lead them.

One speculation is the decreased use in Premarin and Prempro since the announcement of the WHI conclusions. The transition to fewer women replacing their hormones with synthetic derivatives could have played a role, but given the short interval between the reports from the WHI study and the change in breast-cancer incidence data, this seems unlikely. Also of note, the report states “No sudden decrease has yet been reported for breast-cancer incidence in heavily screened populations.” So speculation about routine screening also may enter the equation. Clearly, much still needs to be evaluated.

What the authors completely overlook, or at least fail to mention in their speculation, is that a great paradigm shift has begun. More people are realizing the healthy benefits of having their hormone levels measured and then replenished to levels of wellness, not replaced with a foreign hormone. They are seeking balance in their hormones, not supra-physiologic dosing or replacement.

They mention the change in diet that many women have chosen. More and more women are learning that substances such as Diindolemethane, CoQ10, anti-oxidants, vitamins A, E, & D, and iodine are important for breast health. Furthermore, they recognize the benfits of replenishing melatonin, progesterone and DHEA, as they all play a role in decreasing cancer states.

So by choosing bio-identical therapies, or by avoiding synthetic hormones that further suppress endogenous bio-identical hormones, women may be finding better breast health.

Further investigation is definitely warranted to elucidate the true correlations to this possible decline in breast-cancer incidence rates. Guesses are being made without getting the full information. Have prescription rates increased for compounded and pharmaceutical bio-identical hormone therapies? What are the serum DHEA-S , estradiol, progesterone, Vitamin A & E, 25 hydroxy vitamin D, free and total testosterone, dihydrotestosterone, melatonin, homocysteine, anti-oxidant levels and 24 hour urine iodine challenge test results of the women that do present with breast cancers? And those that never get cancer?

The other issue at hand is whether anabolic steroids should be available over the counter. Despite the fact that vitamin D is a very beneficial steroid hormone, it is not receiving the same scrutiny for access as dehydroepiandrosterone is. Where does this put us in our understanding of the value of DHEA? Researchers have found a potential benefit in using DHEA to kill androgen receptor-positive breast cancers. Another study suggests, however, that there no relation exists between DHEA-S or DHEA and overall breast cancer risks. There may be some association of DHEA with estrogen receptor-positive/ progesterone receptor-positive breast cancers, but it’s unclear how these levels were balanced in the study with the subjects’ other hormones and nutritional statuses.

Such fragments of data can be confusing. This is why it is so important that patients work with physicians who are thorough in their approaches to care, and understand the value of balancing hormones bio-identically, instead of suppressing them synthetically.

I am hopeful that breast cancer rates are truly declining, not just in 2003. We have much to assess, and it is far too soon to jump to full blown conclusions. May true health prevail.

Ravdin PM, Cronin KA, Howlader N, Berg CD, Chleblowski RT, Feuer EJ, Edwards BK, Berry DA. The decrease in breast-cancer incidence in 2003 in the United States.
New England Journal of Medicine. 2007 April, 356(16):1670-74

Tworoger SS, Missmer SA, Eliassen AH, Spiegelman D, Folkerd E, Dowsett M, Barbieri RL, Hankinson SE. The association of plasma DHEA and DHEA sulfate with breast cancer risk in predominantly premenopausal women. Cancer Epidemiol Biomarkers Prev. 2006 May; 15(5):967-71.

Labrie F. Dehydroepiandrosterone, androgens, and the mammary gland. Gynecol Endocrinol. 2006 Mar; 22(3):118-30.

Hardin C, Pommier R, Calhoun K, Muller P, Jackson T, Pommier S. A new hormonal therapy for estrogen receptor-negative breast cancer. World J Surg. 2007 April 4.

Aceves C, Anguiano B, Delgado G. Is iodine a gatekeeper of the integrity of the mammary gland? J Mammary Gland Biol Neoplasia. 2005 Apr; 10(2):189-96.

Natalie Kather, MD
Family and Anti-Aging Medicine physician

Asbestos and Malignant Mesthelioma

May 6th, 2006

Many people are wondering about the risks of asbestos exposure and getting malignant mesothelioma. Mesothelioma is a type of cancer on the pleura, or lining of the lungs. It can lead fluid in the lungs, difficulty breathing, and eventually death. When it comes to how our bodies age and handle illness, 65% depends on the environment, like the things we feed, expose, and do to our bodies. The remaining 35% is due to genetics, that wonderful nuclear and mitochondrial DNA that we got from ours parents and mothers, respectively.

When we think about environment, consider the following study. A 35-year period evaluation of workers in an asbestos factory in Poland revealed that increased rates of lung cancers, pleural mesothelioma, and all malignant cancers were higher in these workers than in the general population. Of the 4,187 subjects studied (2805 men and 1382 women), five died from pleural mesothelioma. Also, the risk for these types of illness did not differ between those that had a preceeding documented diagnosis of lung asbestosis and those that did not. So, where people work, and the polutants they are exposed to, clearly influence disease risks.

Now with genomics laboratories, investigation of disease risk is taken to a new level. A recent study in Northwest Italy evaluated single nucleotide DNA polymorphisms in 4 genes responsible for DNA repair. Polymorphisms are like typos in the DNA language. The assumption was that sloppy DNA repair increased the risk for this cancer when a gene-damaging substance like asbestos was thrown into the picture. It’s like trying to fix an important system with an entire chapter ripped out of the repair manual. So seven different variations of these 4 genes were studied in 81 malignant mesothelioma patients and 110 of their age-matched and sex-matched controls. All subjects were residents of Casale Monferrato, a town polluted with asbestos. The results showed that with one type of polymorphism (or DNA typo) a 2.147 oddds ratio existed for this disease, another variant (or DNA typo) had a 4.09 odds risk ratio. These genetic variations can certainly put people at an increased risk of developing the cancer. This is valuable information because the residents of this town can now look at their family genetics and give more consideration about whether or not they should move out of there!

Environment and genetics…we are getting more options now than ever before to learn about our risks of getting cancers, like malignant mesothelioma. If you have any concerns about a history of personal asbestos exposure, I encourage you to explore with your physician or health care provider what diagnostic tools are available for further evaluation.

Dianzani I, et al. Polymorphisms in DNA repair genes as risk factors for asbestos-related malignat mesothelioma in a general population study. Mutant Res. 2006 Marc 23; (epub ahead of print)
Wilezynska U, Szymezak W, Szeszenia-Dabrowska N. Mortality from malignant neoplasms among workers of an asbestos processing plant in Poland: results of prolonged observation. Int J Occup Med Environ Health 2005; 18(4):313-26.

The Metabolic Plan

May 1st, 2006

Now at Best Seller status with 250,000 sales, “The Metabolic Plan” by healthy aging expert Stephen Cherniske is a must-read for anyone interested in a high quality of life. Cherniske has the great understanding and insight that healthy aging requires much more than a good diet and exercise. As an international expert on DHEA, he reveals his own aging process. The before and after photos strikingly demonstrate his healthy recovery and on-going improvement. Quite frankly, he shows how the metabolic approach to health improved his cholesterol levels, blood pressure, lean muscle mass, and appearance. Page 40 shows photos of him at 40 years old and 48 years old. At 48 years old, he looks much younger, healthier and more handsome. Cosmetic physicians are astounded when I share this book with them and explain that he’s had no cosmetic procedures done. With over 400 scientific references, the concepts and data presented in this book are very true and tested. Healthy aging is not just for the elite. When can use the benefits of nature to grow younger and healthier naturally. Cherniske shows us how we are all able to attain a level of health that is above average, without having to spend outrageous amounts of money on outrageous procedures. His book focuses on the wisdom of nature and science to create health.
For longevity gurus, this book serves as a strong foundation for studying anti-aging medicine. I am particularly grateful for this book as it helped me to understand important concepts in preparation for my American Board of Anti-Aging Medicine exams. The Metabolic Model of Aging is an important concept for us to understand at any age for healthy living. It is a delightful read and great reference. It lists important tests that are needed to assess longevity and health. Read this book now and get 5 more copies to give to friends- they will appreciate it!

Medical Lab Tests

May 1st, 2006

Many people go to their doctors and get a set of lab tests to evaluate risks for heart attack and disease. But the set of tests that physicians order are not all the same, and many risk factors and longevity markers go untested. The book “Medical Tests That Can Save Your Life: 21 tests your doctor won’t order…unless you know to ask” by David Johnson PhD, David Sandmire MD, with Daniel Klein is a great resource for planning a preventive medicine visit to your health care provider. It can serve as a quick reference and is an easy book to read. I highly recommend it. We must all be advocates for our own health and this books helps show us one of the ways to do that.

Some Common Questions About Food Allergy Testing

April 6th, 2006

Food allergies are an important thing to consider, especially in people with abdominal bloating or belly discomfort after they eat. Many people don’t realize how such allergies can be a cause or contributing factor to diarrhea, constipation, abdominal pain, joint aches, fatigue, depression, rashes, or inflammation (AKA inflamm-Aging!) Many people wonder about the value of testing. As a physician, here is my view of this testing.

Q: Will these food allergies always exist? Can I grow out of them?

A: Food allergies may not persist forever. That’s the benefit of rotating the diet. We can actually become allergic to new foods if our diet becomes monotonous on them. That’s why a natural organic highly varied diet is most healthy. The risk of allergies, in general, increases with biological aging. The benefit of slowing or reversing this process allows us to tolerate our environment better. Unfortunately, becoming invincible to foods as allergens is not yet possible!:)(If it was, I’d enjoy eating ice cream on a regular basis, sigh!)

Q: A friend of said I should avoid all the foods I’m allergic to for at least a year. Is that true?
A: A year is a long time to avoid such foods. Kudos to your friend who was able to do that! I recommend avoidance for as long as is possble, knowing that everytime I weaken and eat something I’m allergic to that I have just damaged my gut, increased my inflammatory response, and increased my risk for chronic illness. My personal eating habits are “good” for a while, have a moment of weakness, experience the pain and depression of my chemical mistake, then clean up my diet again. Will I ever learn?!

Q: How often should I test or retest for food allergens?
A: Retesting food allergies is helpful for people that have many allergies and want to monitor improvement or changes. Some people take the data of the first test, correlate it to what they experience when they eat foods that they are allergic to, then use subsequent experiences to guide their diet choices in the future. Also, some people may not be allergic to a food, but they realize that it impairs their health for other reasons, and need to avoid it anyways. This is especially true for patients with blood sugar balance problems. For example, a woman may not be allergic to corn, but if she suffers tremors and headaches a few minutes after eating some, she may suffer hypoglycemia…or a reaction to all the pesticides put on it…but that’s a whole other issue!

Q: Why do people even get food allergies?
A: Our vulnerability to foods as allergens depends on 2 main issues: the health of the gut and the intelligence of the immune system.

Q: Can food alergies be seasonal?
A: Because food allergies depend on gut and immune sytem function, they could be seasonal. For example, the immune system may become more stressed and incompetent during your hayfever season. Your gut may be sicker after you drink alcohol or consume sugar during the holidays.

Q: Are the food allergens listed on the test the only foods I should avoid?
A: Again, even though a food may not appear reactive on the test, listen to your body. Does it feel REALLY good when you eat it? If so, you may be having an allergic or blood sugar reaction to it. Do you feel tired, sad, itchy, irritable or bloated after eating something? If so, it might be an unhealthy reaction to that food. Be a detective. Watch for coincidences and correlations.

I hope this information has been useful. Best wishes in healthy eating!
Dr. Natalie

Hot Pepper Kills Prostate Cancer

March 18th, 2006

U.S. and Japanese researchers have announced results of a study showing that capsaicin, the chemical that makes peppers hot, can cause prostate cancer cells to kill themselves. ‘Capsaicin led 80 percent of human prostate cancer cells growing in mice to commit suicide in a process known as apoptosis, the researchers said.’ This led to tumors one fifth the size of those in untreated mice.

Thoughts about Bulemia

February 25th, 2006

As the new year gets into full swing, some of us are thinking again about the size and shape of our bodies. And for women, it is a common topic of concern. Unfortunately, this is often tied into emotions, and one’s self-image. We humans will hunger for fulfillment of our needs, but will mistakingly choose a different form of “nourishment” than what we really need. Or perhaps we will exchange one form of control in our lives for another. We will use food as our control, instead of addressing the real issue at hand. A study in Tacoma, WA in 1999 demonstrates how common this problem is. Lauder,TD and colleagues examined the eating behaviors of women in the military and found 33.6% at risk for eating disorders, like Bulemia. 8% actually qualified for a full diagnosis of an eating disorder. (Lauder TD, Williams MV, Campbel CS, Davis GD. Abnormal eating behaviors in military women. Med Sci Sports Exerc 1999 Sep;31(9):1265-71.)
The growing awareness for such conditions is reflected in organizations’ missions. A friend/patient of mine recently introduced me to “Pocket Nutrition ,” with a tasty sublingual vitamin B complex spray. I found the dlivery system easy and palatable, and was interested in the company’s mission regarding treating eating disorders. The founder’s daughter suffers from anorexia nervosa. The founder herself had an interesting history of competing in beauty pageants.
The cycles that a person experiences in Bulemia is confusing and frustrating to that person, and those around them. There is a hunger for something…physical and emotional nutrients…that cannot be satified with calories and chewing. And there is a need for control, even if it is ultimately self-destructive. Then there is the guilt, realizing how futile and damaging the binge has been. And then follows unhealthy, unrealistic efforts to undo the previous metabolic damage.
If you think that you may have an eating disorder, I strongly recommend that you seek care with a health care provider who is versed in treating such disorders. This is not something a person can “fix” with help from friends. It is dangerous, physically and emotionally.
For those of you who would just like to find better ways to control the amount of food calories you consume, here are a few hints about human feeding patterns.
1. The brain is non-specific in asking for the nutrients in needs. It is unable to consciously state “I need to eat 2 oysters and an additional selenium supplement of 200mcg today to fulfill my selenium needs for the next 9 hours.” Instead, it just says “I’m hungry!”
So, before meals make sure to consume a nutrious green drink, like Metagreens , so that the appetite is less ravenous. Also, supplement the diet with a good multivitamin, like 30 Day Renewal, and other nutrients as recommended by your health care provider. Even Dr. Nicholas Perricone, a healthy aging expert, points out that chromium helps decrease his appetite. Many people suffer chromium deficiencies, especially if they have a high sugar intake. So think about the need nutrients, not calories.
2. Eat in the company of people that you are VERY attracted to, enough that they make you a little nervous. That love-interest with the great body, gorgeous eyes, and incredible mind is a perfect dinner mate for keeping the calorie consumption to healthier limits. Besides, the love interaction that follows such a meal is more exciting when the lovers are satisfied, but not bogged down by stuffed bellies. Ever wonder why the makers of Viagra and other erection meds recommend not to use it after a heavy meal? It’s because it slows the arousal physiology.
3. Leave the plates and remains of food in your sight at the table to remind you of how much you have consumed.
4. Don’t eat when you are rushed, feeling emotionally stressed, or can not concentrate on the meal before you. I know, it’s easier said than done. In the movie “Kate & Leopold ,” I appreciate that the character of Leopold, played by the gorgeous actor Hugh JacKman, points out that the meal is a compilation of reflection. So please enjoy each meal for what is supposed to be. Make time for it to be special, nutrious, organic and shared.
And if no love-interest is available for tip #2, then just imagine that you are dining with Hugh Jackman!
5. Take control of your life! If you don’t like the situation you are living in, then move out! If your job is driving you crazy, then get a new one. If you are being emotionally or physically abused then seek help. Change your life and you can change your eating habits, because you will respect and love yourself more. And that chemical high or relief that you are seeking from food now, instead will be satisfied by the buzz and mystery of life itself.
Bon Apetit!

Celebrate Valentine’s Day with Soy Isoflavones

February 13th, 2006

Do your heart and that of your lover’s some good with including soy isoflavones in your diet. A heart-shaped block of tofu may seem like an unconventional Valentine, but it promises more health than a powdery sugar confection with the message “Be Mine” inscribed on it.

Give it to Some Bunny you love:
Soy isoflavone diets have been tested on rabbits, with positive results seen in decreasing atherosclerotic plaques. In other words, it helps decrease hardening of the arteries. To create hardening of the arteries, the research bunnies were fed casein, a protein found in cheese and some “nutritional” drinks (yikes!). But some bunnies were also fed 5mg/kg/day of isoflavones with this casein diet. The isoflavone plus casein diet bunnies showed 36% less bad cholesterol (LDL), 36% less aorta wall cholesterol, and twice as much good cholesterol (HDL) than the other group. They also had lower rates of the heat shock proteins related to atherosclerosis. (1) These isoflavones, especially genistein, has been found to protect the cells in the walls of human blood vessels at the DNA level. So the picture of vessel damage is not just about cholesterol levels and deposits. Genistein inhibits and reverses the cell death propcess that the toxic amino acid homocysteine creates. (2) It heals and protects!

Go at it like rabbits!
Nutritional supplements like soy isoflavones, vitamin E, selenium and lycopene can help protect against prostate cancer . (3) Some worry, though, that the hormonal modulation effects of soy isoflavones may interfere with fertility. A metabolite of isoflavones called Equol has the potential to decrease 5 alpha dihydrotestosterone, a very potent form of testosterone. (4) However, a study done in 2004 showed no alteration in male rabbit fertility, even at doses of 5 mg/kg/day. Some of the biochemistry in the rabbit semen even improved, like HDL levels.(5)
So when you want to make your true love a heart-healthy, sex healthy treat this Valentine’s Day, include soy isoflavones like that in tofu, on your holiday menu! Happy Valentine’s Day!

1 Rosier Olimpio Pereira I Saes Parra Abdall D. Soy isoflavones reduce heat shock proteins in experimental atherosclerosis. Eur J Nutr, 2005 Nov 24
2 Fuchs D, et al. Genistein blocks homocysteine-induced alterations in the proteome of human endothelial cells. Proteomics. 2005 Jul;5(11):2808-18
3 Kucuk O. Chemoprevention of prostate cancer. Cancer Metastis Rev2002;21(2):111-24.
4 Lephart ED, et al. ILAR 2004; 45(4):443-54
5 Yousef MI, et al. J Environ Sci Health B. 2004;39(5-6):819-33

Natalie Kather, MD

Bioenergetic Substances: Do you get enough in your diet?

January 28th, 2006

Bioenergetic substances are chemicals that help your cells’ energy production improve in a healthy, non-stressful way. Stimulants, like caffeine and nicotine stress the adrenals and central nervous system, but bioenergetics just help the body’s energy system work better. Inside each cell are many, many power houses called mitochondria. These little factories incinerate fatty acids and turn them into ATP, the currency of biologic energy. Bioenergetics benefit this process by either improving the mechanics of the process, or by providing anti-oxidant protection to the mitochondrial structure.
For example, L-carnitine acts like a worker that stokes the fire by putting or pulling fatty acids into the mitochondrial incinerator. Co Q10 and alpha lipoic acid are important anti-oxidants that protect the incinerator structure from the “rusting” that occurs with this highly oxidative process. The fire of this process is the Kreb’s Cycle. Components of this cycle and processes feeding into it also act as bioenergetics, including magnesium aspartate, potassium aspartate, alpha ketoglutarate, and pyridoxal-5-phosphate (the MOST bioavailable form of vitamin B6).
It’s best to combine the substances that improve the mechanics with those that serve as anti-oxidants so that these energy factories run optimally and also stay in good shape . In other words, protect the Kreb’s cycle with anti-oxidants. So if you’re feeling sluggish, don’t reach for that cafeinated drink, reach for a great bioenergetic supplement instead! Your body will love you for it, and you will have better energy all around in the long run.
This is Dr. Natalie’s personal list of bioenergetics and anti-oxidants that she takes to optimize her energy and health:
acetyl L-carnitine (it helps brain function too! She gets this in her Oasis Life Sciences Ageless Prime.)
pyridoxal-5-phosphate (Oasis Life Sciences Ageless Prime and AgelessXtra)
alpha lipoic acid (Oasis Life Sciences AgelessXtra)
Selenium (Vitaline formulas)
Zinc (Solaray)
Vitamin E ( mixed forms are best, not just alpha tocopherol. Gamma tocopherol is a better choice. Did you know there are at least 8 different forms of vitamin E, including tocopherols and tocotrienols?)
Vitamin C
Magnesium malate
Anti-oxidants from fruits and vegetables (Oasis Life Sciences Metagreens, Metaberry, Aloe Gold and AgelessXtra)
N-acetyl cysteine (detoxifies the brain and liver! Oasis Life Sciences Ageless Prime)
CoQ10, EPA, DHA (purified fish oil Metapower from Oasis Lifsciences)
Bio-identical hormone replenishment (Yep! They are bioenergetics too! Just remember to also include the above substances also because with hormones, the speeds of processes are increased. So what little supply of vitamins, minerals, anti-oxidants, and etc. are there, will get used up even faster.)
Vitamin D (cholecalciferol. It’s actually an anabolic steroid!)
Thyroid hormone
Dehydroepiandrosterone (DHEA)
7-keto DHEA

Bioenergetics are awesome substances, helping the body to function better and become healthier! Include them in your diet everyday!
Best Wishes in Health,
Dr. Natalie