Women embrace a unique physical and biological journey throughout life with changes initially manifesting themselves during puberty with the onset of menses, subsequently with pregnancy, motherhood and later menopause. These stages of the female lifecycle bid significant physiological, emotional and neuroendocrine adaptations. Combining healthy diet and lifestyle with appropriate nutrient and botanical support can facilitate and ease these lifecycle changes, promoting metabolic and hormonal harmony. Further, there are several lifestyle, nutrient and botanical options for the challenges women experience when facing pre-menstrual syndrome (PMS), pregnancy and menopause.
PMS
PMS is estimated to affect 30-40% of menstruating women, with peak occurrences among women in their 30's and 40's. Some of the more common symptoms include depression, anxiety, irritability, fatigue, abdominal bloating, breast tenderness, water retention and food cravings. Many of these symptoms overlap and there is no single cause to explain PMS in every case. Cyclic symptoms commonly appear during the second half (luteal phase) of the menstrual cycle with a symptom-free phase during the first half of the cycle. The most common physiological changes, which occur in women with PMS are an elevated estrogen to progesterone ratio, elevated prolactin and aldosterone levels, hypothyroidism, impaired liver function and reduced serotonin and endorphin levels 1. Effective treatment in most cases of PMS involves lowering the estrogen to progesterone ratio during the luteal phase. An elevation in this ratio may be the underlying factor in the hormonal, neurotransmitter, endorphin, and other physiological disturbances in most PMS cases1.
Diet & Lifestyle: Dietary and lifestyle habits can have a dramatic effect in addressing PMS-related symptoms. Reduction of alcohol, caffeine, salt, refined sugar and carbohydrate intake, along with consuming small to moderate quantities of meat and dairy products could be helpful in reducing symptoms. In addition, a diet rich in organic whole foods including fruits, vegetables, legumes, seeds and nuts may help reduce exposure to "xenoestrogens" (foreign chemicals, which act as "estrogen mimics" found in pesticides, plastics, chemicals, toxins), which have been linked to elevated estrogen levels. Consuming fatty fish, such as salmon, mackerel, and tuna as well as adding ground flaxseed or flax oil to the diet can increase anti-inflammatory prostaglandins, which can in turn reduce the severity of PMS-related symptoms.
Probiotic bacteria, such as acidophilus and bifidus, also play a role in the possible treatment of PMS. Regular probiotic use increases the health of the gastrointestinal flora. Healthy bacteria can ensure the activity of the enzyme beta-glucuronidase, which plays a role in helping the liver to detoxify cancer causing chemicals. In addition, because the liver plays such an important role in estrogen detoxification, healthy gastrointestinal flora are crucial to the detoxification process as a whole 2.
Finally, many studies have shown that women who are engaged in a regular exercise program do not suffer from negative mood states and physical symptoms nearly as often as sedentary women3.
Nutritional Supplements: Vitamin B6 (pyridoxine) promotes healthy levels of neurotransmitters and endorphins, which can be negatively affected by the excess estrogen common in the luteal phase. Due to this role, vitamin B6 has been shown in many studies to be helpful in alleviating PMS symptoms, including breast tenderness, depression, irritability, water retention and bloating (at a dosing of 50 - 200 milligrams (mg) per day) 4. Some people have a difficult time converting pyridoxine into its metabolically active coenzyme form pyridoxal-5-phosphate, so using the coenzymate form may be recommended.
Magnesium deficiency is strongly implicated as a causative factor in PMS as levels in patients suffering from PMS have been shown to be significantly lower than in normal subjects 5. The role magnesium plays is multifactorial. Magnesium is essential for new bone, cell, protein and fatty acid formation. It is also involved in more than 400 magnesium-dependent enzyme systems, is necessary for activating B vitamins and is crucial for energy production. It is thought that chronic intracellular magnesium depletion is a major predisposing factor toward emotional and nervous destabilization 6. In fact, one clinical trial that examined magnesium supplementation showed a reduction of 89% in nervousness, and 96% in breast tenderness (using 360 mg 3 x daily) 7. In another double-blind study, higher-dose magnesium supplementation was shown to dramatically relieve PMS-related mood changes 8.
There are extensive interactions between vitamin B6 and magnesium, as they work together in many enzyme systems. One of the ways in which vitamin B6 may relieve the symptoms of PMS is by increasing the accumulation of magnesium within the cells of the body. In fact, without vitamin B6, magnesium will not get inside the cell.
Calcium is also an important nutrient in relieving PMS related symptoms. Studies show that calcium at 1000-1336 mg per day can improve mood and decrease water retention. It is theorized that calcium improves the altered hormonal patterns, neurotransmitter levels and smooth muscle responsiveness noted in PMS 9, 10.
It is also worthwhile to mention vitamin E in the treatment of PMS. Vitamin E is a potent lipid-phase antioxidant with cardiovascular protective properties. Double-blind studies have shown vitamin E to be helpful in reducing the symptoms of PMS, such as depression, anxiety, low energy, insomnia, fatigue, breast tenderness and food cravings at a dose of 100-400 International Units (IU) per day 11.
Chromium is a trace mineral that plays an important role in helping the body to maintain normal blood sugar levels and is indicated for sugar cravings, which are a common symptom for many women during PMS. Chromium functions in the body as a key constituent of the "glucose tolerance factor" and works closely with insulin in facilitating the uptake of glucose into cells.
Botanicals: As mentioned previously, a key concept in PMS treatment is healthy liver detoxification. If liver function is compromised or "sluggish" then estrogen metabolism is inadequate, which may lead to excess estrogen levels and augmentation of an "estrogen-dominant" state. "Sluggish liver" is also referred to as "stagnant liver qi" in Traditional Chinese Medicine (TCM).
Xiao Yao Wan, a traditional Chinese herbal formula meaning "free and relaxed wanderer," is designed to move stagnant liver qi and tonify the spleen and blood. It is traditionally used for the breast tenderness, fatigue, headache and abdominal distention associated with PMS. Improving liver function provides a multitude of health benefits to hormone and enzymatic pathways for numerous body systems, resulting in healthy estrogen detoxification, improved digestion, enhanced hormonal balance and stable mood.
Vitex is one of the most important herbs for regulating hormones in women. Current scientific literature supports its use for a wide variety of hormonal imbalances including spotting between periods, shortened cycle, lengthened cycle and premenstrual symptoms. Vitex seems to lower prolactin levels, which can be high in women with PMS. In fact, in a recent study of 1,634 women vitex dramatically reduced PMS related symptoms within three months of use. Researchers concluded that "Vitex was proven to be effective with respect to all psychic and somatic symptoms" of PMS with an excellent safety profile 12.
St. John's Wort is commonly used for depressive moods, anxiety, and nervousness and could therefore be an important tool for women with PMS. There have been five separate meta-analyses of St. John's Wort in human trials and in all five articles researchers concluded that St. John's Wort is an effective anti-depressant for mild to moderate depression 13,14,15,16,17. St. John's Wort is thought to affect serotonin levels in the brain. Serotonin is a neurotransmitter associated with the regulation of mood and behavior. An earlier study on St. John's Wort concluded that it must act as a monoamine oxidase (MAO) inhibitor, thereby increasing serotonin levels in the brain.
Later research, however, has produced somewhat conflicting results. Studies have also shown that St. John's Wort might act to inhibit the re-uptake of serotonin, much like the pharmaceutical drug Prozac-a selective serotonin reuptake inhibitor (SSRI)-or that it might interfere with the serotonin receptors, therefore making serotonin more available to the brain. In a recent study of women with PMS, researchers found that St. John's Wort improved PMS-related symptoms by at least 50% in over two-thirds of the women that participated in the study 18.
In summary, it is important for women who regularly experience PMS to know that there are many alternatives that can be used to alleviate the symptoms. Women suffering from monthly PMS can restore themselves to good health by combining a good diet, an exercise program and supplementation.
Pregnancy
Pregnancy is a dynamic state in which the female experiences many physiological stages to miraculously produce new life. Within several weeks of conception, a new endocrine organ-the placenta-is already formed and secreting hormones that affect metabolism of nutrients. Adjustments in nutrient metabolism are driven by hormonal changes, fetal demands and maternal nutrient supply 19. Health status of the mother can impair fetal growth and development but women's bodies are somewhat resilient and can dictate the need for various nutrients by making the nutrients more bioavailable during these periods. The first half of pregnancy is primarily a time of preparation for the demands of rapid fetal growth that occur in the third trimester, so consuming a healthful diet prior to and throughout pregnancy is essential for health of the mother and baby. Although a good diet is the first and foremost way of providing the proper nutrient levels during gestation, a smart supplementation program can also play a critical role in pregnancy outcome.
Key Nutrient Support: Folic acid is the most well-researched and critical of nutrients for pregnancy because of its function in preventing birth defects of the brain and spinal cord called neural tube defects (NTD's). The neural tube is the embryonic structure that develops into the brain and spinal cord. It starts out as a tiny ribbon of tissue but by the 28th day a spinal cord begins to form. When this process goes awry and the neural tube does not close completely, NTD's can result. Folic acid is intricately involved in this process and has also been suggested to help prevent other birth defects including cleft lip and palate. Defects of the spinal cord originate in the first month of pregnancy, before many women even know they are pregnant. This is why it is so critical for a woman to have enough folic acid in the system prior to conception as studies show that 70 % of neural tube defects could be prevented from folic acid supplementation!
Folic acid plays other important roles during pregnancy including helping the mother to produce additional blood cells, aiding in the growth of the placenta and fetus and producing new DNA as cells multiply.
It is recommended that women eat a diet rich in foods containing folate (the natural form of folic acid found in foods). Orange juice, dark green leafy vegetables, broccoli, peanuts, and whole grain products are good sources of folate. But Centers for Disease Control (CDC) statistics show that the average folate intake, from food, for women ages 18-50, is only 236 mcg 20. Currently, it is recommended that all women of childbearing age take a multivitamin, which contains at least 400 micrograms of folate-a requirement that doubles to 800 micrograms a day during pregnancy. The March of Dimes estimates that 50% of food folate is absorbed by the body, while approximately 85% of folic acid in fortified foods and 100% of folic acid in a vitamin supplement are absorbed. However, once in the bloodstream, the body cannot distinguish the origin of the vitamin and thus the function is the same.
Iron is a very important mineral during pregnancy, especially in the second and third trimesters. It plays a critical role in red blood cell division and is required for the manufacture of hemoglobin in both maternal and fetal red blood cells. The fetus acts as a parasite assuring its own production of hemoglobin by drawing upon iron stores from the mother. This can result in iron deficiency anemia, which places the mother at risk for toxemia, labor and delivery complications and an increased risk of a pre-term or low birth weight infant. The blood volume of the pregnant woman increases by about 50% from conception to eight months of pregnancy. As a result, nutrients and synthesis of blood must keep up with this volume. Absorption of iron can increase from a normal level of about 10-30% during pregnancy. The recommended daily intake (RDI) for pregnancy is 30 mg, which is adequate for most women when combined with a healthy diet. Moreover, vitamin C is known to enhance iron absorption when taken with meals.
Calcium also has a wide variety of functions during pregnancy and is important for both the mother and for fetal development. The RDI for calcium increases from 122% to 167% (from 1,000 mg to 1,300 mg) during pregnancy over that for non-pregnant, non-lactating adult women 21. Adequate intake during pregnancy can help prevent hypertensive disorders, decrease the risk of pre-term delivery and reduce leg cramps. Hormonal changes in the mother can also cause extensive adjustments in calcium metabolism, so it is important to provide a consistent supply. Calcium is so crucial to the development of the fetus that during pregnancy the body will attempt to compensate for chronically low intake levels of calcium by making the existing calcium more bioavailable 22. Calcium is also necessary for fetal bone development throughout gestation, although the fetus acquires most of its calcium in the last trimester when skeletal growth is rapid. Some studies show that during the last trimester the fetus will acquire as much as 250-300 mg of calcium from the mother each day, which is equivalent to the amount of calcium found in a glass of milk. Due to its role in absorption of calcium and calcium homeostasis, vitamin D is also essential during pregnancy.
Vitamin A plays many roles in the human system. It is critical for vision, reproduction, integrity of membrane structures, immune response and growth and development. It is therefore a concern that many women of childbearing age consume vitamin A 23. The RDI and recommended maximum level for vitamin A intake during pregnancy is 8,000 IU's per day. The RDI for non-pregnant women is 5,000 IU's per day. Birth defects stemming from lack of vitamin A intake have been reported worldwide but are much less prevalent in the U.S. than many other countries. There has also been extensive research into toxic levels of vitamin A, which have been shown at dosages above 10,000 IU's per day, to be associated with an increased risk of birth defects.
This evidence falls into three categories, which include the extrapolation of data from animals; the equivocal association of high intakes of vitamin A in pregnant women to babies born with defects and the extremely high risk of teratogenicity associated with prescription drugs that are derivatives of vitamin A 24. The risk for toxicity is related to pre-formed vitamin A (retinyl esters) and not pro-formed vitamin A (beta-carotene). A study in 1995 found that women who take more than 10,000 IU's of supplemental vitamin A have a one in 57 chance of delivering a baby with a birth defect 25. For this reason, it is best to limit combined supplementation and dietary intake of vitamin A to 8,000 IU's per day. Again, beta-carotene, found in green and yellow vegetables, has the same positive effects as vitamin A and has not been associated with toxicity in humans or animals 26.
Most physicians do not recommend supplementation beyond the basic multivitamin, due to lack of safety information. In general there is not enough data showing the effect of dietary supplements on fertility, fetal development and breast feeding. In part, this lack of data can be attributed to the ethical issues involved in testing this population group. Three nutrients, however, have been safely studied for their beneficial effect on morning sickness. Vitamin C has been shown to be effective in alleviating morning sickness when combined with Vitamin K. A study dating back to 1952 showed 25 mg of vitamin C combined with 5 mg of vitamin K, over a three-day period, was effective in treating nausea in 91% of the population 27. Vitamin K may alleviate morning sickness symptoms by decreasing placental capillary permeability and preventing the transport of various toxins into maternal circulation. Vitamin B-6 supplementation has also been linked to relief of nausea from morning sickness. In an experimental study, 75% of women taking B6 at 25 mg three times per day experienced complete relief from symptoms of morning sickness, however, 25% did report nausea 28.
Botanicals: Several botanicals have been used traditionally to address some of the digestive upsets such as morning sickness and indigestion that so often occur during pregnancy. Ginger has been used in TCM as a digestive aid for thousands of years.
There have been a few randomized controlled clinical studies on ginger for the following maladies-seasickness, morning sickness and chemotherapy-induced nausea. According to one meta-analysis of these ginger studies, all of the studies "collectively favored ginger over placebo" 29. The Botanical Safety Handbook, published by the American Herbal Products Association, lists dried ginger as contraindicated during pregnancy, but classifies fresh ginger as safe during pregnancy. Fresh ginger, according to TCM, has very different therapeutic properties than dried ginger and is more commonly used in herbal formulations.
For treatment of indigestion associated with pregnancy, hawthorn fruit and German chamomile can be helpful. In TCM, hawthorn fruit is used specifically as a digestive aid, for reducing symptoms of what is referred to as "food stagnation," which includes symptoms such as abdominal pain, bloating, gas, belching and diarrhea. German chamomile soothes the digestive tract and is also useful for indigestion and intestinal cramping. There is some confusion surrounding use of chamomile because there is another species of this herb, Roman chamomile, which is contraindicated during pregnancy and nursing. The Botanical Safety Handbook and several other reliable resources rate German chamomile as safe when used appropriately 29.
Red raspberry is another commonly used botanical during pregnancy for its ability to gently tonify the uterus and facilitate labor. Stinging nettle contains a variety of trace vitamins and minerals, has a high chlorophyll content, and can help relieve fatigue due to blood deficiency. Finally, American ginseng is used for chronic fatigue, depression and nervousness related to stress and depleted adrenal glands. It is tonifying without being too stimulating and can therefore be safely used by pregnant women.
In summary, it is important for all women who are pregnant, or are thinking about becoming pregnant, to not only eat a healthful diet but to supplement appropriately. A practitioner who is well versed in gestational care is essential for assisting the pregnant woman in the design of a nutritional and botanical program that will address her unique needs.
Menopause
Menopause, defined as the cessation of menstrual bleeding for one year, can occur in two ways; women can reach menopause naturally, usually between the ages of 40-58 or it can happen suddenly either by the removal of both ovaries or by damage to the ovaries from chemotherapy or other medical treatments. Women often experience uncomfortable symptoms due to changes in hormone production beginning before menopause, known as peri-menopause. The post-menopausal years refer to the time after menopause occurs, in which the risk of heart disease and osteoporosis increases due to less estrogen production.
Although menopause is not considered a disease and many women have a relatively easy transition with little or no symptoms, other women struggle through the hormonal changes. For example, two-thirds of North American women experience hot flashes, especially in the two years post-menopause 30. In addition to hot flashes, women may also experience night sweats, insomnia, decreased cognitive function, irregular bleeding, vaginal dryness and mood swings.
Hot flashes are the most commonly reported menopausal symptom but what exactly causes them remains a mystery. One theory is that the body's thermostat resets itself during the peri-menopausal years and incorrectly perceives an excess of heat, directing the body to cool down. As a result, blood vessels near the skin surface dilate, causing blood to rush to the surface. This action creates flushing and sweating in the body's misguided attempt to cool off. When hot flashes occur at night, accompanied by profuse sweating, they are referred to as night sweats. Sometimes women can identify specific triggers that lead to increased hot flashes. For many women, alcohol, spicy foods, caffeine, emotional upsets or just a warm day can bring on hot flashes.
Avoiding these triggers can help reduce the frequency and severity of hot flashes.
Hormone replacement therapy (HRT) still remains the treatment of choice for many women in relieving menopausal symptoms. In 1966, Robert A. Wilson, M.D., author of the book, Feminine Forever, revolutionized the way in which the medical profession treated women with menopausal symptoms. He argued that menopause was a disease that was the result of "estrogen deficiency" and that regular use of estrogen replacement therapy could keep women youthful and vibrant forever 31. Estrogen replacement therapy (ERT) thus became the treatment of choice by the medical profession for menopausal women. Unfortunately, many years later, researchers discovered that ERT more than quadrupled a woman's chances of getting uterine cancer. As a result, a form of progesterone-progestin-was added to estrogen to reduce the risk of uterine cancer. The progesterone/estrogen duo is known as hormone replacement therapy, or HRT. HRT relieves hot flashes and also reduces the risk of osteoporosis. It was also formerly thought to reduce the risk of cardiovascular disease, but this benefit is now in question as recent research has indicated HRT might increase the risk of heart attack and stroke, especially in women who have a history of heart disease. It was these findings that prompted the American Heart Association (AHA) to issue a statement in July, 2001, which said HRT should not be used in women with pre-existing cardiovascular disease, and that there is insufficient evidence to justify using HRT as a preventative treatment for women that do not have heart disease 32.
Because of the risks associated with HRT and ERT, many women are choosing alternative routes to address their menopausal symptoms. Diet, exercise, nutritional supplements and botanicals are just a few of the tools that might help to curtail symptoms related to menopause, while providing added protection against heart disease and osteoporosis.
Diet: Phytoestrogen-containing foods, such as soy, are theorized to reduce hot flashes and related symptoms. One recent study found a link between soy consumption and reduced hot flashes in Japanese women 33. Another study found that a 100 mg dosage of isoflavones from soy alleviated hot flashes and offered cardiovascular protection 34. And yet another study found evidence that regular consumption of soy foods may protect against bone loss in menopausal women 35.
For many women, the addition of soy to the diet or perhaps a soy supplement could prove to be advantageous for symptomatic relief as well as for providing long-term health benefits. It is important to note that soy is not the only source of phytoestrogens. Legumes (black beans, lentils, peanuts, split peas, red beans, pinto beans, chick peas, and lima beans) are also rich phytoestrogen sources. Legumes, in addition to soy, would be helpful to add to the diet on a daily basis. However, because approximately 10-20% of the Western population have difficulty digesting soy, it is important not to become overly soy-focused.
Lignan containing foods, such as cereals and grains, are also important to add to the diet. Lignans are also phytoestrogenic, possess anti-cancer properties and have an antioxidant effect in the body. Flaxseeds are the richest source of the phytoestrogenic lignans and are easily added to the diet by grinding and sprinkling onto salads and cereals.
Omega 3 oils are also valuable to menopausal women for their anti-inflammatory and cardiovascular protective effects. The best sources of omega 3 oils are found in fatty fishes, such as salmon, mackerel, tuna and sardines. In addition to alleviating dry skin, constipation and boosting the immune system, long chain omega 3 oils (EPA and DHA) can balance hormones and increase cognitive function. Flaxseed contains omega 3 oil, which requires a conversion to EPA, whereas fish oils require no such conversion, rendering EPA and DHA readily available.
Nutritional Supplements: In addition to a healthy diet and an exercise program, a multivitamin can be an important addition to daily regimens as women go through menopause. Multivitamins provide antioxidant support as well as B vitamins, including folic acid, B6 and B12, which play an important role in reducing the homocysteine factor, therefore protecting against cardiovascular disease. Furthermore, multivitamins provide some calcium and vitamin D, along with other important minerals to support healthy bones.
In addition to a multivitamin, however, it is important to add calcium and vitamin D supplements for bone health. In fact, one study found that HRT worked better for protecting bones in elderly women at a lower dosage when combined with calcium and vitamin D 36.
Many alternative guides recommend the use of vitamin E for hot flash relief and vaginal dryness based on preliminary studies, but additional research is needed for confirmation 37. Vitamin E does play an important role in helping to prevent heart disease. One large clinical trial showed that even a low dose of vitamin E can decrease risk of heart disease and stroke in women 38.
Botanicals: Black cohosh is a phytoestrogenic herb that has been shown in some studies to reduce many menopause-related symptoms, including hot flashes, vaginal dryness, anxiety and depression. In at least one randomized double-blind study, it was shown to reduce menopausal symptoms. In this particular study, researchers compared black cohosh to estrogen over a 12-week period and found that black cohosh performed better than estrogen or placebo in reducing hot flashes, night sweats, depression and increasing vaginal lubrication 39. It is important to note, however, that black cohosh is for reducing symptoms such as hot flashes and other menopause-related symptoms, but it has not been shown to reduce the risk of heart disease or osteoporosis.
Ginkgo biloba can help increase mental clarity, concentration and libido, which are often adversely affected during the peri- and post-menopausal years, as well as alleviate poor circulation. In relation to these symptoms, ginkgo can serve three purposes; there is a plethora of evidence indicating ginkgo as efficacious in improving memory and concentration; ginkgo increases blood flow to the periphery of the body and could potentially help in reducing cold hands and feet that sometimes plague post-menopausal women and there is preliminary evidence suggesting ginkgo may be helpful in reducing sexual dysfunction in post-menopausal women.
Tien Wan Bu Xin Dan is an ancient Chinese formula that is helpful for reducing anxiety, encouraging healthy cardiovascular function and promoting restful sleep. It is used by both men and women in China as a long term daily tonic. It could be a useful tool for menopausal women who have difficulty sleeping and tend towards anxiety or depression. It can also be used as a tool to strengthen heart function.
Liu Wei Di Huang Wan or Zhi Bai Di Huang Wan are two Chinese formulas that are often prescribed for women with hot flashes and night sweats. In TCM, menopausal symptoms are often thought to arise from a Yin deficiency. Yin is the part of the body that has to do with coolness and fluids. If the Yin is low people can experience heat and sweating due to the Yang, or fire, becoming dominant without the cool, nourishing Yin to keep it in check. Both formulas nourish the Yin of the body and are often helpful in relieving menopausal symptoms.
Alternatively minded practitioners also recommend dong quai as one possible remedy for hot flashes, but dong quai is not typically used by itself in TCM to treat menopausal symptoms. Instead, it is often prescribed with other herbs, and then only if a woman exhibits blood deficient symptoms, such as pale face and fatigue. It may be helpful for some menopausal women but because dong quai is a blood tonic, it should only be recommended to women with blood deficiency. A study conducted a few years ago in California confirmed that dong quai by itself is not a useful remedy for menopausal symptoms and showed that it had no phytoestrogenic activity 40.
In summary, it is important for women who are experiencing menopausal symptoms to know that there are many alternatives that can be used in addition to, or instead of, HRT. Although this article discusses a few of these alternatives, many more exist. Each woman will need to evaluate her degree of menopausal symptoms along with her risk of heart disease, cancer and osteoporosis with a physician educated in all treatment options, or with a combination of a Western trained physician and alternative health care practitioner in order to design the best nutritional, botanical and hormonal program that will address her unique needs.
About the authors: Marci Clow, Susan Beck and Michele McRae are part of the R&D team at Rainbow Light Nutritional Systems, Santa Cruz, CA. Marci is the director of research and quality and is a registered dietitian with a master's degree in nutritional science; Susan Beck is the senior manager of herbal science and is a licensed acupuncturist with a master's degree in Traditional Chinese Medicine (TCM) and Michele McRae is the manager of nutrition and formulation and is a certified nutritionist with a BS in nutritional science and dietetics. They can be reached at 800-635-1233; Website: www.rlns.com.
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