integrative medicine


I add this post written by Lissa Rankin, MD…because she writes well and with passion about health and wellness. 

As a doctor, I always thought that, to be healthy, you simply had to eat well, exercise, get enough sleep, take your vitamins, and follow doctor’s orders. But after twelve years of education and ten years of medical practice, I took a job at an integrative medicine practice in Marin County near San Francisco, where most of my patients were “health nuts” doing everything right- but some of them were sicker than ever. I was baffled. I mean, these folks drank their daily green juice, ate a vegan diet, worked out with personal trainers, slept eight hours a night, took their vitamins, and saw the best doctors.

Compare this to when I worked in a clinic where many of my patients were from the inner city of Chicago. I understood why they were sick. They ate poorly, rarely exercised, smoked, drank, didn’t listen to the doctor, and got sick. That made sense to me.

But the patients in Marin didn’t. From everything I had learned in medical school, these people should have been in perfect health. But many of my patients felt tired, they weren’t sleeping well, their libido went down the tubes, their bodies ached, they gained weight, they suffered from a host of chronic medical conditions- they lost their mojo really.

So, I tried to help my patients by running batteries of tests – some of them common, some of them specialized. And, yes, sometimes I’d pick up something surprising that, would rid my patient of all his or her symptoms. But mostly, I’d find nothing earth-shattering and wind up shrugging my shoulders. It was clear that there was still a big, missing piece of the health puzzle missing. I just couldn’t figure out what it was.

So I changed my patient intake form. I started asking them things like:

  • Is anything keeping you from being the most authentic, vital you?
  • Are you in a romantic relationship? If so, are you happy? If not, do you wish you were?
  • Are you fulfilled at work? Do you feel like you’re in touch with your life purpose?
  • Do you express yourself creatively?
  • Do you feel financially healthy or is money a stressor in your life?
  • What rules do you follow that you would wish you could break?

And the two big doozies:

• What might lie at the root cause of your health condition?
• What does your body need in order to heal?

When I asked my patients what their bodies needed in order to heal, they said things like:
• I need to leave my toxic relationship
• I need to quit my job
• I need to forgive my father
• I need to finally write my novel

The patients who had the courage to follow their own “Prescriptions” started experiencing radical improvements in their health. It was as if by healing their emotional landscapes, their bodies followed! I was hooked. My new book Mind Over Medicine is the result of the exploration that followed into what really makes us healthy and what really predisposes us to illness.

What does YOUR body need in order to heal?

Are you confused about supplements? Most of my clients are! Their “vitamin habits” run the gamut from never or rarely taking vitamins to taking upwards of 20 or 30 vitamins and supplements a day.

More than half of adults in the U.S. take supplements, and spend about $23 billion on them, according to a recent National Institutes of Health report. Most expect that they will feel better and have less chronic disease because of the supplements. But here’s the kicker: Most of us in the healing professions have had little or no training in nutritional supplementation! Unless we’ve enrolled in fellowships or had additional training, we don’t know how to guide clients in this area.

A lot of those vitamins and supplements are running through the gut and kidneys and aren’t even absorbed. (I don’t mean to trivialize this, but it does give new meaning to the phrase “money down the drain.”)

By definition, a vitamin is a compound in food that results in a deficiency disease if it is removed from the diet. The term “vitamine” was coined in 1912 by a Polish biochemist, Casimir Funk. It comes from the Latin word “vita” meaning life combined with “amine,” because the substance that Funk isolated from the husks of rice, called thiamine, was a chemical derivative called an amine. Funk proved that beri-beri (a weakening disease leading to paralysis and confusion) was caused by inadequate thiamine in the diet.

In the U.S., large-scale fortification of the food supply started in 1924, when iodine was added to salt to prevent goiter (a swelling of the thyroid gland.) In 1933, vitamin D was added to milk to prevent rickets (a disease of soft bones); 1941 saw flour fortified with thiamine, riboflavin, niacin and iron in response to nutritional deficiencies seen in World War II military recruits.

It is rare to see obvious deficiency diseases in America, but it is not rare to see poor nutrition or under-nourished people. We now know that vitamins affect all aspects of our health.

Most vitamins are isolated from plants; in fact there is a lot of data to support the many benefits of a diet that is high in vegetables and fruits. But it is apparent that commercially-grown vegetables have been bred to look nice in the store with a long shelf life. Nutritional concerns are often secondary. It’s clear to me we just can’t get everything we need from food alone. We are gradually figuring out the individual genetic “fingerprint” and now know, for example, that 30% of us don’t have the ability to break down folic acid to its active form. This genetic “glitch” can lead to neural tube defects, Downs’ syndrome, arthritis and more. Adding extra folic acid or supplementing with the active form of folic acid overcomes this genetic problem.

So until we have inexpensive technology to show us our individual genetic “blueprint”, then two questions remain: What nutritional supplements should I take? And where should I buy them?

My usual recommendations include a minimum of these six vitamins or supplements: a high quality Omega-3 fish oil, a multivitamin and mineral complex, a broad spectrum B vitamin, additional Vitamin D, additional iron (menstruating and pregnant women only), and a broad spectrum antioxidant. I add in other supplements based on clients’ specific needs.

I recommend high quality vitamins and supplements from a reputable company. I look for companies that can offer information on product quality (batch testing of each lot of supplement along with testing for contaminants) and are formulated to be absorbed into the bloodstream and body. Otherwise, your money might be going down that drain.

But the very first step to optimal health is good nutrition and a healthy digestive system! Check with your healthcare provider and/or a nutrition specialist, and get on the right track.

I am writing a couple of articles for a nutraceutical company and it’s giving me a chance to pause and reflect on my top recommendations for optimal health and well being. With more than twenty years of medical practice experience, I’ve come to honor the ability of our bodies to come into balance and heal. On the other hand, I see that there are several individual choices we can make to encourage this healing and balance. Here are the top ten recommendations – in reverse order of course!
10) Pay attention to the cycles of nature around you. When the earth is resting in the wintertime, slow down! Dormancy and rest are important times in our lives. These can be distilled down to a monthly conscious awareness of the moon cycle. During the new moon each month, pause and reflect on what you want to grow in your life as the moon waxes to full. During the full moon, consciously pause to acknowledge your accomplishments – we are quick to remember “negatives” in our lives and oh so slow to connect with the positives. For guidance in this process, I recommend studying with Lisa Michaels and the Natural Rhythms Institute. I joined nine Natural Rhythms experts to collaborate on our book “Nature’s Success System” which was published through Hay House last year.
9) Assess the relationships in your life. Do they continue to serve you? Do the friends and family you interact with offer unconditional love and support? Do you offer unconditional love and support to your friends and family? We all know people that “drain” us – recognize who and what circumstances make this worse. Find a mental health professional and explore the reasons why you stay in relationships that are unhealthy.
8 ) Become conscious of your physical health along with your core strength and posture. Move your body every day: walk, run, bike, swim – whatever! Abdominal exercises and pilates can help; yoga, tai chi or chi gong can help you become more conscious of how you hold your body as you stand, sit and exercise. I have gained an appreciation for chiropractors, massage therapists and other body workers through the years. They “repair” the damage that poor posture and overuse and inflammation have caused.
7) Ask your doctor to measure your 25-OH vitamin D3 level. Supplement as needed to the 50 – 80 range. For some people the best dose is 400 IU daily, for some it is 5000 IU. Some people need 50,000 IU weekly for three months to build up their stores and then 1000 to 2000 IU daily. I disagree with “one dose fits all” and suggest that following vitamin D levels is the ideal way to know how much of this important vitamin to take.
6) Add a high quality fish oil to your diet or eat ocean-caught fatty fish (tuna/salmon/mackerel etc) three times a week. Most people benefit for 2000 mg of EPA and DHA daily. Ask for advice from your integrative physician about whether or not you need a higher dose or an adjusted ratio of the two fats if you have an autoimmune or inflammatory disease. Avoid bargain discount fish oil and look for supplements that have had heavy metals like mercury removed. If the brand you’re using gives you a fishy “burp-back”, find a supplement that has had the fish proteins removed from the fat and keep the bottle in the freezer and take the capsule frozen.
5) Learn and practice some time of relaxation breath work every day. It can be as simple as paced breathing – counting on the inhalation to three, holding for a count of three, counting on the exhalation to three and holding for a count of three. While you’re breathing, become alternately aware of the bottoms of your feet and your connection to the earth and the crown of your head and your connection to the sky or cosmos. My favorite type of paced breathing like this connects with a prayer or an affirmation. An example would be an in breath with the mental recitation of psalm 23; I might inhale with the thought “The Lord is my shepherd” and then during the pause I’d consider what it means to have a shepherd. I would then exhale and pause and with the next inhale I’d recite “I shall not want” and then during the pause I’d consider what it means to have all my needs provided. I’d continue through the psalm line by line, stopping and pausing with each breath purposefully.

4) While you’re breathing, learn and practice other types of stress management. For you it may be prayer, meditation or listening to a guided imagery cd. Seek out practitioners who can teach biofeedback techniques or Heartmath™. Consider an energy medicine appointment with practitioners that do Reiki or Healing Touch. Try a “spirit walk” in a nearby park or woods – breath in as you walk on your right foot, breath out as you walk on your left foot. Whatever you choose, make time to do it daily. It is as important as eating and sleeping!

3) Grow your connection to your creator. Honor the gift of life you have been given today. Look with gratitude at the opportunities and blessings that you’ve received. Seek out pastoral or spiritual support to help in this area if needed.
2) Pay attention to the quality and quantity of sleep you receive each night. Sleep is our opportunity to restore our neurotransmitters and remove toxins from our body. What is interfering? Is your brain still wound tightly with worry or anxiety? Is your body sore or inflamed? Is your spirit troubled? Is your nutrition sub-optimal and filled with stimulants like caffeine and sugar? Explore this with your integrative physician – the solution is NOT solely a sleeping pill!
1) Nourish your body with lots of whole grains and colorful, organic, locally-grown vegetables and fruit. Learn to can and freeze the produce when it is abundant to last you through the winter. Add lean protein in a small amounts and keep the processed food to a minimum. Your life force energy is fed by the quality of your food!

May these suggestions guide you to a path of health and healing…Be Well!
Claudia E. Harsh, MD

I know you are out there. You are curious about what supplements you should be taking. The conflicting stories and boastful marketing claims have you overwhelmed and either trying everything that comes your way or stopping everything because of confusion and doubt. You are wondering about a vague ache in your shoulder or a stiffness in your back or a bowel change. You’ve read the internet and you aren’t sure where to go or what to do.

You are wondering if the prescription your PCP gave you in your last 8 minute office visit is the only option for your health issue. You have questions about that same prescription and your PCP’s assistant efficiently checked you out and collected your co-pay, but couldn’t or wouldn’t answer. And you haven’t had a call back from your doctor despite two days of trying.

I know you are out there. You have a comfortable relationship with your body and are watching with bemused interest as it changes metabolically and physically with age. The term “anti-aging” baffles you as you wonder what the alternative to growth and aging means. Is it hormones? Hair dye? Plastic surgery procedures? You are bombarded by the marketing. You catch yourself pulling back the skin at your temples and winding back the clock.

Is happiness a line-less forehead or a lack of silver hair on your head? Is peace a dress size? Is it a breast size? Is contentment a social calendar filled with fund-raising dinners and committee meetings? Because, you see, I’ve spoken with you and I know you want more.

I know you want more focused time with your partner and your children and your parents. And you want that time to be un-rushed and unencumbered by deadlines. I know you want to squeeze in a quiet interlude into your days as you learn to meditate or learn paced breathing. I know you want to prepare quick and nourishing meals. I know you want to move your body daily. You want to address your pattern of work and play, sleep and wake, active and quiet times in a conscious and intentioned way.

I know you are out there. You want to explore the balance of emotional, mental, physical and spiritual life with a physician who can act as a coach, an advisor, a researcher for your specific questions or an advocate for you as you interact with the rest of western medicine.

While this election cycle is playing out, the news is currently full of  pitched discussions on contraception and women’s health.  I’m posting an article here that I wrote a few years ago that was also published in my book, “Finding Grace and Balance in the Cycle of Life: Exploring Integrative Gynecology.” 

First, the numbers. Statistics show that the average American woman wants to give birth to two children during her reproductive life. Since her fertility stretches from her teens to her upper 40’s, this represents several decades of a monthly decision about pregnancy. The Allen Guttmacher Institute reports that among the 42 million fertile, heterosexual, sexually active women who do not want to become pregnant, 89% use contraception of some type during their reproductive years.

To achieve the control of this many cycles, she must use a contraceptive method for roughly three decades.  The type of contraception is generally age-specific. Younger women mostly use condoms or birth control pills, while women over 35 years of age are more likely to use female sterilization.

Are contraceptive options uniformly safe, easy to use and available to all women and their partners who wish to use them? The short answer is no. And here’s an important point: We know that the health of both women and their children is improved when contraception is available to space pregnancies and assist in the prevention of sexually transmitted infections. We also know that the worldwide access to contraception and family planning is closely tied to promoting economic growth and social stability. But this very personal decision has been questioned and debated a lot lately – especially when the question of payment for the options is considered. The truth of our pharmaceutical pricing is that the same pack of birth control pills can be anywhere from $2.00 at a clinic to $40.00 without insurance coverage.

I’ve recognized the controversy around contraception since my early medical school days. My classmates and I all received free materials from a local organization that had a strong opinion about contraception and family planning services. As my practice experience continued, I learned how to ask questions so that I could learn at the yearly office visit if contraceptive advice was desired without offending a woman who felt contraception was not in line with her religious beliefs. There are excellent resources available through the Couple to Couple league for natural family planning information. (www.ccli.org) If this appeals to you, stop reading now. The rest of the article is for women or couples who do not want to rely on this method of family planning.

Women have an array of methods for preventing pregnancy. Barrier methods such as male condoms are widely available and relatively inexpensive. Their first year contraceptive failure rate can vary from 2% in a “perfect user” to 17.4% in a “typical user”. Condoms can decrease (although not eliminate) the spread of sexually transmitted infections. They are relatively easy to use with rare side effects. A female condom has been on the market for a few decades; its cost ($4.00) is roughly four times the price of a male condom.

The FDA first approved the birth control pill in the 1960’s. The formulation and strength of synthetic estrogens and progestins have varied from pill to pill. The first year contraceptive failure rate for the pill varies from 0.3% for a perfect user to 8.7% for an average user. The pill works by adding synthetic estrogen and progestin hormones throughout a menstrual cycle to mimic early pregnancy and prevent ovulation or egg release during the cycle. In addition to preventing pregnancy, there are also non-contraceptive benefits to using the pill. The lifetime risk of ovarian cancer is decreased in women who have used the pill for at least three months. Menstrual cycles are lighter; menstrual cramps are less intense for women on the pill. The pill can also effectively treat acne and some other skin conditions.

On the other hand, there are downsides to the pill. There is an increased risk of blood clots and stroke in pill users – this risk increases in smokers. The pill is less effective in women with a body mass index (BMI) over 27 (equivalent to a 5’4” tall woman weighing 160 pounds or more). In addition, the lower dose pills require a regular pill-taking routine. Lower hormone levels from missing a pill, taking it late or taking a medication that increases the clearance of the hormones from the body can lead to spotting and/or an unplanned pregnancy. The birth control pill does not prevent sexually transmitted diseases.

Because of the inconvenience of daily pill consumption, drug manufacturers have offered three month injections, five year implants (no longer on the market), vaginal rings, and patches (no longer on the market). There is also a formulation that skips the “monthly” cycles and change the bleeding pattern to quarterly.

Intrauterine devices (IUD’s) are designed to prevent pregnancy by mainly preventing fertilization (changing cervical mucous to prevent sperm penetration). There are currently two types of IUD’s on the market. They’re inserted in the uterus during a pelvic exam in your physician’s office. Most women who choose the IUD like the convenience and have had at least one child. The disadvantages of the method are the risk of infection and potential sterility. The risk is essentially non-existent when both partners are monogamous and committed to the relationship.

Tubal ligation and vasectomy can be performed once a couple’s family size is complete. The failure rates are low for both procedures; risks are slightly higher for tubal ligation because it is done at a surgery center with general anesthesia while the vasectomy is done in the physician’s office with local anesthesia. Permanent sterilization shouldn’t be scheduled unless a couple is certain that they never want to conceive.

All the contraceptive options have risks and benefits. Ideally it’s a shared decision after a thorough review of options by your physician, nurse practitioner or midwife. It is NOT, however, a decision that should be made by your Senator or Congressman or President!

 


Are you confused by healthcare marketing? Can you get good solid information from nutraceutical or pharmaceutical companies or practitioner organizations or nationally-known integrative medicine practitioners without running into marketing? The short answer is no, but I thought I’d describe some of the strategies I see around me – then maybe you can look at what you’re reading or hearing with more grounded and informed eyes.

Full disclosure: I am an integrative gynecologist and medical acupuncturist who is marketing her practice here in Dallas, Texas. I practice in a manner that is different from a traditional medical practice, because I’m going to explore with you what you eat, what you feel and what you think about while you eat and drink and work and play. If we work together, we will be looking at root causes for symptoms. We will be exploring what you need to potentially add to and/or remove from your body for your optimal emotional, mental, physical and spiritual health. And, of course, I use this blog to talk about integrative approaches to health and wellness….and you bet that’s a type of marketing! End of full disclosure.

Healthcare Marketing Strategy 1: Marketing to the illness – You see black and white pictures of a tired, achey woman (usually) who is withdrawn from her environment because of her symptoms. More often than not the marketing is suggesting a  prescription drug to make the symptoms go away. Final video clip is of the same woman in full color this time, smiling and gardening or dancing with her loved ones. The last few frames include verbal and written warnings of an increased risk of blood clots or death or seizures. The same strategy is used for erectile dysfunction in men: here’s the couple cleaning out the garage or working in the kitchen and then wow! the scenery magically changes to a campfire with a rushing stream (wink, nudge) and a glorious sunset.

Healthcare Marketing Strategy 2: Offering Expertise – A noted integrative physician offers a “vitamin advisor” through his website. If you’re confused about what dose of Vitamin D you should be taking or how much or what ratio of fish oils you should take, they can individualize a formulation for you. Websites like these trade on the exhaustive experience of their creators, and are likely managed by someone who is paid to develop the content based on their books or speeches. Of course, the websites also sell the nutraceuticals through their shopping carts for your convenience. Is is possible to get optimal advice without a personal relationship with a practitioner? I’m skeptical.

Healthcare Marketing Strategy 3: We Have the Best (fill in the blank) – often used by hospitals or medical practices. Is one hospital better than another for robotic surgery or heart attacks or strokes? Is one medical staff better than another? Does one doctor in your community perform better bariatric surgery or lasik surgery or spine surgery than another? Here’s my answer based on 25 years of medical practice including 18 years in a traditional hospital-based practice when I was helping with quality assurance for an insurance company and working on a medical records committee for a hospital: No. Marketing does NOT equal good medical care. Marketing does not equal good bedside manner. Marketing is just that: marketing.

Healthcare Marketing Strategy 4: The answer to health is in a (fill in the blank) Lose weight with this pill. Heal your arthritis with this bracelet. Sharpen your mind with this (practitioner-done) technique. Your mental response should always be: where’s the data? Is the claim based on science? (is there a plausible explanation for the claim?) Is there FDA approval? (have studies been done?)

I’m constantly amazed and consistently filled with wonder by our body’s ability to balance and heal when a “lean, clean and green” diet is accompanied by focused and consistent stress management techniques. Start there. Pay attention to where tension and stress show up in your body. Find a body worker who can listen with you and explore posture and other holding patterns of pain. Then “rewrite” the pattern and tell your own story!

Conscious thoughts today. Conscious (noticing with a degree of controlled thought or observation) thoughts (an action or a process of thinking) today (this segment of time). Conscious of the mind chatter that starts up with the habit of remembering, planning and thinking almost as soon as I bring my awareness to the moment. The Zen saying “gate-less gate” is at once a “thing” to pass through in our mind and also a “no-thing” that acts as distractions to our own heightened awareness.

I am reading about meditation today because I am starting a meditation group that will meet each month in the new moon window this year. I am “re-minding” myself of the different paths through the gate-less gate. I have experienced this type of connection through prayer at church, through listening to or singing music in a large music hall or around a campfire, through backpacking on the Appalachian trail, through workshops and lectures, and through my integrative medicine fellowship.

There is no single path through the gate-less gate for anyone. I hope to explore several approaches and techniques and allow the participants to practice a few of them. The benefit of meditation for me has always been a clearer focus and a lighter mood. David Fontana PhD writes in his book, “Learn to Mediate: A Practical Guide to Self-Discovery and Fulfillment”:

There are four different levels of thinking. The first and lowest level is negative thought, which includes feelings of anger, fear, sadness, regret and unease. Negative thought makes us egotistical and lazy. The second level is wasteful thought, when we waste our time worrying about things that might not happen, or about things that are outside our control. the third level is necessary thought, such as “I must not forget to pay the electricity bill” or “I must remember to send a birthday card”. the highest level is positive thought, which encourages peace, harmony, creativity, love and happiness. In meditation we can free our minds from negative and wasteful thoughts and elevate them to the highest level.

There is science behind this thought dichotomy, too. HeartMath uses the combination of breath work, focused breathing and the addition of a positive thought or memory or feeling to achieve coherence in heart rate variability – a physiologic state which has shown to decrease anxiety, lower blood pressure and improve healing.

So I explore conscious thoughts today. Join me at Living Well Dallas on Monday, January 23rd for the first “Monthly Meditations in the New Moon Window”. Whether you are new to meditation or a seasoned meditator, please feel welcomed to our group. We will begin promptly at 7pm, so please plan to arrive 10 to 15 minutes early so you can be settled and comfortable.

I spoke with someone by phone today who is looking for a physician who prescribes bioidentical hormones. I’ll frequently speak by phone to prospective clients and explain my perspective and philosophy and approach. This saves us both time and saves her money, because really if I don’t agree with an approach to therapy that she wants, why come see me?  This woman outlined her current therapy and explained what she was looking for in a doctor. Unwinding her menopausal story was so much more than hormone levels and lab tests! I heard phrases like “I look great for my age” and “not the way my mother’s menopause happened” and recognized immediately that many of her issues are rooted in a real fear of aging and especially a fear of playing out an aging pattern that her mother or aunt or cousin experienced.

51 is the average age of menopause – which by definition means no menstrual cycle for a year.  The time frame five to ten years prior to menopause is called the perimenopause or climacteric.  Most symptoms associated with menopause begin during the perimenopausal period.  Hot flashes, changes in sleep patterns, mood changes (especially anger or depression), libido changes and weight gain are all common concerns. I find that menopausal symptoms are different for every woman, however, and the suggestions and treatment plans are just as varied. I also see that often chronic stress can mimic the majority of menopausal symptoms, so sometimes the best treatment isn’t always adding hormones to the milieu!

But why does menopause occur?  The simple medical answer is that our ovaries gradually stop producing the hormones estrogen and progesterone.  Without the signaling, the lining of the uterus or endometrium stops building up and sloughing.  But why does this occur?  Why not cycle our hormones indefinitely?  (or are you asking: Why not be fertile to the ends of our lives?) We really don’t know the answer. Regardless of the reason, it appears we were designed to start cycling at puberty and stop in our fourth or fifth decade.

In my role as a physician, my job is to make sure that the menstrual cycle changes aren’t because of an anatomic problem with the uterus or ovaries or a problem with one of the other hormones such as thyroid or adrenal hormones.  In addition, this is an excellent platform to discuss health in general and encourage health screenings such as pap smears, mammograms, blood work, colonoscopies and bone density screenings.  Lifestyle habits such as regular exercise, healthy nutrition, and regular meditation or prayer can be reviewed and encouraged.

Aging gracefully is not an accident.  We bring our genetic predisposition to age-related illnesses such as heart disease or arthritis, but our future is not rigidly set.  We can bathe our genes in the “environmental cues” of nutritious and colorful organic fruits and vegetables.  We can move our bodies and stretch each day.  We can acknowledge our life stressors and continue to work towards life balance and resilience.  Our attitude and our outlook pave the way for healthy life choices. We can surround ourselves with people that support us in our choices. And we can practice laughing.  A lot!

Just read a great blog post about approaching our lives as women in a balanced and thoughtful way….read the post here
may grace shine on all of us.

Sometimes my life has a theme. The same concept shows up in various media or in various conversations from various friends or clients. I’m getting better at recognizing the themes. (I mean really, how often do we just travel life’s road blithely; unconscious to the themes or patterns around us?) So this week’s theme is gratitude. And NOT just because we’re edging closer to the Thanksgiving holiday. and NOT just because I subscribe to gratefulness.org’s word of the day. It’s more than that. Here’s an article from the huffington post that came through a friend’s Facebook page. And here’s a Ted talk by the photographer Louie Schartzberg that also talks about gratitude with a combination of eloquence and beautiful pictures.

So I’m taking it as a sign that it’s time to re-double my efforts at gratitude. Daily. C’mon along!

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