Acupuncture, Herbs, Nutrients and Foods for Bone Health

by John & Barbara Connor, M.Ac., L.Ac.  

Barbara & I would like to share with you today studies on the benefits of acupuncture, nutrients, herbs, foods and exercise in building strong bones.  We hope you find this article useful in appreciating the value of acupuncture, certain nutrients, herbs and foods as well as exercise in your quest for optimal bone health.

Table of Contents

  • Introduction
  • Studies on the Benefits of Acupuncture  for Bone Health
  • Beneficial Nutrients, Herbs and Foods for Bone Health
  • Studies on Beneficial Nutrients, Herbs and Foods for Bone Health
  • Studies on the Beneficial Effects of Exercise on Bone Mineral Density
  • Studies on the Relationship between Vitamin D and Bone Mineral Density
  • Studies on the lmportance of Combining Vitamin D with Vitamin K
  • Studies on Other Issues Concerning Bone Health

Introduction

Almost 30 million Americans are affected by osteoporosis, and women are 4 times more likely to suffer from this disease than men. (Kerstetter et al 2003) Fractures associated with this disease affect one in three women and one in five men over the age of 50 years. (Sacco et al 2013)

Women are vulnerable to increased bone loss during and after menopause. Maintenance of bone health with aging is attributed to genetics, sun exposure (maintaining vitamin D levels), exercise and diet. (Gunn et al 2015) PMID: 25856221

Of interest to the bone field is the number of population-based studies published in the latter part of the 20th century, and between 2001 and 2006, which have demonstrated a consistent, beneficial effect of fruit and vegetable intake on indices of bone health across a wide range of age groups including young boys and girls, premenopausal women, perimenopausal and postmenopausal women, and elderly men and women. (Lanham-New S 2008) Cross-sectional studies have shown a positive association between higher fruit intake and higher bone mineral density. (Shen et al 2012) PMID: 23244535

A bone protective diet can be characterized as a diet rich in fruits and vegetables, dairy products, seeds and nuts, whole grain and soy products and moderate amounts of fish, eggs and lean meat. This diet provides sufficient amounts of protein, calcium, magnesium and vitamins (e. g. K, C, folic acid, B6 and B12), which are important for bone development. (Strohle & Hahn 2016)

Bone is constantly being remodeled in a dynamic process where cells called osteoblasts form new bone and cells known as osteoclasts break down bone tissue.

The active ingredients derived from natural plants that are efficacious in suppressing osteoclastogenesis (the development of osteoclasts from blood cells) and bone resorption include flavonoids, terpenoids (sesquiterpenoids, diterpenoids, triterpenoids), glycosides, lignans, coumarins, alkaloids, polyphenols, limonoids, quinones and others (steroid, oxoxishhone, fatty acid). (An et al 2016) PMID: 27131574 

The two nutrients essential for bone health are calcium and vitamin D. Reduced supplies of calcium are associated with a reduced bone mass and osteoporosis, whereas a chronic and severe vitamin D deficiency leads to osteomalacia, a metabolic bone disease characterized by a decreased mineralization of bone.  The main sources of calcium in the diet are dairy products (milk, yoghurts and cheese) fish (sardines with bones), few vegetables and fruits. The optimal way to achieve adequate calcium intake is through the diet. However, when dietary sources are scarce or not well tolerated, calcium supplementation may be used. (Gennari C 2001) PMID: 11683549

In patients with low calcium intake supplements are warranted aiming for a total calcium intake of 800 to 1000 mg/d together with adequate vitamin D replacement. (Meier & Kranzlin 2011)

Calcium supplementation is only for those unable to get enough calcium in their diet. Examples of foods high in calcium include yogurt (415 mg/serving), mozzarella, sardines with bones, cheddar cheese, milk; salmon pink, canned, solids with bone; cottage cheese, turnip greens, kale (94 mg/serving).  (NIH Office of Dietary Supplements website)

Many factors influence bone mass. Protein has been identified as being both detrimental and beneficial to bone health, depending on a variety of factors, including the level of protein in the diet, the protein source, calcium intake, weight loss, and the acid/base balance of the diet. (Heaney & Layman 2008) PMID: 18469289  There is agreement that diets moderate in protein (in the approximate range of 1.0–1.5 g protein/kg) are associated with normal calcium metabolism and presumably do not alter skeletal homeostasis. (Kerstetter et al 2003)

With regard to calcium and vitamin D, the International Osteoporosis Foundation recommends a daily intake of 1200 mg calcium and 800–1000 IU vitamin D for postmenopausal women. Elderly women, or those with reduced physical activity and sunlight exposure, may need higher levels of these nutrients. For these high-risk for fracture individuals, the measurement of 25-OH Vitamin D levels is recommended and high dose vitamin D supplementation given if deficient. For other postmenopausal women receiving aromatase inhibitor (AI) therapy, a dose of at least 800 (and up to 2000) IU of vitamin D every day is recommended to maintain replete levels. (Hadji et al 2017) PMID: 28413771

In general, calcium from food is as well absorbed as calcium supplements, but there are differences in bioavailability. Some foods decrease calcium absorption, such as oxalic acid (spinach, collard greens, sweet potatoes, rhubarb and beans), or phytic acid (fiber-containing whole-grain products and wheat bran, beans, seeds, nuts and soy isolates). Others enhance calcium absorption, such as lactose and certain caseinophospho peptides formed during digestion of caseins from milk. This explains—for instance—the high availability of calcium in broccoli and kale, which is low in oxalate, and the low availability of calcium in spinach, which is rich in oxalate. Therefore, equivalent calcium contents do not guarantee equivalent nutritional values. (Bruckhardt P 2015)

Total homocysteine (tHcy) is negatively associated with bone mineral density (BMD) of the total femur. The contribution of tHcy to explain the variance of BMD is small (2% of the total variance) but clinically relevant, considering the high prevalence of osteoporosis among post-menopausal women and the possibility to lower tHcy by vitamin supplementation. (Bucciarelli et al 2010) PMID: 20603040

Studies on the Benefits of Acupuncture on Bone Health

In Chinese Medicine osteoporosis is recognized as an aging and degenerative condition caused by insufficiency of Kidney Qi in line with the theory of traditional Chinese medicine (TCM) in the ancient book of the Inner Canon of Huangdi , and acupuncture as well as herbs have been widely applied to treat it for the past 2000 years. (Guo et al 2016)

In Chinese Medicine the Kidneys govern the bone marrow (a substance which is the common matrix of bones, bone marrow, brain and spinal cord) and bones. If the Kidney-Essence is strong, the bones will be strong. (Maciocia, The Foundation of Chinese Medicine, page 96)

  1. Eighty-five postmenopausal patients were randomly divided into an observation group (43 cases) and a control group (42 cases). Both groups were treated with oral administration of caltrate-D tablet, 600 mg per day.  After treatment, the BMD in the observation group was significantly increased; the improvement in the observation group was more significant than that in the control group (all P<0. 05). After treatment, the index of bone metabolism in the control group was increased, and the serum bone gla protein, the hydroxyproline/creatinine in the control group were higher than those in the observation group (both P<0. 05). The authors conclude that the treatment of warm needling combined with element calcium on postmenopausal osteoporosis is significant, which is likely achieved by reducing the bone metabolism of postmenopausal patients. (Cai et al 2015) PMID: 26721135
  2. The clinical effect of acupuncture combined with TDP for treatment of postmenopausal patients with deficiency of liver and kidney syndrome is significant, and it can increase bone mineral density, decrease endometrial thickness and obviously regulate the estrogen level. (Wang JF 2009) PMID: 19947264
  3. The therapeutic effect of warm needle moxibustion on osteoporosis is better than that of oral administration of tablet Caltrate with Vit D2 and it can increase levels of hormones and delay bone loss. It is an effective method for preventing and treating postmenopausal osteoporosis. (Zhao et al 2008) PMID: 19127918
  4. A rapid lowering of the bone mass in postmenopausal women is also related to the lowered gastrointestinal absorption capacity for calcium and other nutrient substances due to hypo function of the various systems with ageing. Therefore, Caltrate D was administer to this series of patients. The therapy with acupuncture plus drug has a been shown to significantly increase the bone mineral density (P<0.01), with a therapeutic effect much superior to that of the control group (P<0.05). (Ouyang et al 2002)

Beneficial Nutrients, Herbs and Foods for Bone Health

  1. Beta-carotene, vitamin C, zinc and sodium
  2. Boron
  3. Calcium
  4. Dairy products
  5. Dried plums
  6. Epidmedii herba
  7. Fish oil
  8. Lactoferrin
  9. Magnesium
  10. Mediterranean diet
  11. Omega-3 fatty acids
  12. Sodium
  13. Ursolic acid
  14. Vitamin C
  15. Vitamin D
  16. Yogurt
  17. Zinc

Studies on Beneficial Nutrients, Herbs and Foods for Bone Health
Beta-carotene, vitamin C, zinc and sodium – In postmenopausal Korean women, β-carotene, vitamin C, zinc and sodium intakes were positively associated with bone mass. Furthermore, frequency of vegetable consumption was positively associated with femoral neck and total hip T-scores. (Kim et al 2016) PMID: 27664069

Boron – There is a suggestion that boron may increase the efficacy or utilization of vitamin D. Indeed, it has been reported that boron can alleviate marginal vitamin D deficiency. (Jugdaosingh et al 2015) PMID: 26665155

Calcium – Adequate calcium intake is essential for normal growth and development of the skeleton and teeth and for adequate bone mineralization. Optimizing bone mass accretion in youth and adolescence is critical to attaining peak bone mass in adulthood. In adulthood, low calcium intake has been associated with increased risk for osteoporosis, bone fractures, and falls. (Bailey et al 2010) 

Calcium – Adequate intakes of calcium and vitamin D are essential preventive strategies and essential parts of any therapeutic regimen for osteoporosis. However, calcium supplementation is not without controversy and benefits on skeletal health need to be balanced against potential risks on cardiovascular disease. The published data so far suggest a potential detrimental effect of calcium supplement on cardiovascular health (i.e. myocardial infarction) although further prospective studies are needed to clarify the gradient of risk. Since food sources of calcium produce similar benefits on bone density as supplements and dietary calcium intake does not seem to be related with adverse cardiovascular effects, calcium intake from nutritional sources needs to be enforced. (Meier & Kranzlin 2011) PMID: 21882122

Dairy products – In this study of elderly black and white men and women, dairy nutrients contributed significantly and interchangeably to a predictive model of total hip and femoral neck BMD that included weight, age, race, and sex. Milk was the primary source of calcium in all groups. All subjects ingested calcium at intakes well below the requirement for this age group, but the insufficiency was least in the black men. Dairy consumption predicted total hip BMD in the black men but not in the white men and not in the women of either race. Nevertheless, a calcium supplementation intervention was equally effective in protecting against bone loss in the white men and women. Elderly persons who had lower previous dairy intakes and who were younger than 72 y experienced the greatest positive benefit of calcium supplementation. Overall, this study suggests a positive role for dairy foods in the diet of the elderly. (McCabe et al 2004) PMID: 15447921

Dried Plums – These results confirm the ability of dried plums to prevent the loss of total body BMD in older osteopenic postmenopausal women and suggest that a lower dose of dried plum (i.e., 50 g) may be as effective as 100 g of dried plum in preventing bone loss in older, osteopenic postmenopausal women. This may be due, in part, to the ability of dried plums to inhibit bone resorption. (Hooshmand et al 2016) PMID: 26902092

Epimedii herba – is one of the most frequently used herbs in formulas prescribed for the treatment of osteoporosis in China. The main active flavonoid glucoside extracted from Epimedium pubescens is icariin, which has been reported to enhance bone healing and reduce osteoporosis occurrence. In this study, we demonstrate that in vitro icariin is a bone anabolic agent that may exert its osteogenic effects through the induction of BMP-2 and NO synthesis, subsequently regulating Cbfa1/Runx2, OPG, and RANKL gene expressions. This effect may contribute to its action on the induction of osteoblasts proliferation and differentiation, resulting in bone formation. (Hsieh et al 2010)

Fish oil – Findings from human studies largely show that greater intake of total polyunsaturated fatty acids (PUFAs), total n–6 PUFAs, total n–3 PUFAs, and fish is associated with higher BMD or lower risk of fragility fracture in women. Less consistent benefits to bone health are associated with higher intake of long chain n–3 PUFAs or when the dietary ratio of n–6 to n–3 PUFAs is considered. The strongest evidence for benefits to bone is from studies of fish intake. Regular consumption of fish and seafood not only provides high quantities of PUFAs but can also be rich sources of protein, vitamin D, calcium, and other vitamins and minerals, all of which are necessary for the maintenance of strong, fracture-resistant bones. (Longo & Ward 2016) PMID: 26098476

Lactoferrin administered to rodents accelerates bone healing and prevents bone loss induced by ovariectomy. Therefore the use of lactoferrin or milk whey in osteoporosis treatment and prevention is postulated. (Wlodarski et al 2014) PMID: 25154204 

Lactoferrin has powerful anabolic, differentiating, and antiapoptotic effects on osteoblasts and inhibits osteoclastogenesis. Lactoferrin is a potential therapeutic target in bone disorders such as osteoporosis and is possibly an important physiological regulator of bone growth. (Cornish et al 2004) PMID: 15166119

Lactoferrin is an anabolic peptide that has been proven to induce bone growth in vivo. Cornish et al. have suggested that lactoferrin acts on bone cells at periphysiological concentrations and might have a therapeutic role for bone repair. The data from the current study indicate that a combination of 3 mg of bovine lactoferrin-loaded gelatin microspheres and bovine-derived hydroxyapatite promotes bone regeneration in defects around implants. (Gormez et al 2015)

Lactoferrin inhibits formation of osteoclasts (which break down bone) and stimulates formation of osteoblasts (which build bone.) The results of one animal study suggest that bovine lactoferrin treatment could promote bone regeneration during distraction osteogenesis in the test animal. The results indicate that the OPG/RANKL/RANK system might be a major mechanism for increased bone formation and decreased bone resorption in distraction osteogenesis with bovine lactoferrin treatment. (Li et al 2015)

Magnesium – is an important contributor to bone health. In several studies on animals, dietary magnesium restriction promotes osteoporosis, fragility, microfractures of the trabeculae and reduction of bone’s mechanical properties. Dietary sources of magnesium include almonds, cashews and peanuts, raisin bran cereal, potato skins, brown rice, kidney beans, black-eyed peas and lentils. A modest supplementation with 250 mg/day of magnesium is reasonable to support bone health.  (Pepa & Brandi 2016) PMID: 28228778

A note about magnesium – Since magnesium (Mg) is a calcium antagonist it is feasible to propose that high concentrations of magnesium alter calcium/Mg ratio, thus leading to dysregulated cell functions. Accordingly, an in vitro inhibitory effect of high Mg on osteoblast differentiation and mineralizing activity has been shown. (Castiglioni et al 2013) PMID: 23912329 However, in a study on bone-related minerals during denosumab (Prolia) administration in post-menopausal osteoporotic patients it was concluded that since denosumab may not improve Mg, it is better to obtain Mg supplementation during the therapy. (Suzuki et al 2017) PMID: 28805705

Mediterranean diet – The results demonstrate a positive correlation between bone health status and adherence to Mediterranean diet (MD), suggesting that a high adherence to MD promotes bone health. The observations here reported confirmed that a specific dietary approach, such as MD, can represent a modifiable environmental factor for osteoporosis prevention. (Savanelli et al 2017) PMID: 28438173

Omega-3 fatty acids (FAs) – A higher dietary ratio of omega-6 to omega-3 FAs was associated with lower hip bone mineral density (BMD) in 1532 community-dwelling subjects aged 45–90 years. The ratio of dietary LA to ALA was inversely associated with hip BMD, independently of hormone therapy. A higher ratio of total dietary omega-6 to omega-3 FAs was also associated with lower BMD at the spine in women not undergoing hormone therapy and at the hip in all women. In summary, bone health is significantly correlated with omega-3 status. (Molfino et al 2014)

Sodium – Hyponatremia (low sodium) directly contributes to osteoporosis and increased bone fragility by inducing increased bone resorption to mobilize sodium stores in bone. Low extracellular sodium directly stimulates osteoclastogenesis and bone resorptive activity through decreased cellular uptake of ascorbic acid and the induction of oxidative stress; these effects occur in a sodium level-dependent manner. (Negri & Ayus 2017) PMID: 27664044

Ursolic acid – The results of this in vivo study suggested that ursolic acid has the anabolic potential to stimulate osteoblast differentiation and enhance new bone formation. (Lee et al 2008) PMID: 18822379 

Ursolic acid – The results of another in vivo study suggested that ursolic acid has the anabolic potential to stimulate osteoblast differentiation, enhance new bone formation, and suppress absorptive function of osteoclast. (Yu et al 2015) PMID: 26097549

Vitamin C – Higher vitamin C intake levels were associated with a lower risk of osteoporosis in Korean adults aged over 50 with low levels of physical activity. However, no association was seen between vitamin C intake and osteoporosis risk in those with high physical activity levels. (Kim & Lee 2016) PMID: 27134348

Vitamin D3 is fat soluble and is stored in the body fat. Vitamin D deficiency results in abnormalities in both calcium and phosphorus metabolism. The major function of vitamin D is to maintain serum calcium concentrations within the physiologically acceptable range. It accomplishes this by increasing intestinal calcium absorption. In a vitamin D-deficient state, the intestine typically absorbs 10-15% of dietary calcium. In a vitamin D-sufficient state, 30% typically is absorbed from the diet; as much as 60-80% can be absorbed during periods of growth and pregnancy or lactation, with increased demand for calcium. (Holick M 2004)

Vitamin D in the human body is mainly derived from skin after ultraviolet light exposure and from dietary sources.  There are two main forms of Vitamin D, Vitamin D3 (cholecalciferol) and Vitamin D2 (ergocalciferol). Currently the biological effects of Vitamin D are divided into two categories: First, in calcium and phosphorus metabolism, considered the classical activity; and second, the non-classical or alternative pathway that mainly affects immune function, inflammation, anti-oxidation, anti-fibrosis and others, as wells as inhibitory effects on the many kinds of malignancies. (Wang et al 2017)

Yogurt – In this cohort, higher yogurt intake was associated with increased BMD and physical function scores. These results suggest that improving yogurt intakes could be a valuable public health strategy for maintaining bone health in older adults. (Laird et al 2017) PMID: 28462469

Zinc has been considered an important factor in bone metabolism since bone contains approximately 30% of the zinc in the body. Zinc has been known to promote bone formation and inhibit bone resorption in in vitro studies. In a previous study, we demonstrated that dietary zinc deficiency decreased bone formation and increased bone resorption in rats. (Suzuki et al 2016) PMID: 27013778 

Studies on the Relationship between Vitamin D and Bone Mineral Density

  1. Vitamin D deficiency coexists with low bone mineral density (BMD) in our study group. Serum 25(OH)D needs to be documented in women having low BMD. Calcium and vitamin D need to be supplemented as part of therapy in post-menopausal women. (Harinarayan et al 2011)
  2. Vitamin D3 & Calcium – Combined calcium and vitamin D3 supplementation was effective in reducing the rate of bone mineral density loss in women with moderate chronic kidney disease. (Bosworth et all 2012)
  3. Vitamin D – In utero and during childhood, vitamin D deficiency can cause growth retardation and skeletal deformities and may increase the risk of hip fracture later in life. Vitamin D deficiency in adults can exacerbate osteopenia and osteoporosis, cause osteomalacia and muscle weakness, and increase the risk of fracture. (Szabo A 2011)
  4. Vitamin D – In addition to enhancing calcium absorption from the intestine and mineralization of the osteoid tissue, vitamin D has many other physiological effects, including neuromodulation, improving muscle strength and coordination, insulin release, immunity and prevention of infections, and curtailing cancer. (Wimalawansa SJ 2011)
  5. Vitamin D plays a major role in bone mineral homeostasis by promoting the transport of calcium and phosphate to ensure that the blood levels of these ions are sufficient for the normal mineralization of type I collagen matrix in the skeleton. (Haussler et al 1997)

Studies on the lmportance of Combining Vitamin D with Vitamin K

  1. Vitamin K acts synergistically with Vitamin D on bone mineral density (BMD) and positively influences the balance of calcium, a key mineral in bone metabolism.  Addition of vitamin K to vitamin D and calcium supplements in postmenopausal Korean women increases the L3 BMD and reduces the undercarboxylated osteocalcin concentration.(Sang Hyeon Je et al 2011)
  2. Vitamin D with K1 promotes beneficial effects on the elastic properties of arterial vessel walls: It is concluded that a supplement containing vitamins K1 and D has a beneficial effect on the elastic properties of the arterial vessel wall. (Braam et al 2004)

The presence of calcification in any arterial wall is associated with a 3-4-fold higher risk for mortality and cardiovascular events. (Rennenberg et al 2009)

  1. Vitamin D3 and K2 induce mineralization in human osteoblasts: In the present study, it was demonstrated that the vitamin K metabolic cycle functions in human osteoblasts as well as in the liver, the post-translational mechanism, by which 1,25(OH)2D3 caused mineralization in cooperation with vitamin K2 was clarified. (Miyake et al 2001)

The 1,25(OH)2D3-induced mineralization promoted by vitamin K2 was probably due to the enhanced accumulation of osteocalcin induced by vitamin K2 in the cell layer. These results suggest that the mechanism underlying the mineralization induced by vitamin K2 in the presence of 1,25(OH)2D3 was different from that of vitamin K2 alone, and that osteocalcin plays an important role in mineralization by osteoblasts in vitro. (Koshihara et al 1996)

Both types of vitamin K treatment – menaquinone-4 (MK-4) and vitamin K(1) – decreased the expression of receptor activator of nuclear factor kappaB ligand/osteoclast differentiation factor and enhanced the expression of osteoprotegerin/osteoclast inhibitory factor in the stromal cells. Vitamin K might stimulate osteoblastogenesis in bone marrow cells. (Koshihara et al 2003)

  Studies on the Beneficial Effects of Exercise on Bone Mineral Density

  1. We report significant improvements in bone mineral density (BMD) at the spine, hip, and whole body for female cancer survivors who completed 26 weeks of combined aerobic and resistance-training (CART). This investigation demonstrates the possible effectiveness of CART at improving bone health and reducing risk of osteoporosis for women who have completed cancer treatment. The Improving Physical Activity After Cancer Treatment (IMPAACT) Program appears to be a safe and feasible way for women to improve health after cancer treatment. (Almstedt et al 2016) PMID: 28580396
  2. Women who began training with the lowest initial values had the greatest improvements in hip bone mineral density (BMD), hip abductor strength, leg power, and postural stability. These results support the training principle of initial values and suggest that this training program may be most successful in premenopausal women with lower values of musculoskeletal indices of fracture risk. (Winters-Stone & Snow 2003) PMID: 14523306
  3. A 5-year program of weighted vest plus jumping exercise maintains hip bone mineral density (BMD) by preventing significant bone loss in older postmenopausal women. Furthermore, this particular program appears to promote long-term adherence and compliance, as evidenced by the commitment of the exercisers for more than 5 years. (Snow et al 2000) PMID: 10995045
  4. This study provides the first evidence that low-repetition, light-load power training significantly increases pelvis BMD in postmenopausal women with sarcopenia. Since this training program does not require high-load exercise, high levels of adherence would be anticipated due to its ease of implementation. We conclude that low repetition, light-load power training would be an effective form of training exercise for sedentary adults who are at risk for osteoporosis and wary of heavy loads and/or fatigable training. (Hamaguchi et al 2017) PMID: 28464798

Studies on Other Issues Concerning Bone Health

    1. Be aware of medications that can increase fracture risk – Drug-induced osteoporosis is a type of secondary osteoporosis. Glucocorticoids are the most common cause of drug-induced osteoporosis. But other drugs can increase fracture risk, such as thyroxine overdose, gonadotropin-releasing hormone (GnRH) agonists, aromatase inhibitors, thiazolidines, proton pump inhibitors, loop diuretics, anticoagulant drugs, selective serotonin reuptake inhibitors (SSRI) , tricyclic antidepressants, anticonvulsants, and so on. (Suzuki H 2013)
    2. Do not smoke – It is suggested that the number of hip fractures in the world will increase from 1.66 million in 1990 to 6.26 million by 2050. There is a demonstrated research show that approximately 19% of all hip fractures were attributed to cigarette smoking, and the relative risk for current smokers comparing with never smokers was consistently higher in males than in females. (Wu et al 2016) PMID: 28036356
    3. Avoid high intake of cola – This study demonstrates that over a 10-day period high intake of cola with a low-calcium diet induces increased bone turnover compared to a high intake of milk with a low-calcium diet. Thus, the trend towards a replacement of milk with cola and other soft drinks, which results in a low calcium intake, may negatively affect bone health as indicated by this short-term study. (Kristensen et al 2005) PMID: 15886860

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Compassionate Acupuncture and Healing Arts, providing craniosacral acupuncture, herbal and nutritional medicine in Durham, North Carolina. Phone number 919-309-7753.


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