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THE TALE OF HYPOGLYCEMIA

On December 28, 2010, in A FEW OF MY THOUGHTS, Lifestyle, by Dr. Tuchinsky

The vicious cycle of insulin.

Many people go through the glucose-insulin yo-yo throughout most of their days, which leaves them feeling very fatigued. The problem lies in the unbalanced nutrition. The old 40/30/30 rule still holds true- the best way to eat is to consume roughly equal portions of carbs, protein and fat throughout the day.

Most of us are not well versed enough in nutrition and do not have sufficient enough control over our meals to achieve that. We tend to consume too many carbohydrates and simple sugars. Some lucky people have very adoptable pancreas and liver that can handle it well, but for the rest of us this results in postprandial over-secretion of insulin.

The mechanism of hypoglycemia after meals.

The carbohydrates and sugars are quickly digested but the insulin remains floating in our blood for another 4 or 5 hours, causing mild hypoglycemia and fatigue. You may not even detect the low blood sugar with conventional glucometer, but this is because your body is working hard to keep it normal – a process that involves mobilization of glycogen and conversion of fatty acids which use up your energy stores. In addition, the insulin excess also triggers a whole wide range of unnecessary biochemical reactions in your body that may contribute to your fatigue. In other words, the delicate chemistry of your body is off balance.

How to avoid insulin ups and downs.

These blood sugar highs and lows can be avoided, when one consumes five or six small balanced meals throughout the day. This will insure more even levels of blood glucose and prevent “bottoming out” in between meals. Think of a typical breakfast choices we make- a bowl of frosted cornflakes. A croissant with coffee. These are 100% carbohydrate melas that are guaranteed to send you sugars and insulin on a wild spin and leave you feeling starved by mid-morning. On other hand a bowl of oatmeal with a generous serving of nuts and a yogurt, or a toast with ricotta cheese would last you much longer in terms of energy reserve and hunger suppression.

READ MORE ABOUT FATIGUE CAUSES

<p><a href=”http://www.freedigitalphotos.net/images/view_photog.php?photogid=151″>Image: Suat Eman / FreeDigitalPhotos.net</a></p>

THE FUTURE OF DEPRESSION

On December 17, 2010, in MEDICAL FACTS, by Dr. Tuchinsky

It’s all about receptors!

 The modern medical science  has yet to figure out all of the organic causes of depression. Interestingly, the brain receptors that traditional drug makers have persistently disregarded so far, have become the golden mine for the illicit drug industry.

1. Endorhins.

It is a known fact that some people are completely indifferent to pain pills, while others become addicted after taking only a few Vicodin after a dental surgery. The answer to these varying degree of susceptibility may be hiding in the emerging theory of Endorophine System Deficiency. Opioids are substances that stimulate the same receptors as endorphins that are produced in our body naturally. Some people are born with lower than normal levels of these endorphins than others and spend their lives feeling for the most part unhappy and miserable deep inside. Until one day, when they discover opioid narcotics and begin to self medicate their depression.

Unfortunately, their initial bliss is short lived. The majority of narcotic pain meds are not suitable for long term use as tolerance and dependence develops very quickly, requiring higher and higher doses to achieve the desired effect. The way these drugs were designed and the euphoria they tend to induce makes them very prone to abuse. In fact, quite the opposite- the depression is likely to worsen during the periods of abstinence.

2. Endocannabinoids. Another system that definitely plays role in our mood is endocannabinoid system. A few years ago, Sanofi-Aventis released an anti-obesity drug called Rimonabant on the European market. The drug worked by blocking the cannabinoid receptors of the brain, -the effect exactly opposite to the one exerted by marijuana which stimulates them. The idea was based on the logical conclusion that since cannabis are known to stimulate appetite in most people, the drug with the opposite action on the same receptors will lead to reduced appetite and weight loss. The theory proved it be correct: Rimonabant worked but its time under the sun was cut short as it was withdrawn from the market just a few years later. The reason it was pulled off was due to the reports of the serious side effects, namely severe depression and suicide in people who took it. This confirms that endocannabinoid receptors play a crucial role in our mood.     READ MORE ABOUT DEPRESSION

Image: Boaz Yiftach / FreeDigitalPhotos.net

THE HISTORY OF DEPRESSION

On December 17, 2010, in MEDICAL FACTS, by Dr. Tuchinsky

It’s all about neurotransmitters!

The modern theory about neurotransmitter origin of depression is relatively new and is likely destined for significant revision in the next 10-20 years.

The idea that there is a chemical imbalance behind depressive mood began to emerge in the middle of the twentieth century. Immediately drug companies began a desperate search for the “happy pill”.

First generation of antidepressants.

The first generation of anti-depressants, mainly tricyclics and drugs such as trazodone and nefazodone, had limited success marketing success due to the fact that such high doses were required to achieve even marginal benefit that the side effects were intolerable to most people.

The second generation of antidepressants.

Then in the mid seventies- hallelujah- came the famous SSRIs (Selective Serotonin Reuptake Inhibitors). The chemical mystery of depression appeared to be solved, and it all came down to low levels of the brain neurotransmitter called serotonin, or at least that was the belief imposed on the population by the robust marketing campaign that enabled Prozac to become one of the most successful prescription drugs in history. Unfortunately, soon it became clear that while some people clearly did benefit from SSRIs, at least just as many who still remained depressed. (The interesting ploy in the SSRI story is that patients are told to give it six weeks before the medication will take its effect – and many may experience natural improvement in their depression by that time anyway. Also, it is unclear how many people simply benefit from the placebo effect that medication gives them, rather than due to the pharmacological effect.)

The latest players on the market.

The pharmaceutical scientists began to scratch their heads and wonder if perhaps they have overlooked something. Maybe serotonin was not the only substance that affected our mood. Soon, we were presented with new and more advanced preparations – Effexor (venlafaxine) which affected not only serotonin but norepinephrine as well, and Wellbutrin (burpopion) which also helped to raise dopamine levels. Other brand name antidepressantas began to flood the market-Lexapro, Cymbalta, Savella, Pristiq- just to name a few in the most recent years… And once again,there were some people who found miraculous cure in those drugs, while others noticed nothing but the side effects.

The Quackery.

There are some savvy medical offices out there that advertise themselves as “providing the most advanced treatment in the history of depression.” Supposedly, they test the patient blood for different levels of neurotransmitters and choose the one that is most appropriate for them based on the results of the tests. The patients need to foot a hefty bill that is not covered up by their insurance. The only problem with this seemingly logical approach is that there is no correlation between levels of neurotransmitters in the blood with those that are found in the brain. And it is only those molecules that are present in the brain that really matter. It may be actually possible to measure the level of brain neurotransmitters but it could only be achieved by testing cerebrospinal fluid, not blood, and I am not aware of this being done anywhere outside of research labs.

Conclusion.

The science of depression is just beginning to emerge. I am optimistic that somwhere down the road the diagnosis will be much more straightforward, with either a genetic screen or an advanced brain imaging scan, the work of guessing where the problem lies will be virtually eliminated. And even if the serotonin theory eventually becomes disproved, it will never be discounted. The main achievement of Prozac’s ad campaign was that it lifted the veil of stigma and changed public opinion from viewing depression as a weakness or a personal choice to the one of the legitimate disease. And to each depressed person who took it, even if merely as a placebo, it gave something far beyond a high serotonin dose. It gave them Hope.  READ MORE ABOUT DEPRESSION

Image: Boaz Yiftach / FreeDigitalPhotos.net

TESTOSTERONE: THE VIRILE HORMONE

On June 12, 2010, in Hormones, MEDICAL FACTS, by Dr. Tuchinsky

The Supreme Hormone.

Testosterone is a magnificent hormone. It is the hormone of energy, desire, and ambition. (Of course it has a dark side to it as well, being responsible when present in excessive quantities for aggression and promiscuity). Both men and women depend on testosterone for their bodies to function well, however men require it in the amounts that are hundred-fold higher than women. I have already touched on testosterone deficiency in women in the post about birth control, and  now I would like to focus on testosterone deficiency in men. On one hand testosterone is often abused by young  athletes and bodybuilders who push their testosterone from normal to supra- normal levels to improve muscle mass and performance. This is unhealthy for the body and can cause serious medical problems. On other hand, there are plenty of men out there who have low testosterone but may never even find out about it. Decreased testosterone in men (medically known as hypogonadism) is more prevalent than most people think. Over the last few decades, testing older men for testosterone deficiency has become more widespread.

The Replacement.

Testosterone replacement is also part of the commercial anti-aging therapies. The group that is most often ignored in diagnosis of testosterone deficiency is men in their 20s-40s who may have subtle decrease in their  testosterone level. The range for testosterone is wide (200-900)  and younger men should test toward the higher end of the spectrum. I believe that it is even more important to test for “free testosterone”, rather than customary total level, which is the biologically active form of the hormone. Sometimes the total testosterone appears misleadingly normal while the active form is low due to increased binding to serum protein. It should be noted that mild testosterone deficiency often presents only with decreased sexual drive and low energy.  The amount of body hair, testicular size and erection may often not be affected at this level. I recommend checking testosterone for every man who complains of persistent fatigue and/or low sex drive.

Causes of Low Testosterone.

There are many reasons for testosterone deficiency: medications, chronic illness, pituitary disease, obesity, liver problems. However, often there is no good explanation at all  that can be found –particularly in the mild cases. Perhaps, one day the multiple endocrine disruptors that are present in our environment will be implicated as a cause or perhaps it is just the genetic “draw of luck” for some.

Therapy Options.

There are many treatment options on the market, including biweekly injections, gels and patches. There is also implantable form of testosterone pellets. Some experts, however, recommend using drugs to stimulate testosterone production such as beta-HCG (the hormone produced in pregnancy) and clomiphene (the female fertility drug) to boost the production of testosterone, rather than replace it with an artificially synthesized hormone. This approach is particularly preferred for younger men, given that replacement of natural testosterone would suppress their testicular function and that in turn may result in infertility. Fortunately, this  is usually reversible upon discontinuation of the drug but it may take a long time. Many men with low testosterone who have had their levels raised to normal, feel as if  their lives “have been shifted back into full gear” and report better satisfaction at work and personal lives.  READ MORE

Allergies are very common.  Most people experience allergies at one point or another. Allergies are exceedingly common in industrialized countries and particularly in urban areas, with up to 30% of adult population affected. Due to this overwhelming presence of allergies in our lives, we often tend to regard them as trivial matter. However, a fatigued person should not underestimate the impact this condition can have on their overall wellbeing.

How is allergy related to fatigue? Allergic rhinitis (in other words: nasal allergy) that persists over time, results in chronic inflammation of the mucosal lining of your nose. This, in turn, results in constant stimulation of your immune system, which can make you feel very tired. Another link between allergies and fatigue is their effect on sleep. Studies show that people who suffer from allergies do not get restful sleep. As we have discussed before, sleep disturbance is probably the largest culprit among all of the fatigue causes. Therefore, tackling your allergy symptoms can result in significant improvement of your fatigue as well.

Diagnosis. Nasal allergies are usually easy to diagnose but to figuring out the exact culprit is more difficult. There are blood tests available that test for antibodies to common seasonal allergens to determine which one may be responsible but they are not comprehensive.

Allergy Treatment.
Ceramic Neti Pot - Nettie the Elephant

1. Irrigation.   The first step to combating allergies is daily nasal irrigation. You will need either a squeeze bottle or a neti pot to do that. You can prepare your own solution with non-iodized salt and baking soda or buy a sinus wash solution packages in the drug store (my ENT recommends NealMed brand). Then it is just the matter of figuring out the right technique and getting used to the process. The sinus wash will remove the inflammatory substances, allergens, viruses and other pollutants from your nose. It will also make it easier for your nasal medication to reach its target.

2. Nasal Steroids.  Most doctors consider prescription nasal sprays to be the best first line therapy. There are several different types available. Nasal steroids (such as Flonase, Nasonex, Nasacort and many others) work very well, but only when used regularly and for prolonged period of time. Their side effects are considered to be rather minimal. Nasal anti-histamine sprays (Astelin, Patanase, Astepro,etc) begin to work immediately and relieve symptoms fast, but they do not reverse the inflammation like nasal steroids do. Oral anti-histamines (such as Claritin, Allegra and Zyrtec) mainly help with sneezing, watering eyes and runny nose but do not significantly affect nasal congestion or post-nasal drip. On occasion, doctors prescribe a medication called Singulair, which is more often used in children.

3. Decongestants. Pseudoephedrine (Sudafed) is still one of the best medications out there for immediate short-term relief of severe nasal congestion. In most states however, the Sudafed that is stocked on the pharmacy shelves contains a different ingredient (phenylephrine) and you have to ask the pharmacist for the “real thing” which they keep behind the counter. Keep in mind that Sudafed is not a good drug for people who have high blood pressure or enlarged prostate. It is better to stay away from using over the counter nasal sprays – they often result in rebound runny nose, which can be very difficult to treat.

4. Other. In more severe cases, a visit to allergist may be recommended to perform skin testing for various allergen and a treatment called allergy desentization.  READ MORE ARTICLES ABOUT FATIGUE

Image: Yaron Jeroen van Oostrom / FreeDigitalPhotos.net

 

 

FATIGUE AND YOUR DIET

On April 18, 2010, in A FEW OF MY THOUGHTS, Lifestyle, by Dr. Tuchinsky
  1. 1.Protect your body from the impurities.

Ask any mechanic about the advantage of using regular gasoline over premium (as indicated in my car manual) may give my car less power and poorer mileage. It seems to me as a perfect analogy to the connection between diet and fatigue. Your body was designed to  function optimally when fueled by diet that is rich in nature-derived nutrient and not in chemical additives, preservatives and artificially manufactured fats that invaded our food market in the 20th century.

 Unfortunately the standard American diet is full of the substances that are toxic to our bodies and short of the vital nutrients our organs require to function properly. Thus, many metabolic and hormonal pathways become affected, and this in turn results in fatigue. It is known for a fact that most people today do not consume enough omega 3 fatty acids, antioxidants, vitamins and healthy fats to ensure optimal function of their bodies.

2. Don’t go for a quick fix.

One might be misled to believe that taking a daily multivitamin or some supplements is enough compensate for a nutritionally poor diet. While they are a nice addition to an otherwise good diet, they are not a redemption for a poor one. It appears that human body does not seem to utilize and store vitamins and elements very well if they are delivered in a pill, rather than in organic form. In addition, some nature-derived nutrients are simply impossible to recreate in the lab.

While vitamin supplements are a good back up option, the only real solution to defeating fatigue is a healthy diet. Unfortunately, this requires time, money, effort and will power that for most of us are hard to find. So, rather than failing one cumbersome diet plan after another and resorting to the old habits, here is a simple plan that actually can be achieved. It’s not the perfect diet but my philosophy is that if you set more realistic goals you’ll be more likely to follow them.

3. Seven easy changes for everyday diet.

  1.   Eat ½ cup serving of green leafy vegetables for lunch.
  2.   Eat  ½ cup yellow or orange vegetables with your dinner.
  3.  ¼ to ½ avocado (depending on the size) 3 times a week (read Time to Pardon the Fats post).
  4.  If you really crave something sweet, save it for after lunch or dinner but  do give in to temptation in between meals (this will prevent insulin spikes that make you hungry and tired – read The Tale of Hypoglycemia post).
  5. Eat some fresh blueberries or raspberries daily.
  6. Add a spoon of milled flax seed to your cereal or yougurt
  7. Buy whole wheat bread and pasta, and brown rice instead of white

If you stick with these daily habits for several months, you will notice that your energy level and mental capacity begin to improve.

READ ABOUT MORE CAUSES OF FATIGUE

 

Image: Carlos Porto / FreeDigitalPhotos.net

THYROID DISEASE

On April 5, 2010, in Hormones, MEDICAL FACTS, by Dr. Tuchinsky

Low thyroid hormone is extremely prevalent. Most doctors would tell you that one of the first tests they order when a patient complains of fatigue are thyroid hormone. Hypothyroidism (lack of sufficient thyroid hormone production) is extremely common, particularly among female patients.

How are thyroid problems diagnosed?   The doctor will also touch the area of your neck where thyroid gland to see if there is any abnormal enlargement or nodules.The test we order to check thyroid function is called TSH. It stands for Thyroid Stimulating Hormone, and measures a substance produced by pituitary gland in the brain, which works on the thyroid gland to stimulate production of the thyroid hormone. Sometimes the thyroid hormone itself is within the normal range but TSH is elevated.
What does elevated TSH mean?  This usually means that the thyroid gland functions at suboptimal level and requires extra stimulation to deliver what it should. There is some controversy as to the significance of this situation, which is called “subclinical hypothyroidism”. Some physicians believe that as long as the thyroid gland is still managing, no treatment is necessary. Others believe that patients are affected with their vital organ being stretched like that, and that during times of increased stress the worn out thyroid gland will not be able to keep up with stress, resulting in transient hypothyroid states, and therefore treatment is indicated.
What should be considered the normal TSH has been challenged as of lately. Some experts still believe that it is 5.0 mU/L, while others insist that it should be 2.5 mU/L. The recent trend for clinical labs has been to accept lower and lower cutoff for TSH value, which means that a lot more people are hypothyroid to some extent than previously thought. In my practice, I usually offer treatment to patients with subclinical hypothyroidism if they have any corresponding symptoms (including decreased energy), have elevated cholesterol or their TSH is greater than 10 mU/ml.

What causes it?  Most people develop hypothyroidism due to a virus that causes inflammation of the thyroid gland. The infection may be silent and the person often is not aware of having it. The symptoms of low thyroid function include cold intolerance, fatigue, somnolence, poor memory, constipation, menstrual abnormalities and muscle aches. Mild weight gain or difficulty loosing weight is also common. It can also lead to elevated cholesterol levels. In addition, hypothyroidism is one of very common and easily treated causes behind depression. READ ABOUT OTHER CAUSES OF FATIGUE

 

FATIGUE AND CHRONIC DEHYDRATION

On April 4, 2010, in Lifestyle, by Dr. Tuchinsky

Water is everything.

Let’s talk about another one of very common and overlooked causes of fatigue: mild chronic dehydration.
Water comprises about 60% of human body composition (although this number is slightly lower in women) and is involved in thousands of essential chemical reactions in the cell.
Now, you probably heard the common recommendation about drinking eight glasses of water per day. Well, let me tell you that there is absolutely no scientific proof to this statement. Someone, somewhere came up with this number, which looked like a good number to most people, and therefore it really took off and stuck around.

So how much water do we need?

There is no scientific evidence to support this statement and no studies have ever been done to prove it. The truth is that the amount of water your body requires will vary depending on many factors: such as your diet (e.g how much caffeine you drink, how much salt you consume, foods with high water content in your diet, etc), your intestinal function, your exercise and activity level, the temperature and humidity outside and many others.  Some days you might need only six, while other days you might need twelve – but the good news is that you really don’t need to keep track or make any calculations to figure it out. The nature endowed us with a very sensitive hypothalamus, which is constantly checking our water level and immediately signals about any significant drop.  Feelings of  thirst and dry mouth typically develop at dehydration  levels of 1%, while fatigue and brain fog begin at the levels of 2%- a design that is meant to ensure a  good safety net . Therefore, as a rule of thumb, as long as you consume a drink with every meal and drink something whenever you experience the earliest symptoms of thirst, you will avoid dehydration.  The other clue is the color of urine- a clear or very light yellow urine is generally consistent with being well hydrated, while the darker shades imply dehydration (there are some rare exceptions to that, such as in cases of liver and kidney disease).

There is no physiological advantage or health benefit to drinking more water to become “overhydrated”. There is usually no harm either (as long as the amount is not extreme) with the exception of an additional bathroom trip as your kidneys diligently get rid of the excess. So don’t feel obligated to force that eight glass of water in you, if you really don’t feel like drinking it.

What causes chronic dehydration?

The main reason why people become dehydrated is because they are so busy and caught up in what they are doing  that they tend to ignore or disregard their thirst. These particularly applies to people who work in high paced stressful jobs during the day. If you allow yourself to go dehydrated even for a few hours, you may suffer consequences for some time afterwards as your body restores its balance.

Dehydration has also recently sparked some interest in the cancer prevention studies. Although the research is still preliminary, they have suggested that chronic dehydration can result in higher incidence of cancer. The link appears to be particularly strong in the case of bladder cancer, likely due to the higher presence of toxins in the concentrated urine that remains in the bladder for a longer period of time. READ MORE ARTICLES ABOUT FATIGUE

Image: Suat Eman / FreeDigitalPhotos.net

SLEEP REVELATIONS

On March 16, 2010, in Lifestyle, MEDICAL FACTS, by Dr. Tuchinsky

We live in the world of sleep deprived people.

The sleep science has been booming with new and exciting data over the past few decades. Once recording brain waves during sleep became possible, we learned that there is slow wave sleep and REM sleep. Each one is very important to our wellbeing.  During REM sleep, we experience dreams and our brain neurons are working hard at data clean up and storage. Lack of this type of sleep will result in impaired memory and concentration as well as decreased thinking capacity.

The slow wave sleep, is the dreamless “shut down” mode,  which allows your body to undergo all the necessary housekeeping and maintenance.  Vital hormones are produced during this time and molecules, and the buildup of toxic byproducts is eliminated on the cellular level. The mechanisms that govern our sleep are so complicated and enigmatic, that modern science still is only glimpsing into it, but even that glimpse is enough to convince us that the value of sleep is absolutely crucial to our well-being.

The role of sleep in medical illness.

Recent breakthrough in treatment of fibromyalgia, a condition associated with chronic pain, depression and severe fatigue, revealed that the disease had its root in lack of slow wave sleep. So even when the fibromyalgia patient sleeps more than eight or nine hours per day, their brain for a number of reasons spends less in the slow wave sleep than necessary. Among many other things, this results in decreased production of the very important neurotransmitter serotonin and decreased production of human growth hormone. The result is depressed mood, low energy and in fibromyalgia patients also causes increased sensitivity to pain. While not everyone is genetically predisposed to develop fibromyalgia, most people will feel the diminished lack of sleep to certain degree.

So how much sleep do you really need?

There are some people who require less sleep than others, usually due to their ability to go through sleep cycles with higher efficiency than others. Most people, however do require a minimum or seven or eight hours to complete the required amount of sleep cycles. If you always wake up to the alarm clock, you are probably interrupting one cycle in the middle; if you have trained yourself to wake up at certain time on your own then your then your  brain will adjust to complete the cycle on time.

READ MORE ABOUT SLEEP

GINSENG POWER

On March 9, 2010, in A FEW OF MY THOUGHTS, Natural remedies, by Dr. Tuchinsky

Panax Ginseng:  Truth vs  Myth.

Ginseng often comes up when one talks  about natural remedies for fatigue. There appears to be a lot of  misconception around it. For example, paying money for a ginseng tea, depending on where you buy it, will turn out in the best case just wasting a few dollars on a drink with barely detectable concentrations, and in the worst case getting something that contains secretly hidden ephedra to give you a false energy boost.

In reality, if you want to give ginseng a chance , you must be patient and expect to see the results only with regular use over a long period of time (expect at least a month or two to notice the difference).  It is neither a stimulant nor an instant energy booster, but rather what the natural healers refer to as “tonic” and medical scientists call “adaptogen“. These are names for  substances that increase resistance to stress and build up vitality. The wisdom of traditional Chinese medicine advocated use of ginseng for almost two thousand years. Now its popularity has reached the Western world and even spiked curiosity among some medical researchers.

How Does Ginseng Work?

The studies on Korean red ginseng root and some varieties of American ginseng were shown to contain substances called ginsenosides, which are hypothesized to induce production of cortisol by adrenal glands over period of time (see Adrenal Fatigue).  It has also been shown to improve immune system function.  A recent study performed in Mayo clinic showed that there was significant improvement in fatigue of cancer patient treated with high dose ginseng extract. On other hand, there were some studies that tried to measure performance in athletes who were taking it and found no  significant  difference in oxygen consumption or muscle strength. However, that’s the problem with  Western medical science-it often insists on measuring the unmeasurable. Perhaps, ginseng does not boost the  athletic performance but it does not preclude it from improving the daily energy  level and the sense of well-being in fatigued people, valuables that are trickly to measure, particularly when the change is gradual and over long period of time. Ultimately, however there is still a lack of good quality research on the subject of ginseng.

A Few Other Tips about Ginseng.

Another problem, is that because natural remedies are not regulated by FDA or any other governing agency, and as a result some extracts of ginseng contain much less of the substrate than they claim and sometimes none at all. It is imperative to buy all herbal medicines from  reliable manufacturer.Of course, like any medication, ginseng can cause side effects in some people. The most common ones quoted are usually observed in high doses and include headaches, nausea and insomnia. These risks can probably be minimized if you start at a lower dose and work your way up. Also, keep in mind that Siberian ginseng, which is a cheaper alternative that populates the store shelves, is actually a completely different chemical and contains no ginsenosides.

Here is a link about proper ginseng dosing regimens:

READ MORE ABOUT FATIGUE