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How many times a day do you hear “I should…” statements run through your head? Everyone always wants to tell us what we “should” and “shouldn’t” be doing in literally every area of our life.
Our moms, our relatives, our friends, our co-workers, complete strangers, our health-care providers, the media…
What we should do with our life, what we should weigh, what we should eat, how we should raise our kids, how we should look, who we should be, what we should know, how we should take care of ourselves, what skills we should have, how we should age, how we should dress, how we should do our hair or our make-up, what things we should care about in life, how we should have sex or “please our men”, how we should decorate our house, what we should read, what we should think, how we should act…
We get programmed by outside influences to believe all these things we “should” be doing and then we obsessively remunerate over them — usually while flogging ourselves because we haven’t or don’t.
There’s literally a “women should” piece of advice for EVERY single aspect of our lives, they usually differ depending on who you talk to and we often we tend to carry way too many of them with us every day, as though constantly reminding ourselves is going to make us do them.
Then, we judge ourselves accordingly based on how we think we’re measuring up – or not. Usually not.
And we wonder why we walk around with guilt, shame, anxiety, depression & obsessed with food every day?
“Should statements” are all of those things you’re telling yourself you “should” be doing every day — but don’t.
They’re one of many cognitive distortions (or negative thinking patterns) that contribute to stress, fear, worry, guilt and shame.
“I should be eating better and losing weight and I can’t ever stop reminding myself of that every single day until I die — because then I’ll never do it.” “Ugh, the house is such a mess, I should be cleaning it. What’s wrong with me? Why I can’t I just make myself get up and clean the stupid bathroom?”
“I’ve been so busy lately, I haven’t spent enough time with the kids. I should be doing more with them. I’m the worst mother.”
The next time you hear an “I should” thought run through your head or statement come out of your mouth, stop.
Notice what happens next. How do you feel about yourself in those moments? Empowered, happy and good? Or hopeless, helpless and bad?
And do you immediately follow that statement and those feelings by doing that thing you’re telling yourself you “should” be doing? Or not? See, the reason they’re problematic is they almost never result in more positive choices or the outcomes we want.
Rather, they make us feel badly about ourselves and often more hopeless about actually being able to do that thing we’re telling ourselves we “should” be doing.
“I should be eating that…” usually results in NOT eating that thing because we start thinking, “why can’t I have more self-control with food? I know what I’m supposed to be eating, why can’t I have some willpower and do that?”which reinforces feelings of being helpless to our circumstances and our choices not being within our control.
“I should be exercising more…” usually results in NOT exercising more because we follow it with, “but I’m just so lazy. If only I had more motivation.” which again, reinforces feelings of the choice being out of our control and makes us feel hopeless about changing it. We “should” be… but we’re just too lazy, we believe. So we carry around this belief that we’re unworthy or that we’re destroying our health because we’re too lazy to do the exercise everyone tells we “should” be to be healthy, or hot or skinnier or stronger or whatever.
And should statements aren’t limited to just what we eat and our exercise habits. We use them for everything – our parenting: “I should have more patience with my kids”,our homes: “I should be a better housekeeper”, our relationships: “I should be a better wife, mother, daughter, sibling, friend”… etc. Should statements are just one of many cognitive distortions that contribute to depression, anxiety, panic and can even keep us stuck in the weight & food battle.
And cognitive distortions often don’t act alone. Should statements, all or nothing thinking, and labeling/mislabeling can, and usually do pile on top of each other in one nasty thought bubble whenever we “fall off the wagon”.
“I should be eating salad but I really want pizza. Screw it, I may as well just have the pizza. I always just end up screwing up eventually anyway.” which then leads to “I may as well have a beer with it, and some chips and ice cream for dessert since I already ruined today. I’ll just start over tomorrow.” which then leads to “God, I’m such a pathetic screw up. I always do this. What’s wrong with me?”
That’s a should statement, all or nothing thinking, and labeling/mislabeling – a common threesome of cognitive distortions that often results in overeating (or in some cases a full-on binge) in people who struggle with weight & food all because they just wanted a piece of pizza.
Cognitive restructuring is a helpful cognitive-behavioral technique that I’ve incorporated in The Cognitive Eating Academy. It’s designed to help you overcome should statements and other cognitive distortions that keep you stuck in these faulty and self-destructive ways of thinking – and as a result, behaving.
The day I gave up should’ing myself to death was one of the best days ever. Now, when I hear myself thinking or saying, “I should…” before something, I next ask myself, “says who? Who says I should be doing that? What do I WANT? What does MY body need? What’s best for me? What do I need most right now?”
Rather than making ourselves miserable by trying to live up to what everyone else determines we “should” be doing, this switch gives us our power back. It gives us the power to start learning what makes us happy, what’s best for our own mental, emotional and physical health – and how to follow our own hearts, minds, bodies and dreams. And if you need it, I created The Cognitive Eating to help.
Pharmacy practice is filled with amazing individuals. We all know Pharmacists that stand out for various reasons. Lately there has been a climate of intolerance towards those that come to Canada or the U.S. from another country. This confuses me given the history of successful immigration not only in Canada but other countries as well. Pharmacy practice is no stranger to this and I have found it necessary to share the brief stories of just a few of the many immigrants to Canada that have and continue to contribute to the profession of Pharmacy. My regrets are that I couldn’t include more people here and that their stories are so abbreviated in the interest of space. These are the stories of just 3 such individuals to spotlight their paths of immigration and contribution to Pharmacy and to Canada.
My first call was with Kyro Maseh, a Pharmacist from the Toronto area. He came to Canada in August 1996 with his family from Egypt. The main reason for their move was the growing religious discrimination they were seeing and decided it was time to leave. He was 8 years old when they arrived. His mom was a Pharmacist, which helped their acceptance into Canada. At the time Canada was looking for Pharmacists from Egypt and his parents read that it was a good place to raise a family. His dad was a well-known and respected vetrinarian of livestock in their area but gave up that profession when they came here. Kyro had very little English language and no alphabet skills when he came here but you would never know that now. He now speaks French, English and Arabic. His early days in Canada were modest by his standards today and back in Egypt. Their furniture came from what they could scrounge up from the garbage and housing was not luxurious to say the least. To add to the family’s stress, his mother was diagnosed with cancer after their arrival.
Kyro eventually returned to Cairo for his Pharmacy education. At a metropolitan centre he wouldn’t experience the same discrimination as his family did in Asyute where he was born. One day a mother came into the pharmacy and told Kyro that her son didn’t wake up that morning, he had overdosed. She said to him that she wished someone had warned him. It was in The Beaches area of Toronto where there is a small community feel. He began to feel at this moment that it was his calling to help educate others, particularly young people about addiction and prevention of addiction. Mental health and addiction became an area of focus for Kyro from then on. He feels that as pharmacists we are good at talking to people and we are knowledgeable in science. Teaching then becomes an important and natural part of our job. His #EndTheCrisis campaign tries to focus on kids on awareness of addiction. His warning in hesitancy of immigration points to the case of Raymond Schinazi, who was forced from Egypt, only to become instrumental in the development of antiviral medications we use in pharmacy today. He says there is strength in diversity, something he is living proof of.
Tina Privado Azzopardi (Christina) grew up in a relatively poor setting with both of her parents, 3 brothers and 1 sister on the beautiful island of Cuyo in the Philippines. It’s an area that is quite isolated transportation-wise from the urban areas of the Philippines and very much more laid back. To see this tiny spit of land on a map verifies the isolation they lived in. She moved to the more metropolitan centre of Manila to pursue a degree in Pharmacy and graduated in 1997. This would not have been possible without the scholarships she received and monetary help from an Aunt she moved in with during that time in Manila. Her Aunt was a business owner and fairly well to do. In return, Christina would help out with the bookstore business as was needed. Upon graduation, she was employed as a lab instructor at the private University she had attended and worked there for 5 years. The pay was not high in this position.
Pharmacy practice and overall healthcare in the Philippines is quite different than here in Canada. She recalls the system as very sad and medications can be difficult to obtain with little structure to any healthcare system, little private insurance, and expensive prescriptions. The Physician is rarely challenged on a prescription when it comes to switching to a generic or dealing with an interaction. Physicians are held in high regard like they are here, but it is more of an authoritative role. Collaborative care with a Pharmacist’s input is not common. Brand name reps often visit the physicians and leave samples. This leads the physician to often write for the brand name of medications and there is no switching to generics unless it is written for. Christina tells me it is still this way today back home. It is not uncommon for antibiotic prescriptions to be filled for part of the total days supply due to the cost. Being on a chronic medication can financially ruin a family that tries to pay for them.
Christina eventually saw a benefit in working in Canada. With the help of a broker that spearheaded the move for Zellers who was looking for pharmacists, she prepared herself for the transition, which included 3 qualifying exams. She recalls this as an unsure time as scams were often present with such brokers. At the time, the internet wasn’t as widely used as today and verification of such scams was more difficult. Eventually, through friends of hers that knew the friends of the broker she was fairly satisfied this was above board and made the move with a group of 5 others; all academia and non-retail in background. This particular group came from Centor Escolar University and from the University of the Philippines. Unfortunately for Christina and her family her father passed away of cancer before her time to leave came.
She recalls her arrival in the GTA after 24 hours of travel when the 3 girls in the group opened the door to their new apartment and realized it was completely devoid of furniture. It was a feeling of emptiness she recalls. She recounted having the bed sheets she travelled with that night and they eventually got some furniture that was donated by other Philippino families living in the building. It was in a building that had many other immigrants from the Philippines. She lived in Barrie for three years where she worked and paid off her commitment to Zellers. Making the switch from academia to retail in a corporate environment was tough but she was mentored during that time and felt comfortable becoming a store-owner after that. She embraced the chance to become involved in the independent Pharmacy world. She now owns a store on her own and partly owns three others. She purchased a home, got married and has a 6 year old son in Tottenham, Ontario, about 70 km from Toronto. Her mom stays with her for ¾ of the year and goes back to the Philippines for the remainder. Her commitment to the pharmacy profession is obvious but her 6-day weeks with 4 stores will hopefully become 4 day weeks to give her more family time eventually.
Johnny Marya has no direct recollection of his birth country of Greece. His parents were Christians living in Syria, a minority group in that country. His father started work when he was 13 with Johnny’s grandfather in the jewelry business in Syria. It was a family of 6 children and a life of productive work looked more favorable than school. Early on they knew that North America offered more potential than they saw in Syria, including education for Johnny. Before Johnny was born they moved to Greece where they lived for a short time around his birth. His Father became a jeweler – making a fairly good living there. They decided to begin the work to start the path to Canada and his father moved his wife and Johnny back to Syria while he went to the U.S. to begin the paperwork to have the family moved over here. The year was 1989. This is a process that lasted nearly three years. During this time he didn’t see his father, who supported the family from the U.S., undoubtedly a long period for Johnny. Finally, in 1992, when he was 2 ½ he moved to Montreal with his mom to be reunited with his dad.
Growing up in Canada offered Johnny and his family (which also now includes a sister) opportunities and education they would not have had back in Syria. Johnny saw the value of education. As an immigrant it was instilled in him to get an education first in order to be successful and to work hard to get what you need. He went to work at small jobs at the same age his father did as a young boy. His first job was at a grocery store, receiving orders and preparing fruits and vegetables for sale. His next jobs included a Subway, a Theatre, a paper route, a duty free shop at the airport, snow removal, a forklift driver at a warehouse, a truck driver for a delivery company, and a clothing salesman for H&M. With his family they also started a tourist agency and a popcorn company, both of which they ended up selling.
As Johnny started his 4 year Bachelor’s degree in finance, he approached his father to rekindle the jewelry business that he had started to wind down. Johnny developed a business plan and incorporated a proposal that included updated technology and smaller batch custom-made jewelry production with little to no overhead in inventory. This was a busy time for him, working 40 hours per week while in university. During this time he interned for a live broadcasting company that expanded and offered him a great job that he couldn’t refuse so he took that job and still offered to help his dad with the jewelry business. He was 22 years old at this point. He worked there for a year and turned to a recruiting agency to find a job in finance. He was immediately offered a job with the recruiting company and within 2 years he was one of the top producers, mainly with pharmaceutical companies. This is how he started to learn about drug companies, including McKesson. His sister also became a Pharmacist. After some extra legwork he convinced his future employers at McKesson that the recipe to a successful hire of a salesman isn’t in the salesman’s background in what they sold in the past (like automation), it’s in the ability of the individual to sell. After all, Johnny spent a long time with the recruiting company coaching others in how to nail an interview. Johnny has become Regional Sales Manager for Atlantic Canada and been doing that job for 3 years.
Johnny’s extended family has also immigrated. An uncle who was a physiotherapist back home, now works in Canada as a masseuse, another uncle is a successful physician in New York, and a cousin is with the Canadian Army. Johnny’s story underscores the belief that immigrants often have a strong work ethic, come to Canada because they recognize the simple formula of education and hard work leading to success, and can be hired by companies that recognize this value and potential in this country. While he not a Pharmacist, Johnny represents one of the many immigrants that have come to this country and contribute immensely to healthcare through their special expertise, not to mention the contribution of his family that also came to North America. He has contributed to the success of many Pharmacies in this country.
The stories from immigrants were all equally interesting for differing reasons as I interviewed them for this blog. I soon realized it was going to be difficult to tell their stories fully to and keep the blog’s length appropriate. Immigration has proven to contribute to the success of Pharmacy in Canada. Its benefits are seen both directly through immigrants who began here with a Pharmacy career and flourished, but also through the children of descendants that have come here from abroad. Something I have learned through this exercise is how Pharmacy operates in other parts of the world. From the examples I have heard, Canada is actually an excellent country to practice this profession, given the complaints we may have here in this country. The respect given to Pharmacists and the value of pharmacy as a profession is strikingly higher here comparatively. Thanks to all for their contributions in helping to promote the value of immigration through our profession.
This past Spring I had the privilege of attending the 16th conference of the International Society of Travel Medicine in Washington D.C. Among the interesting topics of the conference were talks about first aid kits (by Sheila Seed), natural medicines (Karl Hess and Derek Evans) and avoiding insect bites (Larry Goodyear). Canada’s own Sherilyn Houle (columnist for Pharmacy Practice + Business) also presented on how we as pharmacists can integrate travel medicine into our practices. All were great talks that helped pharmacists bring their patients up-to-speed in keeping healthy during and after travel.
I find it can be worthwhile to attend a CE session even when you think you know all you need to know about a topic. Often, doing so will will reinforce your confidence in what you are telling your patients; but you may also learn some interesting new ideas that you can add to your tool box to inform patients.
Having said that, many of the points reviewed during the conference reviewed common discussion topics—the things we would typically tell our travelling patients. Of course, the advice errs on the side of caution, keeping in mind that people may not be able to access any treatment at any given time while travelling. While the standard travel consult advice often includes assuming the patient will be dropped in the middle of the desert, common sense tells us that it’s possible to streamline their medical bag with a sit-down discussion that includes a plan for their actual destination.
Commonly-mentioned talking points for a travel consult include: pack meds in your carry-on bag; bring something for travellers’ diarrhea, nausea, pain, UTI and yeast infection, and pack plenty of sunscreen.
One important note is to add tweezers to your patient’s travel kit for safe removal of ticks, splinters or other items that may become embedded into the skin. And although as pharmacists we should always promote vaccines, this is especially true with travellers. I always have the most up to date edition of the CDC Yellow Book for recommendations to patients who are travelling, and most of us have customers who travel. Whatever helps to make you the “go to pharmacist” promotes your brand. Although as pharmacists we should always promote vaccines, this is especially true with travellers.
Latest research on natural supplements for travel
Natural supplements was a big topic at the conference. Here are some key takeaways:
Altitude sickness: Garlic, ginkgo biloba and vitamin E have been researched for their antioxidant and antiplatelet effects. None have been proven effective and all have an increased risk of bleeding or hemorrhagic stroke. (Source given was Micromedex and CDC Yellow Book).
Common cold while travelling: Echinacea, vitamin C and zinc are often asked about. 1-3 g daily of vitamin C, and zinc 9-24 mg daily (gluconate) have been shown to reduce the duration of the cold by 1-2 days in studies. Echinacea may reduce cold risk by 58% and reduce duration by 3 days. (All info based on CDC Yellow Book and Natural Medicines Database.)
Insect Repellents: Riboflavin and thiamine were both shown with negative results. Garlic dosed at 1200 mg daily for 8 weeks showed a reduced incidence of tick bites, but no supporting evidence for other bite sources. (Source: Natural Medicines Database for all)
Jet Lag: Fairly good evidence here for kava, melatonin and valerian. Kava’s rationale is as an anxiolytic and shows evidence for 100mg-200mg for anxiety associated insomnia with a safety issues involving hepatotoxicity. Melatonin has been researched here for alertness and daytime fatigue/performance. Melatonin at 0.5-5 mg at bedtime has been shown to be beneficial for eastbound flights over 5 or more time zones. It is unclear if this effect happens in westbound flights. Valerian has been tested for its possible effects on sleep quality and sleep latency. Using 400-900mg 2 hours prior to sleep is generally well tolerated and may improve sleep quality by up to 80% and decrease sleep latency by 14-17 minutes. It should be tapered if used for long periods of time. (references cited were Micromedex, Natural Medicines Database and CDC Yellow Book).
Motion Sickness: Ginger and pyridoxine. Ginger at 500 mg-1000 mg 4 hours prior to travel has shown conflicting subjective improvement in both nausea and increased latency before onset of nausea. Pyridoxine dosed at 10-25 mg every 8 hours has no supporting evidence for motion sickness (CDC Yellow Book, Micromedex and Natural Medicines Database)
Prebiotics and probiotics in travellers’ diarrhea: To say the least, study results are all over the map. Early studies and meta-analysis showed safe and effective conclusions in studies. We became aware of the need for specific strains in making recommendations. This makes meta-analyses difficult because of the number of strains tested. A specific prebiotic, B-GOS has been shown to have positive results in travellers’ diarrhea, especially if started a week before the trip. I personally recommend saccharomyces boulardii in prevention.
Mosquito repellents: When it comes to mosquito repellants, don’t mess around— use DEET at the highest concentration available (i.e. 50%). Apply 0.5-1g per arm (1mg/sq cm). Nets treated with a pyrethroid have excellent evidence for efficacy and disease prevention.
Those are just a few highlights that may be helpful in your consults with patients preparing to travel. You don’t have to label your pharmacy as a Travel Medicine Clinic to be helpful to your customers. Regardless of your current level of comfort in making travel recommendations, I would highly recommend attending an International Society of Travel Medicine conference (with which, by the way, I have no connection or affiliation). You may convert a perceived niche offering into a welcome strengthening of your pharmacy toolbox.
We’re bombarded with weight loss and diet advice every dayand everyone says the same thing about theirs – “scientifically proven”, “best way to burn fat”, “easy to follow”, “secret fat burning system”, “lose stubborn fat and keep it off”… literally, they all claim the same things.
Yet, most people who start a diet fall off it before even losing any weight and 95-98% of those who do lose weight, regain it all within a year and as many as 2/3’s of them will be even heavier than when they started within 5 years.
So, what’s with that? Do they work or not?
Yes. And most definitely no. The truth is, ANY diet that puts you in a caloric deficit, IF consistently followed for long enough, will result in weight loss. Yes, ANY diet that puts you in a deficit. You don’t even need to do a “diet” …as long asyou’re eating less than your body is burning, you will lose weight.
Despite their claims, multiple meta-analysis of long-term diet studies have shown that no one diet really works a whole lot better than any other in terms of how and how quickly they help shed body fat – there’s often not much more than a 1-3lb difference between them.
And, ANY diet that you consistently continue to follow AFTERyou reach your goal, will help you keep the weight off – again, no one diet really works any better than another here either.
Notice the key point in those two truths?
Without consistency, they are all completely worthless – actually, worse than worthless. Dieting often causes a whole host of other problems, both mental and physical, in a large majority of people.
So, CONSISTENCY is the biggest factor in determines whether or not you’ll be successful at losing weight and keeping it off. Without it, nothing will work. With it, just about anything will.
But consistency is the exact thing that people struggle with most. That’s why so many people spend so many decades hopping back and forth between dozens of different diets – trying to find that magic one that they can FINALLY be consistent on.
But it rarely works.
There are several reoccurring themes I’ve seen over the years that most commonly keep people from being consistent.
The seven biggest ones in no particular order are:1. Habits. Our brains are incredibly complex and have, since the beginning of time, been designed for survival. They have all kinds of annoying little tricks to make sure we stay alive and our habit center is one of them. What’s the first thing that happens when certain foods are off limits? Pretty much the second you decide a food is off limits you suddenly can’t stop thinking about it and craving it, right? That’s a survival instinct that’s literally been hard wired into our brains since the beginning of time. Food equals survival so when food restriction is introduced, our brains get scared and start trying to force us to “cave” and eat that thing we think we’re not supposed to have. Then, when we finally do cave, our brains get rewarded because they love food! That’s when the habit center kicks in and start wiring the cycle of craving and caving as an auto-pilot habit that we don’t even really control after awhile. The more you do it, the more you teach your brain that cravings = rewards and the harder it becomes to “stick to” anything. Have you noticed that when you first started dieting it seemed easier to stick to them and the more years that have passed the harder it’s become? That’s why. The longer this cycle repeats, the more ingrained the act of “caving” becomes. This is one of the biggest reasons most people struggle with dieting – because diets, especially the super restrictive fad ones, are SO restrictive of food. It’s also why eliminating food rules & restrictions is required.
2. Self-sabotage from limiting beliefs/the way we feel about ourselves. When we don’t trust ourselves or believe in our ability to be successful, we self-sabotage – because why on earth would we keep going when things get tough if we don’t think we can do it anyway? If we’ve already decided going in that we’re just going to screw up because we always do, we’ll just keep quitting as soon as it gets tough or inconvenient.Also, when we don’t like or love ourselves, we self-sabotage because we don’t believe we deserve to be successful. Unless and until you change those things, consistency will always be a struggle.
3. The change model. Again, another fun little trick our brains play on us because of their faulty programming. It’s a normal cycle when we’re trying to change because our brains do NOT like change and do everything they can to keep the status quo. So, the change model looks like this: First, there’s the discontent. We don’t like something like say our weight. Second, the breaking point. This is when we can’t take it anymore and brings us into the next phase of the cycle, the declaration. “This is IT this time, I’m really doing it!” which brings us to the next phase: fear. When we start doing things differently and our brains get scared. Remember, they don’t like change so they start making up a bunch of things for us to be afraid of. When it gets too overloaded with fear, it kindashuts down which brings us to the next phase in the change model: amnesia. This is where we start forgetting why we wanted to change in the first place. The goals we set weeks or months ago start feeling completely unimportant and we just stop caring about them. Which leads to back tracking on any progress we may have made while we slip back into the old habits that are brains are comfortable with.. until we start to feel that discontent again and the cycle just keeps repeating. The change model: Discontent > breaking point > declaration > fear > amnesia > back tracking > repeat will just keep replaying until you recognize it for what it is and learn to manage it.
4. Fear. Fear is a huge reason we struggle with consistency. Not just because our brains don’t like change but often, carrying extra pounds often makes people feel safe – if there’s a history of physical or sexual abuse, this is especially true. Often people who are struggling with their identity will also feel safer with extra weight because it helps them feel more invisible. No matter where the fear is coming from, it will cause self-sabotaging behaviors if you’re not aware of it and don’t have a plan to manage it.
5. Emotional eating. Some level of emotional eating is pretty normal for most people on occasion but if you’re someone who relies heavily on food for everything, whenever you’re bored, or stressed or upset, or anything… you’re going to keep falling back on your go-to copying strategy and consistency will suffer until you learn to change it.
6. Don’t want it bad enough. This is a really common one. If your why isn’t big enough, if you don’t want it badly enough, you’re going to struggle with consistency every time it starts getting hard.
7. The weight centric paradigm that defines success. This is something I’ve seen derail SO many people – defining success based on what the scale says and nothing else is such a fundamentally flawed premise. What do we often say to ourselves when the scale doesn’t say what you want it to say one morning?
“This sucks, I’m never going to get this weight off, screw it, I’m eating whatever I want today.”
Or even if it goes farther in the direction we want it to than we expected.. “Oh wow, I’m doing so awesome, that’s more than I thought I lost… I deserve a treat!” which usually ends up in overeating.
The other reason that the weight centric paradigm is flawed is because it’s terrible motivation. Trying to force yourself to eat in a specific way today because maybe at some point down the road from now it’ll make you skinny and happy is terrible motivation to change eating habits that almost never works. Today you doesn’t really care about what the next week you is going to look like, today you just wants to eat what you want. There’s no immediate gratification when we live from a weight centric approach.
But switching from that weight centric model to focusing on how you feel changes everything because there is immediate gratification there. The things you decide to eat right now, will either make your body feel good or make it feel bad. If you’re trying to force yourself to eat what someone says you’re supposed to eat in order to make the scale go down at some later date, you lose sight of what your body wants and needs. It all becomes a fight over what you’re supposed to eat versus what you think you want to eat because your brain’s survival instinct is driving cravings. If instead, you start learning to trust your body and just asking yourself, “how will I feel if I eat that?” and “do I want to feel that way?” you start learning that your choices impact you right now and the more immediate the reward or the consequences, the more likely you are to be consistent.
I created cognitive eating to help address all those reasons and more. If any of that sounds relatable and you need help navigating your way through changing it all, you can contact me or find more info on the Cognitive Eating Academy here.
We are lucky to have partnered with Roni in helping patients with their weight loss issues. Contact us for more information.
Boost Your Professional Credibility & Contribute to your Profession with Research
Practicing pharmacy has proven for me to be much more than I had planned when I was accepted to Dalhousie University’s College of Pharmacy 30 years ago. Of course it created a career where I used the most available evidence based treatments for just about any medical conditions that I was asked about. This degree put myself and my colleagues on a level that resulted in more people listening to us and taking our recommendations than we had ever experienced in our lives before. All of a sudden, with such a degree on our wall and a license to our name, people would follow our beliefs without question. Pharmacy can be a powerful profession with regard to public credibility, even when it involves treatments that have very little evidence or no evidence (such as homeopathy). The mere presence of a treatment in a pharmacy and the recommendation of a pharmacist is all the public needs to blindly follow us in many cases.
We normally aren’t asked or required to supply randomized placebo controlled trials to back up our recommendations in the front store nor is that commonly asked for in our prescription world either. Most of us simply give recommendations without readily knowing off hand any particular study that backs up what we are saying at all. Giving public presentations may be an opportunity to show an audience where the foundation of our claims come from in the scientific world. It turns out that the public can be information nerds like we are sometimes and are quite interested in presentations like this.
As pharmacists, we are tied to the study designs of others when it comes to our recommendations. The weakness of their designs becomes the weakness of our recommendations. For years we recommended docusate sodium as a stool softener, only to hear that it really doesn’t do what we claimed all these years. 10 years ago I was lucky enough as an owner to pursue a niche in compounding, a subset of pharmacy I was exposed to as a student working in a pharmacy a block away from the College of Pharmacy in Halifax. Pain compounding became the focus of my practice. The evidence for these ingredients was positive but didn’t involve hundreds of thousands of patients. It consisted of many smaller studies that together added up into a strong base from which to recommend this treatment modality. Active ingredients like amitriptyline, clonidine, gabapentin, ketoprofen, ketamine and lidocaine were all mentioned in the literature, but something was missing for me. In order to put some stronger faith from the public in this, I needed to show some way that I was in some way involved with the evidence base of treating people this way for pain.
Turns out, universities are eager to showcase their research and are very helpful in sourcing out grants to fund scientific studies. It has always been a drawback for a situation to exist in scientific study whereby the “promoter” that stands to make money is funding and driving the study forward. However when we consider that this is how most prescription meds came to market it becomes more acceptable. I believed it would be a strong asset to show that I spearheaded a study through my pharmacy that proved for the first time the permeability of these six ingredients through the skin would happened simultaneously. A visit to the local university and they helped us with the application procedure for a grant that covered the cost of the study, new equipment included. The money went completely to the lab with our pharmacy handing over three sample creams in three different bases. With very little effort on my behalf, I went from wanting to prove I could drive these molecules through the skin to having a typed manuscript with graphs showing flux over time that I could bring to prescribers and show to recipients of the cream to instill confidence in their medication. This completed study is soon to be published.
As a follow up, we applied for and were accepted for a grant with the local pain clinic to use the same pain cream with the local pain clinic on 40 patients with nerve pain. What better way to put your money where your mouth is than to put your own hand picked ingredients on the spotlight and test whether or not they actually work. We were that confident based on hundreds of patient results.
In another study, we partnered with The Propel Centre at The University of Waterloo to supply data on the aftermath of discontinuing the sale of sugary beverages at our pharmacy in 2014. In this case they approached us on starting this study, which was finally published in 2016 and became the subject of a Thesis presentation after that. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4947263/
My point is, based on the funding available out there, why not take a treatment concept you either feel strongly about or want to clarify that has been conventionally accepted for years (either prescription or non prescription) – lots of opportunities exist in the front store here without taking on big pharma. Meet with the university scientist that will design the study and share your thoughts on what you are trying to unveil. Allow them to introduce you to the grant application personnel, (or vice versa). It becomes an incredible strength to refine your knowledge of study design you’ve learned from your pharmacy degree. You don’t have to be an expert on study design. Allow the researcher you are collaborating with to develop the study with your input. Nothing beats having your name on a study that shows that you are so committed to your profession and your recommendations that you are willing to be involved in an actual study to clarify our understanding of a topic. Being known as a research pharmacist gives extra credibility to your commitment to your profession as well as increases your knowledge base for your recommendations to your patients and your physicians. Your contribution to your profession will not go unnoticed, and the next time a customer asks you if you are aware of any studies on a particular topic, you just might be able to quote one directly.
Graham MacKenzie Ph.C.
Most Pharmacies have a patient (or more) that is a centenarian. Living to the age of 100 is quite an achievement, considering these patients grew up and lived the prime of their lives in an era that had a healthcare model quite different from today. Knowledge of how diet, exercise, nutrition and medicine interplay to result in a long life wasn’t as advanced as it is today. Some may say the diet 100 years ago was superior to today’s diet. They probably wouldn’t be wrong. Sanitation, pasteurization, and crop control were at a different stage at this point in time than they are today.
I had the pleasure of sitting down with Margaret MacPhee, 103 years old from Baddeck, Nova Scotia recently to ask her what her life experiences that may have helped get her to this age. In an interview that was hopefully not patronizing, she opened up about her life from childhood to today.
Margaret was born at home during the wintertime of 1915 and grew up in a house in Upper Baddeck (Big Baddeck) the fourth oldest child in a family of 11. She wonders how she managed to be living at all growing up back then let alone survive to be 103. Her house had no electricity or phone and was heated from one central stove. Her father was a farmer and her mother “had lots to do with all the children”. This was not uncommon for the families that grew up in the area as every family seemed to be large. She went to school in Upper Baddeck for 11 years then went out working from home to home in the area doing housework. She was married to Charles D MacPhee in 1946 until he passed away in 1992. They had one daughter (Catherine), a large difference from her family size growing up.
Margaret didn’t smoke or drink alcohol during her life. She didn’t recall taking any type of vitamin or herb growing up. As a child she doesn’t directly recall most of the healthcare or medicine of the time. She recalls early in her life coming home from Sydney and then coming down with Scarlet Fever. She doesn’t remember what Dr MacMillan gave her at that point but she survived this. She clearly tells about being quarantined alone in her room where her mother soaked a blanket and hung it in the doorway of the room to keep the germs from spreading to the rest of the house. Given the lack of modern day entertainment sources for children back then, it must have been a lonely time for Margaret during the long hours of the days and nights while she recovered. No one else came down with the disease in the house. She also had measles and as well had whooping cough, which she recalls almost dying from. She lost a brother to the whooping cough (a twin of another brother). Another brother died from croup at a just a few months old. There were no vaccines at this point for them of course and routine visits to the doctor weren’t all that common unless there was a need. Given the lack of antibiotics and vaccines back then, childhood was a journey with pitfalls not seen today that made it more of an accomplishment to get to adulthood than it is now.
When asked of her sleep habits she says, “now I’m sleeping all the time. If I lay down at all I’m asleep!” She says living as a young girl on the farm you were up early to do your chores and then get ready for school. When you came home you started into the chores again. There were three meals a day, breakfast and supper and home and lunch was taken to school. Food eaten back then was grown on the farm. Herring and codfish were also staples as were beef and pork from the farm. Whole food was the norm. Processed and ultra-processed food we see today weren’t the food choice back then living on the farm.
Margaret isn’t one for social media, and as mentioned,growing up they had no phone. They burned kerosene lamps for light at night. Electricity wasn’t something she had in a home until she got married and moved out on her own. One of the biggest differences between then and now was the direct social network everyone had. There wasn’t a night in the winter regardless of how stormy it was, that there weren’t people over at the house. Family or friends and neighbors would visit until 11:00 at night every night. A common activity was playing cards and it wasn’t uncommon for visitors to travel with snowshoes back home. Picturing what it would be like with no power or contact with the anyone (TV, cell phone, social media, email or texting) makes it more understandable how long evenings were passed with groups of visitors every day. She says there isn’t anything like this today. In fact we have seen survival rates from some diseases like cancer have a better survival rate when the patient has a better direct social network available to them. If there was a storm, there were no plows but for two days after the storm everyone would be out with their horse and sleighs making a path on the road.
One of her earliest recollections in the house was a day when her father was out working, perhaps out in the woods, and her mother was out doing chores outside of the house briefly at noon. She was left in the house with her two older brothers, one of them being in charge while she was out. She recalls it being a stormy day, her mother was out feeding the animals and when she came out of the barn she smelled smoke. Looking in the direction of the house her mother saw smoke coming from the house and chimney. Her father smoked and instead of using matches he would use long thin sticks to light his pipe that he lit in the fire. Her babysitting brother found some of these laying around and grabbed one and put it in the fire. There was an open chimney behind the stove with bark, kindling, and papers in it. He threw the stick in the chimney causing everything in it to catch fire. By the time her mother made it back to the house, her brother had taken the younger brother out of the high chair and ran with him into the bedroom off of the kitchen and closed the door, leaving Margaret crawling around on the floor. When her mother got to Margaret she was almost to the blazing chimney. Her mother had her hands full.
Today only two sisters, Agnes (Baddeck) and Marion (Sydney) are still alive. Marion’s daughter was raised for a while by Margaret’s mother when Marion went to Sydney to work, so she thinks of her as a sister. Her siblings lived to be in their 70’s for the most part. Her mother died 4 months shy of her 100th birthday. Margaret remembers her mother as being a hard working woman. She wasn’t a nurse but she feels she could have been and would help deliver babies, was good around animals and people. Her father passed away of a heart attack at 69 years of age.
In looking at what contributes to Margaret’s long life, we can certainly attribute her DNA passed down by her mother as being a major contributing factor. There wasn’t a lot of money to go around the family growing up, but like the other families in the area they got through it. Living on whole unpasteurized milk (not recommended today), curds, butter, cream, butter milk, vegetables and fresh farm raised meat. Today she eats a little differently, margarine and 2% milk, and some processed food she might heat up in the microwave. Aside from being forgetful with names, she is still quite active and comes into the pharmacy regularly. A good sleep habit and regular physical activity are undoubtedly helping her to age in a healthy manner. As a child and an adult, she had no cell phone to keep her up at night disrupting her sleep. Finally, a strong network of other contacts that she regularly saw reflects the results we’ve seen in longevity from other studies.
Margaret has no major regrets looking back. She supposes back growing up there were a lot of regrets of what she had to do but nothing lasting. She recalls a story of two men in their 80’s for how she feels of this stage of life. One says to the other how great he feels and wakes up everyday wanting to take on the world. The other one says he feels just the opposite. He feels like a baby, “I have no hair, no teeth, and I just wet myself”. Margaret also has a good sense of humor.
I’d like to thank Margaret for yet another down to earth talk with her and her willingness to share her experiences with everyone.
Omega 3 supplements have been taking a beating lately with regard to cardiovascular outcomes. One thing that we have seen is the questionable cause and effect of the wide variety of commercially available Omega 3 supplements available on the market and the dose required for any effect at all.
Clinically, one indication I see Omega 3 supplements used for successfully is pain relief. It works along the same pathway as anti-inflammatory medications. But what does the evidence tell us about the effectiveness of such supplementation in an era where vitamins, herbs and supplements are more and more becoming a punching bag for quackery? Is there hard evidence for treating pain without the use of (oral) NSAIDS, opioids, muscle relaxers, antidepressants, counterirritant rubs, and anticonvulsants? Transdermal pain compounding comes to mind, but is there an OTC product you can start today in giving your customers to begin safely reducing their pain?
First of all you need to set expectations. If you are someone in chronic daily pain, you need to be upfront with them as a pharmacist by telling them that 100% pain relief is not a concept that we entertain. Your discussion with goal setting with them should inquire what they want to get out of this. Most patients in chronic pain don’t necessarily need to be pain free, they have learned for years how to live and cope with pain. What they may share with you is the desire to play with their grandkids, to go to church with their spouse, to go for a walk with their dog every day, or to just simply get out of bed and make a meal for themselves.
There have been a number of pain patients I can recall who have claimed that by taking this one supplement, they are able to do some of these activities. As evidence-based healthcare practitioners, we must strike a balance between following anecdotal evidence we’re presented with in the pharmacy and using the invaluable clinical evidence we see as healthcare professionals that really no one else sees. This balancing act inevitably involves stumbles where we fall for an N of 1 to strongly and apply it to everyone we speak to. In other moments of clarity, we look back at the results of our recommendations and accumulate a non-trial-based clinical judgment that we feel strong enough about to make recommendations for in the front store.
Recommendations to use Omega 3 supplementation in relieving pain are based on good quality evidence. When we look at the use of Omega 3 with rheumatoid arthritis (RA) specifically, it is important to reinforce with patients (and to ourselves as pharmacists) that this is not meant to replace what we use conventionally. Disease modifying antirheumatic drugs (DMARDS)should not be dropped in favor of Omega 3 supplementations. In fact DMARDS can help induce the remission of the disease when used early. They can, however, be used in conjunction with them.
Being a disease connected with the immune system, rheumatoid arthritis treatments that work with the body’s immune system are an attractive way to combat the problem. Omega 3 has been shown to affect our immune system. Arachidonic acid, which is an omega 6 product, flows into pathways that create inflammatory molecules which are involved in rheumatoid arthritis, including inside immune cells. The EPA and DHA in marine Omega 3 supplements reduces arachidonic acid. They follow a pathway which results in anti-inflammatory products and affects dentritic cell and T cell function. Additionally, it reduces reactive oxygen species by leukocytes and inflammatory cytokine production by macrophages. But the work on this area and how it pertains directly to RA is less understood. (1)
In a systemic review of 23 studies of Omega 3 use, modest but fairly consistent benefits were seen in relation to joint swelling, pain, the duration of morning stiffness, and the global assessments of pain and disease activity.(1) There was also a benefit in the amount of NSAID therapy used in these patients.
In explaining just how omega 3 has a cause and effect relationship with RA and how studies show that it helps to reduce pain, we look to the similarity in effect between NSAIDS and Omega 3 in the body. Prostaglandin E2 (PGE2) is involved in all processes leading to the classic signs of inflammation (redness, heat, swelling, pain and edema). (2) A typical NSAID blocks the production of Eicosanoids including several prostaglandins as well as thromboxane proinflammatory products involved in pain and inflammation. Omega 3 reduces the production of mainly PGE2. Therefore you get the benefit of reduced pain and inflammation while avoiding the other problems with NSAIDS on the stomach. Unfortunately, the blood thinning still occurs, so those at risk for bleeding or on blood thinners need to be mindful of this. In reducing the dose of Omega 3 to avoid this, patients may put themselves in a dose range that is ineffective for RA. As you may have guessed, Omega 6 supplements increase arachidonic acid which is responsible for the production of these pro-inflammatory products, so combination 3-6 or 3-6-9 products are not recommended.
Based on current data, doses above 2.7g per day of combined Omega 3 ingredients in the fish oil are required for this response, which may be delayed for two to three months before results are fully realized.(3)
A systematic review that looked at the effect of marine fish oil on the pain of arthritic disease determined that it did in fact reduce pain in that population (4). An excellent source for references comes from the Australian NPS MedicineWise from April of this year. Over all it lays out a number of encouraging studies that can put another tool in the pharmacist’s toolbox for helping your RA patient.
Looking back to our “front store experience N of 1 world,” Omega 3 supplementation and joint pain relief always remind me of my 101-year-old customer who reminds me that she wouldn’t be moving at all without this supplement.
Graham MacKenzie is a compounding pharmacist in Baddeck, N.S., and a graduate of Dalhousie College of Pharmacy.
- Miles EA, et al. Influence of marine n-3 polyunsaturated fatty acids on immune function and a systemic review of their effects on clinical outcomes in rheumatoid arthritis. Br J Nutr. 2012 Jun;107 Supp; 2:171-84
- Emanuela Ricciotti Et. al . Prostaglandins and Inflammation. Arterioscler Thromb Vasc Biol .2001 May; 31(5):986-1000
- Rees D, et al Dose-related effects of eicosapentaenoic acid on innate immune function in healthy humans: a comparison of young and older men. Am J Cin Nutr. 2006 Feb;83(2):331-42
- Senftleber NK et al Marine Oil Supplements for Arthritis Pain: A systematic Review and Meta_Analysis of Randomized Trials. Nutrients 2017.
Stone’s Drug Store in Baddeck, Nova Scotia will no longer carry homeopathic products, citing a lack of clinical evidence about their effectiveness.
“Concerns have been raised about the effectiveness of homeopathic products,” said Graham MacKenzie, pharmacist and owner of Stone’s Drug Store. “This led me to review the clinical evidence and I came to the conclusion that these products should no longer be sold at our pharmacy.”
Homeopathy was founded in Germany in the late 1700s and is based on the principle that “like cures like”. The basic concept is that the substances that cause illnesses such as the cold, flu, sleep disturbances, allergies, headaches and baby teething discomfort, will, in diluted form help the body to heal the condition.
“While I can accept the merit behind “like cures like”, as this is the basis for many vaccines, the fact that these substances are so diluted raises concerns,” said MacKenzie. “If homeopathy products can relieve symptoms of so many conditions, how can it do so in such diluted concentration? Where is the evidence?”
Over the past twenty years, the Cochrane Database of Systematic Reviews has conducted reviews of the studies and trials of homeopathic treatments on seven different conditions and found a lack of evidence to support their effectiveness[i]. The Australian National Health and Medical Research Council came to the same conclusion in 2015, stating “[t]here was no reliable evidence from research in humans that homeopathy was effective for treating a range of health conditions.”[ii] Furthermore, the UK National Health Service stated in 2017 that there is “no clear or robust evidence to support the use of homeopathy.”[iii]
Homeopathy products do not require a prescription, are not classified as drugs by Health Canada and can be purchased in most pharmacies as self-selection in the over-the-counter aisles.
“As a pharmacist, my first priority is to provide a wide range of safe and effective health products but if I do not have a professional comfort level with a certain product, I have a duty not to sell it,” said MacKenzie. “I do not see the removal of homeopathic products as restricting the range of choice for patients. Rather, it is an invitation to discuss their health care concerns and to review other options that may be more appropriate, cost-effective and successful for them.”
Stone’s Drug Store had carried five homeopathic products – two for cold and flu, two for sleep and one for teething. These products are no longer available there.
Stone’s Drug Store is located in Baddeck, Nova Scotia. It is a full-service pharmacy that includes a compounding lab to tailor medicines to the needs of patients. Graham MacKenzie has been a pharmacist for 25 years.
June 17, 2017 : looking back hardly a day or two goes by since this year began when a question about medical marijuana or as we call it out here “marijuana” and what is going to happen next July when it becomes real is asked. Last month I was asked by a group of Nurse Practitioners to present on a topic I rarely speak about but fill prescriptions for often – BioIdentical Hormone Replacement Therapy. I like to use the term supplement instead of replacement but it really made me think about the tough upward climb this category has had and continues to have based on a few position statements from such groups as SOGC and NAMS.
Looking at the marijuana issue, never before have we seen a couple of ingredients leap onto the potential healthcare market with the claim to relieve or cure so many, many health issues. Never before have so many N of 1, anecdotal reports driven an entire category of mostly unproven therapies. Granted there are some valuable uses of the drug that have been used for years but many have been very overblown with the main selling point of “no one has died”.
Turning to my upcoming presentation, I started mulling over the studies that have shown for years the benefits and limitations of all types of hormone therapy that I have collected and still continue to collect on the topic. Speaking to the public on a subject is different than talking to medical professionals. I speak to both groups all the time on all topics. To narrow down an hour worth of meaningful, compelling, convincing data that flows easily on a medical treatment that is foreign to a professional group so that you don’t lose them is daunting.
If I present on a topic I have a clear conflict of interest with such as this, I always open with that and some literature from the other side of the argument. There is no problem here with BHRT as lots of naysayers exist. In truth, I have found there are as many cases of overblown promises with BHRT and there are complete opposite downplay of any proven benefits and exaggeration of adverse effects. A segment from Climacteric from just this year was the best I could find that slammed this type of therapy over a dozen sentences. We now see less of an issue with the term BioIdentical, since estrogen and progesterone are both found in the commercial prescription drug industry in Canada more and more in a bioidentical form, especially since the Women’s Health Initiative Study over a decade ago that effectively stopped conjugated equine estrogen and medroxyprogesterone acetate from being dispensed overnight. So at least Big Pharma has caught up with compounding in some ways.
I continue in my talk to disprove the issues just laid out from the climacteric slide: that hormones do pass predictably through human skin and give resultant increases in the body (given the correct fluid is tested), that the stability of the hormone in the right base is predictable, that saliva testing is legitimate and useful in showing levels of active hormones (especially for topically applied hormones), and that all hormone therapies have benefits and risks associated with them, regardless of what hormone therapy that entails.
Given the criticisms the WHI received, one thing we did find from the CEE/MPA regimen was the decrease in fracture risk. With the older average age of the subjects in that study and the lack of topical hormone or actual BHRT used, there is very little to pull from that study for this talk. There are however many studies that can and do show the benefit of BHRT. Most of these are smaller studies than we are used to in the prescription world. One point to take away though is we have seen a top seller in our prescription market fall away to nothing and the public is looking at us and asking how could we be so wrong all these years about something that was so blatantly clear in a study that it cut the study short? Evidence slowly grows on bioidentical hormones but is showing even to our commercial drug industry that it is a safe benefit.
The International Journal of Pharmaceutical Compounding published a three part study on the topic of BHRT. In this small study, surveys were given to women on HRT. The response rate was 70 on BHRT and 53 on synthetic hormone therapy. Each survey consisted of 15 questions that probed such topics as symptom relief, reasons for starting hormone therapy, side effects, age of starting therapy and type of therapy. In the areas of hot flashes, night sweats, sleep quality, dry skin/hair, vaginal dryness, foggy thinking, mood swings and decreased libido, bioidentical therapy outperformed synthetic therapy in all counts. In side effects from therapy, bioidentical was preferred over synthetic for side effects like difficulty sleeping, weight gain, breast tenderness, bloating, upset stomach, breakthrough bleeding, foggy thinking, mood swings and leg pain. Drowsiness occurred more frequently with bioidentical than with synthetic.
A huge concern with bioidentical and compounded hormones is the threat of cancer in hormone therapy. In 2008 a study that looked at over 80,377 post menopausal women, 2354 of them developed invasive breast cancer. Compared to the women that never used HRT, estrogen alone therapy was associated with a 1.29 fold relative risk, 1.69 with estrogen/progestagen and a relative risk of 1 with the estrogen/progesterone women.
In other studies we have seen the benefits from BHRT in areas of insulin resistance, blood pressure, lipids, endothelial function, arteriosclerosis, thrombotic risk, and neuroprotection. More and more we are seeing studies unfolding showing not only is BHRT a healthy and safe option for women of all ages but is also brings quality of life to these patients that they have lost since the Women’s Health Initiative Study came out. Saliva testing for topicals is also shown to be useful as topically applied hormones aren’t reflected in blood draws like oral is. Oral hormone therapy has shown itself to be an unhealthy route for women and topical application has proven itself to be the preferred choice longterm.
So yes, thank you Marijuana, or more correctly CBD:THC. Your very sudden rush to the market has been touted for virtually every medical issue going right now. There are definite benefits in areas such as pain, perhaps PTSD (and a few others) but completely untested and unproven “benefits” in so many other areas. It has shown us that there are areas like BHRT that we’ve been told we had zero proof for but really do have volumes of proof when we compare it to the complete lack of proof in marijuana for many of the areas it is being used for.
Orozco ,P. et al. Salivary Testosterone is associated with higher lumbar bone mass in premenopausal healthy women with normal levels of serum testosterone. European Journal of Epidemiology 16:907-912,2000
Wright, JV. Bio-Identical Steroid Hormone Replacement. Selected Observations from 23 years of Clinical and Laboratory Practice. Ann.N.Y.Acad.Sci. 1057:506-524 (2005)
Hofling, M, MD et al. Testosterone inhibits estrogen/progestogen-induced breast cell proliferation in postmenopausal women. Menopause:The Journal of The North American Menopause Society. Vol 14, No.2, pp 183-190
Holtorf, MD. The Bioidentical Hormone Debate: Are Bioidentical Hormones (Estradiol,Estriol, and Progesterone) Safer or More Efficacious than Commonly Used Synthetic Versions in Hormone Replacement Therapy? Postgraduate Medicine, Volume 121, Issue 1, January 2009
Schwartz, E.T. MD. Hormones in Wellness and Disease Prevention: Common Practices, Current State of the Evidence, and Questions for the Future. Prim Care Clin Office Pract 35(2008) 669-705
Deleruyelle, LJ. Menopausal Symptom and Side Effects Experienced by Women Using Compounded Bioidentical Hormone Replacement Therapy and Synthetic Congugated Equine Estrogen and/or Progestin hormone Replacement Therapy: Part 3 . International Journal of Pharmaceutical Compounding Jan/Feb 2017 pp 6-16
Stephenson, K. MD FAAFP. Salivary Hormone Profile. International Journal of Pharmaceutical Compounding vol 8 no 6 November/December 2004
Wepler, ST. A Review of Bioidentical Hormone Replacement Therapy. International Journal of Pharmaceutical Compounding Vol.6 No.2, March/April 2002