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The four-day event (May 20–23, 2010) provided a wide range of information to an audience of healthcare professionals from 21 different countries. The large international interest may be indicative of a growing global interest in functional medicine and innovative thinking surrounding integrative oncology.

During her presentation, Mary Hardy, MD, medical director for the Simms/Mann–UCLA Center for Integrative Oncology, told the audience that patients with cancer visit the doctor twice as often as other patients. She explained that the primary care physician (PCP) often takes a step back during cancer treatment; however, there is a need for PCPs to step forward and play a more active role with their cancer patients.

Hardy, who was on the development panel for the symposium said, “Our goal was to empower IFM/IM primary care physicians to do the things they already know how to do well. This will give the cancer patient the best blend of conventional and complementary care leading to the best outcomes and least toxicity.”

The focus of the symposium was to view cancer as a chronic disease and then address issues associated with the care and healing from this illness. Some key topics included

• oncogenetic expression;
• genetics, epigenetics, and environment;
• antioxidants;
• confusion about vitamin D;
• diet and lifestyle;
• offsetting side effects of conventional treatments; and
• enhancing conventional treatments via an integrative approach.

This is the first time that the Institute for Functional Medicine tackled the issue of cancer care in one of its symposia. “This conference really brought together some of the best clinical practitioners in integrative oncology,” said Tina Kaczor, ND, FABNO, senior medical editor of the Natural Medicine Journal, who also attended the symposium.

“I was pleased to see that several of my colleagues who are Fellows of the American Board of Naturopathic Oncology— specifically Lise Alschuler, Tim Birdsall, Paul Reilly, and Dan Rubin—were speakers at this event,” said Kaczor. “I think naturopathic oncology has a lot to offer in terms of focusing on the patient and using natural agents that benefit our patients throughout their course of treatment. Our education makes us uniquely positioned to understand and integrate various modalities to improve each patient’s quality of life, as well as affect their risk of recurrence.”

Each morning of the symposium Bland provided a synthesis of the information presented the day before. This snapshot not only added Bland’s perspective to the various topics, it also neatly encapsulated points of interest and appeared to be well received by the audience. “This was the class I wish I had available to me years ago when I was struggling to learn how to support cancer patients,” Hardy concluded.

One of the highlights of the symposium was the presentation of the Linus and Eva Helen Pauling award to Dean Ornish, MD, who was also a presenter at the symposium. “Dean Ornish was the first to see that treating the underlying metabolic and nutritional causes of disease was more powerful than conventional medical and surgical approaches to chronic disease,” explained Mark Hyman, MD, who presented Ornish with the award. “Receiving the 2010 Linus Pauling Award is recognition of his seminal contribution to the field of nutritional and functional medicine.”

The United States Census Bureau projects that between 2000 and 2030 the number of Americans 65 years old or older will double. The aging of our population, combined with many other factors, will likely contribute to a corresponding increase in serious illnesses such as cancer. In fact, it is now estimated that 1 in 2 men and 1 in 3 women will develop cancer in a lifetime. Concurrently, an increasingly high number of individuals are living beyond their prognosis. In 2007, more than 11.7 million people were living with a history of cancer.

Cancer continues to put a strain on our healthcare system, not only in terms of increasing prevalence but also increasing costs per individual. A recent report published online in the journal Cancer indicated that the cost to treat cancer has nearly doubled in the past 20 years.

Additionally, if we remain on this course, the number of people diagnosed with cancer will soon far outweigh the number of oncologists available to treat them. Additionally, if we remain on this course, the number of people diagnosed with cancer will soon far outweigh the number of oncologists available to treat them. Data from Erickson and colleagues published in 2007 pointed to a projected shortage of more than 4,000 oncologists by the year 2020.5 The conclusion based on the data was that “a multi-faceted strategy will be needed to ensure that Americans have access to oncology services in 2020. … Among the options to consider are increasing the number of oncology fellowship positions, increasing use of non-physician clinicians, increasing the role of primary care physicians in the care of patients in remission, and redesigning service delivery.”

Primary care physicians may be able to fill some of the gaps now emerging in cancer care. Primary care physicians can help manage side effects and after effects of conventional treatment, counsel patients on diet, and provide practical lifestyle advice that can enhance survivorship and help prevent a recurrence. As it turns out, the increasing prevalence of cancer as a chronic disease provides an increasing opportunity for the primary care physician. This could also be good news for the patient. For example, preliminary research shows that utilization of primary care in the early phase of lung cancer treatment reduced mortality risk.

The 17th International Symposium on Functional Medicine was designed to engage the primary care community in integrative cancer treatment. In his opening presentation, Jeffrey Bland, PhD, FACN, CNS, who founded the Institute for Functional Medicine with his wife Susan, asked the question “How can we deliver better care to our patients?” To a sell-out crowd of doctors, nurses, and other healthcare professionals, featuring a large number of primary care providers, Bland and the other expert presenters attempted to teach how functional medicine can play a role in cancer care. “We need to look at the soil in which these oncogenes can grow,” says Bland. “For many patients, cancer has become a chronic disease that demands long-term management.”

Study Medication and Dosage
Infants were randomly assigned to receive either L. reuteri DSM 17938 [10(8) CFU] or placebo daily for 3 weeks. Parental questionnaires monitored daily crying time and adverse effects. Stool samples were collected for microbiologic analysis.

Key Findings
Those taking L. reuteri experienced a significant decrease in daily crying time. Stool microbiology revealed an increase in lactobacilli and decrease in Escherichia coli in the treatment group. L. reuteri was well tolerated and no adverse effects were noted.

Breastfeeding may serve as an equally powerful treatment, since it improves the microbial milieu of the gut.

Practice Implications
It is well known in the naturopathic field that probiotics address many gastrointestinal conditions effectively, even as a monotherapy. The same authors conducted a similar study in 2007, which found that a related probiotic strain, L. reuteri ATCC 77530, resulted in a decrease in colic symptoms in 95% of the treatment group vs. 7% in the control group.1 Critics of that study point out that it was unblinded, and controls were treated with simethicone.2 Therefore, blinding both groups in this study and removing interfering medications adds strength and significance. The mechanisms behind probiotics’ benefits are not fully understood. However, there are some clues in the literature: Savino and colleagues state that probiotics may improve gut motility and function and decrease visceral pain. Additionally, other research has shown that altered fecal microflora is found in infants with colic, and those children are found to have elevated levels of calprotectin in their stools. Interestingly calprotectin is a marker of intestinal inflammation and possibly increased intestinal permeability and can serve as a predictor of irritable bowel disease later in life. Breastfeeding may serve as an equally powerful treatment, since it improves the microbial milieu of the gut. This explains why a review of 79 articles shows babies who are breastfed have a decreased risk of irritable bowel disease development later in life. At this time, there is no general consensus on the most effective probiotic strains for the treatment of colic. Additional strains that have shown efficacy in colic include Bifidobacterium lactis and Streptococcus Thermophilus.10 It is quite likely that other strains also have benefit, warranting further research in this area.

Although pain and function were not measured, most participants reported an enhanced relaxation response after treatment.

The cranial therapy was associated with changes in NO levels in exhaled breath. The level of NO increased from 13.3 +/- 2.09 (SD) to 15.0 +/- 2.95 (SD) ppb (P=0.001, based upon the paired t tests of the subjects). The median level of NO before the cranial therapy was 13.0 ppb (ranging from 8 to 17 ppb); after cranial therapy, it was 16.0 ppb (ranging from 6 to 18 ppb).

Although pain and function were not measured, most participants reported an enhanced relaxation response after treatment; the most relaxed participants were those with the highest post-treatment exhaled NO levels.

Practice Implications
This study is the first to explore the physiological effect of cranial therapy on NO production. These finding are significant, especially since we are increasingly learning of the important role that NO plays in various aspects of health. It is also a big step for the cranial community, because despite having a long, rich history and an immense archive of anecdotal evidence, cranial therapy lacks substantial clinical research studies. Currently an explanation of how cranial therapy can produce an increase in exhaled NO levels remains theoretical.

Traditionally, elevated exhaled NO levels have been closely associated with chronic pulmonary conditions such as asthma. This is why it was so vital to choose participants who were qualified as “healthy adults.” Since there were no asthmatic participants, and those with post-treatment elevated levels of NO reported an enhanced relaxation response, I would hypothesize that there is an intimate connection between naturally increasing the body’s ability to produce NO and being able to decrease the devastating effects that stress has on the body. The article also states that this therapy could be a key adjunct in the prevention of coronary artery disease (CAD) and diabetes—both of which damage epithelial lining of blood vessels (indicative of low NO production). When lowered NO levels allow damage to the blood vessels to occur, the endothelium is less able to produce the necessary amount of NO, thus facilitating further endothelial damage. This, over time, can manifest into serious pathological conditions. Given the noninvasive nature of the procedure, this cranial therapy could potentially be an incredible asset to those treating such conditions.

Since the 1990s, NO has been aggressively studied—its relationship to cardiovascular health only discovered in 1998—and it has been found that too little NO, as seen in CAD and diabetic cases, can have a damaging effect, but too much can also be detrimental. In the instance of an excess of NO, further research to examine whether this cranial maneuver may have a modulating effect on NO levels would be interesting, as colleagues in the cranial field have reported positive results with asthmatic patients.

Although this study is small and uncontrolled, which is not typically the type of study highlighted in this column, these findings are relevant to clinical practice. NO is, as we’ve seen, a critical component in maintaining health. In the clinical field, NO and its precursors are being utilized in a variety of ways, ranging from treatment of pulmonary vascular disease in pediatrics, to pain associated with angina, to erectile dysfunction. It’s also becoming a staple for preventative and anti-aging protocols.

We’ve long known that there are noninvasive, effective methods of increasing NO levels, whether through supplementing with arginine or even regular exercise, but until now there has not been a physical modality that has shown a possible systemic increase in NO. These findings also suggest that various healthcare providers and readers of this column may, in addition to their current prevention or treatment protocols, begin to incorporate this type of cranial therapy into their practice.

The dietary supplement world is awaiting some critical guidance regarding new dietary ingredients from the FDA due to arrive by the end of June 2011. In anticipation of this guidance, chatter in the industry has increased, and this has even made the news. An article published in the Salt Lake Tribune on May 1, 2011 focused on this anticipated communication.

One of the provisions that Congress included in the Dietary Supplement Health and Education Act (DSHEA) addresses the safety of new dietary ingredients. This provision gives the FDA the right and responsibility to review new dietary ingredients for safety prior to their being marketed in dietary supplements. “New” is defined as any dietary supplement ingredient that was not marketed in the United States before October 15, 1994. It is the manufacturer’s responsibility to make this determination, and if new, submit a new dietary ingredient (NDI) application to document the safety of the new ingredient. If the FDA does not respond within 75 days after the application is submitted, the manufacturer can introduce the ingredient to the marketplace. It is important to note that a “successful” NDI submission does not mean that FDA has confirmed that the ingredient is safe for its intended use.
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Despite the growth in the number of natural products since 1994, Daniel Fabricant, the director of the FDA’s Division of Dietary Supplement Programs, reported that the FDA has received only 700 new dietary ingredient applications since 1994, out of an estimated 60,000 dietary ingredients in use. One of the reasons for this is that, in the absence of clear guidelines, the industry has been confused about what to submit. The FDA guidance expected by the end of June should clear up this confusion. And that is where the change is likely to start happening.

The requirements to prove safety may be quite onerous for smaller companies.

Depending on the requirements to demonstrate safety, hundreds to thousands of products may in be jeopardy of discontinued sales until their safety is proven. The requirements will also affect the introduction of new ingredients into the marketplace. This includes both advanced technology ingredients and botanical ingredients from other parts of the world (if not marketed for use prior to 1994). The requirements to prove safety may be quite onerous for smaller companies. A somewhat similar situation has recently taken place in the European Union. In the EU, the 7-year transition period set out in the 2004 Herbal Directive (2004/24/EC) has expired. This means that, as of May 1, 2011, only medicinal products that have been registered or authorized can remain on the shelves. A manufacturer who wishes to register a traditional herbal medicinal product must provide documentation showing that the product is safe for its intended uses. They must also provide evidence that the product has been used safely for at least 30 years, 15 of them in the EU. Although this legislation is different than the NDI requirement in the United States, the intent and approach is quite similar. Smaller herbal manufacturers in the EU are already voicing their concerns about their ability to comply with these requirements. This is, in part due to the scope of the documentation necessary to establish safety. Whether the clarified NDI requirements will present a similar challenge to smaller manufacturers in the United States remains to be seen.

Dietary supplement manufacturers are watchful of events in the EU as they await the NDI guidance. The implications to availability, and potentially cost, of affected dietary ingredients are yet to be determined. If a product is found to contain an NDI that does not have an application filed, that product is considered adulterated and will likely be removed from commerce. It’s possible that the FDA could require retailers and healthcare practitioners to pull thousands of products off the shelves as it determines the safety of these new dietary ingredients. This will also trigger remedial action on the part of the manufacturer. Despite the potential implications, most manufacturers are eager for NDI clarification. Ultimately, this guidance is what the industry has been asking for since 1994. Defining these requirements should help manufacturers submit what the FDA requires. This, in turn, will provide greater assurance of safety to dietary supplement users. Getting there may be somewhat painful, but the destination should be worth it.

Study Medication
Subjects received either prunes or psyllium to provide 6 grams per day of fiber for 3 weeks. After a 1-week washout period, therapies were switched.

Outcome Measures
The test subjects maintained a daily symptom and stool diary in which they tracked number of complete spontaneous bowel movements per week, global relief of constipation, stool consistency, straining, tolerability, and taste.

Key Findings
The number of complete spontaneous bowel movements per week (primary outcome measure) and stool consistency scores improved significantly (P<0.05) with dried plums when compared to psyllium.
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Practice Implications
Prunes work. That is, prunes appear to do exactly what everyone has always thought they do; they act as a mild laxative. Although some would think this action is obvious, this study by Attaluri et al may be among the first human clinical trials published in the peer-reviewed literature that demonstrates prunes’ efficacy.

The results of a 2002 clinical trial comparing the effects of prunes versus dried apples on factors that affect bone density “suggest that dried plums may exert positive effects on bone in postmenopausal women.”1 Though the results were favorable, they did not confirm whether prunes act as laxatives.
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Two 2010 studies hinted that prunes might act as stool softeners. Both studies compared eating prunes as a snack against cookies. A June 2010 paper that appeared in the journal Appetite informed us that prunes were more effective than sugar cookies at suppressing hunger and creating a sense of satiety.3 A September 2010 article in the Journal of the American Dietary Association reported that snacking on prunes lowered triglyceride levels more than sugar cookies and mentioned a tendency for prunes to soften stools.

Few experienced practitioners or consumers will view these data as new. Instead most will be surprised that this study had to be done in the first place.

There is another paper involving prunes that is worth noting. Appearing in the Journal of the American College of Nutrition in 2007, a review paper compared the effect of eating prunes against eating berries or other fruits on serum antioxidant capacity (AOC). While data from a series of clinical trials “demonstrated that consumption of certain berries and fruits such as blueberries, mixed grape and kiwifruit “increased plasma AOC,” eating prunes or drinking prune juice did not alter measured levels of antioxidant capacity.

With the publication of the current Attaluri et al study, the use of prunes as a laxative has taken the first step away from being the product of “old wives’ tales” (OWT) toward the realm of evidence based medicine (EBM). Adherents of EBM may now prescribe prunes to patients suffering from constipation with less fear of criticism. It should be pointed out that there are weaknesses to this current study: It was single not double-blinded, participants were overwhelmingly female, little is known regarding the etiology of participants’ constipation, and obviously, one study is far from conclusive.

This new advancement in medicine does have an element of the absurd to it. Few experienced practitioners or consumers will view these data as new. Instead most will be surprised that this study had to be done in the first place; the action of prunes on the human digestive tract is self-evident.

The attraction that many us have to EBM, and our resultant desire to find support for therapies in published studies, meta-analyses, or—the Holy Grail of all papers—the Cochrane Reviews, on the surface seems both reasonable and commendable but may become an obstruction to achieving best patient outcomes.

Until now, the evidence suggested we employ psyllium seed fiber as it is more efficacious than sodium docusate.6 Yet practitioners who rely on anecdote, commonsense, and the data obtained via OWT have been using prunes to soften and increase stool frequency all along.

This story about prunes brings to mind how my colleague Steve Austin, ND, when writing years ago about breast cancer, pointed out the distinction between type 1 and type 2 errors in statistics and how different medical professions put greater emphasis on preventing one form of error over the other. For a medical oncologist who prescribes chemotherapy, the demand is to be sure the drugs will have benefit against the cancer. One needs to be certain the drugs will bring benefit as the side effects are so great.7 For naturopathic doctors who employ nontoxic therapies, in this case prunes, the demands should be the opposite. If there is a chance a therapy may help, then we should be interested in trying it: the classic ‘it won’t hurt and it might help’ view of practice.

As for prunes, however, we can now prescribe them with confidence; they have officially graduated from unproven OWT to the trustworthy EBM.

Participants
Ten patients undergoing “fecal bacteriotherapy,” or what in the United States is often termed “fecal transplantation.” In this process the bowel is cleansed with antibiotics and then fecal suspensions from healthy donors are administered daily. In this study the first infusion was administered through a colonoscpe and subsequent doses were given over a 60-minute period through a nasal jejunal tube or via enemas. Bowel flora was analyzed at 4, 8, and 24 weeks post-initial infusion and compared with the initial infused donor fecal suspension to determine whether the donor flora had become a stable microbiota of the feces.
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Key Findings
At each of the post-infusion intervals in which sample were evaluated, “the bacterial populations in the patients’ fecal samples consisted predominantly of bacteria derived from the healthy donor samples. … This is a landmark study and suggests that the manipulation of the colonic microbiota is effective and holds promise for new therapies in the treatment of colonic or metabolic disease.”

Fecal transplantation is not a new. Case reports describing this technique date back at least to the late 1950s. A report by Eiseman el al published in 1958 is credited as the first to describe using fecal enemas, in this case for treatment of pseudomembranous enterocolitis.

This is a landmark study and suggests that the manipulation of the colonic microbiota is effective and holds promise for new therapies in the treatment of colonic or metabolic disease.

Since that time there have been a number of reports using donor stool delivered both rectally or via nasogastric tubes. Most of these reports focus on treating recalcitrant Clostridium difficile infection.

Two other reports on fecal transplantation were published in the same September issue of the Journal of Clinical Gastroenterology as the Grehan et al study. They are of almost equal significance as Grehan’s study and deserve specific mention.

In one, Yoon et al from Montefiore Medical Center in the Bronx reports on 12 cases of C. difficile successfully treated using donor feces transplanted into the colon through colonoscopy. The second paper by Rohlke et al reports on 19 patients again with C. difficile treated with fecal transplantation delivered via colonoscopes. The treatment was successful in all 19 patients treated, and the patients remained disease-free on follow-up of 6 months to 4 years.

This therapy may be beneficial for treating other types disease besides gastroenteritis.

Borody et al reported striking results in a small trial using fecal transplantation therapy to treat ulcerative colitis (UC) in 2003. They treated 6 patients with “severe, recurrent symptoms and UC had been confirmed on colonoscopy and histology.” Utilizing “retention enemas … repeated daily for 5 days, complete reversal of symptoms was achieved in all patients by 4 months … by which time all other UC medications had been ceased. At 1 to 13 years …, there was no clinical, colonoscopic, or histologic evidence of UC in any patient.”

Borody is currently recruiting participants for a trial using fecal transplants to treat patients with Parkinson’s disease.12

At a conference in September 2010, Anne Vrieze and colleagues described the results after transplanting fecal flora from lean donors into patients with metabolic syndrome. Their study was a double-blind, randomized, controlled trial. Starting with 18 male subjects with newly diagnosed metabolic syndrome, half received fecal material from lean male donors and half were implanted with their own feces to serve as controls. At the conclusion of the study, fasting triglyceride levels in those subjects who received donor feces were significantly reduced. No effect was seen in the control group re-instilled with their own feces. Peripheral and hepatic insulin sensitivity significantly improved after 6 weeks in the experimental group but not in the control group.

Current knowledge suggests that the intestinal community of bacterial flora contains at least 1 x 1014 bacteria made up of from 500 to 1,000 different species of anaerobic bacteria.14 Clearly our current methodology of testing these using agar culture media to identify only a handful of species and treating with several limited strains of ‘probiotics’ may be too simple an approach to achieve lasting benefit. Fecal transplantation, although sounding to be primitive, may in fact be a more sophisticated option and have the ability to duplicate a healthy bowel ecosystem in the unwell. As unappealing as it may sound, this may prove to be a useful therapy in coming years.

Interactions
Most herbs and supplements have not been thoroughly tested for interactions with other herbs, supplements, drugs, or foods. The interactions listed below are based on reports in scientific publications, laboratory experiments, or traditional use. You should always read product labels. If you have a medical condition, or are taking other drugs, herbs, or supplements, you should speak with a qualified healthcare provider before starting a new therapy.

Interactions with Drugs

Interactions with Herbs and Dietary Supplements

Safety
The U.S. Food and Drug Administration does not strictly regulate herbs and supplements. There is no guarantee of strength, purity or safety of products, and effects may vary. You should always read product labels. If you have a medical condition, or are taking other drugs, herbs, or supplements, you should speak with a qualified healthcare provider before starting a new therapy. Consult a healthcare provider immediately if you experience side effects.

Allergies
Since glucosamine can be made from the shells of shrimp, crab, and other shellfish, people with shellfish allergy or iodine hypersensitivity may have an allergic reaction to glucosamine products. However, some research suggests that there is not enough shrimp allergen in glucosamine supplements to trigger reactions in patients who are allergic to shrimp. Nevertheless, caution is warranted. A serious hypersensitivity reaction including throat swelling has been reported with glucosamine sulfate. There are reported cases suggesting a link between glucosamine/chondroitin products and asthma exacerbations.
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Side Effects and Warnings
In most human studies, glucosamine sulfate has been well tolerated for 30 to 90 days.
Side effects may include upset stomach, drowsiness, insomnia, headache, skin reactions, sun sensitivity, and nail toughening. There are rare reports of abdominal pain, loss of appetite, vomiting, nausea, flatulence (gas), constipation, heartburn, and diarrhea. Based on several human cases, temporary increases in blood pressure and heart rate, as well as palpitations, may occur with glucosamine/chondroitin products. Based on animal research, glucosamine theoretically may increase the risk for eye cataract formation.
It remains unclear if glucosamine alters blood sugar levels. Several human studies suggest that glucosamine taken by mouth has no effects on blood sugar, while other research reports mixed effects on insulin. When glucosamine is injected, it appears to cause insulin resistance and endothelial dysfunction. Preliminary studies show no effect on mean hemoglobin A1c concentrations in patients with type 2 diabetes mellitus. Caution is advised in patients with diabetes or hypoglycemia and in those taking drugs, herbs, or supplements that affect blood sugar. Serum glucose levels may need to be monitored by a healthcare provider and medication adjustments may be necessary.
In theory glucosamine may increase the risk of bleeding. Caution is advised in patients with bleeding disorders or taking drugs that may increase the risk of bleeding. Dosing adjustments may be necessary.
In several human cases, abnormally high amounts of protein were found in the urine of patients receiving glucosamine/chondroitin products. The clinical meaning of this is unclear. Glucosamine is removed from the body mainly in the urine, and elimination of glucosamine from the body is delayed in people with reduced kidney function. Acute interstitial nephritis, a condition that causes the kidneys to become swollen and possibly dysfunctional, has been reported in a patient taking glucosamine. Increased blood levels of creatine phosphokinase may occur with glucosamine/chondroitin, which may be due to impurities in some products. This may alter certain laboratory tests measured by healthcare providers.
Early data suggest that glucosamine may modulate the immune system, although the clinical relevance of this is not clear.
One patient developed liver inflammation (acute cholestatic hepatitis) after taking glucosamine forte.

Pregnancy and Breastfeeding
Glucosamine is not recommended during pregnancy or breastfeeding due to lack of scientific evidence.

Tradition/Theory
The below uses are based on tradition, scientific theories, or limited research. They often have not been thoroughly tested in humans, and safety and effectiveness have not always been proven. Some of these conditions are potentially serious, and should be evaluated by a qualified healthcare provider. There may be other proposed uses that are not listed below.
AIDS, athletic injuries, back pain, bleeding esophageal varices (blood vessels in the esophagus), cancer, congestive heart failure, depression, fibromyalgia, kidney stones, migraine headache, immunosuppression, osteoporosis, pain, psoriasis, skin rejuvenation, spondylosis deformans (growth of bony spurs on the spine), topical hypopigmenting agent (combination product containing multiple ingredients), wound healing
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Dosing
The below doses are based on scientific research, publications, traditional use, or expert opinion. Many herbs and supplements have not been thoroughly tested, and safety and effectiveness may not be proven. Brands may be made differently, with variable ingredients, even within the same brand. The below doses may not apply to all products. You should read product labels, and discuss doses with a qualified healthcare provider before starting therapy.

Adults (18 years and older)
In most available studies, 500 milligrams of glucosamine sulfate has been taken by mouth as tablets or capsules three times daily for 30 to 90 days. Once daily dosing as 1.5 grams (1,500 milligrams) has also been used. Limited research has used 1,500 milligrams daily as a crystalline powder for oral solution or 500 milligrams of glucosamine hydrochloride three times daily. Dosing of 20 milligrams per kilogram of body weight daily has also been recommended in some publications. One study used a dose of 2,000 milligrams per day for 12 weeks.
Another kind of glucosamine that has been used is a topical form in combination with chondroitin for a four-week period. Safety and effectiveness of these formulations are not clearly proven.
Glucosamine hydrochloride provides more glucosamine than glucosamine sulfate, although this difference likely does not matter when products are prepared to provide a total of 500 milligrams of glucosamine per tablet.
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Children (younger than 18 years)
There is not enough scientific evidence to recommend the use of glucosamine in children.
Research in children has shown that there could be a relationship between the ingestion of MSM (methylsulfonylmethane) and autism; whether it is beneficial or harmful is unclear. MSM is often marketed with glucosamine as a dietary supplement and at this time should be avoided in children.

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