# Current Labs, Looking for Clarification



## bwhughes (Aug 11, 2013)

I haven't yet fully introduced myself on this Forum yet... sorry I haven't had the time. But I'm going to a free clinic tonight (Wednesday, west coast) and the 15 minutes that I'll get is not likely to be a walk in the park, in terms of my situation being handled with optimal hypothyroidism knowledge. (In other words, I'm preparing for some resistance to what I want.)

I could share some background info on why I find myself going to a free clinic at this time, and what my history with thyroid medication is, but for now, I'd just like to post the test results that I had from blood drawn on Friday and back in June.

I've been taking Armour Thyroid for several years. I have only just learned that Armour should probably be divided into two doses per day. I never knew that. So the first thing I would hope from my clinic visit is that I could get two prescriptions to make it easy to divide. The next thing is that they would agree to keep me on the current dosage. At least, I think that's what I need to do. But I'm looking for some experienced feedback from others.

For quite a while I had been taking 180mg per day of Armour. Then, a doctor who I was contacting via phone through a service called Ameridocs (a service offered through my self-employment association membership) refused to keep me at that dosage. In July of 2011, my TSH was 0.015 and my FT4 was 1.20. And I felt GREAT. I didn't have the FT3 test at that time. I was on 180mg for at least 1 1/2 years, if not longer (I wish I had kept records).

For various reasons, I had to find the cheapest possible medical care. In summertime of 2012 (can't remember what month), the Ameridocs doctor refused to keep me at 180. He said 120mg only. And remember, our contact was only by phone. So I started the 120 and began to feel not-very-good. I had a decidedly reduced quality of life at that time. When the time came for me to talk with him after a month or two, I pleaded with him to increase my dosage again. I couldn't even afford more tests at that time, but I tried my best to convince him how I was feeling... and how I HAD felt before.

It was no go. I wrote an email to the company about needing to find another doctor in their system. That's when I heard from them that were dropping me as a customer. None of their doctors would agree to "treat" me, and they wouldn't even keep prescribing the Armour. So then I was without a doctor (again) and..... in a few weeks without thyroid medication altogether.

So I went for several months without medication.

By January of this year, I found a local service (Portland area) called Zoomcare, a chain of clinics where you can get same-day, 15-minute medical appointments for a flat rate. In many ways, they are a good service with well-intentioned, progressive policies. The doctor I saw (for a paid visit) insisted on starting me out with a minimal dosage of Armour: 30 per day for 2 weeks, then 45 per day for another 2 weeks, etc. She suggested that I go to the free clinic the next month in February, because she understood my financial constraints, and told me that any tests I needed would also be free.

A TSH and a Free T4 were ordered for me at my free clinic visit in February. I told the doctor that night that I was really suffering the hypothyroidism symptoms. Unfortunately, they "forgot" the FT4 because it's not one of their standard tests. My TSH came back at 5.19, with a range of 0.5-6.0.

Not at all surprising the TSH was that high! They agreed to immediately bump me up to 120mg per day instead of continuing with the gradual increases. I took that for a few months. I then went into my free clinic visit on June 12, prepared to insist upon receiving the FT4 as well as the TSH, which they agreed to do, but they said the FT3 was not something they could offer for free. The results came back:

TSH -- 2.44 (range 0.5-6.0)
FT4 -- 0.65 (range 0.75-1.54)
My record shows that the doctor notated: "Patient STRONGLY requests we run both TSH and FT4 regardless of TSH level." Like, that's unusual??

No one called me about my results. But I clearly saw the need to increase my dosage. So I used their email system (one of their more progressive policies). Unfortunately, two different "providers" at Zoomcare, in addition to the doctor I saw at the clinic, also refused to increase my dosage, calling my results "normal." I told them that I wanted to aim for at least 1.0 for the TSH and the FT4 was clearly low. I was told that the FT4 was merely "very slightly low" (so not worth being concerned about).

I gave them what for (politely, but powerfully). And then you know what? The MEDICAL DIRECTOR of Zoomcare called me from his vacation around the 4th of July to tell me that he wanted to help me! We talked on the phone for at least 45 minutes. He agreed quite positively that my TSH would be better if it were lower. He was concerned about going back up to 180, but agreed to have me try 150. At first he suggested 135, but that would require two prescriptions in order to get the proper dosage (which would cost more). He totally "got" that I was pinching pennies. So he gave me 300mg tabs because they are scored, and that way I could get my 150 per day.

Well, I have definitely been feeling much better. I'm sure I've got all kinds of hormonal imbalances, and I would like to address my adrenal situation as well. But for now, I see some improvement. I had my blood drawn on Friday. _(I was able to find an online service that offers these tests in a panel for an extremely inexpensive $59! For all three!)_ Here are the June results again, followed by my most recent results:

*June 12*

TSH -- 2.44 (range 0.5-6.0)
FT4 -- 0.65 (range 0.75-1.54)

*August 9* _(at a different lab)_

TSH -- 0.525 (range 0.45-4.5)
FT4 -- 0.72 (range 0.82-1.77)
FT3 -- 3.0 (range 2.0-4.4)

My FT4 still looks kind of low. But I'm just learning about FT3 and that it needs to be taken twice a day, so the Armour should be divided into two doses. I realize that to do that, I will have to buy two prescriptions: 60mg and 15mg, but at least it's very inexpensive medicine. Then I could take 75mg twice a day.

Am I correct in understanding that the FT4 could still be so low because it is having to work so hard to convert into FT3? What kind of effect could I expect if I start dividing my dosage into 2 times per day? And what is the optimal FT3 result that I should be aiming for? I know that the Zoomcare doctor probably won't be able to address this question, because they don't even consider the FT3 to be essential. Even the friendly, helpful Medical Director considers it "interesting, but not essential."

Judging by these results, it looks like they would be happy with the TSH, because it's at the extreme end of "normal," but at least it's normal. So I don't think I'm in danger of them wanting to lower the dose.

But do you think that I should go back up to 180mg, when my TSH was 0.015 and my FT4 was 1.2? That's when I felt the best! Would dividing the dose in two have any effect on the TSH?

Thank you so much for any interpretations offered!

P.S. I should probably also add this: When I was on 180mg, I was also involved in an expensive hospital-based weight loss program, which I had to discontinue because I ran out of money. I managed to release 50 pounds in a period of about 4 months. That was in November of 2011. I have gained all of the weight back, and even though I am now walking one mile at least every other day, it's such a struggle because of how I feel in general. I weigh 290 pounds (I'm tall, at least). It appears that the amount of thyroid I'm taking is doing little to help me lose weight. *The fact that I was on 180mg for a good long time and I never went hyPERthyroid (which is the fear) should be considered, don't you think?*


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## Andros (Aug 26, 2009)

bwhughes said:


> I haven't yet fully introduced myself on this Forum yet... sorry I haven't had the time. But I'm going to a free clinic tonight (Wednesday, west coast) and the 15 minutes that I'll get is not likely to be a walk in the park, in terms of my situation being handled with optimal hypothyroidism knowledge. (In other words, I'm preparing for some resistance to what I want.)
> 
> I could share some background info on why I find myself going to a free clinic at this time, and what my history with thyroid medication is, but for now, I'd just like to post the test results that I had from blood drawn on Friday and back in June.
> 
> ...


Oh, boy! What a mess and I am so sorry for you about all of this. And I understand the financial constraints big time. Many of us are in dire straits these days.

A very unfortunate and sad story. I do believe you are still undermedicated. 3.2 is mid-range of the range given by your lab. Most of us require the FREE T3 to be at least 75% of that range. And TSH @b 1.0 or less.

Another factoid; when taking exogenous T3, it is normal for the FT4 to be low.

Therefore, the FT4 is no longer suitable criteria for titrating your Armour. Nor is the TSH. Only FREE T3 should be used as a guideline combined w/the clinical evaluation of the patient.

Understanding the Thyroid: Why You Should Check Your Free T3
http://breakingmuscle.com/health-medicine/understanding-thyroid-why-you-should-check-your-free-t3


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## bigfoot (May 13, 2011)

Ahhh, yes, good ol' ZoomCare. IMHO, I think you are barking up the right tree. You are hitting on the thyroid, FT3/FT4, and bringing up adrenal and other hormones. Some docs 'get it', some don't. Sadly the latter outnumbers the former.

Good to hear you are at least feeling a little better! As you probably know, the adrenals and thyroid go hand-in-hand. I'm trying to think of cheap(er) things you can do to address overall health here...

- Selenium, no more than 200 mcg / day.
- Vitamin D3, especially if you are low (aren't we all in the PNW), 4-5,000 IU.
- Vitamin B12, as "methyl-" variety, not "cyano-" variety.
- Vitamin C, buffered, 2-3,000 IU. Throttle back if diarrhea.
- Good quality one-daily multivitamin.
- Quality fish oil for Omega 3's (Carlson's is good).
- Stay away from soy and goitrogenic veggies.
- Avoid or eliminate gluten completely, if you can.
- Less coffee (easier said than done!).
- Plenty of veggies and water.
- Healthy fats are okay -- meat, avocado, etc.
- Little to no dairy.
- Less processed and sugary foods, less soda pop.
- Exercise if you can, more sleep.


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## bwhughes (Aug 11, 2013)

Andros said:


> Oh, boy! What a mess and I am so sorry for you about all of this. And I understand the financial constraints big time. Many of us are in dire straits these days.
> 
> A very unfortunate and sad story. I do believe you are still undermedicated. 3.2 is mid-range of the range given by your lab. Most of us require the FREE T3 to be at least 75% of that range. And TSH @b 1.0 or less.
> 
> ...


I wish I had time to respond, Andros. Unfortunately, I have to get going to meet my fate tonight. But I'll put this question here: I don't understand the "75% rule." 75% of what number? The top of the range, or the mid-range? If it's the top, that would mean I'd have to aim for 3.3, right?

Would dividing my dose in two have any effect at all on the results I'd get from the T3 test? (I'm sorry, I will have to read the article when I get home tonight, and maybe that will have more answers for me.)

Thank you so much for your time,advice, and sympathy!


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## bwhughes (Aug 11, 2013)

bigfoot said:


> Ahhh, yes, good ol' ZoomCare. IMHO, I think you are barking up the right tree. You are hitting on the thyroid, FT3/FT4, and bringing up adrenal and other hormones. Some docs 'get it', some don't. Sadly the latter outnumbers the former.


Thank you, bigfoot! I will reply in more depth when I have more time. Gotta run!


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## jrohrigj (Aug 30, 2012)

I believe 3.8 would 75% in the range given. (2-4.4)
and 3.2 would be midrange


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## bwhughes (Aug 11, 2013)

jrohrigj said:


> I believe 3.8 would 75% in the range given. (2-4.4)
> and 3.2 would be midrange


In the process of running out the door.......

Thank you, but I don't understand how you figured that. Can you provide the math?

Thank you!


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## jrohrigj (Aug 30, 2012)

For midrange 2+4.4=6.4 6.4/2=3.2

For the 75% take the top of the range - the low end of range and multiply by .75 take that number and and the bottom of the range number.

4.4-2= 2.4 , 2.4*.75=1.8 , 1.8+2=3.8


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## bwhughes (Aug 11, 2013)

jrohrigj said:


> For midrange 2+4.4=6.4 6.4/2=3.2
> 
> For the 75% take the top of the range - the low end of range and multiply by .75 take that number and add the bottom of the range number.
> 
> 4.4-2= 2.4 , 2.4*.75=1.8 , 1.8+2=3.8


Thank you, jrohrigj!

Boy, I would not have been able to figure that out at all. I'm going to have to write that down. Does any other test besides the FT3 require that we aim for a percentage of the range?

Being the incurably curious person that I am, I'm wondering what this math is "called." I mean, I know how to figure a percentage of one number. I don't recall ever learning how to do a percentage of a range of numbers...... and if anyone can explain it, I'm curious as to WHY this calculation works! (I'm sorry, I know this isn't a math class. I just always like to know WHY things are done the way they are.)

So I have another question about this calculation. Why are we advised to use the lab's values (where our blood was drawn)? Why isn't there a standard range that thyroid patient advocates agree upon and aim for those numbers? Is this a strategy to get more agreement from a doctor when they look at the lab ranges?

I guess this brings up an even larger question: WHY do different labs establish different "normal" ranges? Does it have to do with how they do the testing?

Anyway, thank you very much. This Forum really empowers thyroid patients to take care of themselves, and I'm glad I found you.


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## bwhughes (Aug 11, 2013)

Andros said:


> Oh, boy! What a mess and I am so sorry for you about all of this. And I understand the financial constraints big time. Many of us are in dire straits these days.
> 
> A very unfortunate and sad story. I do believe you are still undermedicated. 3.2 is mid-range of the range given by your lab. Most of us require the FREE T3 to be at least 75% of that range. And TSH @b 1.0 or less.
> 
> ...


Well, I have some good news from my free clinic visit.

First, thanks for using the term "exogenous." I looked it up and learned something new!

From my visit this evening, it appears that my two phone conversations and extended email communications with the Medical Director of Zoomcare has had an effect on the staff. At least it has with me... but perhaps this will be extended to other patients as well. The doctor did thank me for giving him the information about the option for patients to purchase their own lab tests online, inexpensively. He said to me (in email), "Thank you. This is a great find. I think many of our patients will be excited to see this!"

I saw a PA-C this evening, not the medical doctor I saw in June. She was extremely open-minded and friendly, totally interested in what I was telling her. You know, when I'm sitting with someone like that, I can be completely "reasonable" and have a true give-and-take of opinions, questions, and suggestions. I can be duly respectful of the professional sitting across from me. In contrast, when I'm faced with the kind of attitude I was met with in June ("We trust and rely on only the lab numbers"), then I automatically lose some degree of respect for that individual, because I'm now feeling extremely self-protective of my own best interests. I then get the kind of condescending comments noted in my last set of records. I've had quite a lot of experience with this scenario. It's hard to predict when you'll get what kind of response. Years ago, I met with a very holistically minded doctor who fought me furiously over thyroid tests. At that time, I was also dealing with antidepressents. I was kind of a mess. His attitude was surprisingly unsympathetic. Go figure. They lose respect for me and I lose respect for them. And so it goes. You do what you can to move on to the next person, always mindful, of course, of what it's going to cost! (And ever hopeful that the next one will be a good match.)

So the PA-C first noted that I was "last seen by [name]" (the Medical Director). I explained that he didn't actually see me -- we had talked on the phone. But at least that showed me that it was all in my records.

I had been able to email my recent lab results, so they had them in my chart. (I love this ease of communication -- more doctors should offer it.) We talked back and forth about the pros and cons of raising the dosage. I explained to her that I had "heard" lots of different kinds of advice from other thyroid patients. But I acknowledged that it can sometimes be challenging to the doctor when patients present themselves like that. Because of my willingness to meet her open mind with my own, we reached an easy understanding.

*Here are my most recent results again from August 9*:

TSH -- 0.525 (range 0.45-4.5)
FT4 -- 0.72 (range 0.82-1.77)
FT3 -- 3.0 (range 2.0-4.4)

She agreed that my dose definitely shouldn't be lowered. I explained to her that I had always felt very good on 180 and I don't *think *that I had hyPERthyroid symptoms.

I told her that I had "heard" that it's sometimes OK for the TSH to go to Zero when you're taking Armour. She kind of wrinkled her nose at that, but she didn't put up a wall of resistance. (It's the energy, you know? The give and take.) I agreed with her that maybe that wouldn't be ideal (but I don't know, what do you guys think? Would my former 0.015 that so scared one of my previous doctors be OK for me?)

I also asked her about the "75% of range" theory for the FT3. She hadn't heard of that. She liked that my 3.0 was nicely almost in the middle of the lab's 2.0-4.4 range. But again, she didn't put up a big wall of resistance when I suggested that perhaps it should be higher.

She strongly felt that the FT4 should probably be higher, despite what I'm hearing in this Forum that it's OK that it's low. I asked her if it's low because so much of it is being converted into FT3. She said that's why there needs to be more of it.

So I guess I'm still confused about the relationship between FT4, FT3 and EXOGENOUS FT3. From what you're telling me, Andros, doctors can safely totally ignore the TSH and the FT4. And that's BECAUSE I'm taking Armour Thyroid, is that right? This wouldn't be the case with unmedicated situations or plain T4 medication?

She also agreed it would be good to experiment with two doses per day, but she couldn't offer a lot of advice on how to do that (admitting that she had never done that with a patient before). The bottom line is that *she agreed to increase my dosage to 165mg per day!* I'll be taking a 60mg and two 15mg pills in the morning (90mg) and a 60mg and one 15mg pill in the evening (75mg).

I will do that for one month and then get more lab tests next month, to see how this is going.

Questions: I have a very erratic sleep schedule. I take my one dose whenever I get up. But sometimes I'm up all night and go to sleep in the morning! So I take my dose when I wake up, which could be around 3 pm (or wildly variable other times). So if I had a "normal" kind of schedule, what would be the best time for me to take my second dose? Say I woke up at 8 am and took my first dose then. Should I take the second dose sometime in the afternoon? At dinnertime? Or bedtime? Or when? Knowing this, I can translate that into the times I'm actually awake.

Does it matter if my schedule changes so wildly? Should I be more concerned about taking my doses at the *same time every day*, _no matter when I'm awake_? _Or should I vary the times I take my doses according to when I'm actually awake/asleep on any given day (as I have been doing)?_

Depending on the results of my next tests, I will be sure to come to this Forum to get some good advice and be prepared with information and questions for my next free clinic visit. That will be on Wednesday, September 11. I will aim for getting my blood drawn on Monday, September 9.

I want to say... I am so grateful for having this Forum to turn to. Thank you so much to those who are providing so much helpful advice!

BWHughes


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## bwhughes (Aug 11, 2013)

bigfoot said:


> Ahhh, yes, good ol' ZoomCare. IMHO, I think you are barking up the right tree. You are hitting on the thyroid, FT3/FT4, and bringing up adrenal and other hormones. Some docs 'get it', some don't. Sadly the latter outnumbers the former.


The "right tree" being Zoomcare? Or the "right tree" being insisting on all three thyroid tests? As for the adrenals and other hormones, I don't expect to be able to get care for this in my 15-minute free clinic visits. It's challenging enough to deal with the thyroid dosages... at least until I'm stablized on the right dosage. At least with Zoomcare, you know that you're in a very well organized system and clean surroundings.

But I have read on Dr. Rind's website (I *think *it was on his site) that it might be better to address the adrenal insuffiency PRIOR to dealing with the hypothyroidism. Zoomcare has recently added a Naturopathic Care Team, but I would have to make an appointment for one of their 15-minute, $105 visits... which I can't really afford at this time. And I don't think 15 minutes is really adequate for a complete picture, anyway.

What is your experience with Zoomcare?



bigfoot said:


> Good to hear you are at least feeling a little better! As you probably know, the adrenals and thyroid go hand-in-hand.


Yes, I'm learning about the adrenal-thyroid relationship.

I am very hopeful about the new health insurance policies that are going to come into place in January of 2014.

For 12 years, I have been paying relatively low monthly premiums for private health insurance through my membership in the National Association for the Self Employed. Great premiums... LOUSY coverage. I had to test out their hospitalization coverage once during this period (plus an overnight stay at another time), and it was pretty good in this regard. But for regular, preventative medical care, lab tests, in-office procedures, etc.... LOUSY. They will only cover ONE doctor's visit per quarter, and of that, the maximum they will pay is $60. They once refused to cover $600 worth of lab tests because they were "preventative." They once refused to cover an ant getting flushed out of my ear because it was "in-office surgery." No mental health. No dental coverage. No vision coverage.

A few weeks ago I received a notice that they will no longer be offering service in my state starting January of 2014. This is because of "Obamacare" and the new "health care marketplaces" that each state is setting up. I will have to research new health insurance starting October 1st and find something to replace my current coverage starting January 1st. The GREAT news about this is that no one can be legally turned down for "pre-existing conditions." This in itself is a godsend. It's a step in the right direction.

The other good news is that among the policy choices that will be offered in my state, all of them will be including mental health, chiropractic, the usual preventative care-type things, and I believe also dental and vision (not sure about that).

And another bit of good news is that, while this insurance is going to cost more for me, it won't be WILDLY more expensive. I currently pay just $253.98 per month, plus $45 for the association membership.... so about $300. From the projections I've looked at, and because of federal subsidies on low incomes, I'm probably going to have to pay maybe $400 or $425. And I won't have the association membership, if I decide to cancel that (health insurance is really the only reason I've kept it). PLUS, I'll be paying a lot less out of pocket, and I'll be actually able to CONSIDER getting certain kinds of treatments that I've just had to totally deny myself for at least 12 years!

So as I said, I'm hopeful that this will be an improvement in the quality of my life. I can hold off on finding a good, regular, holistic minded doctor until next year, when my options for affording such care will be greatly improved.

I know this isn't the Forum for such a discussion, but I dream of the day when "health insurance companies" are a thing of the past and the right of every single person in this country to be given the same kind of healthcare as "rich people," no matter what their income, is the law of the land.......



bigfoot said:


> I'm trying to think of cheap(er) things you can do to address overall health here...


Thank you for this list of healthy suggestions! Let's see.....

Selenium, no more than 200 mcg / day.
I'm getting 250 mcg in my daily multivitamin. Why no more than 200?​
Vitamin D3, especially if you are low (aren't we all in the PNW), 4-5,000 IU.
I have been taking 5,000 IU daily, plus 1,000 from my multivitamin. A couple of years ago, I was tested and my level was 4! My doctor at the time told me that was "scary low." She put me on a prescription for 100,000 IU taken once per week. After about 4 months (end of 2011), I tested at 24. I know that I should be trying for higher, so I recently decided to add another 5,000 pill, so 11,000 IU per day. I'll have to get tested again soon, because it's been almost two years.​
Vitamin B12, as "methyl-" variety, not "cyano-" variety.
I'm getting 225 mcg of the "cyano-" variety in my multivitamin. I intend to keep taking this particular product (see below). Is there harm in that? What's the difference between the two?​
Vitamin C, buffered, 2-3,000 IU. Throttle back if diarrhea.
I've been ignoring C, but I'm getting 120 mg in my multivitamin. Not sure how that translates into IU.​
Good quality one-daily multivitamin.
Check! I'm taking Alive! Once Daily Women's 50+ Ultra Potency. Look it up, it contains a whole bunch of good stuff.​
Quality fish oil for Omega 3's (Carlson's is good).
I've been ignoring this, and I can't tell if I'm getting any in my multivitamin. It contains a whole bunch of "exotic" "blends," but I'm not sure if they contain Omega 3's. Just the ingredients of the blends are listed. How much is recommended?​
Stay away from soy and goitrogenic veggies.
Not sure if I've been able (or am able) to do this. We eat a lot of packaged food. (Yeah, I know.) My husband buys all the food, he buys what we can afford and what's convenient. At least we shop mostly at Trader Joe's. He does all the cooking as well as working long hours. The only way we will ever be able to completely and radically alter our dietary lifestyle would be for me to start making a ton more money.... and I need to get healthy in order to do that. (Yeah, I know... a Catch-22.)​
Avoid or eliminate gluten completely, if you can.
We don't eat bread at home. But we do eat pasta, pizza, and bread out on occasion, and we eat the packaged foods (as healthy as possible while still being affordable). See above comment.​
Less coffee (easier said than done!).
Easy! We don't drink coffee. Ever.​
Plenty of veggies and water.
LOTS of water.... probably not enough veggies.​
Healthy fats are okay -- meat, avocado, etc.
Nuts? I like pistachios and almonds, but I tend to binge. We eat plenty of chicken, and have fish at least once a week.​
Little to no dairy.
We drink no milk; not a lot of cheese; occasional yogurt.​
Less processed and sugary foods, less soda pop.
See above comment about the types of foods we currently buy; I like dark chocolate; I drink NO soda pop. Ever ever ever. Never have, even as a kid.​
Exercise if you can, more sleep.
Trying to walk one mile (1/2 hour) per day (haven't totally reached that goal, but I DID walk for 15 minutes every day for about three months before I increased my time/distance. Now I have to get back to doing it daily, whether it's just the 15 minutes or the increased route. I'm even keeping a blog about it! I walk with nordic walking poles, so the benefits are increased over "plain" walking... calories burned, muscles used, etc. As for sleep, it would probably help if I were to get onto a more regular schedule. For a number of reasons, that is proving difficult to implement.​


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