December 2007
The medical mainstream clings to measuring cholesterol levels as if they were the last life raft in the sea of civilized medicine. It seems as though too many doctors have been programmed to believe that cholesterol numbers are the defining criteria for the presence or absence of heart disease. The truth of the matter is that this pigeonhole approach has made them miss the bigger picture.
This national obsession with cholesterol isn’t really a surprise when you consider who’s helping to drive it—the drug companies. Cholesterol drugs aren’t just another product in their profitable inventory. Lipitor alone is a $13 billion plus-per-year payday for its maker, Pfizer, and that’s hardly small potatoes.
But your cholesterol number is just one of the many pieces making up your heart-health puzzle. No matter what the clever ad campaign says, there’s more to protecting your heart than just solely focusing on lowering your cholesterol levels. Here’s an eye opener for you: Nearly half of those who suffer from an initial heart attack have normal cholesterol levels. I remember one night when I was on call in our little 24-bed hospital. I had admitted two patients with heart attacks, and both had rock-solid, normal cholesterol levels. One of the patients was even on Lipitor.
So much for the grand herald of heart disease. It’s time to set aside the snapshot approach to your heart health, because it’s just not enough. The last thing I want is for you to have a heart attack when you thought you were in the clear, all because you were told your cholesterol level was normal.
And there are some surprising links to heart disease that tend to get brushed aside in favor of the cholesterol fanfare.
Cholesterol’s conniving instigator
I’ve talked before about the insidious nature of inflammation. It’s a chameleon, quietly blending in with and playing in the background of numerous disease processes. Those diseases get the medical limelight once onstage—but no one finds the underlying cause to be glamorous enough to give much attention. And it’s the very thing we should be keeping a close eye on.
Inflammation is how your immune system spells “confusion.” That turmoil results in a barrage of beatings to the rest of your body, changing the role of the immune system from protector to a destructive force. And where your heart’s concerned, ongoing inflammation aggravates any existing plaque, making it more likely to break open and block an artery, causing a heart attack.
Inflammation also injures the lining of the blood vessels that supply nourishing blood to your heart. That injured lining provides a birthing ground for the formation of cholesterol-laden plaque, which can eventually break open and cause a heart attack.
The best measure of inflammation is the highly sensitive C-reactive protein (hsCRP) blood test. Let’s focus on three main factors that feed the inflammation beast: blood sugar, insulin and fat cells. Too much of any of them is a bad thing. Too much fat, especially centered around your middle, promotes inflammation. Even a 10 to 20 pound weight loss can make a big difference.
Insulin lowers blood sugar by pushing it into your cells where it gets burned up as energy. Diabetes occurs when your pancreas can’t make enough insulin to get the job done. By then, both your insulin and blood sugar levels are too high. Even before diabetes happens, there’s a period—often years—where your blood sugar may look “normal,” but you’re making too much insulin for your own good. High levels of insulin suppress your blood sugar levels. Your body’s cells try to resist insulin’s efforts to push sugar into them from your blood. This is called “insulin resistance.” Genes are a factor but the main causes are a lousy diet, excess body weight and too little physical activity.
High insulin levels—even in the presence of “normal” blood sugar levels—are a menace: They contribute to the formation of atherosclerotic plaque, promote the oxidation of LDL cholesterol into its more harmful form, and increase the likelihood that you’ll form artery-blocking clots. They also make you retain water and sodium, which elevates blood pressure and boosts blood triglyceride (TG) levels—adding to your risk of heart disease.
This is an intricate, dynamic interplay between insulin and cholesterol, and that’s a big reason why snapshot cholesterol levels barely scratch the surface.
Let’s be clear: Cholesterol is actually an important molecule in your body, serving as a building block for your hormones. It’s also an integral part of your cell membranes and works as a repair molecule. Cholesterol is doing all sorts of things, depending on what your body needs. But when inflammation gets in the mix, it basically instigates cholesterol to misbehave.
For example, high blood-sugar and insulin levels tell your liver to package up LDL “bad” cholesterol, also created in your liver, into apo-lipoprotein B-100, Apo B-100 for short, where it can accumulate on your artery walls as dangerous plaque.
On the flip side, you have apolipoprotein A1(Apo A1), which packages up your HDL “good” cholesterol and carries it away from the artery walls and back to your liver. There, it gets broken down and eventually excreted through your bowels. So the balance between cholesterol influx (into the artery wall) and efflux (back to the liver) is a key factor in what’s really going on with cholesterol and how likely it is to cause heart trouble.
Is your cholesterol fluffy?
Heart-disease risk involves more than just how much Apo B and Apo A1 are in your system. It’s a classic case of when size matters, and I’m talking specifically about your LDL and HDL particles. If you have small, dense LDL particles, they’re more likely to insinuate themselves into your artery walls. Once implanted, they’ll form that highly undesirable and potentially artery-blocking plaque. LDL particles that are large, buoyant––fluffy, even—are much less likely to do so.
But having large particles is not the best-case scenario when it comes to your HDL. When HDL particles are smaller, they’re more agile and can transport that much more cholesterol back from the artery walls to the liver where it gets broken down, which is a good thing.
To recap: Large LDL particles = more benign, and small HDL = more helpful.
These should be your particle-size goals. (I’ll be explaining how to find out what yours are in a moment.) It’s important to know that your LDL and HDL numbers can look perfectly normal on standard blood tests—without particle size having been taken into account. If you happen to have the more dangerous particle-size patterns, you could very well be a heart attack waiting to happen. Once again, so much for “normal.”
LDL’s brutish buddy
Lipoprotein(a) doesn’t get much press but should. It’s a nasty little particle made in the liver that attaches itself to cholesterol particles, aiding and abetting their building up in your artery walls. High levels are inherited and can be present in the face of perfectly “normal” cholesterol levels. I often see elevated levels in someone with a family history of early heart disease and normal cholesterol levels.
Bill, a patient of mine, comes to mind. When I first began treating him and took an extensive medical history, I asked him about any family history of heart disease. He looked puzzled a moment but then sat back and replied, “Well, my dad had his first heart attack when he was 48. We always thought he was healthy as a horse up ‘til then. Normal cholesterol. He didn’t smoke and was skinny as a rail. He even chopped wood all his life! The heart attack came as a real shocker.”
Niacin and estrogen will lower levels some. Niacin in particular has been found to lower LDL and triglyceride levels, raise HDL levels, and have a positive influence on lipoprotein(a). If your lipoprotein(a) level is elevated, your best bet is to get aggressive about addressing all of the risk factors of heart disease that we’ve talked about. Let’s start with the first step.
A journey of a thousand miles begins with a few tests
Right off the bat, you need to get clear on what your numbers are. Here are the things you need:
(1) Glucose and insulin testing After an overnight fast, you’ll be given a blood test that will measure your fasting insulin and blood sugar levels. A level over 90 could mean diabetes, unless you start making changes today. A fasting insulin of 5 to 6 is ideal. Anything over 10 spells trouble down the road. Measuring both glucose and insulin two hours after a 75-gram drink of sugar water can be useful, especially if your fasting numbers are borderline.
(2) VAP test This one will let you know how much Apo B and Apo A1 are in your system and also analyze your LDL and HDL particle sizes. The ideal ratio between Apo B-100 and Apo A1 is 0.7 or less. Go to www.thevaptest.com to learn more. Similar tests are available from Berkeley Heart Labs (www.bhlinc.com) and SpectraCell (www.spectracell.com). Check the fine print of your medical insurance coverage to be certain you follow their lab-work guidelines.
(3) Highly sensitive C-reactive protein On this test that measures inflammation, less than a 1.0 is ideal. Anything between 1.0 to 3.0 is borderline, and the higher it runs over a 3.0 spells a corresponding increase in risk for heart disease.
You can also use your triglyceride (TG) level as a rough guide to both LDL particle size and how well your HDL is working. A high TG level is bad news, another risk marker of heart disease. An ideal level to aim for is under 100. A low ratio of TG to HDL is also desirable. If it’s over 4-to-1, your risk of heart disease will increase. Shoot for a ratio of 2-to-1 (e.g. a TG level of 100 and an HDL level of 50).
A few folks inherit high TG levels—I’ve seen them well into the hundreds and even, in very rare cases, higher than a thousand. There’s also an inherited pattern of moderately high TG levels (over 200) and low HDL levels (less than 40) that often accompanies diabetes. So be aware not just of your numbers but what they mean.
I have my numbers…now what?
There are some natural remedies you can use to get your numbers in alignment. To lower your TG levels, try niacin, which is good old-fashioned vitamin B3. As a bonus, it’s also one of the few agents that’ll boost HDL. As you raise your HDL level, it’ll go to work to clean up your LDL. The higher doses needed for this purpose, 500 to 2,000 mg per day, are doses one might take when using it as a drug rather than as a supplement. Take it before bedtime.
It can cause flushing and has some potential liver toxicity, so use it under the supervision of a health-care professional. A “natural” form of niacin, inositol hexaniacinate, is essentially flush-free with a much lower risk of liver problems but is generally much less effective at moving the numbers in the right direction. It’s certainly worth a try, though. If it works, you’re in business—without having to try high-dose niacin and risking the side effects.
The truth is, most of you can normalize your TG levels with diet, exercise and fish oil. That same regimen will confer an overall anti-inflammatory effect. This is the very thing we started out looking at as a risk factor. Adopt a healthy whole-food diet, eliminating all the processed foods loaded with high-fructose corn syrup and trans fats (aka hydrogenated and partially hydrogenated fats). As for fish oil, you’ll want to take 2 to 3 grams total EPA and DHA (check the figures on the label and add them up yourself). It can also boost HDL levels, lower Apo B-100 and help maintain healthy blood sugar levels. I like a product from Nordic Naturals. Go to www.nordicnaturals.com to locate a store near you that carries their products. You can also look for Carlson, Spectrum, or Jarrow products.
Do you want to feel better all the time and have a healthier immune system? Then gird your gut for the task, because it does play a central role—literally and figuratively.
A poorly functioning gut can’t even begin to adequately process the 40 to 60 tons of food you’ll consume in a lifetime. It already works overtime to sort out the good stuff from the bad.
When your gut doesn’t perform well at this so-called “barrier” function, the result is an overloaded immune system and a surge in inflammation throughout your body. That will put you at risk for a whole host of chronic degenerative diseases that plague modern societies. The list includes heart disease (for more on heart disease, see the front-page article of this issue), diabetes, arthritis, dementia and cancer.
Many of my patients complain of suffering from heartburn. It’s a common misconception that heartburn is simply the result of too much stomach acid. But as you age, you produce less stomach acid—slowing down your digestion. Also, the protective mucosal layer of the esophagus and stomach can thin out—increasing the likelihood of heartburn symptoms and ulceration.
Heartburn is a common symptom (along with bloating) of gastroesophageal reflux disease (GERD). Stomach acid backs up into your esophagus when the valve between your stomach and your esophagus doesn’t close properly. It’s associated with one of the fastest-growing cancers in this country—esophageal cancer. Acid has no business visiting your esophagus, because it will burn your esophageal lining.
As you might guess, I’m not a big fan of acid-blocking medications like little purple pills. These weren’t originally intended for long-term daily treatment except for certain rare disorders. Yet they’ve somehow transitioned into a daily habit for millions of Americans, no doubt to the never-ending delight of the drug companies.
A typical lazy response: Band-aid a symptom and ignore the underlying causes.
What you need is to strengthen your gut—and you’ll be happy to hear that it doesn’t require sit-ups. These are my top 10 picks—and common-sense suggestions—for building and protecting your mucosa, for improving your digestion by breaking down food more efficiently, and for promoting healthy gut bacteria.
Flora friendly
Your gut hosts a population of bacteria, or flora. They’re a varied lot, made up of both healthy and disease-causing bacteria that must live in a balanced state for optimum health. Common gut-flora strains that aid in digestion include the Lactobacillus and Bifidobac-terium groups. Here’s a fact you can wow your friends and neighbors with: Over 70 percent of your immune system is located in your gut, where all of the sorting goes on for everything you put in your mouth. And in order to promote the health of your immune system, you need a zealous population of healthy bacteria—probiotics (meaning “for life”). They also act against candida albicans, the overgrowth of which results in candidiasis (or “thrush”). Probiotics also protect against food-borne toxins, enhance the absorption of vitamins and minerals, and support toxin removal from the colon.
Even gut flora get support
Prebiotics are undigestible fibers found in fruits and vegetables. They support probiotics in their role of maintaining gut health by promoting their growth. Fructooligosaccharides (FOS) are a commonly mentioned type of prebiotics. You can ingest them naturally from many foods, including garlic, onions, Jerusalem artichokes, asparagus and chicory. And it seems that as a country, we’re not getting enough. The average daily ingestion of prebiotics is about 2 grams, but 5 to 6 grams are recommended. A good supplement comes from NOW and it’s called Inulin Prebiotic FOS, available in many vitamin and health food stores or via the internet.
Increase your acidity
As I mentioned, gastric-acid production decreases as we age. Add to that the regular administration of antacids, anything from self-prescribed TUMS to power prescription meds like Nexium, Prilosec and Prevacid, we’re further aggravating the situation. Let’s be clear: You need stomach acid. It’s necessary for the initial breaking down of food in the stomach. It’s also required for the normal release of pancreatic and biliary enzymes and for aiding the availability of nutrients. Large proteins only partially broken down can pass into systemic circulation, provoking a generalized inflammatory response. Digestive enzymes are therefore beneficial, improving digestion, helping to treat a slew of conditions ranging from GERD to eczema, and even having the potential to prevent age-related macular degeneration (ARMD). You can get these digestive enzymes in a formula. Look for one that includes at least protease (100,000 USP units), lipase (20,000 USP units), and amylase (100,000 USP units). Take 2 to 3 tablets just before meals. Betaine HCL is commonly used to promote increased stomach acidity, best under the supervision of a health-care professional. Here’s a natural way to fend off meal-related symptoms such as heartburn: Simply slow down your fork transit and take the time to chew your food thoroughly. It’s called “drinking your solids and chewing your liquids.”
Myth-busting
There’s a common misconception that stress promotes acid secretion, burning the holes in your stomach that we call ulcers. The fact is, stress provokes hormonal changes that cause your digestion to slow down and the protective mucosal layer of your stomach to thin out and break down. Most of us don’t make enough stomach acid—again, especially as we age. Adequate stomach acid is necessary for the proper absorption of nutrients like calcium and magnesium, for protein digestion, and for control of harmful bacteria.
Gut killer without conscience
Antibiotics have been used irresponsibly for years, sparking the advent of resistant super-germs. They wreak havoc on the normal balance between healthy and unhealthy gut bacteria, disturbing immune-system function. If you ever do need an antibiotic, take a high daily dose of a probiotic. I recommend 10 to 20 billion colony-forming units. This will protect against diarrhea. There’s one potentially fatal bowel infection associated with antibiotics, called C. difficile colitis. A probiotic yeast, Saccharomyces boulardii, is especially helpful against it. Frequent antibiotic use in women may be a factor in breast cancer. Not to mention, all of those antibiotics freely prescribed by pediatricians for ear infections, which can cause long-term compromise of the immune system in kids.
Toss these gut shredders
Don’t let these seemingly benign pills fool you: They’re all potential statistic makers. Nonsteroidal anti-inflammatory drugs like ibuprofen (Motrin, Advil), naproxen (Naprosyn, Aleve), celecoxib (Celebrex), and indomethacin (Indocin) are respon- sible for an estimated 15,000 deaths per year. They compromise the integrity of the mucosal lining of your stomach, provoking ulcers and bleeding. Amazingly, few people outside of the medical profession are aware of this. It’s a rare day in the hospital when I don’t have to care for an elderly patient, usually from a nursing home, who has suffered gastrointestinal bleeding due to NSAIDs. Daily use is also inviting other problems such as heart attacks and kidney failure. Intermittent use—a few times per month, for example—for no more than a few days at a time should be OK for most. But there are safer options. Fish oil is a great remedy: Take 2 to 3 grams total EPA and DHA of it daily.
Take your bitters
The substances found in bitter-tasting plants help stimulate gastric acid, aid the flow of bile in the liver and repair the gut wall. The value of a bitter “digestif” before a meal has been recognized and practiced for thousands of years by many cultures. Strangely, it’s a flavor left out of most American diets—to our detriment. Examples would be dandelion and mustard greens, escarole and chicory. There’s also a fine tonic called Swedish Bitters, widely available in most natural food stores. You can also get it online at www.swedishbitters.com.
Apply a soothing gut glue
Demulcent is just a fancy word used to describe some useful old-time favorites: licorice and marshmallow. I’m referring not to the candy store variety, but specifically to the remedy versions, deglycerinated licorice (DGL) and marshmallow root. These are soothing, mucilaginous (“gluey”) substances that quell gut inflammation. They help build and support a healthy mucosal layer. Regular licorice has an “aldosterone-like” effect. (Aldosterone helps regulate your sodium and potassium levels.) It can cause salt retention and high blood pressure in some people while in others it’s useful for exhausted adrenal glands, but best used only under the care of an experienced practitioner. DGL doesn’t cause the retention or a blood-pressure problem. It’s great for healing ulcers, though.
Mellow your middle with this Mediterranean native
This broad-leafed succulent plant, native to Mediterranean climates, has been used for thousands of years in many cultures, spanning from ancient Egypt to China. It has a gel rich in tonifying polysaccharides (a type of carbohydrate), which contains some of that famous healing component. It can also function as a soothing demulcent and is excellent for gastroesophageal reflux disease (GERD), heartburn being the main symptom. Be sure to use an aloin-free gel formulation, which most are. Aloin is a powerful, cathartic laxative that inevitably causes diarrhea.
Mucosal mender
One study showed that when you give a powerful NSAID like Indocin (indomethacin), gut permeability increases threefold. But zinc carnosine, taken in a dosage of 37.5 mg twice per day over a five-day period, prevents this. It protects the gut and stabilizes and heals its mucosal lining. It’s excellent for healing ulcers as well as treating “leaky gut” syndrome. (Leaky gut syndrome can be caused by NSAID and antibiotic overuse—surprise, surprise.) Two high-quality products are Zinlori by Metagenics (available only through certain healthcare practitioners—go to www.metagenics.com to locate one) and PepZinGi by Jarrow (www.jarrow.com and also available in grocery stores and pharmacies).
By the way, no smoking is allowed. You can add GERD and stomach ulcers to the long list of diseases in which smoking is implicated.
This plant grows in dense thickets, and could make your hair do the same
Patients come to me with a variety of health concerns. There are some with quite serious illnesses but others who have simply the nagging little annoyances that any of us can be afflicted with from time to time.
Self-esteem is as important a piece of the total health picture as, say, eating right or getting plenty of fresh air and exercise. One thing that some of my friends and patients are concerned about is hair loss. And while some decide to embrace their hair loss—one of my patients has taken to shaving his head in a “Mr. Clean” tribute, others want their hair back.
The main cause of over 95 percent of the hair loss in men is what we call androgenic alopecia. A key factor is the excess conversion of testosterone to a form called DHT via an enzyme known as 5-alpha-reductase. The well-known drug finasteride (Propecia, Proscar) blocks this enzyme. Studies have shown it reduces DHT levels in the scalp and encourages hair growth. As a result, it is FDA-approved for male hair loss.
But who wants yet another prescription to take? I’ve heard a few anecdotal reports through a friend about using saw palmetto for this very purpose—and it seems to work. So, I decided to do some research.
Normally, saw palmetto is associated with treating prostate problems. It has a long history of use in treating mild to moderate enlargement of the prostate, called benign prostatic hypertrophy (BPH). However, it may work in a similar fashion on the 5-alpha-reductase enzyme.
Finasteride is a drug with considerable side effects, including erectile dysfunction and loss of libido (making loss of hair seem almost mild in comparison). It may also encourage an especially aggressive form of prostate cancer. Not many men want to sign up for these types of problems and are obviously reluctant to risk them by taking this drug. Though I do have to say that for some guys, when it comes to their hair—all bets are off. So it’s important to find a safer solution.
Very little research has been done to date, but the good news is that there has been some. One small study was done with 19 male participants ages 23 to 64. All of these gentlemen had mild to moderate androgenic alopecia. Each of them received 200 mg of saw palmetto plus 50 mg of beta sitosterol, a plant sterol that is used both to treat high cholesterol and BPH. In the prostate, the exact way it operates has yet to be understood. At any rate, at the end of the study, 60 percent of the participants showed improvement. Obviously, larger studies are needed—and I suspect we’ll begin to see more.
What this means for you, however, is this. It’s worth a try for three months. If it works for you, you’re in business—no side-effect-laden prescriptions needed. Go ahead and include the beta sitosterol if you wish, though, from the research, it’s unclear whether it helps or not. Saw palmetto is pretty inexpensive and easy to find on store shelves. (I like the widely available, high-quality product made by Nature’s Way.) We don’t yet understand all the reasons as to why it works for some individuals and not for others. But it’s safe (certainly safer than finasteride), and here’s a bit of a bonus to go along with it: Some men report that it boosts their libido. That should be a little extra incentive for you to at least give it a three-month trial period.
Mysteries that have been known to work miracles
Q.I’ve heard that spirituality can promote good health, but I’m wondering if that’s not just a “new age” idea. On occasion, I’ll feel a little anxiety, but not so bad that I want to take a drug for it. I’ve been thinking that I should try doing something spiritual, maybe even going back to church, just to find that natural sense of calm I used to enjoy. I’m intrigued by people who are quite spry even after having conquered various physical ailments that would fell most. I notice they all tend to have a strong spiritual core in common. What’s your take on this?
––A. Spruce, Reno, NV
A.You’re not alone in your curiosity. There’s a remarkable story that has been developing about the connection between spirituality, faith and living a longer, healthier life.
It seems that modern medicine—with all its bells and whistles—still leaves something to be desired, literally. Healing is a multilayered practice, and I believe we’ve only scratched the surface of fully understanding all there is to know—if it’s even fully knowable.
There’s an impressive history in our religious traditions of rituals that have been conceived of and practiced for thousands of years that promote good health.
These rites run the gamut: Prayer, meditation, meaning-making (finding meaning for your life), deep breathing, music, communal worship, forgiveness and compassion. That’s a buffet of options and it provides an opportunity for truly complementary medicine.
That’s not to say that there aren’t many wonderful miracles provided daily by medicine. Thank God that today we do have so many options available to us and that we don’t live a thousand years ago (at which time I may have only been able to offer my patients a good blood letting!)
Medicine is powerful, but it seems that the majority of practitioners in the medical field feel we must make a choice: That we somehow can’t mix high-tech gadgets with things that we can’t necessarily see or quantify but many of us believe—and some of us even know from personal experience —works.
And you can’t practice medicine for too long without running up against a case that you just flat-out can’t explain. It’s not in the medical books, and there’s only one way to describe it (I’ve even heard seasoned medical professionals refer to it this way): a miracle.
Your body is a marvelous system that continuously works to repair and regenerate itself. There are mind processes that, though we can’t see them, have effects on our bodies. They can be measured in our brain waves, as seen in studies done with meditation. Prayer is a similar mind-and-body process, though the “how-it’s-done” part of the equation may be different.
Scientists have long been curious about this whole subject. More and more research has been done, con-firming what has been known through faith, intuition, insight and personal practice for ages.
I am especially interested in the role that I see faith and participation in a worship group plays in my patients’ health. Research actually suggests something that is already believed and practiced by many: That gratitude, forgiveness, worship with a group and having a belief in a higher power are associated with reduced risks of depression and anxiety problems.
Also, these very things form the foundation of addiction and recovery programs—helping folks create positive intentions that take them down the path to recovery and provide deeper meaning in their lives for support.
Prayer has also been associated with a reduced risk of heart disease. In folks facing a chronic disease or terminal illness, spiritual beliefs and practices have been associated with greater life satisfaction, a greater degree of content-ment, and diminished pain and anxiety. There’s also evidence that attendance at religious services improves the likelihood of living longer, even after taking into account such common health risks as smoking and high blood pressure.
There’s a phenomenon called “self-efficacy”, which is the ability of people who are determined to get better or lick a certain health problem to actually find a way to do it—just as you mentioned. I see this over and over in my own practice. It’s often associated with a firm belief that we have had the primary tools for achieving repair and healing all along—it’s just a matter of practicing with them.
Now, that’s what I call a positive attitude—and it goes a long way in the healing process. Hey, how many people believe in the power of pharmaceuticals and the best wishes of the drug companies? But they’ll laugh off these phenomena just because they can’t see them, touch them, or shake them out of a bottle—much less explain them.
As the research continues, I imagine the topic will remain a controversial one for some time. In the meantime, I encourage you to attend to your spiritual side—defining what that means to you. It’s a personal decision, whether it be learning to meditate, adding regular prayer to your daily ritual, or going back to church as you mentioned. You’ll be amazed by how any of these practices can bring you results that you thought were available only in a prescription bottle.
The text contained herein does not constitute medical advice. Health Revelations advises that you consult your own physician before acting on any recommendations contained within this publication.
Posted in Newsletter.
