Supplements - Dangerous, Essential or Useless?

[Technoid]

Wizard recently made an interesting post on the "drive to minimize supplementation" that I wanted to respond to in-depth.

The post: healthunlocked.com/pasoc/po...

I decided a long form response would be better, thus my separate post here. Apologies if the post jumps around a bit!

There is an interesting section on supplementation "myths" in a widely used reference book for dieticians, that I'm currently reading, the "Complete Food and Nutrition Guide" from the Academy of Nutrition and Dietetics (USA). One of their claims is that:

"Emotional Stress doesn't increase nutritional needs"

But this flatly contradicts currently available research, described in a review paper that looked at the effect of stress on micronutrient concentrations in the body based on previous research and including human or animal models.

The American Nutrition Society has a useful article on the subject that references the paper:

nutrition.org/nutrition-and...

The conclusion of the paper was that:

"Although research is somewhat limited and the robustness of research is variable, the bulk of evidence suggests psychological and physical stress can influence concentrations of several micronutrients."..."The largest body of evidence demonstrates stress-induced depletion of magnesium and zinc, although several studies (both human and animal) demonstrate the effects of stress on calcium and iron concentrations."

“The Effects of Psychological and Environmental Stress on Micronutrient Concentrations in the Body: A Review of the Evidence"

ncbi.nlm.nih.gov/pmc/articl...

So here you have a widely used textbook and reference for dieticians which is out of step with the current evidence on whether the body may need more of certain minerals during times of stress. Concerning to say the least. This is a 2017 testbook but still...

This also brings to mind a podcast I listened to recently on Andrew Huberman, the popular podcaster and neuroscience professor:

conspirituality.net/episode...

A referenced McGill article has some further interesting points:

mcgill.ca/oss/article/criti...

At one point in the Conspirituality podcast the guest describes vitamin supplements as largely being only useful for producing "expensive urine". He also mentions there being concerns with risk of toxicity from taking large amounts of the fat-soluble vitamins, which he says can "bio-accumulate".

These are honestly pretty common opinions in mainstream medical science and even in significant portions of the dietetic and nutrition field. When I had my vitamin B12 level tested, there was significant concern over whether I might be taking "too much". There was no recognition of the fact that B12 does not have a tolerable limit and toxicity has never been conclusively demonstrated. There was also no understanding of how much B12 was necessary to supplement, or how frequently, if my diet did not contain it (which I was clear to them it did not).

Despite this, confident supplementation recommendations were made to me for B12 which were 30x less than the recommended minimum maintenance frequency. All on the basis of a serum B12 test which is known to be unreliable and showed high serum B12 (~600) for reasons that are not entirely clear. There is a widespread belief that its is always safer and more recommended to get any specific nutrient from foods (or sunlight) rather than a supplement. But this is not always the case and safe vitamin D supplementation can be a better approach than lengthy sun exposure for example, which risks sunburn and thereby increased skin cancer risk. There is not a one size fits all answer for every case.

Speaking to many others who dealt with doctors here, I found they experienced a common trend of extreme concern over supplementation. I'm not saying that supplementation is always safe, or even necessary but there seems to be near zero acceptance that dietary supplementation could be something that can be part of a healthy diet, not just to treat deficiency, but as a complement to the diet, in the long-term to ensure particular nutrients are not falling short on a regular basis.

In the case of low stomach acid or poor absorption, the possibility that supplementation may be needed even if the diet is excellent seems to be poorly understood/recognised in the medical field, as many here have discovered.

Please don't misunderstand as I'm NOT saying that supplementation can fix an unhealthy or poorly planned diet. It certainly cannot. There are benefits such as phytonutrients, various types of fibre, many minerals and some vitamins which supplementation cannot replace. Plants contain thousands of phytonutrients which have been poorly studied for their health benefits. It is not known which phytonutrients provide health benefits, in what form or provided with which others in which food matrix. So we have no idea if a small selection of isolated phytonutrients provided in supplement form would have the same, or any, beneficial effect.

Dietary diversity is also very important for gut microbiome health. Diet comes first, I agree 100% with this.

But many dieticians and doctors seem to think a desirable end goal is always to have a diet that does not include any supplements. I cannot agree with this as there are many cases in which supplementation will be useful or indeed absolutely necessary. The obvious one for me would be a vegan diet. The reality is that if I had religiously taken a simple multivitamin supplement every day for the last 15 years, I would never have become deficient and never would have ending up seeing the doctor who disastrously misdiagnosed me.

A good example for the general population is vitamin D. Most people will need a moderate vitamin D supplement over the winter or if not getting sufficient sun in the summer months. But yet most doctors seem to have a mortal fear of vitamin D supplementation and are loath to advise patients with low vitamin D to supplement regularly long-term. They are happy to treat a deficiency with megadoses but then stop supplementation entirely when the deficiency is corrected. Leaving the patient with a recommendation to "get more sun". Which is not going to be possible or sufficient in the winter months in more Northern Latitudes, or even on overcast summer days. Vitamin D deficiency in the general population is such a stupidly easy problem to solve (for many people in the developed world) if there was a general recommendation for safe supplementation over the winter months or when staying inside, such as between 1000IU and 2000IU. Some may need more than this if overweight or with absorption issues but there is no risk of overdose or dangerous "bioaccumulation" at such doses. The safe upper limit of 4000IU was set very conservatively and even such doses can be safely taken due to vitamin D needing to undergo several steps before it converts to the active form, a conversion rate very well controlled by the body to prevent harm.

Another good case for supplementation is older individuals who are not getting many calories and would otherwise risk falling short on certain vitamins/minerals or macronutrients, especially protein. Protein requirements do not change as we age but reduced stomach acid means its not as well absorbed which along with reduced caloric intake can mean sub-optimal protein absorption. Thus it may make sense to consider moderate protein supplementation for older age groups.

You may be used to following a certain dietary pattern and not wish to change it, even though you can see that certain nutrient intakes are low via a tool like Cronometer. You may not want to eat certain foods that contain high amounts of the lacking mineral or vitamin, either because of the taste, the botheration of cooking or preparing them or for ethical/allergy/tolerance reasons. It makes perfect sense in this case to make up the shortfall with a dietary supplement. I find my Calcium intake a bit lower than I like it so I take a 250mg supplement to make up the (small) shortfall.

With lower caloric intake overall, other vitamins or minerals also may not reach the RDA, thus a moderate RDA-level multivitamin and mineral makes a lot of sense. Of course, diet should be improved first, but beyond that, a multivitamin may make a lof of sense in these populations.

There are sometimes concerns over supplement quality, something which third-party testing attempts to alleviate. I have mentioned Labdoor in the past and I regret that because I was just made aware of the following incident with their testing:

m.youtube.com/watch?v=bchTV...(Not working as expected?)

I still think third-party testing is useful but the example of Labdoor shows that caution is warranted and that this is not a foolproof strategy either.

Here's an interesting documentary on the topic from CBC News:

m.youtube.com/watch?v=SmFu8...(Not working as expected?)

There can also be legitimate concerns about interaction with other medication which certainly should be considered and taken into account on an individual basis.

However a lot of concerns with vitamin supplementation derive from trials where huge supplementation doses were provided. You can see this for instance in many trials of Vitamin A, Beta-Carotene and Vitamin E:

ref: pubmed.ncbi.nlm.nih.gov/173...

In these cases negative outcomes resulted in a recommendation in some quarters not to ever supplement these nutrients at all. But dosage amounts are key - the conclusion should not be that any amount of supplementation is unsafe just because doses well in excess of the RDA (as used in most of the trials) had negative effects. Anti-oxidant supplements seem on balance to be ineffective and even harmful when they upset the natural balance of oxidants+anti-oxidants in the body.

B6, as we know, is somewhat infamous for its neurotoxicity, in certain forms, at certain dosages. The EFSA recently revised downward the B6 tolerable upper limit to 12mg a day, suggesting possible toxicity from some forms even at moderately high doses.

Many medical practitioners only appear to have paid attention briefly during their nutrition training (if they had any) and simply picked up the general guideline that there is a bell curve for most nutrients where low amounts lead to deficiency but large amounts can be toxic.

In GENERAL this is true but it is not true for all nutrients and where intake is absent or sub-optimal and cannot be corrected by diet for whatever reason, then supplementation becomes a viable, even necessary strategy.

Celery Juice though, is probably NOT the answer 😉

abbylangernutrition.com/is-...

Treatment with massive doses of particular nutrients, in the absence of deficiency, is a particular form of quackery with a long history dating back to the 1950's, known as "Orthomolecular Medicine" but most recently revived by popular YouTubers like Elliot Overton.

quackwatch.org/related/ortho/

But I accept that it is possible that in the future we may discover that optimal levels of health can be achieved by supplementing one or more nutrients beyond whats available even from an excellent diet - but I think thats best left to nutritional science to prove rather than personal experimentation.

Where personal experimentation is concerned it is not possible to discount placebo or nocebo effects and there is by definition no control group and often no way to realistically control or account for confounding factors that may have influenced the result. And of course there is the question not just of efficacy but of personal safety. B12 being an honourable exception.

Final comments on recommended supplements and other relevant resources:

Omega 3 EPA/DHA is a sensible supplement to most diets:

m.youtube.com/watch?v=bwdPh...(Not working as expected?)

Creatine is another excellent, extensively tested supplement that is a good idea for most people, not just bodybuilders:

m.youtube.com/watch?v=29nyG...(Not working as expected?)

Athough supplements are beloved by many naturopathic doctors and those who promote orthomolecular medicine, you should be very skeptical of any claims from them as this talk illustrates:

m.youtube.com/watch?v=3NrkE...(Not working as expected?)

Finally, here is an informed discussion on multivitamin supplementation with a very experienced nutrition researcher:

m.youtube.com/watch?v=N83s8...(Not working as expected?)

[WIZARD6787]

That is a lot to digest. Sorry I could not help myself.

[Technoid in reply to WIZARD6787]

😀 i know, sorry😆

[Mixteca in reply to Technoid]

Never say sorry for your thorough and inquisitive mind - a long but very interesting read, thank you!

[Wheat]

Thanks for posting this, it will probably take a few days to view though. 🤔🙂

[palmier]

It's not very healthy to try to sort out a b12 deficiency with food, because b12 is found in animal products and it can be both expensive and unhealthy to increase intake that way. About a century ago the only cure for pernicious anemia was to eat lots of liver daily. Regular food was not enough.

Especially when b12 deficiency is typically caused by an absorption problem. People would need to eat immense amounts of meat, fish, egg and milk daily to get enough b12. Which would be a huge waste of money and disastrous for one's health.

But that's not all. One of the b12-containing enzymes in the body handles substances formed when certain amino acids (and odd fatty acids) are metabolised.

So imagine an ignorant doctor instructing a b12-deficient patient to simply get more b12 from food. It may not help, it may be ridiculously expensive, and while still deficient the last thing you need is that extra protein that your body struggles to manage because of reduced activity in the b12-dependent enzyme Methylmalonyl-CoA mutase. Those with a genetic defect in that enzyme (a condition called methylmalonic acidemia) may be prescribed a strictly protein-controlled diet. Why then do doctors think that b12-deficient patients should simply eat more food with b12, ie more animal products, i e more protein?

B12 as strong supplements and/or injections is both cheaper and safer, and a healthier way to treat a low b12. When the b12 deficiency have been treated, and if there's no absorption problem, then levels could probably be maintained with a healthy diet. But only then, and only for some.

[Technoid in reply to palmier]

"So imagine an ignorant doctor instructing a b12-deficient patient to simply get more b12 from food."

I dont need to imagine it, because at my 2nd diagnosis, 2 years after the neurological damage started and having been reassured it wasnt B12 related and told to reduce my B12 supplementation, my GP then measured my B12 at 210 and advised me to start eating meat! I would have laughed if it wasnt such a serious situation that I knew I was in.

2 years of untreated deficiency caused by drastically low supplementation on their medical advice and suddenly the solution is eating meat!

Of course I did no such thing but instead was fortunate enough to get a proper diagnosis and adequate treatment from specialists, which was extremely unpleasant but necessary. I would say I cannot believe how stupid his suggestion was but honestly I'm never disappointed in medical staff anymore, I just expect ignorance as a matter of course and if I get something other than that its a unexpected but pleasant surprise 🤣

[Nackapan in reply to palmier]

Yes. I've seen a diet change can work if no absorbtion problem. No supplements needed

I've seen even a diet that's kept a person ( my sister) healthy for over 30 yesrs A vegetarian diet .

Because of which b12 was tested at intervals

Then the menopause hit.

Same diet but not absorbing enough now.

Oral supplements worked to top up the unchanged diet .

Symptoms of b12 deficiency went completely.

I however need b12 injections as although my diet very good things changed again after the menopause .

A known risk factor with hormonal changes.

Yet on a 50 + health check b12 level not done ????

What is missed is enough b12 testing .

My first ever level measured at 57

despite having obvious symotone 2 yesrs earlier.

I actually asked for iron to be tested .

Knew something wrong.

Routine testing shoukd be done with bloods .

At least we would know what we operate on.

Everyone has a tipping point.

I will never know what I functioned well on.

I think and hope more b12 testing is being done now.

So it's getting the right advice at the right time ??

I will look at the links one by one over a few days .

A few not working .

Interesting .

[Technoid in reply to Nackapan]

double-checked the hyperlinks there Nackapan and everything seems to be working.

[Nackapan in reply to Technoid]

I got grey boxes saying Sorry try again ??

So I will today

[Narwhal10]

Thanks again Technoid,

To be digested at a later date. I like Eliot Overton’s work and I take creatine. Essential micronutrients are very poorly understood. The fact that we are all so different in height, weight, activity, body shape, tone and metabolism is not taken into account.

I believe the bog standard BMI is a bit of a joke. Years ago, someone was really taken aback when they asked my weight. I weighed the higher end for my height. So, asked them if they wanted an arm wrestle. Rolling up my sleeves. Their mind clicked, so, I asked if they wanted to see my legs as well ? By definition my body type was athletic. 😆

[Technoid in reply to Narwhal10]

😁 reminds me of these dudes being humbled:

m.youtube.com/watch?v=D8zBz...(Not working as expected?)

[bookish]

Great post and thank you for taking the time. Interesting link about stress and nutrients - hadn't realised magnesium was so strongly affected. COMT is magnesium dependent and mine is (theoretically) genetically slow, so after years of unrelenting stress it is unsurprising that I felt a whole lot better with magnesium supplements along with the B12 and methylfolate. I know that B12 gets hit hard in my own family, as everyone who has ended up with PA has done so after a major stressor, and for those of us with symptoms but undiagnosed cause our serum B12 drops noticeably when under stress, even with (oral) supplementation continuing at a regular level.

[Parlay]

Thank you so much for such an excellent article. It is an excellent write up. I supplement but I source organic wholefood vitamins and minerals. I think our food sources now are heavily depleted of any goodness and we need to supplement. I will not use any shop bought supplements as they are pharmaceutically made (my opinion only) preferring whole food. I’m very lucky in that my son is a strength and conditioning coach who is an avid supporter of creatinine and protein intake etc. again thank you for your time in writing this superb information for us.

[Cornwaller]

Mega dose vitamin treatments shouldn't be dismissed as quackery but considered on their merit. For example B1 high doses are used to treat a range of disorder such as Wernicke-Korsakoff Syndrome and alcoholics. There is growing data that the treatment can radically improve outcomes in other diseases such as Parkinson's (Google Antonio Constantini).

I think it is incredibly important that we are open minded and assess the evidence - accepting that evidence cannot be solely in the form of randomised double blind trials because such a constraint would prevent the rapid progress needed in so many areas of medicine- not least PA.

Thank you for such a stimulating post.

[Technoid in reply to Cornwaller]

I agree that they should be assessed on their merit but the examples you cited are cases where there is a thiamine B1 deficiency. In the case of Wernicke-Korsakoff syndrome, a very severe one. I am not saying that megadosing is never warranted. Indeed it is almost always warranted in the case of deficiency.

That's why I used the phrase "in the absence of deficiency" in relation to megadosing.

Technically 5g of creatine is also megadosing but since the dose has been well-tested I'm pretty happy with the safety profile. For most others, I think I'd like to see evidence of benefit and substantional evidence of safety before I would consider trying them.

I agree with being open to assessing evidence of benefit as it comes in for sure!

[Cornwaller in reply to Technoid]

Thanks for your considered reply. I think we are very much on the same page. I would recommend reading Antonio Constantini's work. He suggests that high dose B1 can help a number of disorders, not by correcting a whole body gross deficiency, but by enabling defective biochemical pathways which are thiamine dependent and the high dose restores the pathway to function at the cellular or tissue level. Having said that it is a hypothesis to explain the results he obtained.

It is somewhat akin to b12 functional deficiency.

Best wishes.

[Sunshine1932]

Thank you for such an informative post. My opinion and belief is that a balanced diet and good non or minimal synthetic supplements make for better health. I do also believe that a lot of sickness/pain/disease comes from blocked emotions.

Another good read is Dr Wahls if you have not already referenced (I skim read your post) she is a scientist and has MS. She didn't believe in supplements and thought good old pharmaceutical drugs would cure her until she realised they were not. She takes a ton of supplements and a shed load of different vitamins and minerals from plants. Her motto is the more colourful your plate the more the body is receiving what it needs. Plus she only eats grass fed meat. She believes gluten, sugar and dairy make you ill so she removed them and

eat her way into remission eating nutritional dense food.

I'm obese and I see myself as malnourished and I say that because to get fat I didn't eat salad and veg everyday I eat cake.

I now eat 100% clean as I'm sick of being sick and want my size 10 waist back 😂

Happy weekend all. 😊

[Technoid in reply to Sunshine1932]

I think this post from a clinical neurologist is a fairly informed take on Dr.Wahls:

theness.com/neurologicablog...

My favourite takeaway was these lines:

"The myth of nutrition gurus, however, is that – if only you were properly fed, you would be a superhuman, immune to all disease, with a flawless immune system and limitless energy. This is fantasy, not reality."

A colourful plate or whats sometimes called "eating the rainbow" is a good rule of thumb but it does need to fit into the context of a healthyfully planned diet. It is possible to have a colourful plate but still have an overall dietary pattern that is not nutritionally adequate.

It is not necessary to eat "100% clean" all day every day of the year. The occasional cookie or blow-out dessert on the weekend is not going to destroy your health if the overall diet is healthy the rest of the week. It is possible to take the idea of "eating clean" to extremes which are not necessary for good health and may cause other issues like making travel or eating out more difficult than it needs to be. In the main, focusing on whole foods and avoiding most ultra-processed ones, not going overboard on calories and keeping saturated fat, added sugars and refined carbohydrates low (or completely absent) for at least 5,6 days out of a week will do most the heavy lifting. The nuances of macro and micro nutrient intake can be ironed out with something like Cronometer, along with correcting any absorption issues if possible or supplementing adequately if they cannot be resolved.

If you have celiac disease or non-celiac gluten sensitivity it makes sense to avoid gluten, but there is no reason for the general population to avoid it and in fact doing so could result in unnecessarily cutting out wholegrains which can be a very healthy source of nutrition.

m.youtube.com/watch?v=IMPEd...(Not working as expected?)

I am not anti-supplements. Far from it. I take many different kinds of supplements. My take on supplements is a lot more nuanced and thats why I needed such a long post to cover it.

[MrsTuft]

As a coeliac I have trouble absorbing micronutrients so I supplement - as my doctor told me to when I was diagnosed aged 12 (now 47). Nice post.

[Mixteca]

I'd be a good test case with my ongoing stress and rising cortisol! I'm still at the 'curse general practice' stage myself, fighting to get support and the right tests done 🤬

[Mixteca]

Read this long read by Dr Malcome Kendrick on a Thyroid UK post - all about vitamins. Thought it might interest you:

drmalcolmkendrick.org/categ...

[Technoid in reply to Mixteca]

Yikes! Malcolm Kendrick 😦

rationalwiki.org/wiki/Malco...

[Mixteca in reply to Technoid]

Yikes indeed! Thanks Technoid 🤗

[WiscGuy]

I watched the interviews on omega 3 and on creatine. Both were very interesting. I ordered omega 3 and will dose daily at 0.75 g, not quite the recommended 1.0 gram daily. I was getting fatigued from all the numbers among the various manufacturers and this was an easy route. Outside of a bit of occasional olive oil, I think I have been getting little to no omega 3, so for me this will probably be a big increase. I also plan to order creatine and plan to do the 3-5g/day for 30 days. I am not sure what to do after that, and would be interested in any suggestions anyone cares to offer.

[Technoid in reply to WiscGuy]

I take 5g Creatine daily (usually pre-workout but also on rest days) and around 1.1/1.2g combined EPA/DHA (liquid 800mg in the morning and a ~ 350mg capsule at lunch). I've always taken EPA/DHA but was taking at lower doses before last year (400mg or so). I started creatine originally only for weight lifting but now take it also for the possible brain benefits I learned of. I'm pretty happy with the safety profile and use reputable suppliers for all the above.

[WiscGuy in reply to Technoid]

Thanks for this info.

[Bertiepuss in reply to Technoid]

Hi Technoid, fellow vegan here. I tried creatine, result was terrible wind and I mean terrible in the amount and also smell! Do you find any side effects such as this? I've read it can happen. What one do you use please because I'd like to try again?

I also supplement EPA/DHA, as algae oil, around 800mg twice per day. Do you have a favourite brand?

[Technoid in reply to Bertiepuss]

Haven't had any effect like you describe. Regards Creatine I recently upped the dose to 6 grams a day, split into 3 grams in the morning and 3 grams in afternoon or the evening. I use Optimum Nutrition Creatine Monohydrate. There is no effect on my digestion that I noticed (any digestion issues I had seemed to resolve after a few months into B12 deficiency treatment) and have not re-appeared. I use Arctic Blue Omega 3 EPA/DHA oil, approximately 1.2g day.

[Bertiepuss in reply to Technoid]

Thanks Technoid, much appreciated 😊 I will consider trying the creatine again and risk the musical bum! 😁I don't consider I have digestion problems, as long as I stay off the gluten, but then I'll take something that's supposed to be good for the gut (probotics, digestive bitters, acv) and it wrecks havoc...

[Technoid in reply to Bertiepuss]

I personally would'nt bother with probiotics as pre-biotics have much more impact. The amount of beneficial bacteria in most probiotics is tiny in comparison to the overall gut microbiome population. The evidence for benefit is overblown in the alternative health space. Not a fan of apple cider vinegar but I cannot eat without drenching my food in balsamic vinegar (its an addiction I think). Not using it for gut health, I just love the taste.

Can try introducing the Creatine more slowly, see if that reduces side-effects?

[Bertiepuss in reply to Technoid]

Yum, balsamic 😋 I love acv too but in small doses. Yes, my little intestine people prefer not to be disturbed by others, so I just feed them lots of fibre. Will try the creatine in a very small starting dose as you suggest.

[Technoid in reply to Bertiepuss]

Balsamic Vinegar comes out on top in Mic's recent coverage of vinegar. Shame its the most expensive kind

m.youtube.com/watch?v=5cQz1...(Not working as expected?)

[Bertiepuss in reply to Technoid]

Interesting, I always thought ACV with the Mother was superior but good to know balsamic actually does have some health benefits as I didn’t think it did.

[grlewycky]

only take what you definitely need

these super/mega vitamins might disrupt your good values in your blood work

clear it with your docs and be sure the ones you get arent mostly SUGAR

[Technoid in reply to grlewycky]

Could be tricky with Glycine as the name glycine is derived from the Greek word for “sweet" 😁

I'm not opposed to taking things I don't "need" but which have a good safety profile and may show benefit. This includes Taurine, Creatine, Beta-Alanine and Astaxanthin. Of course one should do one's due diligence, research safety and ensure reputable suppliers etc. Although I generally agree on avoiding megadosing there are exceptions such as Creatine where there is excellent safety data and good evidence of benefit in well-run clinical trials.

If you're taking a medication that would interact with a supplement, have a health condition that would affect it, or affect bloodwork before a test it makes sense to clear it with or mention to your doctor. For example, Biotin can affect thyroid tests. And supplementing a significant amount of B12 before a test could result in a missed diagnosis of B12 deficiency.

But I do not take medications or have any serious conditions so the number of my supplements which I will be clearing with my doctor is zero.

[NanoMRI]

excellent read - thank you. My thinking is unchanged - perhaps even supported by the discussions. If the worst of my supplement regime to (theoretically) fight cancer stem cells is expensive urine, I will continue to flush it. 🫠

[Treesong2023]

My, that was a long....and interesting... one.

I only dipped into a few of the videos, but I am struck by the difference in "professional" opinions that we have out there. The YouTube "Dr Terrify You" Grifters are the worst.

Given my GP's told me it was all in my head in 2021 and gained nerve damage in my feet and hands in 2022...I tend to steer my own learnings as I know you do Technoid. The food absorption angle is only good for those with out digestion issues, so setting out smart supplementation regimes would seem a logical step for any Gastro / Neurologist worth their salt.

Thank you for the share Technoid.