An Interesting Theory of How We Become and Stay Overweight

An Interesting Theory of How We Become and Stay Overweight

Researchers have long been curious- how does significant weight gain happen?

Most theories propose that the key mechanism is that intake of energy (i.e., calories via food) exceeds output of energy (metabolic rate, exercise).   That is, if you need say about 2000 calories a day to meet all your internal and exercise related energy needs, and you eat 2500 calories a day, you will gain enough extra weight over time to cause severe obesity.

An interesting fact:  A calorie really is a unit of energy.   In fact, it is the amount of energy to raise 1 kilogram (about a quart) of water, 1 degree Celsius.

One observation made many years ago, but seems to be still held as true, is that the average excess intake of calories needed to reach obesity is surprisingly small.  It only takes 2% over your needs for 10 years to add 100 extra pounds.  Using the model of 2000 calories a day for someone, that person would only need to take in an average of 2040 calories a day, for 10 years, to gain 100 extra pounds in 10 years!

The New Observation

The new look at this issue puts more of the blame on insulin- and its great trigger, sugar and starch.
Insulin is a hormone that has many effects, a major one is to store energy.  Whenever you eat more than you need, insulin is produced to help store the extra fuel for later use.

Now, if I boosted my insulin level over where it needed to be, much of the fuel circulating in my body would suddenly be placed in storage.  At that point, my body would suddenly miss its fuel, and my brain would start screaming for more fuel, I would suddenly become wildly hungry, even with plenty of energy and fuel at hand, in storage.

Of course, most people, even those with diabetes, never give ourselves extra insulin beyond what we need.
But there is something any of us can do, and most of us do so frequently, to give ourselves a big jump in insulin levels:  eat sugar or starch.  Starch turns out to be a long string of sugar, and once eaten, becomes sugar.   Whenever we eat sugar or simple carbohydrates, insulin levels are raised.

So, when we eat candy, pretzels, bleached flour bread, cookies, chips, crackers, etc. we boost insulin, fuel gets stored, and appetite soars.  It is this last step that creates a serious urge to eat that then causes the obesity.  If the urge to eat is slaked by sugar or starch, storage is promoted leading to even more obesity.

Bottom Line
Eating more than you need is still a bedrock cause of obesity, but these new observations add another caveat:  not all foods cause obesity equally- cookies, crackers, chips, pretzels, and candy trigger the insulin cycle- increasing obesity and appetite.

Dr. Lavin

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*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

Pregnancy, Cravings, and Aversions

Pregnancy, Cravings, and Aversions

Food and pregnancy have a powerful and complicated relationship.  Obviously one of the key goals of pregnancy is for Mom to deliver nutrient to the baby-to-be.  

So it is curious that so many odd events happen to the pregnant woman's appetite.  Cravings for items that don't help, aversions to foods that are helpful, and of course the bane of nausea and vomiting all seem to block an easy approach to eating well for the baby.   What are the cravings and aversions about?

First of all, they are very common.  Both cravings and aversions occur in about 50-80% of all pregnancies.

Some say the most common craving is for ice, but many studies document the top craved foods are strong tasting foods (sour, savory, sweet), ice cream, fruit, and milk.   

Common aversions include coffee, fish, meat, and fatty foods.

Curiously, some reports suggest that aversions often follow bouts of vomiting, and the food that one avoids simply is the one associated with a heavy bout of vomiting.

Vomiting itself varies widely from population to population with some groups in rural Africa only seeing about 3% rates of nausea and/or vomiting.  Whereas, more developed societies such as the US see rates for both of about 20%.

Pregnant women also tend to have very sensitive sensory function.   They notice nearly any stimulus more easily and so many sensations are more irritating, particularly odors.

Many have wondered, why does pregnancy cause nausea and vomiting?  What causes the cravings and aversions?

Turns out we still do not know.  A popular theory is that the nausea and vomiting and aversions protect the growing embryo and fetus from toxins in foods, but no proof has been found for this idea.  In fact, some studies suggest it is not so.

Perhaps the most intriguing observation we saw was that many babies whose mothers had the most severe nausea and vomiting were more drawn to salty fluids at age 12 weeks than other babies.

We may not know why, but pregnancy clearly alters our sensory functions, heightens reactivities, causes lots of nausea and vomiting, and cravings and aversions still happen.

We wish all those pregnant an easy gestation and hope all these sensory phenomona are gentle to you.

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*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

Baby acne

Baby Acne

Nearly every baby born develops a rash on their face.

But not all newborn facial bumps are acne.

Baby acne is just what is sounds like- red round bumps that look like and are pimples that can come to a white head filled with pus.  

But as noted, there are many causes for facial rashes at birth.  It could be the result of reactions to foods, clothes, air even.  And those reactions could be mild red bumps or more inflamed skin that gets coarse and cracks- suggesting eczema.  Or rashes can occur for no known reason, which is a common problem as nearly all infants get facial rashes.

If it is acne, no treatment is necessary.

If it is eczema, use of vaseline or other mild treatments are helpful if the rash is severe enough to require intervention.

Bottom Line

Nearly all baby's develop some rash on their face not long after birth.  Acne does occur, but most rashes are not acne, but rather, reflect mild inflammations, reactions, eczema, or are simply just non-specific bumps.  

Most facial rashes in newborns require no treatment.  Occasionally some mild treatment is indicated.  But baby acne typically requires no interventions.

Dr. Arthur Lavin

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*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

The Path to Development- Each is Unique Knowing when to Worry (and When Not to Worry)

The Path to Development- Each is Unique

Knowing when to Worry (and When Not to Worry)

This note is about the timing of development.  Most guides for parents about development focus on the average age at which a skill is developed.  A sequence is presented, and if your infant does not attain each skill around the average age, one has to worry.  The picture presented is that development should be a smooth process, and about the same from child to child.  The implication is that anyone gaining a skill after the average age, something might be wrong.

There are profound problems with this approach to thinking about the timing of how your child develops. The biggest problem with this perspective is that it doesn't even come close to presenting what actually happens.

When we look at any individual, we see peculiarities and unique qualities to how he or she proceeds along development.  Everyone takes a slightly, or even dramatically, different approach to learning to and actually smiling, sitting, walking, and talking.  Perhaps the greatest variation is obvious in the developmental tasks of walking and talking.

Some kids go from sitting to walking in one gulp.  They suddenly get up and walk around.  More commonly, other kids will slowly reach for standing, pulling oneself up to standing, then walk holding on to furniture (cruising), let go and stand alone, then take some tentative steps, all before getting up and running around.  Still others may get to the cruising stage and then stop progressing, for a long time, finally walking freely months after starting to cruise.  Some may rush to one stage along this walking sequence, take a long time to reach the next stage, then rush again to the next.  And these variations are all in kids who turn out to walk just fine.

So, several important points to make:

1. Variety is good not bad.  Variations in how one approaches gaining a skill almost never indicate the skill will be less than excellent.  The child who rushes to walk and the one who gets their in fits and starts both will end up walking quite well over their lifetimes.
2. Timing is a poor predictor of quality.  When a skill begins in development, within a range, does not predict how well the skill will be done in life.  I often say, when a light switch is thrown on does not predict how bright the bulb will be. Development reflects physical changes in the brain that are like software being installed.  When you install the software has no bearing on how well the program will run.  So, a child who begins to learn to walk at age 9 months and a child who begins to learn at walk at 15 months both will very likely walk well the rest of their lives, and likely will have similar athletic prowess.
3. Range tops average.  The average age of learning to walk on your own is 13 months old.  The range, however, is roughly 8-18 months.   That means that if you looked at 100,000 newborns and noted down the ages at which became able to take first steps alone, the average age for the group would be 13 months old, but the range, for kids who ended up walking very normally, would be about 8-18 months old.  That is, the first kid to walk probably did so no earlier than 8 months of age, and nearly everyone was walking by age 18 months old.  If you really believe the first two points, then you would have to agree, it make no difference is one attains normal walking abilities at 9 months old, 12 months old, or 15 months old.   This point is really saying, how you get there is not as important as getting there.  The choice of approaching learning to walk with caution or abandon, at a younger or older age, simply has no impact on if you will learn to walk, and walk well.  This is important.
4. Half of all people are not delayed.  When one relies solely on the average age at which a skill is attained, suddenly half of all people have a problem.  By definition, for any skill, half of all healthy and skilled people attain that skill after the average age.   If the average age of learning to sit alone is 7 months old, half of all infants will develop the ability to sit at or after the age of 7 months old.  If we define normal as having the skill by the average age, half of all people will be abnormal.  This is a silly idea.  If half of all healthy and normally developing infants and toddlers gain a skill after the average age, it would  be wrong to designate the half that does a good job after the average age as delayed.
5. The greatest variability in any skill is the average age most kids attain it.  This is actually a simple, but powerful insight.  Consider the skill of walking.  No one can walk when only 2 months old.  Every healthy child can walk by age 2 years old and up.  So all kids are about the same when it comes to whether they can walk much prior to and after the time they learn to do so.  A thousand 2 month olds all walk the same way- they don't.  And, a thousand 4  year olds all share the fact they walk.   But around 13 months of age, a thousand toddlers could have 1,000 different stories of how they are coming along.

So, How to Know When to Worry, and Not to Worry

The two big questions in development are:

• What can I do to help my child's development come out as well as possible?
• When should I worry, what signs suggest something is wrong and we should intervene.

When to Worry

Let's start by noting what any worry would be about.  Development is worrisome when something suggests that an important set of skills isn't turning out right.  In infancy and early childhood, the key set of skills we want all our children to be very good at are mainly related to walking and talking, although often we get questions about concerns about teething being late, too.

A key point here is that there is a world of difference between someone starting to do something later on, and not being able to do that skill over time.   Consider the 15 month old who is standing on her own, but not yet walking.  Let's say somehow we knew that when she will turn out to walk wonderfully all her life, starting at 17 months old, and will go on to be a star athlete.  If we knew that, we would say there is nothing to worry about in her current timing of walking.  Yes, she is starting to walk later than the average age toddlers do, but she is going to walk, run, and jump very well.

On the other hand, let's say that we somehow know that this 15 month old girl will go on to struggle to walk, a real problem in motor control emerges over time.  In that case, if we knew that, we would institute physical therapy to optimize walking abilities at the earliest age possible.

The challenge is that we don't know at age 15 months how someone will be later in life.  So we have to make decisions based on best guesses.  If our best guess is that no problems are likely to emerge, we would of course not intervene, but if our best guess is that the skill is not going to emerge normally, we do intervene.

Here are key approaches to knowing that something is wrong:

1. Loss of a skill.  Any child who over time shows less ability to do a major skill, such as walking or talking, needs to be evaluated and seen.
2. No progress.  Once someone starts adding skills, that process should be evident every few weeks or months.  The child who is not walking at 15 months old is less worrisome if he has developed towards that goal from 12-15 months old.  For example, if he started pulling himself to standing at 12 months, cruising at 13 months, and standing alone at 14 months, chances are he'll be walking soon.   If however, he pulled to standing at 12 months, and then nothing new has developed for 3 months, that is of concern.
3. A current sign of illness or abnormality.  No matter when in development, if one sees your child actually suffer a problem or symptom of concern it's time to look further.  If one has a young child who is not yet talking, concerns become immediate if they have other symptoms such as avoiding interaction and eye contact to a severe degree.  The child who is not walking at 14 months old becomes worrisome as soon as a limp is noted.
4. At some point, not able to do a skill after too much time has passed.  Keeping in mind that each person's path to development varies, so the marker of time that means anything should not be the average, but really some point in time where about 95% of kids have attained that skill.  That turns out to be a point in time known for every developmental stage.  For walking that age is 18 months old, for speaking phrases that is about 24 months of age.
5. Making good progress from month to month is reassuring, losing progress is very unusual and of concern.

BOTTOM LINES

1. Not just most, but a vast majority of children develop normally.
2. Every person has their own path and trajectory of development, there is no single normal pathway.  Each path is as unique as each snowflake.
3. The average age for achieving a skill in development is not a helpful guide to knowing when someone should do so.  
4. A much better guide is the range.  That would be the earliest age we see children developing that skill, and the age by which 95% of children have the skill.
5. When a child starts having a new skill does not predict how well a person will do that skill.
6. When looking at your child's development, it is reasonable to start from the expectation that all will proceed normally, and wait to see signs as noted above of concern, before launching interventions.

Dr. Arthur Lavin

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*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

The Brain's Progress in Development

The Brain's Progress in Development

The changes in what an infant can physically do, the course of motor development in early life, is a source of constant and profound amazement.  We all begin life unable to walk, talk, grab,or even smile.  But, within a few short months, our newborns learn to smile, grab, sit, and walk.  Unless some neurologic problem intervenes, every baby born goes through this sequence, in that order, and all in less than a year and half.

In this note, we take a look at that sequence- smile, grab, sit, and walk- and see what the fact this is the order implies.  

One of the striking aspects of that sequence is that it goes from the top of the baby to the bottom of the baby's body.  Smiling takes place only on the face, walking requires the feet.  It goes literally from head to toe.  Why is that?

This move from head to toe reveals that gaining these new skills reflects an astounding sequence in which the cerebral cortex takes over the functioning of the body's muscles.   The cerebral cortex is a thin layer of nerves, about six business cards thick, that manage all the motions, thoughts, and feelings of our lives.  It contains about 100 billion neurons or nerves, each connected to about 10,000 others.  At birth, none of the muscles of the body are connected or controlled by this thin sheet of neurons.  We say none of the muscles are under cortical control.

Cortical control involves special sheathing of the nerves of the cortex to take place so that information moves rapidly enough for control and ease of management to occur.  Those sheaths are made of myelin, and the process of myelin being laid down is called myelination.  Once sheathed, the nerve signal shoots down the nerve many times faster, and once information flashes more quickly, more complicated actions become possible, like walking.

And so, the reason development goes from head to toe is that myelination physically proceeds from head to toe.   One can trace the progress just by looking at your baby.   When the cortex gets control of the muscles of the face, complex facial gestures in response to complex events begin to occur- that is, your newborn can now smile playfully and with love.   As the cortex gains controls of the muscles of the shoulders, arms and hands you can grab purposively.   With cortical control of the back muscles comes sitting, and of the legs and feet, walking.

Two developmental steps not mentioned are also part of this sequence, but not always:  rolling over and crawling.   Rolling over involves shoulder and back muscles and always happens, when it does, after smiling, around the time of grabbing, around 3-4 months of age.  A fairly large number of babies never roll over, maybe as many as 1/4-1/3.  Skipping rolling over causes no harm and is not associated with any later trouble with development.  It truly is an elective, not a required course.

The other elective step is crawling.  More infants crawl than roll over, but not everyone.  In the case of crawling, it is most often skipped in the context of an infant choosing to walk rather than crawl.  Again, skipping crawling causes no harm, and is not associated with any later trouble with development.  It truly is an elective, not a required course, too.   When it does take place, it also is always part of the head to toe sequence of motor development.  It always comes after sitting and before walking, and involves cortical control of the leg muscles.

One more note on the electives, rolling over and crawling.  There is a false idea that remains oddly popular about development.  That is, rolling over and crawling are not elective, they are required, and if they are skipped that can cause serious malfunctions later in life.  It has been proposed that if either are skipped, children will be left with impaired thinking and social skills.   And, further, that if one forces the child later in life to replay the developmental sequence, this time with rolling over and crawling, they will recover their impaired functions.  None of this is true.  Skipping rolling over and/or crawling, as already noted, has no impact on anyone.  Forcing someone to crawl when they do not want to offers no benefit, only anger.

So as we watch our newborns develop the incredible abilities to smile, grab, sit, and walk, enjoy knowing that we are watching our babies' brains develop, their cortical wiring getting upgraded.  Most incredibly, we are watching our babies' imaginative cortical mind take over the operations of their muscles.  From that point on, our muscles now reflect the imagination, purpose, and potential of our minds.


Dr. Arthur Lavin

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*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

Time to Stop Using Codeine, Really

Time to Stop Using Codeine, Really

We just received the May issue of Pediatrics, the top journal in pediatric medicine, and Dr. Alan Woolf, who is one of our nation's most respected authorities on the impact of drugs in children, published a definitive statement against using codeine to treat coughing.

http://pediatrics.aappublications.org/content/133/5/e1354.full.pdf+html?nfstatus=200&nftoken=8b07d062-ad2b-4f1f-ba88-218c6b251ad1&nfstatusdescription=SUCCESS%3a+Login+worked

Dr. Woolfe presents two reasons:

1.  Codeine does not work for coughs.   It does not reduce the severity or duration of coughs.  Plain English:  it does not work.

2.  Codeine can cause very serious side effects.  About 29% of people metabolize codeine so rapidly they are at risk for sudden jumps in opiate levels that can stop breathing and cause other dangerous hazards.

Many people who take codeine can experience severe nausea and allergic reactions as well.  About 2000 children in 2011 suffered toxic ingestions from codeine and codeine-containing products.   Plain English: it is not safe.

Dr. Woolfe notes that at Boston Children's, codeine containing products are now no longer available.  

That makes sense to us.  Why use a drug that does not work and can cause real harm?

Our answer is, we shouldn't.

We frequently get calls asking for something that can at least reduce a cough.  We sympathize. Cough is one of the most terrible experiences a healthy child can have.

And, for many decades, it has been assumed that codeine is a powerful anti-cough medication.  When a cough is keeping someone up at night, or terribly miserable, doctors,  including us, have turned to codeine, or tylenol with codeine, as the powerful drug to stop the cough.

As we have been noting for several years, it turns out codeine does not work.

Now a leading expert has published his call to stop using it.   We agree.

Of course, the decision to no longer using codeine because it does not work and it can cause harm, makes sense no matter how bad the cough is.

To good health,

Dr. Lavin

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*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

Measles, an Unnecessary Hazard

Measles, an Unnecessary Hazard

Measles once was an infection nearly every child experienced.   It was so universal that no one gave it much thought.   But it carried a terrible risk, that is a complication called SSPE (Subacute Sclerosing PanEncephalitis).  SSPE is a rare complication to measles, but devastating as it leaves the brain essentially no longer able to function.  Worldwide, measles is actually a dangerous illness as we see about 5% of all childhood death in the world the result of measles.

And so it is with some sadness that we are seeing the re-emergence of measles in our children.  A full outbreak has been reported and documented in New York City, and several cases are now appearing to be emerging right here in Northeast Ohio.  Two cases in Parma and one in Hudson have presented appearing like measles, actual confirmation is pending.

The good news is that any child in Northeast Ohio has the opportunity to never get sick with measles.  All it takes is immunization with the MMR.  One MMR gives a person about a 95% chance of being immune to measles.  Two MMR's at least one month apart gives a person over 95% chance of being immune to measles.  If every person had two MMR's, then measles would not be in our community.

The sadness comes when we think about the child who got measles and suffered a serious complication, knowing that such tragedies are completely preventable, and therefore, unnecessary.

We are all aware that we live in a time in history when the idea of not giving or delaying or spreading out the provision of protection against serious infectious diseases has been very popular, and caught the imagination.

Immunizations have generated a lot of concern and even suspicion.

Witnessing outbreaks of measles in the United States is a sharp reality check that there can be a price paid for popular ideas that have little basis in fact.   

There is lots of controversy and question surrounding immunizations these days, but the one fact that keeps coming up is that if a community decides to withhold or delay protection for a particular infection, it will come back and hurt someone.

Of course, we continue to respect the family's right to choose which therapies their child receives and welcome any discussion on the issues surrounding immunization.

We do want to add a note of urgency to all those considering not giving the MMR, measles is in our community now, not immunizing for measles does carry a very real risk.  Measles can be a very sad disease.

Dr. Lavin 

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*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

Heads, Helmets, Outcomes

Heads, Helmets, and Outcomes:

Do Helments help Make Infants' Flat Heads Round?

On May 1, 2014, the British Medical Journal published a study of the use of helmets in 6 month old infants whose heads had flattened in back, to see if use of the helmets led to rounder heads by age 2 years. 

http://www.bmj.com/content/348/bmj.g2741

The issue is that as we are dropping the rate of SIDS by having our infants sleep on their back, we are all also seeing many more infants develop some flattening on the back of their heads.  This flattening usually peaks at 6 months of age, since later on infants sit up and spend much less time flat on their back.

For many families, the flattening raises concerns and the use of a computer designed helmet fitted to take the pressure off the back of the head and promote rounder symmetrical head growth has been received as a welcome option for treatment, particularly when the flattening gets severe enough to bend the face.

This is purportedly the first study to look at how helmets did compared to no helmets.  The study was done at an excellent center in Seattle.  A total of 84 infants at age 6 months joined the study.  All had similar degrees of head flattening.  An equal number, 42, had helmet therapy for two years, at 23 hours a day, and has no therapy.  At the end of the study period, examiners who did not know who got a helmet for 2 years and who did not took a look and tried to pick out who had been treated.

The dramatic result was that the 42 children who had helmet therapy had no rounder heads than the 42 who had no treatment.

In this study, the use of helmets offered no benefit over the natural rounding of the head from simply growing.

A nice review is contained in a NY Times article on the publication.  http://well.blogs.nytimes.com/2014/05/01/helmets-do-little-to-help-moderate-infant-skull-flattening-study-finds/?ref=health

You will note that doctors are taking these findings seriously, many are surprised, but they do not dismiss the study.  Curiously, the manufacturers of the helmets dismiss the findings.

My own take on the study is that it presents powerful evidence that the use of computer-modeled helmets to reverse head flattening in infancy does not work for mild to moderate flattening.  The study has little to say about very severe deformities.  Very severe deformities are defined as severe flattening to a point the head shape is altered severely in the face.

Bottom Line

A study with a good control group finds that use of helmets to reverse mild to moderate flattening of the head has no impact on ultimate outcome.   This finding argues against the use of such helmets when the flattening is mild or moderate.  It does not have much to say about severe deformations.

It looks like sleeping on your back will flatten the back of your head, but after 6 months of age it naturally gets rounder.  Not bad news as we drop the risk of SIDS.

Dr. Arthur Lavin

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*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.