New! B12 injections & more

B12 intramuscular injections are useful for those deficient in B12, pernicious anemia, fighting depression, stress or fatigue, diabetic neuropathy, chemotherapy induced neuropathy, herpes zoster (including prevention and treatment of shingles).

Book your Appointment Now

Existing patients:

Injection B12 1000ug + 1mg Folic Acid = $16.00b12folic
Injection B12 5000ug + 1mg Folic Acid = $18.00
You could be at risk for B12 deficiency if you are taking the following medications: Metformin, H2 blockers (Pepcid, Zantac), Proton Pump Inhibitors (PPI’s) (Nexium, Prevacid, Losec, Tecta, Pantoloc, Pariet, Dexilant) , Phenytoin, also long term use of Oral Contraceptives or Aspirin. Excessive alcoholic intake longer than 2 weeks, inflammatory bowel disease, Celiac disease,  gastric or small intestinal resection, prolonged vegan diet, no meat, poultry or dairy product consumption, age over 75 years. Long term supplementation of Folic Acid.

Signs of B12 deficiency: Unexplained neurologic symptoms like paresthesias, numbness, poor motor coordination, memory lapses or cognitive and personality changes.

B12 status is measured through a Complete Blood Count (CBC), blood analysis and Serum B12 (cobalamin), and folate. Related tests include Complete Blood Count, Methylmalonic Acid, Homocysteine, B Vitamins, Intrinsic Factor Antibody, Parietal Cell Antibody, Reticulocyte Count, Blood Smear. It is a good idea to get tested when you have symptoms of anemia such as weakness, tiredness, pale skin and/or tingling or itching sensations, eye twitching, memory loss, altered mental status which are signs of neuropathy. It is useful to have a baseline status before supplementation so you can monitor treatment effectiveness when if you have vitamin B12 or folate deficiency. Ask about costs of testing.

Why is folic acid included?  It helps B12 get into the red blood cell.

Naturally occurring Folic Acid, known as folate,  is found in leafy green vegetables, citrus fruits, dry beans and peas, liver, and yeast. Vitamin B12 is found in foods from animals, such as red meat, fish, poultry, milk, yogurt, and eggs.  Dietary sources of B12 and folate also include fortified cereals, breads, and other grain products.

What else is new?

2) New naturopathic service – Ear lavage – for those with a lot of ear cerumen (wax)  a naturopathic protocol involves home treatments then an in-office ear wash. This will be assumed as part of the appointment fee, however please note we can do this! Some ear cerumen is healthy, but too much or a blockage can impact hearing and can be uncomfortable.

Also a reminder that these services are available to patients:
a) Laboratory analysis pay for service – many of the same lab tests requested by your family doctor may be ordered through Dr. Laura M. Brown, ND, just know you have to pay out of pocket. I cannot post a price list but can provide pricing on an individualized, as needed basis.

b) Urinalysis $3 -additional to appointment fee Naturopathic medicine has great choices for relieving chronic cystitis and acute or persistent urinary tract infections. We also are trained to know when to get the patient to their MD for antibiotics.

c) Strep Throat Swab – $7 fee additional to appointment fee. Rapid Strep Test – the same one your family doc will do, just added convenience of getting some great advice and prescription for natural medicine and antimicrobials, if it turns out you don’t need mainstream antibiotics.

From the heart and mind of your local naturopathic doctor, Dr. Laura M. Brown , ND

Top 5 Tips to Keep You Motivated and Fit Through the Holiday Season

Top 5 Tips to Keep You Motivated and Fit Through the Holiday Season

Here are their top five tips to stay motivated and fit during the most tempting time of the year:

1) Buddy Up for the Holidays
They’re here! Your entire family, all in one place for the holidays. Or maybe it’s your good friends visiting from out of town. Either way, our Master Trainers agree it’s the perfect opportunity to pick a holiday workout buddy, or even a workout group. Hey, the more, the merrier. “Grab a family member(s) or friend(s) who will be your holiday buddy—decide to maintain, not gain during the holiday season by doing workouts together, trying new fitness classes on your holiday days off,” says Jessie Perry.

Lana Holt says it’s up to you to take the lead and have fun with it. “Make fitness a family affair. (Take a) family hike or bike ride or family challenge! Who can do more burpees?” And if friends and family aren’t up to holiday workouts, Sarah Remacle recommends an easy alternative. “Find an accountability partner through the holidays to commit to your favorite group fitness classes!”

2) Keep Your Routine…Routine!
You have a long list of places to go, presents to buy, and people to see. So maybe you don’t have time to work out today. Tomorrow will work, right? Wrong. “Make sure your workouts are still scheduled. Holidays don’t mean a holiday from working out,” says Matthew Taub. Claudia Rose Elfreich offers this simple, effective advice: “Plan, plan, plan. Stick to routines!” And Ron McDonald Jr. says to treat your meal routine like any other day. “Eat all your normal pre-family function meals as you routinely do…Have your normal breakfast, Shakeology, lunch, and in-between meals.”

For many people, the holidays are the most wonderful time of the year, so be sure to maintain a healthy balance to keep it that way. “It’s ok to say ‘no,’” says Teresa Seymour. “Stress and racing from place to place can leave you exhausted, overwhelmed, and out of sync with your healthy routines.”

3) Retreat From Treats
For health enthusiasts and fitness aficionados, the holidays often present a predicament for their palate. They want to eat the tasty treats, but don’t want the “benefits” they provide (a.k.a., calories, fat, sugars, you name it). Master Trainers have been there and done that, so here’s what they do now. “Bring food you know you can eat to parties! There are a lot of clean recipes out there!” says April Adorno. That’s what Heather Godfrey does. “I make the healthy version of my favorite treats and bring those to parties with me.”

They agree that you don’t need to completely ditch the dessert; you can simply exercise portion control, à la 21 Day Fix. “Don’t deny holiday treats BUT have a small portion and of course, be consistent in working out,” says Michelle Olsen. Adds Stephanie Annas Johnson: “Moderation in everything. One Christmas cookie won’t derail me, but 10 will.”

4) Plan Short Workouts
With so much happening during the holidays, it’s easy to commit to everything but your workout. To compromise, say our Master Trainers, commit to short workouts. “Tabata or HIIT workouts are great for getting your workout in with limited time,” says Philicia Moll. Felicia Laba Taub focuses on “efficient routines that are intense and take less time.” And if you have it, she suggests “30-45 minutes on Beachbody On Demand.” Morning workouts. 30-minute workouts. Julie Voris says to take your pick during the holidays, but quickly adds: “Fitness is not negotiable.”

5) Eat Before Your Big Event
Ahh, holiday delicacies. Turkey with all the trimmings. Dessert. How about another cup of eggnog? It feels like the calories are adding up just thinking about it. Our Master Trainers all agree on one strategy that works: Eat before dinners and parties. Missy Cornish likes to “eat something healthy with a large glass of water before heading out to an event.” Mandy Bear opts for Shakeology before attending gatherings. “I show up pretty full and therefore don’t feel the need to have a full plate.” Katie Hake takes it one step further. “Spoil your dinner! Fill up on veggies and fruit before dinner/the party and bring your own healthy dish,” she says. “Remember, the holidays are more about spending quality time with the ones you love.”

And Here’s One Bonus Tip!
Like it or not, we all do it. Holiday shopping. So Master Trainer Kam Niskach suggests turning it into your own form of exercise, but offers some advice to help keep your energy level high. “Holiday shopping is cardio!” she says. “Shopping on an empty stomach will just slow you down and pack on the pounds. Pack your purse with healthy snacks like almonds, an apple, and a shake packet.”

Shared by Dr. Phil McAllister @ Forward Health

Thanks Beachbody.com

How To Carve A Turkey Like A Professional Chef Over The Holiday Season

Found a great way to become the professional turkey carver/slicer and presentation aficionado at our family gatherings overt the years, and wanted to share the tips that have been very helpful as we come into the Holiday Season.

Shared by Dr. Phil McAllister @Forward Health and hopefully this gift of knowledge can be enjoyed for you as it has for our family.

No time to take a crash course on how to carve a turkey before the big day? No worries! In this episode of Culinary Intelligence from the CIA, Chef Brendan Walsh of The Culinary Institute of America gives you step-by-step instructions for not only how to carve a turkey, but also how to slice and arrange it on a platter for the perfect presentation on your holiday table.

Top 10 Questions Regarding Dr. Phil’s 2 For 1 Custom Foot Orthotic Insoles

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Are there are some signs or clues that I might need custom foot Orthotic Insoles?

  • Walking with a limp or your toes pointed in our out.
  • If your posture is poor or altered.  Check to see if your head, shoulders and hip heights are equal heights (normal) or if one side higher than the other (abnormal).  Have someone check your posture sideways.  Your ear should be in line with your shoulder and hip.  Does your head stoop or jut forward with your shoulders rolling in?  This “forward head posture” is abnormal and can cause a variety of health problems.  Abnormal posture can be linked to a foot problem throwing your posture out of balance.
  • Obvious shoe wear, such as excessive wear points or uneven wearing on one shoe or between both feet. Outside heel area wear is often a positive sign for over pronation (flat feet).
  • Knee or hip pain when walking or exercising can suggest a misalignment or instability in the feet.
  • Symptoms of faulty foot mechanics could include localized:
    • foot pain
    • bunions
    • hammer toes
    • arch, heel pain
    • leg, knee, hip or back pain
    • neck pain

How do I know if I need foot orthotics?

During your initial evaluation or during a re-evaluation, Dr. Phil will watch how you walk (gait analysis) and will also do a digital scan (using a 3-D Laser Computer Aided Design/CAD System) to assess how you are weight-bearing on the bottom of your feet, and he will do a postural evaluation and will visually inspect if you have overly high arches or dropped arches (flat feet).

image2 foot mechanics

I have good shoes.  Why do I need foot orthotics?

A high quality supportive shoe is indeed the most important element for your feet.  However, the insole is not custom-made for your foot.  By inserting a custom-made foot orthotic into a good quality shoe, you are ensuring that you give your feet optimal alignment, balance and stability.  Most shoes people wear have an existing insole that easily slips out and the orthotic can slip into the shoe to replace the original insole.

Will I have to buy new shoes?

It Depends!  The foot orthotics are not a thick, hard plastic, or rigid design.  They are slightly thicker than your existing insole, but have good cushion and enough rigidity to correct most foot imbalances.  Your custom orthotic insoles are most effective when used in shoes with good construction, fit, and condition.  Your orthotics are also a guide in assuring new shoes fit well.  If a shoe can’t accommodate a stabilizer which has been custom made for your foot, then that shoe is not the proper size for you.

I have different types of shoes.  Can I use them in all of my shoes?

If your shoes are a similar style you just move you foot orthotic from one shoe to the next.  There are different orthotics for different types of shoes.  For example, men’s and women’s lace up shoes that have a wide forefoot usually need a full-length orthotic whereas a slip on shoe may require an orthotic that is shorter in length.  There is a variety of foot orthotics for a variety of shoes.  To start, we usually recommend buying a pair of foot orthotics for the type of shoe you wear most, and with Dr. Phil’s 2 for 1 promotion, then have a second pair for either a different type of footwear or to have more than one pair of orthotics for similar footwear.  This saves you from having to constantly switch the orthotics from one pair to another.

I wear sandals in the summer.  Can I wear my regular shoe orthotics in my sandals?

No.  However, Dr. Phil does prescribe and dispense very comfortable Sandal orthotics insoles, as well as sandals.

What kinds of foot orthotics are there?

There are a variety of foot orthotics for a variety of shoes:

  • Men’s shoes
  • Women’s shoes and boots
  • Workboots
  • Children’s shoes (ages 5 to 12)
  • Golf shoes
  • Sandals

See the full line of Custom Orthotic Insole Styles: http://www.atlasorthoticlab.com/orthotics/ 

How do I Set Up An Assessment with Dr. Phil?

Get Help Now with Dr. Phil McAllister @ Forward Health or contact the clinic directly by phone at 519-826-7973, or by e-mail: info@forwardhealth.ca

An assessment with Dr. Phil will then be booked for approximately 30 minutes, and during that time he can help order the right kind of foot orthotic for you.

  • The Process

Custom design for foot orthotic insoles are through a 3-D Laser CAD imaging process.

Once the examination is completed, and you decide to go ahead with the prescription recommended by Dr. Phil, then,

  1. The casting kit or digital scan is sent to the Atlas Orthotic Lab (http://atlasorthoticlab.com/).
  2. Skilled technicians build your custom-made foot orthotics using 16 precise measurements based on their analysis of your feet. Your lifestyle, age, weight and activity level are all considered when the custom-made foot orthotics are fabricated.
  3. The foot orthotics are then shipped back to Dr. Phil at Forward Health. Your Orthotic insoles are usually back to the clinic within 1 week.
  4. Instructions will be given on how to wear and care for them on the fitting which is set up by the clinic once the orthotic insoles arrive from the lab.

How much do custom-made foot orthotics cost?

The price for the prescription and provision of the 2 for 1 promotion for custom orthotic insoles with Dr. Phil is $500 in total.  If you only need one pair and don’t need to take advantage of the 2 for 1 promotion, then the cost is $400.00 in total.  There is a $50.00 examination fee for the initial visit and it is built into the total cost if you decide to purchase the custom orthotic insoles.

Most health insurance plans cover some or all of the cost of custom-made foot orthotics.  Check your plan specifically for coverage amounts and who is payable regarding types of practitioners.  Payment is required prior to sending your order to Atlas labs as they charge us as soon they get the order.  If you have insurance make sure you know what they require so you can get reimbursed.  They will require a receipt from us for sure.  Sometimes a prescription letter from us or a note from your medical doctor is required.  Sometimes they require a detailed lab report, so Dr. Phil will always do a full detailed report with the manufacturing process etc.  That way you have all the specific necessities for your coverage.

How long do custom foot orthotics last?

Approximately 2-3 years with everyday usage, and then they should be replaced. Many insurance companies re-new custom orthotic insole prescriptions every 2 years.

 

Looking forward to empowering you to continue to live long & strong, and stay in the Game For Life!

 

Dr. Phil McAllister

ACRB, CTPI, DC. ABFP, CSCS, CCSP

Cholesterol: The New, the Tried and the Natural

Lower Cholesterol

Let’s take a moment to remember what cholesterol is all about, take a look at the traditional statin drugs, some newer medications on the market and talk a little about natural therapies that can provide valuable service to your cardiovascular health.

I want help now

The big push over the last few decades has been to lower cholesterol to lower the risk cardiovascular events such as pulmonary emboli, myocardial infarction, and stroke. Sometimes we get so caught up in lowering one marker, we loose sight of the bigger picture. Cholesterol is only one component to cardiovascular health, however it is one that can be easily targeted with medication and tracked through blood analysis.

Cholesterol is a necessary component and building block for many of our hormones, Vitamin D and substances that help with digestion. We could not survive without it. The trouble comes when excessive cholesterol populates our blood stream, it is easily oxidized and creates deposits called plaques in our arteries.

Excessive cholesterol comes from our diet (cholesterol, trans fat, saturated fats or even if we consume too many carbohydrates) or from hereditary factors that affect cholesterol production. The plaques take up space and narrow the path that our blood flows through. When the plaque builds up enough it can block our blood supply, starving off the tissue it is designed to feed – this is an infarction.

The word infarction means “plug up or cram”.  Sometimes a piece of the plaque can break off (emboli) and float through our blood stream and get caught in areas where the vessels are narrowed like our brain or lung and lead to a restriction of blood supply (another type of infarction).  A myocardial infarction (MI) is when an area of the heart is starved of oxygen and the muscle tissue subsequently dies. A transient ischemic attack (TIA) is where there is temporary interruption of blood flow in the brain. A hemorrhage is where the integrity of the blood vessel wall fails and blood escapes.

Ok, so it makes sense to pay attention to excess cholesterol!

The Stats on Statins

 HMG Co-A Reductase Inhibitors (i.e. atorvastatin/Lipitor, Fluvastatin/Lescol, lovastatin/Mevacor, pravastatin/Pravachol, simvastatin/Zocor, rosuvastatin/Crestor)

Cost at most $300/year CND

Generally: statins reduce LDL by 20-60%, increase HDL by 5-15% and reduce Triglycerides by 7-30% Statins are prescribed more to reduce cardiovascular event risk, rather than to reduce cholesterol levels.

Evidence of being able to treat to target levels doesn’t exist. Research has found that less than half of patients on 80mg per day will achieve at target LDL of <2mmol/L.

Most will find if they have no benefit at 10mg, they will not have any increased benefit at 80mg. Also, on the note of dosage, higher dosed statins affect HbA1c, a factor measuring your blood sugar and risk of type II diabetes. In a pooled analysis of data from 5 statin trials, intensive-dose statin therapy was associated with an increased risk of new-onset diabetes compared with moderate-dose statin therapy.

Women:  For women, unless they have existing cardiovascular disease there is no evidence that lowering their lipids will decrease their risk of coronary heart disease related death.

 Men: For primary prevention in men, the absolute benefit of statins use over 5 years (the reduction of major coronary events) is around 1.5%. That means if their risk of cardiovascular disease was 8 or 9% with no statins, while on statins, their risk is 7%. For secondary prevention in men (meaning they have already had one coronary event) their absolute benefit is 4%. This means if they have had a stroke, heart attack, heart failure, angina, TIA in the past, if they take the statin their risk is 16% where as if they didn’t it would be 20%.

Simvastatin is a first line of therapy. In one study, for every 12 people treated, one life was saved. Another study showed over 5.4 years of therapy for every 31 people treated, 1 death is prevented. Simvastatin will reduce LDL by 35% and usually the prescribed amount is 20-40mg daily.

Most common side effect: Often induces muscle pain (myopathy or at extreme rhabdomylosis).

About 50% of people will stop taking statins after 3 years due to their adverse effects.

Muscle pain aggravated by alcohol, advanced age (>80), chronic renal insufficiency, grapefruit juice, small body frame, liver health, untreated hypothyroidism, gender (women more affected than men), infections, perioperative periods, vigorous exercise, vitamin D deficiency. Drugs that will increase the muscle aches: Amiodarone, Azole antifungals, Calcium channel blockers, Cyclosporine, HIV protease inhibitors, Fibrates, Macrolide antibiotics (clarithromycin, erythromycin), and occasionally Nicotinic acid. If there is potential for drug interaction, the best choice is pravastatin.

 

What about the new drugs?

Alirocumab (Praluent ) about $14,600/yr USD

Evolocumab (Repatha ) about $14,100/yr USD

Benefit is there is no muscle pain however these are at a much higher cost and are self-injected every two to four weeks rather than taken orally. They work by blocking PCSK9 inhibitors, (monoclonal antibodies) and the medication is able to lower the LDL cholesterol circulating in the blood. Research is limited however so far it shows to lower LDL levels by about 60 percent. It also lowers the risk of heart attack and mortality related to heart disease over about a one to two-year follow-up.

What is available naturally?

Limit dietary cholesterol intake to <300mg per day

Restrict transfats and saturated fats

Limit carbohydrate intake

Eat more vegetables and fruit

Increase plant sterol intake to 1g 2x/day

Include up to 40g of fibre per day (most North Americans get <8g per day!)

Limit alcohol to 1 drink per day for women and 2 for men – have some days alcohol free

Regular Exercise

A Good Night Sleep

Supplements to help regulate blood glucose & incorporate healthy fats

There are numerous cardiovascular supplements you may wish to consider with your healthcare practitioner. Too many to mention here and they are specific to an individual’s overall need and one must be careful to have the right dose, duration and be sure there is no interaction with other medications or supplements.

 See Dr. Laura M. Brown ND for your personalized cholesterol lowering treatment plan

Fish Oil

One universal supplement that has been well studied is Fish Oil. Omega 3 and now new to the market Omega 7 has shown to be of benefit for many health factors. Omega 3 is well researched and there are over 20,000 published scientific reports that support its health benefits, including that are cardiovascular health. Fish oil has been shown to reduce serum triglyceride levels. A recent report on Omega 7 shows in a double blind placebo controlled study with 60 subjects and a baseline C Reactive Protein (inflammatory marker) at 2-5mg/L showed a 44% drop in CRP. You can look for Omega 3’s and will find them in most health food stores. On a side note, Metagenics has some serious research behind the Omega 7 and has combined the 3+7 in a formula rightfully called Mega 10. You can find Mega 10 at Forward Health.

 From the heart and mind of your local naturopathic doctor, Dr. Laura M. Brown ND.

References available upon request.

5 Reasons to Regulate Blood Sugar

Blood sugar control is not just for diabetics! Maintain steady blood sugar and it can help you loose weight, sleep better,  balance your mood, increase your mental focus, and fend off chronic illness like diabetes, cardiovascular disease and cancer.

Get help now from Dr. Laura M. Brown, ND

5 Reasons to Regulate Your Blood Sugar

  1. Levels out Anxiety
  2. Helps with Weight Loss – Encourages Fat Burning
  3. Increases Mental Focus
  4. Reduces Chronic Inflammation
  5. Regulates Sleep

Blood Glucose Control

  • Glucose comes from the foods you eat. Every carbohydrate will be broken down to the smallest of sugars – sucrose, fructose, glucose, lactose, galactose.
  • Blood sugar, or glucose, is the main sugar that your body makes from the food you eat. Glucose is carried through the blood to provide energy to your body’s cells.
  • When you take in more glucose than required it is stored as glycogen in muscles and liver and then as body fat (triglycerides)
  • Hyperglycemia means high blood sugar or glucose. Insulin is a hormone that moves glucose into your cells to give them energy. Hyperglycemia happens when your body doesn’t make enough insulin or can’t use it the right way.
  • Hypoglycemia is when there is low blood sugar. This happens after prolonged absence of energy intake or insulin dysregulation.
  1. Anxiety – When your blood glucose rises quickly from a sugary drink or snack or high glycemic load meal, insulin is released to shuttle the sugar into cells, then you are left just as quickly with a low level of blood sugar. This rise and fall can affect your mood. A new word was added to the dictionary this year. “Hangry” is now a word. It means you are hungry and angry when your blood sugar is out of balance. The concept of anxiety and low blood sugar is real. The physiology of the body in both circumstances is very similar and the brain sometimes cannot tell the difference. It’s that same reason why a diabetic might have angry outbursts – their sugars are not well regulated. Help regulate the release of sugar into your blood stream with protein in your meal or fibre with your carbohydrates. That means eating whole grains, legumes or some type of soluble or insoluble fibre.
  2. Encourages fat burning. If you only take in a little carbohydrate at a time, your body has a just-in-time delivery of sugar, or energy to fuel your activity. If it needs a little boost, it will pull the extra from your cells – and result in weight loss. It’s a careful balance, however. Starve your body and it will go into a mode of preservation and shuttle any energy it gets into cells for safe storage – just like a squirrel hiding its nuts for winter. Give your body too much energy, and it will also store it in the cells as fat.
  3. Increases Mental Focus. Your brain has only one source of energy – glucose. If your blood sugar is going up and down like a roller coaster, so too will your ability to focus. Also your brain experiences sugar as a reward – it enhances the dopamine system. So sugar can be addictive if you use it as your only reward. You have 5 senses – taste is only one of them. Enhance your reward system with more than just food, try music, massage, theatre, aromatherapy, or intimate pleasures.
  4. Reduces Chronic Inflammation.  Inflammation leads to cortisol release which over time can lead to insulin resistance which leads to inflammation… a bit of a dog chasing its tail. Reduce stress to regulate cortisol release. Cortisol is released every time you encounter a stressful situation – it was meant to stimulate the physiological mechanism that pulls glucose (energy) from storage so you can go chase the tiger. Problem is if the tiger is a deadline at work and your are madly typing away…it just doesn’t burn the same energy as running and huffing and puffing. So… when you don’t use that glucose the blood sugar remains high and – for reasons we are not entirely sure –  will get re-deposited right around your waist line.  These not so lovely love handles are a contributor to metabolic syndrome and pose diabetic risk. Chronic inflammation also is a precursor to cardiovascular disease and cancer.
  5. Regulates Sleep. If your blood sugar is regulated, you will sleep better because you will not be so restless at night. Sleep time is a time of rest and rejuvenation. Too little sleep and your appetite increases, and this may put you at risk of disrupting your blood sugar balance. Eat your bigger meal at least 2 hours before bed and have a light snack with a little protein in it before you go to bed.

General over all tips to help regulate your blood sugar:

  • Physical activity to counteract the extra energy release
  • Eat only small amounts that meet your activity level, but don’t go below 50g of carbs per day – your brain and thyroid need it.
  • Eat carbs with fibre and protein to prolong release of glucose into blood stream and promote satiety.
  • Pay attention to the glycemic load of foods.
  • Mindful meditation, focused breath to deal with stress response.
  • Get a good night’s rest
  • Support blood glucose regulation with botanical medicines. Check with your health practitioner for the best fit for you with the right dose & duration.

From the heart and mind of your local naturopathic doctor, Dr. Laura M. Brown, ND. drlaura@forwardhealth.ca