Jun
10
2024

About Aging and a Prolonged Life

The topic “about aging and a prolonged life” is always popular with people. CNN recently discussed this topic with the Nobel prize winner and molecular biologist, Professor Venki Ramakrishnan. He shared the 2009 Nobel Prize in Chemistry with Thomas A. Steitz and Ada Yonath for research on the structure and function of ribosomes. Ribosomes are sub particles in the cell responsible for making proteins. In the following I will summarize this interview.

What is aging?

150 years ago, people lived only about to 40 years. Today we can live up to 84 years in most countries. It is because medicine has learnt a lot about the reasons why diseases occur and how they can be cured. Physicians have a number of antibiotics available for those who suffer infections. Heart bypass surgeries and stents can prolong a person’s life when there is hardening of the coronary arteries.

Aging processes

The following aging processes occur all our lives:

  • DNA breaks happen in our cells, but repair mechanisms are in place that deal with this. With older age repair mechanisms are more sluggish.
  • Faulty proteins form inside cells, however, we have mechanisms to take care of that.
  • Chemical damage to molecules in our cells accumulates. The cells can only partially eliminate these.
  • Hormone disbalances occur during menopause and andropause. But anti-aging physicians can correct this by doing hormone tests and ordering bioidentical hormone supplements.
  • There are limits of what anti-aging medicine can do: osteoarthritis affects our joints; our muscles are aging and with it our heart muscle. Degenerative neurological diseases like multiple sclerosis, Parkinson’s disease and dementia occur frequently as we get older with no effective therapies.
  • The immune system weakens with age. To a certain extend vitamin D3 and other supplements can strengthen it, but only to a certain extent.

Systems working together in our body

Dr. Ramakrishnan said that our bodies work like cities. In it are various systems that need to work together to keep us alive. If a major system fails, we die. Some of the essential organ systems are the heart, the brain, kidneys, our gut, the lungs, the bone marrow and all our hormone glands. If one of these organs breaks down, we are in trouble. If an organ donor is not available, we perish. But even when everything is working together well, we are limited reaching a maximal lifespan of about 120 years. This has to do with limits of our cell metabolism and the aging processes mentioned above. Science has not found a way to prolong our maximal lifespan and likely will not find one soon. But there are various lifestyles that can prolong life as I mentioned here before.

Genetic effect on our lifespan

CNN asked Dr. Ramakrishnan what genetic effects there are that would transmit longevity from a parent who lived until 95 or older to a child’s lifespan. He answered the following:There is a correlation between the ages of parents and their children, but it’s not perfect. A study of 2,700 Danish twins showed that heritability — how much of our longevity is due to our genes — only accounted for about 25% of lifespan. Still, researchers have found that mutation in just a single gene can double the lifespan of a certain type of worm. Clearly there’s a genetic component, but the effects and implications are complex.”

Relationship between cancer and aging

The same genes are involved for the growth of the body at a young age, and the older person who comes down with cancer. In old age the same genes can cause cancer and dementia. Dr. Ramakrishnan said: “Our risk of cancer increases with age because we accumulate defects in our DNA and genome, which sometimes cause gene malfunctions that lead to cancer. But many of our cellular repair systems that seem to be designed to avoid cancer early in life also cause aging later.”

Apoptosis (programmed cell death) and senescent cells

The body has two mechanisms in place that counter the danger of developing cancer cells. Dr. Ramakrishnan explained: “For example, cells can sense breaks in our DNA that might allow chromosomes to join in an abnormal way, which could lead to cancer. To prevent that joining, a cell will either kill itself or enter a state called senescence, where it can no longer divide. From the perspective of an organism like us, which has trillions of cells, this makes sense. Even if millions of cells are destroyed this way, these actions protect the whole organism. But the buildup of senescent cells is one of the ways we age.”

Lifestyle changes that help you live longer

Dr. Ramakrishnan said that our grandmothers knew what a healthy lifestyle was. The following is a list of what science now confirms adds years to your life:

  • Don’t be gluttonous. Eating a variety of healthy foods in moderation can prevent the health risks of obesity.
  • Get exercise: this helps us regenerate new mitochondria, which are the powerhouses of our cells providing energy.
  • Avoid stress, which creates hormonal effects that change our metabolism and can accelerate aging.
More life prolonging points:
  • Get enough sleep. This allows our bodies to do molecular-level repair.
  • One of the newer findings is Dr. Longo’s fasting mimicking diet. Do a semi-fast once a month for 5 days with 500 to 600 calories per day. This helps you to shed 0.5 to 0.7 units of body mass index. It also stimulates your immune cells, your stem cells and elongates your telomeres. Long telomeres make you live longer.
  • Replacing missing hormones with the help of an anti-aging physician will add about 10 years to your life. I mentioned this earlier.

A few more points about longevity research

Dr. Ramakrishnan said: “Already the top 10% of income earners in both the US and the UK live more than a decade longer than the bottom 10%. If you look at health span — the number of years of healthy life — that disparity is even greater. Poorer people are living shorter, less healthy lives.” He said further about the concept of “immortality”: “I think this quest for immortality is a mirage. One hundred and fifty years ago, you could expect to live until about 40. Today, life expectancy is about 80, which, as author Steven Johnson has said, is almost like adding a whole extra life. But we’re still obsessed about dying. I think if we lived to be 150, we’d be fretting about why we’re not living to 200 or 300. It’s never-ending.”

About Aging and a Prolonged Life

About Aging and a Prolonged Life

Conclusion

CNN discussed the quest for longevity with Nobel prize winning Dr. Ramakrishnan. He pointed out that the aging process is due to a number of factors that work together. There are DNA breaks, faulty proteins, chemical damage to molecules, hormone disbalances and degenerative changes. We need to watch that we do not overeat, get regular exercise and eat a variety of healthy foods. In addition, we need to avoid stress, get enough sleep and replace missing hormones with bioidentical hormones. A newer boost to your health is the fasting-mimicking diet (FMD) from Dr. Valter Longo that helps you keep your weight in the lower body mass index range. Dr. Longo showed in animal experiments and with humans that the FMD elongates telomeres, which directly prolongs life.

Apply what helps your longevity

While it is far-fetched to believe that we now have a ticket to live for 120 years or longer, it is more important to know that we can do our part to spend our golden years in health and wellness.

Apr
13
2024

Eating the right Food Determines your Health

CNN had an interview with Dr. Leana Wen about the fact that eating the right food determines your health. Dr. Wen is a wellness expert, an emergency physician and adjunct associate professor at George Washington University.

How much does the quality of food we eat influence our health?

There are detailed studies that showed the following effects of healthy food on our lives.

  • If you eat a diet consisting of more vegetables, fruits, whole grains and nuts, the following will happen. You could exceed the age of controls eating unhealthy food by 10 to 13 years.

Specifically, a woman starting such a diet at age 20 would add 10 years to her life, when starting at age 60 she could add 8 years to her life. For men starting this diet at age 20 would allow him to gain 13 years, when starting at age 60 he would add 9 years to his life.

Additional healthy food studies

  • A 2023 Nature study found that men can add 10.8 years, women 10.4 years by switching their diets. This switch was from unhealthy diets to a longevity diet with more whole grains. In addition, the healthy diet contained more nuts and fruits and less sugar-sweetened beverages and processed meats.
  • Another 2023 study from the Jama network followed over 100,000 people for more than 30 years. There was an association between adopting healthy eating patterns and a reduction in early mortality. People on a healthy diet reduced their risk of early death by 20%! The study also noticed that people who ate more whole grains, fruits, vegetables, nuts and legumes had fewer other diseases. They were less likely to die from cancer, cardiovascular illness and respiratory and neurodegenerative disease. These were important findings. 

What kinds of food make you live longer?

Dr. Wen stated clearly that it is only minimally processed, whole food that allows a person to live longer. The highly processed foods like processed meats, sausages, cakes and cookies are a “no go”. They are the ones that cost lives from heart attacks, strokes and cancer. On the other hand, leafy green vegetables, fresh fruits and whole grains associate with significantly reduced mortality. Fish contains omega-3 fatty acids, which reduce heart disease and dementia. It is also a good source of protein. So, stay away from hot dogs and chicken nuggets, instead enjoy salmon fillet or roasted chicken.

Foods that you need less of

Avoid sugar sweetened sodas and energy drinks, as they elevate cholesterol levels and cause heart attacks. Next, stay away from ultra-processed foods like chips and candies. In one study with more than 11,000 participants people who ate a lot of ultra-processed foods had a 31% higher risk of mortality.

With what do you replace junk food?

Here are a couple of examples. Somebody who used to drink a lot of sodas can replace them with water, sparkling water, flavored water or lemon juice, sweetened with stevia. Instead of snacking on ultraprocessed foods like chips, candies or pretzels eat nuts instead. Look at the list of ingredients before you buy anything in the grocery store. If there is a long list of ingredients including chemicals, this is ultraprocessed food. Replace it with minimally processed foods with only a few items on the ingredient list.

Other advice for health and longevity

  1. If possible, eat three meals a day (breakfast, lunch and dinner). Stop eating 2 hours before bedtime to allow your guts to digest the food you previously ate. This avoids heart burn and interference with your sleep.
  2. Exercise regularly. Studies showed that 150 minutes of vigorous exercise per week reduced mortality by 23%.
  3. Take care of stress in your life. Cherish your social life and socialize; it is important for longevity. See your doctor regularly to take care of any medical problems you may have.
  4. Watch your sleep habits. Many studies have shown that adults need 7 to 8 hours of sleep. Sleep restores your hormone glands, gets them ready for the next day, but it is also important for longevity.
  5. Keep your body mass index (BMI) between 21.0 and 24.0. Personally, I keep my BMI between 21.0 and 22.0. Any extra pounds of fat merely lead to elevated cholesterol and triglycerides. Eventually this leads to heart attacks and strokes, but also to diabetes.
Eating the right Food Determines your Health

Eating the right Food Determines your Health

Conclusion

A recent article in CNN described that eating the right food determines your health. One study said that you should eat a diet consisting of more vegetables, fruits, whole grains and nuts. Doing this increases your life expectation by 10 to 13 years compared to controls who ate unhealthy food. It is only minimally processed, whole food that allows a person to live longer. You must eliminate ultraprocessed food. This means you should not consume sausages, fries, chips, pretzels and other overprocessed foods. Instead, eat leafy green vegetables, fresh fruits and whole grains that associate with significantly reduced mortality. Yes, eating the right food determines your health.

Feb
17
2024

Ashwagandha’s Benefits

Medical news today had an article in October 2023 that reviewed ashwagandha’s benefits. I thought it would be useful to discuss this topic in an abridged version. Often things get distorted on the Internet and a reality check helps to separate facts from fiction. Ashwagandha (botanical name: Withania somnifera) is a small shrub that grows in Southeast Asia, Africa and some areas of India. An alternative name is Indian ginseng.  Ashwagandha has been part of Ayurvedic medicine for more than 3000 years.

About ashwagandha’s effectiveness

Ashwagandha is part of natural medicines that go under the name of adaptogens. The effective substances of ashwagandha were isolated. Researchers named them withanolides. They are alkaloids and consist of polyoxygenated steroidal lactones with 28-carbon ergostane skeletons.

People are taking ashwagandha supplements to counter stress and fatigue. But it also increases testosterone, which increases muscle mass. In addition, there is an increase of libido in men as well as in women.

People with insomnia benefit from the relaxing and sleep-inducing effect of ashwagandha supplements. Ashwagandha stimulates the immune system. It also significantly counters the stress response, as it lowers cortisol levels.

The active chemical components of ashwagandha

Various researchers pinpointed the diverse actions of ashwagandha extracts to withanolides, which are the pharmacologically active ingredients. There are at least 25 different chemical structures of withanolides, which are depicted in this reference: This explains the diverse effects of ashwagandha extracts on the immune system, the stress hormone axis, the libido brain centers and testosterone production. One human study showed that within 96 hours of ashwagandha extract administration the immune system was activated; T cells and natural killer cells were measured and were significantly elevated in number in comparison to controls:

Specific clinical trials showing effects of ashwagandha

Effects on the brain

In a small clinical study oral intake of ashwagandha improved performance on cognitive tasks, executive function, attention, and reaction time.

Dr. Amala Soumyanath is a professor of neurology in the School of Medicine at Oregon Health & Science University. She stated: “These laboratory studies show that ashwagandha extracts can act on neurotransmitter pathways including those involving serotonin and Gamma-aminobutyric acid (GABA), and also affect systems like the hypothalamic-pituitary-adrenal (HPA) axis and the sympathetic-adrenal-medullary (SAM) axis.”

What does this mean? It means that ashwagandha contains a mix of withanolides that calm down the brain, particularly when it is stressed. At the same time, it increases serotonin and GABA, which has antidepressant and calming effects. Clinical trials have measured cortisol levels in volunteers and found that cortisol is lowered within a few weeks. This is the strongest evidence that ashwagandha in fact counteracts stress.

Libido and muscle strength

A small human study found that muscle strength was higher after exposure to oral ashwagandha in comparison to controls.

Ashwagandha showed a significant increase of maximum oxygen consumption (VO2max) in healthy adults and athletes, which is a direct measurement of exercise fitness. A clinical trial with 50 overweight males aged 40-70 years, showed that 16 weeks of oral ashwagandha increased their testosterone level by 14.7%. In addition, there were improvements in fatigue, vigor, and sexual and psychological well-being. There was also an increase of 18% of DHEA-S a precursor of testosterone. The authors felt that a larger study with a longer observation time would be beneficial to confirm this study. Overall, the objective effects of ashwagandha are in the mild to moderate category. The mild increase in testosterone affects libido only marginally. Some articles in social media are vastly exaggerating the objective findings.

Health risk of ashwagandha

There are downsides as well. Ashwagandha stimulates the immune system and in doing so may exacerbate autoimmune diseases. It also can increase thyroid hormones, which is important to know for people with hyperthyroidism or hypothyroidism. Men who have hormone sensitive prostate cancer should avoid ashwagandha, because it elevates testosterone.

Researchers pointed out that gastrointestinal upsets, such as diarrhea, nausea, and vomiting due to ashwagandha are common side effects. The higher the dosage and the longer the exposure is, the more likely it is that the patient experiences side effects. Researchers reported a few cases of reversible liver toxicity cases due to ashwagandha. At this point the effects of concomitant medications taken at the same time as ashwagandha is not known.

Ashwagandha’s Benefits

Ashwagandha’s Benefits

Conclusion

Lately social media is full of ashwagandha’s benefits. Rosy reports of increased libido, extra energy and boosts of confidence circulate on the Internet. Men are told that in order to build up muscle bulk with exercise they must take ashwagandha. This review checked the facts. There is a 14.7% rise in testosterone from taking ashwagandha and this may contribute to an increase of muscle mass with exercise, but this is not a huge effect. Also, the mild increase of libido due to the increase of testosterone is not as significant as reported in the social media. The active ingredients of ashwagandha are the withanolides, which researchers isolated. They do help to deal with stress-related problems like lack of energy and insomnia. In addition, they stimulate the immune system to give a stronger response.

Side effects of ashwagandha

But ashwagandha also has some side effects. It can make auto immune reactions worse. It can interfere with both hyperthyroidism and hypothyroidism. Men who have hormone sensitive prostate cancer must avoid ashwagandha because of the testosterone increase. Gastrointestinal upsets, such as diarrhea, nausea, and vomiting from ashwagandha supplementation are common side effects. So far scientific evidence is based on relatively small clinical trials. Scientists must conduct much bigger trials that are going on for several years to provide more in-depth information on the effects of ashwagandha.

Jul
30
2023

Learn about Longevity from the Blue Zones

People who live in blue zones often turn 100 or older, so we can learn about longevity from the blue zones. The 5 most often cited blue zones are in Okinawa, Japan; Sardinia, Italy; Nicoya, Costa Rica; Icaria, Greece; and Loma Linda, California, United States. But there are many more blue zones throughout the world. These zones contain the most centenarians, people who have reached the age of 100. It is thought that it is the people’s lifestyle that makes them live much longer than the rest of the world.

Lifestyle of centenarians

People are active, are bicycling, walking, swimming, constantly on the go and they are careful about what they eat. They stay slim, but are muscular. Their diet consists mostly of vegetables and salads, with very little meat. They may consume a small piece of beef on Sundays, but not during the rest of the week. Fish may be a part of their diet two or three times per week.

Diet characteristic of blue zones

Sandee LaMotte  published an article on March 4, 2023 at CNN, which describes the diet consumed in blue zones. People in blue zones are active, handle stress well, are close to friends, have a purpose in life and are often members of a social or religious group. They eat mostly a plant-based diet and they stop eating before they are full.

The food consists of complex carbohydrates. No processed foods are eaten. The American Heart Association says: “Complex carbohydrates, such as beans, peas, vegetables and whole grains provide vitamins, minerals and fiber that can go missing in processed and refined foods. In addition, they are digested more slowly, and the fiber helps you feel full longer.”

Origin of blue zone foods

The blue zone food has its roots in the African, Asian, Latino and Native American diets. Dan Buettner originally published an article about the blue zones in the National Geographic Magazine. Recently he published a collection of 100 blue zone recipes in book form.

The Mediterranean diet is very close to blue zone eating.

What blue zone meals contain

Buettner said: “The five pillars of every longevity diet, including the blue zone, are whole grains, vegetables in season, tubers, nuts and beans. In fact, I argue the cornerstone of a longevity diet is beans.” People in blue zones eat similar foods as those who eat a Mediterranean diet, but they do not eat as much fish as people on a Mediterranean diet. People on a blue zone diet don’t eat any milk products. On the other hand, goat and sheep’s milk cheeses such as feta and pecorino are part of the blue zone diet. In the blue zones the consumption of purple sweet potatoes, sesame seeds, fresh vegetables and fruit are the major staples.

More info about Blue Zone diet

All of the meals contain complex carbohydrates, micronutrients and a whole variety of fiber.

Perhaps the important difference to the Standard American diet is that in the blue zone there is a lack of beef, hamburgers, processed foods and highly processed carbohydrates like bread, pasta, sugar-sweetened beverages, salty snacks like potato chips, candies, cookies and processed meats (bacon, sausages or cold-cuts). People in blue zones eat very little bread and if they do, they eat sourdough bread, which does not raise the blood sugar level as the highly refined white bread.

Recapturing healthy foods

So, what foods are blue zone people really eating? Tofu, quinoa, mushrooms, lentils, beans, turnip greens, artichokes, asparagus, chickpeas and spinach are the main staples of their nutrition. They stay away from sugar, rarely eat meat (once or twice per week) and otherwise have a healthy lifestyle. Scientists think that longevity comes from the healthy lifestyle and diet, which centenarians practice. Several longevity genes get activated as explained in this publication. This translates into living long lives with very few illnesses and experiencing energy until the end of their lives.

Learn about Longevity from the Blue Zones

Learn about Longevity from the Blue Zones

Conclusion

We can learn a lot from observing what centenarians eat and do. Scientist have investigated the lifestyle of people living in blue zones in various parts of the world. These zones contain the most centenarians, people who have reached the age of 100. People in blue zones eat mostly vegetables and very little red meat. They avoid sugar and processed foods. But they are also very active, have a rich social life and allow themselves enough sleep. Scientists accumulated evidence that genetic longevity switches are activated by the life style of people living in blue zones.  It is the activation of these epigenetic switches that are responsible for the longevity of people in blue zones.

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Apr
23
2023

Help with Menopausal Symptoms

At the 30th A4M Conference mid-December Dr. Anna Cabeca lectured about “Help with menopausal symptoms”. A4M stands for “Conference of the American Academy of Anti-Aging Medicine”. It is a yearly event at the Sand Conference Center of the Venetian Palace in Las Vegas. The following is a summary of the very detailed lecture by Dr. Anna Cabeca.

Definition of postmenopausal symptoms

Dr. Cabeca’s detailed title for her lecture was: “Menopause: Hot flashes, brain fog and vaginal dryness; 3 symptoms women don’t have to experience.”  The first thing to remember is this detailed list of symptoms of menopause:

  • Hormones are disbalanced
  • Unusual behaviors and moodiness
  • Gaining weight (accumulating fat)
  • Tiredness
  • Loss of willpower
  • Sleep disturbance: can’t sleep or sleeps all the time
  • Brain fog and memory problems
  • Lost your “edge”
  • No sex drive
  • Aging rapidly
  • Hair loss
  • Thyroid problems
  • Hysterectomy (to remedy excessive periods)

Hormone changes with menopause

To clarify, there are major hormone changes with menopause as follows. To explain, at the age of 35 progesterone suddenly experiences a major reduction, which completes by the age of 45. In contrast, estrogen levels remain high until the age of 40 when it, too is reduced to background activity by the age of 50. In fact, at this point estrogen production is still more than progesterone synthesis. This is the basis of what is called estrogen dominance.

In general, symptoms of estrogen dominance are: PMS, hot flashes, night sweats, mood swings, weight gain, vaginal dryness, brain fog, irregular periods, less libido, missing or increased periods, bone loss and sleep disturbance.

To emphasize, the production of male hormones, DHEA and testosterone, slows down around the age of 30 and reaches a low plateau around the age of 45. This explains, for example, the lack of sex drive mentioned above. In addition, it is also partially responsible for brain fog, tiredness, hair loss and unusual behaviors and moodiness.

Perimenopause and menopause increase risk for diabetes

By all means, there is a clear relationship between age and the risk of developing diabetes in both males and females. But it must be remembered that the hormone weaknesses in combination with weight increases can also trigger diabetes.

Head-to-toe patient work-up

There are two parts to a patient’s work-up, a thorough assessment and a patient’s education.

The patient’s assessment includes:

  • Energy, mind, spirit
  • Hormone balance
  • Inflammation
  • Assessment of diet and nutritional intervention
  • Gastrointestinal health and digestion
  • Detoxification
  • Structural investigation

Surely, another key point is that patient education is important to be successful in the multiple step intervention to normalize the metabolism, shed excessive weight and help the patient to refocus.

Comments to the patient’s assessment

Indeed, the display of energy in a patient is closely related to hormone balance. Notably, when hormones are measured and they are out of balance, this usually explains the multiple symptoms. It is important to realize that inflammation is measured with the high-sensitivity CRP blood test. This test measures the level of inflammation. Initially, the level may be 30, but with weight loss it often normalizes with values of 2 or 3. At the same time weight loss stabilizes blood sugar (indicated by an initially high, but later normalizing hemoglobin A1C) and diabetes can completely disappear. Frequently, an analysis of the diet often shows that the patient is eating too much sugar and starchy foods.

Faulty nutrition, heavy metals and osteoporosis

In addition, many patients also eat too much meat and processed meat products, which leads to elevated cholesterol and triglycerides. Also, introducing more vegetables and fruit reduces lipids in the blood. Certainly, patients’ blood tests often show high levels of heavy metals like mercury, lead and cadmium. This can be chelated out with intravenous EDTA. Often 6 treatments at weekly intervals will rid the body of these toxins from pollution and the consumption of fish that has high mercury content.

Structural investigation of the bone with bone density measurements can diagnose osteoporosis. An initial remedy for this is supplementation with 5000 IU of vitamin D3 and vitamin K2 200 micrograms daily.

Low carb diet can help rebalance body metabolism

People who are overweight or obese get metabolic changes in their blood that physicians call metabolic syndrome. It raises blood pressure, often leads to elevation of cholesterol, triglycerides and blood sugars and also causes inflammation. A diet like the Mediterranean diet can help stabilize the metabolism. Dr. Anna Cabeca recommended a ketogenic diet, but from my reading a Mediterranean diet will achieve the same. In addition, a ketogenic diet carries a higher risk of heart attacks and strokes. For this reason I cannot recommend a ketogenic diet. The end result is an improvement of organ function, improvement of blood tests and less reliance on medications. Our body simply performs and functions better.

Fasting improves mitochondrial health

Mitochondria are small particles inside the plasma of all the body cells. Their functioning is essential for our energy and for cell metabolism in all of our organs. The energy, which is produced by the mitochondria is stored in a small molecule, called adenosine triphosphate or ATP.  I discussed earlier that heavy metals must be removed from the body by chelation therapy. One known effect of heavy metals is the poisoning of mitochondria. A person who has high blood levels of heavy metals in the body complaints of low energy and brain fog. After several intravenous chelation treatments, the energy returns and the brain fog disappears.

The fasting mimicking diet of Dr. Valter Longo is another tool to reactivate mitochondria.

Bioidentical hormone replacement

Many postmenopausal women require some help with regard to their hormonal balance. There are doctors who specialize in this area. They order a baseline panel of hormones. If there is a lack of progesterone, they order bioidentical hormone replacement, a hormone cream that the patient applies herself to the forearm or abdomen. Hormone saliva tests must show a ratio between progesterone and estrogen of 200 to 1 or higher. Many women have too much estrogen in their system relative to progesterone. By balancing this hormone ratio, the risk of getting cancer from estrogen that is not in balance experiences a significant reduction. The patient will also feel more energy and sleep better.

Help with Menopausal Symptoms

Help with Menopausal Symptoms

Conclusion

Menopause does not have to be the dreaded time in a woman’s life, when her periods stop. With a bit of attention to her nutrition, her hormone balance and other symptoms the physician can help her experience none of the symptoms. It will require some hormone and other blood tests. It may also require some detoxification with intravenous EDTA infusions. At the end that postmenopausal patient will feel energy again, clear up her foggy brain and sleep better. In addition, the woman will regain her sex drive and feel more energy. The physician treats estrogen dominance by adding progesterone cream supplementation. This also assist with regard to sleeping better.

It does take the effort to have all the necessary blood tests and saliva tests to establish deficiencies. A physician who has experience in anti-aging medicine will be of important help to bring a menopausal patient back on the road to wellness.

Mar
11
2023

Hormone Imbalance can Impact Health

Dr. Erika Schwartz spoke at the 30th Anti-Aging Conference in Las Vegas about “hormone imbalance can impact health”.  The talk was scheduled early in the morning on Dec. 10, 2022. She pointed out that when hormones are in balance people have energy, they sleep well, they have normal sexual functioning and they are fertile. But in contrast, when hormones are not in balance, their weight goes up, they suffer from fatigue, depression, and anxiety. In addition, they often have skin and hair changes, changes in menstrual regularity, acne, infertility and decrease in libido. Finally, they may have problems in building muscle mass, women develop vaginal dryness and men erectile dysfunction. However, people also can develop autoimmune conditions and various cancers.

Symptoms of hormone imbalance at various ages

Teens

Most importantly, acne is an embarrassing, but common symptom. Depression, PMS, mood swings and headaches are also very common. By the same token, weight gain occurs frequently from faulty diets (fast food, lack of vegetables and fruit and sugary soda drinks).

The twenties and thirties

The birth control pill interferes with the normal function of LH and FSH resulting in lack of ovulation and infertility. Other symptoms are bloating, constipation, weight changes, libido changes and postpartum depression.

The forties and fifties

Mood changes and irritability, weight problems, menstrual changes, and changes in sexual desire are typical for this age group.

The sixties and over

Hot flashes are common in this age group, but they can start in women from the age of 50 onwards. Other symptoms are night sweats, insomnia, skin and muscle changes. Many diseases of the aging occur like diabetes, arthritis, cardiovascular disease, dementia, degenerative and autoimmune diseases.

Diagnosis of hormone imbalance

The doctor takes a detailed history about exposure to environmental pollutants, the birth control pill in women and medications. In addition, the doctor wants to know whether the patient consumed meat from animals that were treated with antibiotics. Next the physician inquires about physical changes, symptoms of hirsutism, menstrual

irregularities and infertility. There are three steps to diagnosing hormone imbalances:

  1. Listen to the patient and inquire about the subjects just mentioned.
  2. Order extensive laboratory tests including hormone levels.
  3. Review all of the medications and supplements the patient is taking.

How do hormone imbalances affect our bodies? They affect our mental health, our sleep, brain function, libido, energy, weight, digestion (leaky gut), joints and the immune system.

Two clinical examples about hormone imbalances

Dr. Schwartz gave two clinical examples showing how correction of hormone imbalances led to normalization of the hormone imbalance.

Example 1

A 17-year-old female complained about acne in her face, had no periods, was fatigued and had migraine headaches. She was in senior high school and wanted to look and feel better before graduation. Her periods started at age 12, but were irregular. Her physician started her on the birth control pill at age 14. Within one year she stopped having any periods and also started getting hyperpigmentation in her face. Dr. Schwartz noted that she had no allergies and that she did not take any supplements. She took Estarylla (ethinyl estradiol/ norgestimate), a BCP formulation and Excedrin for migraines. Her ferritin level was 12 (11 to 307 micrograms per liter is normal for women). TSH was 5.16 (normal now 0.5-2.5). This meant she was borderline iron deficient and also mildly hypothyroid.

Diagnosis and treatment plan

Dr. Schwartz diagnosed a hormone imbalance. The treatment schedule consisted of stopping the BCP, start a low dose 30 mg NP thyroid in the morning. In addition, the doctor prescribed adrenal support pills and low-dose iron pills with vitamin C. The doctor also addressed lifestyle and self-awareness issues with the patient. 4 months later she was seen again and had regular periods, no more migraines and she felt more energy. The face pigmentation was gone and she felt great.

Example 2

A 42-year-old woman presented to Dr. Schwartz with psoriatic arthritis, weight gain, problems sleeping, brain fog and irregular periods. Her last menstrual period was 6 months ago. Her doctor had recently placed her on a statin drug and put her on the BCP Mirena. This is a progestagen releasing IUD placed in the uterine cavity, which was given to her in an attempt to regulate her periods. She was divorced and a mother of 3 children. At work she was a business partner in a high stress law firm. Personally, she was trying to date, but has been unsuccessful so far. She would like to lose weight and gain more energy. What she was hoping for was that her doctor address her overall health.

Medication and blood tests

She did not have any allergies. Her medications consisted of Rosuvastatin 10 mg daily and Mirena for the last year. As supplements she took Turmeric. Blood tests showed that her hemoglobin A1C was 5.7, the vitamin D blood level was 17 ng/mL (very low). The TSH level measured 1.29 (in the normal range). Estradiol blood level was in the lower range, progesterone level the same. Finally, her testosterone level was low as well. The other blood tests were all normal.

Diagnosis for this patient and treatment plan

Dr. Schwartz diagnosed hormone imbalance due to natural and environmental factors.

She ordered Mirena to be removed and to stop Rosuvastatin. Instead, she started the patient on vitamin ADK ( a mix of vitamin A, vitamin D and vitamin K)– 5000 IU daily. She also started her on Omega3 1000mg daily. In addition, she discussed a well-balanced diet, regular exercise and sleep issues (7-8 hours every night) with her.

Hormone replacements

As blood tests showed a low estradiol level, she started her on Estrogel, a form of estrogen. She also started her on progesterone tablets (Prometrium) 100 mg at bedtime as well. This keeps progesterone and estrogens balanced. As her testosterone was on the low side, she started her on Testosterone cypionate 100 mg/ml (0.4 cc per injection) intramuscularly once a month. Dr. Schwartz also started adrenal support, 2 capsules in the morning. Further she was told to start 3 capsules of NMN (Nicotinamide Mononucleotide Supplements) daily and 5 units of Semaglutide subcutaneously weekly. The latter medication helps the pancreas to release the right amount of insulin when blood sugar levels are high.

Follow-up at 6 months

The doctor reassessed he patient after 6 months. She had developed increased self-awareness. She lost 30 pounds and she slept for 7.5 hours most nights. Her energy level has increased and she improved her dietary choices. She had started regular work-outs. Overall she was now happier at work and at home with her children. She feels now more like an age of 25, and she has been starting to date.

General remarks about hormone imbalance

When hormones are in balance, we are healthy. Hormones can get out of balance at any age; the examples above involved 17 and 42 year old patients. Keep in mind that it is impossible to have optimal health without balanced hormones. Dr. Schwartz said that the more pieces of the puzzle you address, the more likely you are going to truly help improve quality and quantity of life. Lifestyle factors that must be addressed are:

  • Diet
  • Exercise
  • Stress Management
  • Sleep
  • Breathing
  • Mitochondrial and cellular integrity
Hormone Imbalance can Impact Health

Hormone Imbalance can Impact Health

Conclusion

Hormone imbalances occur frequently when our lifestyle factors are slipping. Often untoward side effects of medication are also contributing to the hormone imbalance. The holistic doctor takes a thorough history, examines and takes blood tests including key hormone tests. When imbalances of hormones are detected, this has to be addressed with supplements and hormone replacements. At the end the hormones balance each other and the patients’ abnormal symptoms disappear. It only takes a few weeks before the patient will feel normal again.

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Nov
19
2022

Lack of Sleep Harms the Immune System and Causes Inflammation

A research group from Boston, MA and New York, NY found that a lack of sleep harms the immune system and causes inflammation. This was summarized in this CNN article.

Specifically, they first conducted experiments with a mouse model. They studied the effects of sleep disruption and sleep deprivation and could later confirm identical changes in man. The observation was that a lack of sleep caused the hematopoietic cells in the bone marrow to proliferate, but the cell diversity was less than in people with normal sleep patterns. The same pattern of bone marrow proliferation was present in mice. This research was published Sept. 21, 2022 in the Journal of Experimental Medicine.

Chronic sleep deficit

A chronic sleep deficit caused chronic inflammation and eventually autoimmune diseases. Again, this was a pattern present in both the mouse model and in humans. Next the researchers observed what happened with sleep recovery. In the past it was assumed that with sleep recovery all of the physical changes from sleep deprivation would disappear. However, the opposite was true: both in mice and in humans the bone marrow stimulation and the lack of cell diversity persisted.

In the mouse model the researchers could show that there were permanent epigenetic changes, which were caused by sleep deprivation. The same is true with humans, but this is more difficult to show than in the mouse model. The researchers came to the conclusion that sleep deprivation stimulates bone marrow maturation, but restricts the clonal differentiation. In doing so the body initiates inflammation, which becomes chronic even with sleep restoration.

Human sleep studies

There were 14 volunteers that were the test subjects. One group was the normal sleep control. The other group underwent chronic sleep deprivation. Each group did this for 6 weeks. There was a 4-to-6-week washout period. Following this the previous normal sleep group started a 6-week sleep deprivation program. On the other hand, the prior sleep-deprived group switched to 6 weeks of normal sleep. All of the participants had daily late afternoon blood tests.

There are many sleep disruptions, which cause a sleep deficit

In modern life sleep gets disrupted in many ways. There can be sleep fragmentation, sleep restriction, jet lag, obstructive sleep apnea (OSA), and insomnia.

People with these conditions often oscillate between these various types. They may have a few days of normal sleep, but then have sleep deprivation again for a few days. Every time they have sleep deprivation the bone marrow enhances hematopoietic activity. Normally there is a high leukocyte number in the blood at the end of the day and in the morning a lower leukocyte count. But with sleep deprivation there is a high monocyte count in the blood that stays high even when subjects switch back to a normal sleep pattern.

Epigenetic effect of sleep deprivation on bone marrow cells

The authors found that sleep deprivation affects the genetic control of hematopoietic cells in the bone marrow. They called this the epigenetic effect of sleep deprivation. This is responsible for the evening leukocyte response, the monocytosis and the tendency for autoimmune diseases. They summed this up by saying: “Our findings support the hypothesis that periods of poor sleep, even if followed by sleep recovery, have sustained consequences on immunological health.”

Lack of sleep harms the immune system and causes inflammation says the literature

There is ample evidence that a lack of sleep causes cardiovascular disease, diabetes, depression and more frequent infections. Healthy sleep is important when you want to age well without complications. But enough sleep is also necessary to prevent obesity, diabetes and cardiovascular disease. Experts consider getting enough high-quality sleep as essential as a balanced diet and regular exercise.

Lack of Sleep Harms Immune System and Causes Inflammation

Lack of Sleep Harms Immune System and Causes Inflammation

Conclusion

So far, most researchers believed that when you miss some sleep for a few nights that a afternoon nap or a few nights of longer sleep would compensate for the sleep deficit with no sequelae. Think again, because new research from a group in Boston, MA and New York, NY found that lack of sleep harms the immune system and causes inflammation permanently. Sleep deprivation stimulates the bone marrow cells to multiply and causing proliferation of monocytes, called monocytosis as well. Despite afternoon naps and recovery sleep this condition remains  and can lead to autoimmune diseases. All this was unknown up to now. Our bone marrow cells need regular sleep hours to stay diversified and to optimally fight infections in the body. This prevents autoimmune diseases and keeps our defenses against viral diseases strong.

Jul
03
2022

Can Surgery Help with Snoring?

Snoring is a common problem in people, and so the question is: can surgery help with snoring? About 25% of adults snore regularly, 45% snore occasionally. You are more likely to snore when you are overweight. Other factors are being a middle-aged or older male or a postmenopausal woman. Over the last decades various surgical procedures were in development in an attempt to cure snoring.

Obstructive sleep apnea

A person with obstructive sleep apnea has a problem of a relaxed rooftop in the mouth, where the uvula drops down. At the same time the tongue is falling backwards and together with the relaxed rooftop this leads to intermittent obstruction of the airway. The end result is loud snoring, which can lead to intermittent cessation of breathing. A positive pressure device is a common remedy for this condition, which keeps the airway open during your sleep. It is called continuous positive airway pressure (CPAP). However, this system is somewhat noisy, and about 50% of patients find it disturbing and cannot tolerate it. Many patients prefer a surgical, permanent solution.

Classification of snoring

Most snorers have primary snoring. Among these patients there is a minority who stop breathing periodically, which lowers the blood oxygen content. The patient awakes from this and tightens the muscles in the palatine-pharyngeal area and then breathes normally again for a while. These patients have obstructive sleep apnea (OSA). However, when deeper sleep is reached in OSA patients the cycle repeats itself. A clinical test how to distinguish between primary snoring and OAS is a polysomnography study, which also goes by the name of a sleep study.

Uvulopalatopharyngoplasty

This sounds like a tongue twister! In lay terms it is a surgical procedure which removes the uvula and the adjacent tissues of the palate and throat walls. There are side effects like swallowing problems, throat changes and the permanent feeling of a foreign body in the throat. Since the original design several modifications were introduced, which reduce the side effects of this procedure, but do not entirely eliminate them.

Somnoplasty or radiofrequency ablation

For patients with primary snoring, who do not have OSA a new procedure utilizes low levels of radiofrequency heat energy to create finely controlled localized burns in the lining of the soft tissues of the palate. This tightens the palate tissue and avoids the vibrations that cause snoring. The procedure can be done in the office setting under local anesthetic. It takes only about 30 minutes. When researchers compared pre-treatment scores with scores after three years following two ablation radiofrequency treatments there was a significant reduction of the snoring activity. Somnoplasty is another name for the FDA approved ablation radiofrequency treatment. This treatment works well for patients with primary snoring, but is not so successful for patients with OSA.

Maxillomandibular advancement (MMA)

The physician orders this fairly invasive surgery for patients with OSA who cannot tolerate continuous positive airway pressure. The goal of the surgery is to remove the two obstruction points where the patient chokes at night. This occurs most often behind the palate and behind the tongue. MMA was introduced more than 35 years ago. On the plus side, the success rate is about 90%. The minus side is the fact that it is major invasive surgery where the surgeon moves both the upper and lower jaws forward opening up the two choke points in the back. The surgery lasts about 6 hours and it takes approximately 6 weeks for it to heal.

Hypoglossal nerve stimulation

An alternative for patients with moderate to severe OSA is the use of hypoglossal nerve stimulation. Patients with OSA have a weakness in the muscle tone of the muscles that push the tongue forward. When they fall asleep the tongue tends to fall backwards obstructing the airways. This can be remedied with the use of hypoglossal nerve stimulation that stimulates the muscles that push the tongue forward.

Results with hypoglossal nerve stimulation devices were encouraging, as more than 80% of patients with OAS who had this device inserted had a successful treatment outcome. 4 years later, in the same patients there was still effectiveness of the hypoglossal nerve stimulator and the improvement in quality of life remained the same.

Can Surgery Help with Snoring?

Can Surgery Help with Snoring?

Conclusion

There are several procedures that can help patients with primary snoring or patients with an obstructive sleep apnea (OSA). For patients with primary snoring, who do not have OSA a new procedure utilizes low levels of radiofrequency heat energy to create finely controlled localized burns in the lining of the soft tissues of the palate. This tightens the palate tissue and avoids the vibrations that cause snoring. In patients with obstructive sleep apnea a continuous positive airway pressure device (CPAP) is a common remedy for this condition, which keeps the airway open during their sleep. But only about 50% of patients tolerate this procedure.

More surgical procedures

The uvulopalatopharyngoplasty can help a certain number of patients. Here the ear/nose/throat surgeon removes the uvula and the adjacent tissues of the palate and throat walls. The surgeon does this under general anaesthesia, and patients will take about two weeks to fully recover. Another more invasive procedure is the maxillomandibular advancement (MMA). The goal of the surgery is to remove the two obstruction points where the patient chokes at night. This occurs most often behind the palate and behind the tongue. The surgical procedure is in use for more than 35 years and the success rate is about 90%. However the surgery will take several hours, and recovery of the patient will take about 6 weeks.

Jan
08
2022

Sleep Training to Prevent Insomnia and Depression

A new study describes that sleep training to prevent insomnia and depression is desirable. Notably, the study published in JAMA Psychiatry took 291 people age 60 years and older and followed them for three years. In this case half the participants received treatment with sleep training, the other half treatment with cognitive behavioral therapy. The other half was the control who received sleep education therapy from a public health educator. It is important to realize that both groups received 120 minutes weekly group sessions for two months. That is to say, following training of 2 months the subjects were followed for 36 months. It must be remembered that they completed monthly questionnaires to monitor for depression and insomnia. At the end of the study almost 1/3 of the cognitive behavioral group still were free of insomnia.

The control group who received sleep education therapy initially showed no longer any

improvement. In other words, the initial progress did not last with sleep education only. The study was also published in CNN.

Results about rates of depression

Those subjects of the cognitive behavioral therapy group who had a sustained remission of their insomnia disorder had a rate of 82.6% less depression. This was in comparison to the subjects who did not sustain their treatment against insomnia. Dr. Pim Cuijpers commented that the results of the study show “a completely new and innovative way” of tackling the growing problem of depression. Dr. Cuijpers is a professor of Clinical Psychology at the Free University of Amsterdam.

A brief background about depression in older patients

Depression is common in people above the age of 60. About 30-50% of this age group develop depression. Part of this could be that older people often do not get enough sleep as middle-age or younger adults do. Melatonin production declines with older age and this may play a role in insomnia of older people. On the other hand, one of the major symptoms of depression is a lack of sleep. It seems that a lack of REM sleep, the deep sleep that makes us dream, is responsible for both troubles, sleeping (insomnia) and depression.

Cognitive behavioral therapy administered by a therapist is effective for insomnia

It is important that a therapist administers the cognitive behavioral therapy. There are recordings available online that provide cognitive therapy, but they are not individualised. Dr. Irwin said: “That’s why CBT-I is so effective in person, because the therapist is helping that individual navigate and negotiate with themselves — and it can be really hard work,” Irwin added. “I believe that’s also why CBT-I apps or online tools often don’t work — people get frustrated, disappointed or angry at themselves, and they basically stop the work.”

The rationale for cognitive behavioral therapy (CBT)

CBT for insomnia has five components: Stimulus control, sleep restriction, sleep hygiene, relaxation and cognitive behavioral therapy. Researchers gave the program the name CBT-I. Sleep hygiene and relaxation involve these sleeping habits: going to bed at the same time every day, eliminating noise and blue light from electronic devices. Also, you want to keep your bedroom cool, take warm baths and do yoga for relaxation.

Stimulus control and sleep restriction

Stimulus control involves getting out of bed, if you can’t sleep. Dr. Irvin said: “Most people stay in bed, fretting about not falling asleep, which then turns the bed into a negative space. Instead, people are taught to get up after 10 minutes of tossing and turning, do quiet, non-stimulating activities, and not to come back to bed until they are sleepy.” Sleep restriction means that a person lies in bed only to sleep plus 30 minutes. It is a way to make people with insomnia get out of bed instead of lying there awake.

Cognitive behavioral therapy

Cognitive behavioral therapy disrupts irrational thoughts and beliefs about sleep. Patients with insomnia often think “I can never sleep” or “I might die if I don’t sleep tonight.” A therapist has training to help the patient find a way back to a more realistic mindset. Eventually the patient accepts the bed as a welcoming place.

Cognitive behavioral therapy is effective in preventing depression

Dr. Irwin pointed out that chronic insomnia often leads to depression. A dangerous consequence of depression can be preoccupation with suicide. A certain percentage of patients with depression in any age group want to kill themselves. This is where cognitive behavioral therapy can intervene and make a huge difference. As mentioned earlier almost 1/3 of patients who received cognitive behavioral therapy for two months retained their normal sleep pattern. It was among this group that 82.6% had no depression compared to a control group. These are very important statistics. Dr. Irwin said: “We have shown that we can actually target insomnia with cognitive behavior therapy and prevent depression from occurring”.

Sleep Training to Prevent Insomnia and Depression


Sleep Training to Prevent Insomnia and Depression

Conclusion

A new study in JAMA Psychiatry describes that sleep training to prevent insomnia and depression is feasible. Sleep researchers used cognitive behavioral therapy sessions for two months on subjects who suffered from insomnia. The treatment group had profound effects with respect to improving insomnia and depression. Almost 1/3 of subjects treated with cognitive behavioral therapy returned to a normal sleeping pattern. And this subgroup of patients had 82.6% less depression. The lead author, Dr. Irwin thinks that cognitive behavioral therapy could become the new way of how to treat and prevent depression.

Nov
13
2021

How to Fall Asleep Quicker

Early October 2021 CNN had an article about how to fall asleep quicker. Most people take 15 to 20 minutes to fall asleep.

Sleep environment

It is important to arrange a sleep environment where you can sleep well. This includes bedroom darkening and keeping the room temperature of 60 to 67 degrees Fahrenheit (15 to 20 degrees Celsius). Make sure your bed is comfortable and use your bedroom only for sleeping and sex. Do not read in the bedroom, keep your cell phone in another room and do not have a TV or computer in the bedroom. These produce blue light, which stimulates your brain. This is exactly what you do not want to have in your bedroom.

Normal sleep duration for different ages

There are always exceptions to rules. In this case there is a rare gene that allows the carrier to sleep only 5 hours at night and still have normal energy during the day. It is called short sleep gene.

Here are the hours of sleep that everybody else needs every night in different age groups:

  • Adults: 7-8 hours
  • School-age children: 12 hours
  • Teenagers: 8-10 hours

If you get the proper hours of sleep, but you are still tired during the day, you may have a lack of quality of sleep. Older people often have to go to the bathroom several times during the night. As it takes some time to reach the deepest level of sleep at night (REM sleep) older people often miss significant amounts of REM sleep during which they dream. The end result is a lack of energy during the day.

Conditions that interrupt your sleep

There are some medical conditions that can interfere with a good night’s sleep. Obstructive sleep apnea is one such condition that 25 million Americans have. A person with this kind of condition snores, gasps, chokes or stops breathing periodically during the course of the night. Restless leg syndrome is another condition, which interferes with a restful, deep sleep. Other conditions are chronic pain, heart disease, diabetes, asthma and gastroesophageal reflux. Medication can affect sleep depth as well.

Falling asleep naturally

Despite many studies it is not clear why some people have no problem falling asleep while others find it difficult. Taking 10 to 20 minutes of falling asleep is normal. If you cannot fall asleep after 20 minutes of trying, go to a dim room and do something calming until you feel drowsy again. Then return to your bed. Follow the same procedure, if you wake up in the middle of the night and you have difficulties falling asleep again. Deep breathing, yoga and meditation are proven remedies to pipe down and help you to fall asleep.

Monitoring sleep at a sleep clinic

A sleep study can be very helpful in diagnosing sleep disturbances.  The sleep expert measures several body functions simultaneously. These are heart rate, air flow, blood oxygen level, breathing rate, brain wave activity, muscle movements and eye movements. During a night sleep study, a polysomnogram records all these body functions automatically. The finding helps the sleep expert to diagnose and treat the sleep disturbance.

Self-help supplements for insomnia

My regular sleep supplement every night is 3 mg of melatonin.

Sometimes this is not enough, because I watched an exciting movie or I wrote too much for Quora online. When I can’t fall asleep within 30 minutes, I take a capsule of 500 mg of valerian root. I would say that this helps in 95% of the nights to fall asleep.

If for some reason I still can’t fall asleep, I use 25 drops of  Passion Flower Extract:  I find that this is very reliable and puts me to sleep within 15 to 20 minutes of taking it. This way I am avoiding prescription narcotics and I am not getting addicted to benzodiazepines. The last step (Passion Flower Extract) I require only once or twice a month. The chemical in the Passion Flower Extract is very similar to benzodiazepines, which means you don’t want to take this every night or your system could get addicted to it.

How to Fall Asleep Quicker

How to Fall Asleep Quicker

Conclusion

Falling asleep is something we all can learn. It starts with a quiet and relaxing bedroom ambience. We need to allow for enough sleep duration. Adults need 7 to 8 hours of sleep, children and youth more. Deep breathing, yoga and meditation are proven remedies to prepare you to fall asleep easier. When all fails there are a number of self-help supplements you can take to help you ease into sleep. If you still have problems falling asleep a sleep study can be very helpful in diagnosing sleep disturbances. In a sleep clinic your heart rate, air flow, blood oxygen level, breathing rate, brain wave activity, muscle movements and eye movements are recorded with a polysomnogram. The doctor from the sleep clinic can formulate the diagnosis of the sleep disorder and help you overcome any identified problems.

The subchapter “Self-help supplements for insomnia” was published by me earlier here.