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Teen Nutrition Vitamin D The Overlooked Vitamin Dr. Hister On
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People15 First
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Dr. Hister looks at the pros and cons on the use of antibiotics for ear infections.
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Calcium and vitamin D help build strong bones. Are you getting enough calcium in your daily diet?
D – The Overlooked Vitamin Peoples Pharmacist Ian Lloyd on the many benefits of this powerful vitamin.
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Stronger Bones
Healthy Buys Great selection of quality health and wellness products from Peoples Pharmacy.
Improve Your Hearing Blocked ear passages impairing your hearing? Earol is an olive oil spray that softens and naturally removes ear wax.
Ear Infections
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Vitamins & Supplements Great selection of sale priced supplements for a heathier life.
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Pharmacist Recommended Informative tips on how to reduce your risk of heart disease, a leading cause of death in Canada.
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The Teen Years Darlene Booth talks about teen nutrition and how good nutrition is so vital for a healthy teen.
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Zucchini Cheddar Bacon Bread Brand new feature recipe From Company’s Coming 30-Minute Diabetic Cooking.
Helping People Live Better Lives
Dr. Hister
Managing Ear Infections Menopause There are a number of conditions I could list that would easily illustrate some of the dramatic changes that have occurred in our approach to medical matters over the last 2 decades such as, for example, asthma, ulcers, even breast cancer, but the one that stands out for me for a couple of reasons is ear infections in kids. So, when my first son was yet a toddler and he got his nearly mandatory early-childhood middle ear infection (the middle ear is the cavity behind the outer ear drum), he was nearly immediately smothered by his treating doctor (and no, thank God, that was not me because even I am not fool enough to treat my own family, especially not my in-laws) with the standard practice back then: a prescription for a “broad-based” antibiotic, that is, an antibiotic meant to kill as many different pathogens as can be killed with only one drug. There is an obvious major problem with that approach, however, even when it works properly as it happily did for my son: sure, a blast from a howitzer is likely to kill a fly that’s unfortunate enough to be in the vicinity of that blast, but it will also kill everything else in the vicinity, including a lot of things that you don’t really want to kill but which get caught up in the blast’s fallout anyway. Even worse, though, and this is especially true in the infection-fighting world but also interestingly, it probably holds true (at least to an extent) in the insurgent-fighting world, whatever survives
that blast is going to be very tough indeed, and when it comes back at you, or more likely when they come back at you, as they surely will, hey, you better watch out because at the very least, you are very likely to need a much bigger gun to ward them off, not to mention, of course, that they may have learned enough tricks to evade your weapons even more easily the next time. So in the case of using an antibiotic for ear infections in kids, the fallout problems were quite obvious from the start although they became much clearer over the last 2 decades or so. Number one, a lot of kids who were diagnosed with an ear infection (for which the official name is otitis media) didn’t actually have an ear infection, which may surprise many of you reading this, but here’s the problem: even when an eardrum looks “red” that doesn’t necessarily mean there’s an infection behind the drum. It can be – it too often is, I’m afraid - a bit of a guess as to what’s actually happening in that space that the doctor can’t see into. Two, it became increasingly evident from studies from countries like the Netherlands where they haven’t used routine antibiotics for ear infections for several decades, that a lot of kids – the majority, in fact - get over an ear infection on their own if left alone in nearly the same amount of time as do kids who get antibiotics. Number three, even though ear infections are Continued On Page 11
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Helping People Live Better Lives Polysporin Eye & Ear or Ear Drops
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peoplesdrugmart.com People First 5
Ian Lloyd
Pharmacist, Peoples Pharmacy
Vitamin D
The Overlooked Vitamin This is one of my favourite vitamins to talk about. I feel this supplement is often overlooked. Others believe that it is much more fun to talk about lutein, beta carotene and theanine. These vitamins are exciting, exotic, perhaps even sexy. You might say these supplements are in vogue. Vitamin D is so boring; we can make our own supply whenever we look at the sun. Right? Wrong. Vitamin D should be stylish, because, often we do not have enough exposure to the sun to make enough vitamin D. This is true for those living above the 49th parallel. It is certainly true during the winter months and for shut ins. Every time I read about vitamin D, it recommends that people should take more. Now if that isn't exciting, I don't know what is. Perhaps I should get out more. Where to begin, vitamin D is useful for so many things. Lets start with the most obvious, its ability to promote the formation of strong bones and teeth. Your body needs vitamin D to absorb the calcium from your stomach and works with this calcium to maintain bone strength. This is the main reason why milk is fortified with vitamin D; to make sure your body can use the calcium in milk. Vitamin D can play a role in the absorption and functioning of magnesium. It is believed that not having enough vitamin D could lead to hearing loss. Why would a lack of this important vitamin lead to hearing loss? This is a good question, with a good answer. Inside your ear are three little bones, which are responsible for processing the
sound waves that hit your eardrum. These bones can weaken, and not perform properly, if they don't receive enough vitamin D and calcium. If you don't get enough Vitamin D, you might have problems with your parathyroid glands. This is actually one of the tests that might be performed to see if you are receiving enough vitamin D. When you don't get enough vitamin D, the amount of calcium in your blood can drop. This drop in calcium can stimulate your parathyroid to release more parathyroid hormone (PTH). This increase in PTH causes your body to try and increase the amount of calcium in your blood. This usually results in an increase of calcium absorption from the stomach and an outflow of calcium from your bones. If this state persists in might lead to something called secondary hyperparathyroidism. Symptoms of hyperparathyroidism include kidney stones, abdominal pain, poor memory, muscle weakness and nausea. If you experience any of these symptoms, check with your Doctor and ask if s/he will consider sending you to the lab to have your PTH and vitamin D levels checked. There is also evidence that vitamin D can help prevent certain forms of cancer. In the June 2007 issue of the American Journal of Clinical Nutrition, they found that women over 55 who took 1100IU of vitamin D had a 6% lower risk of developing cancer. I think the study was originally designed to test calcium and vitamin D's ability to help with bone Continued On Page 8
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Ian Lloyd...Continued From Page 6
health. I'm not sure if they published the results regarding bone health, as the vitamin D and cancer finding was the big news. These findings even prompted the Canadian Cancer Society to issue a statement which said that some people should consider taking 1000IU of vitamin D. Some people thought that this was a once off finding. But later that year, a study published in the Archives of Internal Medicine found that people who took at least 528IU of vitamin D per day had a 7% lower risk of dying from all causes. Also in the same year, an article in the Journal of the National Cancer Institute found that people who had a higher amount of vitamin D in their blood, had a lower risk of developing colorectal cancer. They are not sure why vitamin D helps to prevent cancer, but the studies show positive results. There is so much news about vitamin D that it is hard to keep track of it all. I found this report in the journal Pediatrics very interesting. It followed the connection between respiratory illness in newborns
and vitamin D exposure during pregnancy. More than ? of the 156 newborns studied did not get enough vitamin D while in the womb. These babies were then followed for one year. What the researchers found was that infants with low levels of vitamin D at birth were six times more likely to contract a respiratory infection than babies who were born with adequate amounts of this vitamin. This was the first time that vitamin D exposure during pregnancy was shown to help prevent a common infant disease. Another study linked low levels of vitamin D to childhood obesity. In a study that appeared in the Journal of Clinical Endocrinology & Metabolism, 237 healthy children were checked for their levels of vitamin D. Most of these children were found to be vitamin D deficient. Low levels of vitamin D was associated with a higher body mass index (greater weight) and lower levels of good HDL cholesterol in their blood. The researchers even went so far to say that, “Vitamin D deficiency is rampant in American Continued On Page 10
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pharmacist recommended Health & Wellness Information From Your Peoples Pharmacist
Reduce Your Risk Of Heart Disease Heart disease is the number one cause of death for Canadians. To reduce your risk of having a heart attack or stroke, you need to control your risk factors. Stop Smoking • Smoking dramatically increases your risk. If you smoke, your heart has to work harder to push blood through your arteries. • The carbon monoxide in smoke makes your blood less able to carry oxygen. • Nicotine makes your heart beat faster and causes your blood vessels to narrow. • Smoking increases the build-up of deposits in your arteries, which can lead to blood clots. Talk to your pharmacist or doctor about the steps you need to take to quit. Control Your Blood Cholesterol • Your liver makes cholesterol from the fat you eat. Too much can cause fatty deposits to build up on your arteries and block blood flow. If arteries are blocked, a heart attack or stroke can occur. Prevention • Eat a low-fat diet — less meat and saturated fats. • Eat more fruit, vegetables, whole grains and legumes. • Control your weight, don’t smoke and take medication if prescribed. Be More Active • Inactive people have double the chance of having heart disease than active people. Prevention • Do 30 to 60 minutes of moderate activity most days. This does not have to be
done all at once but should be for at least 10 minutes each time. Control Your Blood Pressure High blood pressure makes your heart work harder to push the blood through your arteries. There are no signs or symptoms of high blood pressure; one out of four people with high blood pressure do not know they have this condition. Prevention Control your weight, stop smoking, take time to relax and be more active. Control Your Weight Being overweight can raise blood pressure and blood cholesterol and lead to diabetes, all of which increase the risk of heart disease. Prevention • Be more active. • Change your eating habits to decrease fats and calories. Eat more fruits, vegetables and whole grains. Controlling these risk factors not only reduce your chance of having heart disease but also contribute to healthy living. Talk to your Peoples Pharmacist and see how they can help you live a better life.
peoplesdrugmart.com People First 9
Ian Lloyd...Continued From Page 8
youth.” Keep in mind that vitamin D was not shown to cause obesity or lack of good cholesterol, it was only associated with these conditions. There are few side effects with vitamin D use. In theory, it might cause stomach upset, but none of my patients have mentioned any side effects with using vitamin D. The recommended dosage of vitamin D varies depending on whom you ask. In the past, the recommended dosage was 400IU per day; it was believed that anything higher might be toxic. That thinking has been replaced with the current recommendation of 2000IU per day. This is what I currently recommend. If you are concerned about bone health or have darker skin, I usually recommend that you take more. Health Canada currently recommends that infants (0-12 months) receive 400IU of vitamin D per day. There are many ways to get extra vitamin D. Cod
and halibut liver oils are good sources of vitamin D. Be careful because they are also good sources of vitamin A. Ask your Peoples Pharmacist if cod or halibut liver oil supplements are right for you. I have not been able to find any sources, which could tell me if there is vitamin A or D in other fish oils (salmon, sardine, mackerel). There may be, but I do not think these other oils are a significant source of Vitamin A or D. One new product on the market is a Vitamin D drop. It comes in a 400IU per drop strength for infants and a 1000IU strength for adults. This is a handy product for people who don't like to swallow tablets. With all these great findings about vitamin D, come and ask your Peoples Pharmacist if this supplement might be helpful for you. Written By Ian Lloyd, Pharmacist & Chartered Herbalist, Peoples Pharmacy
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Dr. Hister...Continued From Page 4
still the most common bacterial infection in young kids, some of them are due to viruses, which of course do not respond at all to the antibiotics we use, and even when an ear infection is caused by bacteria, because it’s difficult to get a sample from the middle ear, we have to make an educated guess as to what the real culprit is, and an “educated” guess, as anyone who lost money on educated guesses in the financial meltdown will confirm, is often a very inexact – and wrong – estimate to base your tactics on. So using antibiotics in kids in all those three circumstances is not only a gross waste of money, way more important, because those kids don’t need an antibiotic to get better, they can actually only suffer the risks of taking an antibiotic without ever getting any benefit. But that’s not all. Thus, even when an antibiotic is effective in clearing an ear infection, the “tougher” and more broad-spectrum the antibiotic, the greater the risk of complications, some of which are potentially quite severe (for example, there’s been a huge spike all across the world with C. difficile infections, much of that spurred by the overuse of broad-spectrum antibiotics). And most important, of course, the more antibiotics we use, the quicker the bacteria out there learn to adapt and develop resistance to those drugs, so we’ve now bred strains of super-bacteria that are resistant to nearly all (a few are in fact totally resistant) of the antibiotics we can throw at them, thus bringing us back in many ways to the era before we were even able to use any antibiotics on a mass scale. For a real world example of what this means, as I write this, Hong Kong is experiencing an outbreak of rheumatic fever, a complication of a strep infection that we have rarely seen these past 50 or so but which is staging a comeback because of new and hardier strains of strep that are of course, resistant to many antibiotics. So we no longer use antibiotics for ear infections
PEOPLES PHARMACISTS Helping People Live Better Lives Pharmacists Now Have The Authority To Give Vaccinations. Certain Peoples Pharmacists can provide shots for the seasonal flu or for travel vaccinations. Talk to your Peoples Pharmacist and ask if they provide this health service.
Sheena Motokado
Pharmacist & Owner, Kamloops
We Help With Thorough Consultations. Peoples Pharmacists take the time to properly consult and advise you on your best course of action for your medications and health concerns.
John Leung
Pharmacist & Owner, Abbotsford
We Can Help Manage Your Daily Medications. Talk to your Peoples Pharmacist about Med Manager compliance packaging and how it can safely organize your daily medications.
Dave Young
Pharmacist & Owner, Surrey
Dr. Hister...Continued on Page 13
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Medication Review Service Are your medications working effectively for you? PEOPLES PHARMACY has the answer for you with the new Medication Review Service. This free service is an in-person private appointment with a Peoples Pharmacist.
Medication Review Includes: • Detailed analysis of all medications (prescription and overthe-counter), vitamins and supplements to ensure safe and effective use. • In-depth consultation to improve health outcomes by helping resolve any issues that have arisen due to your medications.
Speak to a Peoples Pharmacist about scheduling a free medication review.
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Dr. Hister...Continued From Page 11
in kids nearly as often as we used to. Rather, here’s what we do now: although any child under the age of 6 months is still routinely treated with an immediate antibiotic cover, older kids are now generally only treated with antibiotics under a few specific situations. One is if they have certain complicating factors such as a cleft palate, for example, or an immune disorder. Two is if the infection is deemed – by the treating doctor - to be producing severe symptoms, although again that’s not very easy to determine. For example I can still recall just how loudly my son howled until his ear pain was relieved, and to me, that surely was a severe infection, although to someone who wasn’t the father of that howling boy, maybe it wasn’t. Three is – and again this depends a lot on the individual circumstances and the prescribing doctor - if the infection is not improving much after 2-3 days. So do we just let a kid howl, you ask, for 72 hours before doing anything? Of course not, in part because all parents would go mad from listening to the painful cries, and in part because a howling kid will surely bring Social Services to your house, sooner rather than later. Rather, most ear infections are now treated as most milder infections should be, with lots of TLC, lots of fluids (you know of course, which liquid source this Jewish doctor thinks is even better than penicillin), medication for pain, as well fever-reducing meds, if, that is, it’s even necessary to reduce fever, which it often is not (again, consult your pharmacist, who is often a parent’s best friend in terms of picking the right drugs for your kids). Will that new strategy stop the steady march of resistance in bacteria? No, but it will surely prevent some needless complications in some youngsters, and that can only be a very good thing.
PEOPLES PHARMACISTS Helping People Live Better Lives We Can Help With Medication Reviews. Medication reviews are in-depth consultations that improve health outcomes by helping resolve any issues that have arisen due to your medications. Ask about the new medication review service
Stuart Howes
Pharmacist & Owner, Salmo
We Can Help Improve Venous Leg Disorders. Select Peoples Drug Marts and Peoples Pharmacy locations offer compression stocking and fitting services which help treat painful venous leg disorders. Check with your local Peoples for this health service.
Anthony Rage
Pharmacist & Owner, Penticton
A Trusted Health & Wellness Source. Besides being your community’s medication expert, your local Peoples Pharmacist is a trusted source on a wide variety of health and wellness issues and other health concerns.
Bill Long
Pharmacist & Owner, Golden
Dr. Art Hister can be heard on CKNW and other Corus Radio Network stations on House Calls on Saturdays at 10 AM, as well as seen on Global TV news on Saturday mornings at 9:20.
peoplesdrugmart.com People First 13
Darlene Booth R.H.N
The Teen Years I have always said that parenting is not for sissies. If you think that surviving the terrible two’s was the whole aim of the game, forget about it; you obviously have not entered the teen years yet. The teen years are unlike no other when it comes to growth spurts and hormonal surges. Your usually upbeat offspring may become about as predictable as a class 5 tropical cyclone and emotions will always rule over logic. Not to worry too much - developmentally, they are right on schedule so just prepare for a few bumps in the road. The good news is that you can smooth out some of those potholes by providing a healthy diet at home and teaching them the value of choosing nutritious foods when out and about. I guess better late than never could apply here but the best way to instill good eating habits in your children is to be the model right from birth. If they are raised in a home atmosphere where nutritious food is the focus, they will develop a preference for it. I learned this when my daughter was in school and I would send her off with a healthy lunch only to find processed food litter in her lunch bag when she returned home. When I questioned her she explained that one of the kids in her class really coveted her healthy lunch and would pressure her to trade. At first the processed food was a novelty, but my daughter also confessed that she really did not like the taste of it. I began to pack a little extra for her to share with her friend and then everyone was happy. The teen years are about an increase in muscle and bone mass. Throw hormonal flux in the mix and you can understand the need for extra fuel and I am not just suggesting an increase in calories. Specific nutrients are needed to help build healthy bone structure, stay alert, stabilize moods, fight fatigue and create optimal conditions for overall wellness. This is the time to make sure that a wide variety of wholesome food is available for meals and snacking. Deficiencies are more prevalent in those who rely on processed food or who may be restricting calories due to body image concern. Our standard supermarket food sources are loaded with calories in the form of sugar and fat but low in nutrition that matters. The two most prevalent
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nutritional deficiencies in the teen population are calcium and iron. Calcium is essential for bone development and density; bone mass built during these years will reduce the risk of osteoporosis later in life. The recommended daily requirement for teens is about 1300 mg daily, which is best derived from whole foods. The most convenient source of calcium is from milk and milk products but even those who avoid dairy can bone up with other food sources including; green leafy vegetables, seaweed, nuts, seeds, dried beans and legumes, canned fish with bones and calcium fortified foods. Iron deficiency can be a concern for vegetarians and young menstruating females. This essential mineral is needed for producing energy, immune response, concentration, muscle function and much more. The daily requirement for teen boys is 11 mg and 15mg for girls. Animal sources for iron include beef, poultry, shellfish and eggs; vegetarian sources include blackstrap molasses, green leafy vegetables, beans, nuts and fortified grain products. Teens are busy people and they usually spend much of their day in the company of peers rather than parents. It is hard to control what they eat outside of the home and this is why it is best to educate them from an early age rather than try to control them in later years. Power controls over food choices usually end badly with both parties suffering. Know that they may experiment with food fads and it is a natural progression to establishing some autonomy. Keep the food sources at home healthy and know that resilience is their best friend at this age; most teens will make it through this period intact. And not all teens need to be taught. Sometimes it is the teen who may bring home a desire to eat a healthier diet. Too often we forget that our children are out in the world assimilating valuable information from their peers and environment. Listen to what they have to say, it might just be what you need to hear. Good Health to You!
Zucchini Cheddar Bacon Bread
with delicious A dense, moist bread way to use up garr bacon bites—anothe th soup for lunch wi e rv Se ! ni hi den zucc or a light dinner.
250 mL 1 cup All-purpose flour 250 mL p 1 cu 1 Whole-wheat flour 60 mL p cu 4 ⁄ se r chee Grated sharp chedda 10 mL . 2 tsp 1 Baking powder 2 mL ⁄2 tsp. 1 Baking soda 1 mL ⁄4 tsp. 1 Salt 1 mL ⁄4 tsp. Pepper 2 2 ten ea 1 Large eggs, fork-b 375 mL ps cu 2 ⁄ 1 peel) 3 Grated zucchini (with lk) 175 mL p ⁄4 cu mi Buttermilk (or soured sp 2 2 cri Bacon slices, cooked and crumbled 2 tbsp. 30 mL Canola oil 2 tbsp. 30 mL ion Thinly sliced green on 2 cups 500 mL Boiling water ll in ts in large bowl. Make a we Combine first 7 ingredien centre. to ts in medium bowl. Add Combine next 6 ingredien d8 ase gre in nly eve d rea Sp ned. well. Stir until just moiste 3 to (2 er pan. Put an even lay of inch (20 cm) springform m tto bo o int of crumpled foil inches, 5 to 7.5 cm, thick) ter wa g ilin bo ur Po w cooker. 5 to 7 quart (5 to 7 L) slo tly on foil, pushing down gen pan ce Pla . ker coo into slow w slo r ove el uble layer of tea tow to settle evenly. Place do 1/2 2 ut abo for h lid. Cook on Hig cooker liner. Cover with out inserted in centre comes k pic en od hours until wo 12 o int ts Cu ol. Co k. e rac clean. Transfer pan to wir es. wedg g Mono, 1.0 g
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are available at participating
PEOPLES DRUG MART & PEOPLES PHARMACY
s; 4.9 g Total Fat (2.2 bohydrate; 2 g 1 Wedge: 129 Calorie mg Cholesterol; 17 g Car Poly, 1.3 g Sat); 40 mg Sodium Fibre; 5 g Protein; 259
www.peoplesdrugmart.com
PEOPLES DRUG MART & PEOPLES PHARMACY LOCATIONS LOWER MAINLAND
VANCOUVER • 7160 Kerr St. 434-2656 • 571 West 57th Ave. 324-2258 BURNABY • 4218 Dawson St. 299-6677 NEW WESTMINSTER • 825 McBride Ave. 525-2474 PORT COQUITLAM • 2529 Shaughnessy 941-2413 COQUITLAM • 137-3030 Lincoln Ave. 464-1033 • 1001 Austin Ave. 936-0024 MAPLE RIDGE • 12005-238B Street 476-1420 ABBOTSFORD • 1945 McCallum Rd. 859-2351
LOWER MAINLAND
VANCOUVER ISLAND CENTRAL NORTH
• SOOKE 8-6716 Sooke Rd. 642-2226 GOLD RIVER • 375 Nimpkish Drive 283-9042 UCLUELET • 1892 Peninsula Rd. 726-2733 COURTENAY • 102-1350 England VICTORIA 334-9311 • 3825 Cadboro Bay Rd. CAMPBELL RIVER 477-2131 • #101-2276 S.IslandHwy. • 15-1594 Fairfield 923-7311 598-9232 • #984 Shoppers Row • 1282 Fairfield Rd. 287-8311 595-5997 QUADRA ISLAND • 2642 Quadra St. • 5-654 Harper Road 285-2275 383-1188 • 3643 Shelbourne St. PORT McNEILL • 1584 Broughton St. 477-1881 956-3126 • #102-2020 RichmondRd. PORT HARDY 370-1166 • 100-8950 Granville St. 949-9522
SURREY • #177- 8138-128th St. 598-3233 • 10212 - 152nd St. 580-7457 WHITE ROCK • 1463 Johnston Rd 531-4636
MACKENZIE • 700 Mackenzie 997-5460
THOMPSON OKANAGAN KAMLOOPS • 103-275 Lansdowne St. 374-3112 KELOWNA • 1715 Ellis St. 712-2484 • #104-330 Hwy. 33 491-1999 • 200-3591 Elliot Rd. 768-7645 PENTICTON • 166-1848 Main St. 493-7200 LYTTON • 531 Main Street 455-6685 ASHCROFT • 403 Railway Ave. E. 453-2553
THOMPSON OKANAGAN KOOTENAYS CHASE • 825 Shuswap Ave. 679-3553 SCOTCH CREEK • 3874 Squilax Anglemont 955-0601
KOOTENAYS
NELSON • 405 Hendryx St. 352-3121 SPARWOOD • 107 Centennial Sq. 425-2015 NAKUSP • 88 Broadway St. 265-2228 CRANBROOK • East Kootenay Hospital 13 -24th Ave. North 420-4133
REVELSTOKE • 555 Victoria Rd 837-5191 TRAIL • 1101 Dewdney Ave. 364-1993 PEACE RIVER ROSSLAND • 2060 Columbia Ave. CHETWYND • 4733 - 51 Street 362-5622 788-3393 GOLDEN • 1104 -10th Ave S. 344-6821 SALMO • 107 - 4th St. 357-9444 st
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*Points awarded on net pre-tax purchases.Certain restrictions apply (check with your local Peoples Drug Mart or Peoples Pharmacy for a complete list of non-eligible medications, services & products). Some stores may use a manual system with a different reward level.
The articles published in People First are for the general information of the reader. While effort is made to reflect accepted medical practice and knowledge, articles should not be relied upon for the treatment or management of any specific medical concern or problem and People First accepts no liability for reliance on the articles. For proper diagnosis and medical care, you should always consult your family physician promptly. Opinions expressed in sponsored articles by, Dr. Art Hister, Ian Lloyd, and Darlene Booth are paid editorials and are not necessarily shared by Peoples Drug Mart stores or Peoples Drug Mart (B.C.) Ltd. Some advertised products are not available in all stores. We reserve the right to substitute products or limit quantities. Prices effective while quantities last. Sale in retail quantities only.
Cystoplus 6 sachets
99
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