Courtesy BrandPoint Content
(BPT) – This post is brought to you by Eisai Inc.

When most people think of breast cancer, they think of the pink movement, and often times, “beating” the cancer. A diagnosis of metastatic breast cancer (MBC), a late stage of the disease in which the cancer has spread beyond the breast, is different. There is no cure and, until recently, the number of people living with MBC in the United States was basically unknown. A new study from the National Cancer Institute (NCI) estimates more than 150,000 people are living with metastatic breast cancer.

Although the MBC population is larger than ever before, an estimated 17 percent increase from 2000 to 2010, the implication is positive as it means people are living longer in spite of their diagnosis and sheds light on the increased need for more services and research focused on MBC.

The NCI study brings attention to a growing community of people with MBC whose meaningful lives and stories are largely unheard. To give voice to those living with MBC and bring to life the reality of living with MBC, #ThisIsMBC Serenity Project was created by METAvivor, an organization dedicated to funding research focused on the metastatic breast cancer, in partnership with Eisai Inc. #ThisIsMBC Serenity Project uses art to empower people with MBC to share their experiences, educate others about this disease and encourage donations for more MBC research.

“The metastatic community really wants to be involved in research. The more people we can educate about metastatic disease, the more money we can raise for research that will ultimately help us to live longer and better-quality lives,” said Leslie Falduto, who lives with metastatic breast cancer and participated in the project. “Participating in #ThisIsMBC Serenity Project was a very powerful moment for me. I felt confident. I felt like art. I felt good about what I was doing for my community and I felt good about myself.”

The 16 people living with MBC chosen to participate in #ThisIsMBC Serenity Project tell their stories through the powerful and artful combination of body painting and underwater photography. Created by Ren and Keith Dixon, a married couple who have both lost loved ones to metastatic breast cancer, the storytelling begins in an interview with Ren Dixon, the body painting artist. After discussing their MBC experience, Ren visually represents each person’s experiences through the use of vivid color and symbols painted directly on their body. Next, Keith Dixon captures the mood and emotion of the patient’s personal journey through underwater photography.

“It is important for women and men to see that you can live a life, a fruitful and loving life, with metastatic breast cancer,” said project participant Sheila McGlown. “I think #ThisIsMBC Serenity Project brought out the boldness in me. It allowed me to express myself and my life experiences in a way I never thought I would be able to and it made me proud – proud of being a voice for young women, proud of being a voice for African-American women, proud of being a voice for veterans and proud of being a voice for the breast cancer community.”

From July 2017 to October 2018, one patient a month will be showcased, through images and video from the photoshoot, on MBCinfocenter.com and METAvivor’s Facebook, Twitter and Instagram accounts (@metavivor). The images will also be featured at an art gallery reception in New York City and made into a calendar. These calendars are available for free with a donation to METAvivor, which can be made at www.metavivor.org/store/. Donations will go to METAvivor to support research specifically for metastatic breast cancer.

A fundamental component of #ThisIsMBC Serenity Project is the belief that women and men with MBC should live their lives as fully as possible and take advantage of all resources available to them. Many educational resources and helpful information about metastatic breast cancer exists at MBCinfocenter.com. To support METAvivor’s ongoing commitment to funding MBC research, which could help those living with this disease, consider making a contribution at https://secure.metavivor.org/page/contribute/thisismbc.

By: Tracy A Lowery MD
Venous Insufficiency (poorly functioning veins) and varicose veins of the lower extremities are some of the most common medical conditions experienced by people in this country. Over 40 million Americans have some degree of venous problems making it the most common chronic medical condition in North America.

Each of us has many veins in our legs, with these veins varying in size and location. Regardless of size and location, each of these veins provides the same function. Blood that is pumped to the legs is collected by these veins and returned to the heart. If the veins are not functioning correctly the legs may develop symptoms or become varicose. Varicose veins can be seen as dilated twisted blood vessels just below the skin surface that appear bluish and may bulge when sitting or standing. Spider veins are red or blue veins on top of the skin surface.

For many years physicians have considered most problems with abnormal veins to be cosmetic and not symptomatic. We now know that poorly functioning veins not only affect the appearance of the legs, but also have a tremendous affect on how the legs feel.

Symptoms of varicose veins and venous insufficiency include pain, aching, heaviness, fatigue, swelling, and restlessness at night. These symptoms may be present with or without any veins being visible to the naked eye. These symptoms may involve one or both legs.

Anyone can develop vein problems, but the risk is increased if there is a family history of vein problems. The risk is also increased as we age, as over half of us over the age of 50, will have some degree of vein problems. Often patients will overlook subtle symptoms thinking that as they age their legs are supposed to be tired and swollen. Women have a higher incidence of vein problems than men, most likely secondary to pregnancy. Other conditions, that may increase one’s risk of developing vein problems, are obesity, sedentary life style, standing for long periods of time on hard surfaces, and jobs that require prolonged sitting or standing.

The evaluation of vein function can be determined in a few minutes by a painless, outpatient ultrasound performed in a specialty vein center. If vein function is abnormal, treatment options include both conservative treatment and more aggressive intervention.

Conservative treatment of venous insufficiency and varicose veins include increased walking, elevation of the legs, and the wearing of graded compression stockings. Stockings can be below-the-knee, thigh-high or panty hose. Stockings do a good job of minimizing leg swelling which tends to improve symptoms of varicose veins.

If conservative therapy does not noticeably improve a patient’s symptoms, then more definitive treatment is available. This treatment of abnormal veins is performed in an outpatient setting; requires no sedation, only local anesthesia; and is covered by most insurance carriers. This treatment, radiofrequency ablation, is used to not only improve the appearance of the legs but also improve the symptoms of venous insufficiency.

If you have veins visible on your legs or symptoms similar to those described above, please call Crestwood Vein Center at 256-429-5346 to schedule your evaluation.
By: Tracy A. Lowery MD
Board Certified Vascular Surgeon
Varicose Vein Specialist
Crestwood Vein Center
185 Whitesport Drive
Suite 2
Huntsville, Alabama 35801

By: Dr Shanna Ndong
Insomnia, or difficulty initiating or maintaining sleep, is a common complaint and approximately 1 in 3 American adults experience it over the course of a year. Sleeping less than seven hours per day is associated with an increased risk of developing chronic conditions such as obesity, high blood pressure, diabetes, heart disease, stroke, and mental disorders. The southeastern United States reports the least amount of sleep of any region and not surprisingly, it also has the highest prevalence of obesity and associated medical conditions.

Many people turn to sleep aids, both over-the-counter and prescription, to help with their sleeping issues. A 2015 Consumer Reports survey found that one-third of U.S. adults had tried a sleep drug in the past year. Prescription sedatives are the most popular treatment for insomnia in the U.S. Although they are meant for temporary use in most people, they are often taken indefinitely. Long-term use of sedatives such as Ambien, Lunesta, and Restoril have been shown to decrease the ability to think clearly, worsen memory, and increase risk of falls. There is also a significant risk of developing drug dependence and a high abuse potential.

Melatonin is a hormone produced in the brain in response to darkness. It helps to regulate the body’s sleep and wake cycle (i.e. circadian rhythm). Melatonin levels decrease with age and may contribute to the increase in sleep issues in elderly populations. Studies suggest that melatonin supplements may help people with disrupted circadian rhythms (such as people with jet lag or those who work the night shift), and those with low melatonin levels (such as the elderly) to sleep better.

Melatonin has been touted as a natural sleep aid and in the U.S., unlike many other Western countries, it’s production and sale is completely unregulated. As a result, over-the-counter doses of melatonin range from 0.3 mg to as high as 20 mg. The dose that most closely resembles what the human body makes is 0.3 mg (300 micrograms). When melatonin receptors in the brain are exposed to too much of the hormone, they become unresponsive. This happens with high initial doses of hormone and may happen after several weeks of melatonin usage leading to loss of effect. As a result, melatonin should be used for short periods of time (a few weeks). A 2001 MIT study comparing treatment of insomnia in patients over age 50 with 0.3 mg, 1 mg, and 3 mg doses found that while all three doses improved sleep, the 1 mg and 3 mg doses were associated with side effects including low body temperature and the levels of melatonin in the blood remained elevated into the daylight hours.

An important first step for anyone with insomnia is improving ‘sleep hygiene’ which means that bedtime and awakening should be consistent everyday, including weekends. Quit smoking and avoid caffeine and alcohol in the evening. Avoid taking naps and decrease the amount of time spent lying in bed. This will increase the likelihood that sleep will be achieved at the appropriate time. Do not watch TV, read, write, eat, or lie awake for an extended period in bed. Keep the sleeping environment quiet and dark; there should be no TV, radio, or lights on while sleeping. Develop a relaxing routine before getting ready to sleep such as taking a warm shower, reading (in another room), or meditating.

The most effective treatment for insomnia after sleep hygiene is cognitive behavioral therapy (CBT), which involves talking to a therapist to learn a new set of behaviors regarding sleep. CBT is as effective as sleeping pills and has been shown to help up to 80 percent of chronic insomnia sufferers. The positive effects of CBT can be long lasting. CBT is offered through licensed counselors and other mental health professionals.

Here are some important tips to remember prior to beginning melatonin: 1) Due to the potential for side effects and interactions with medications, talk to a health care provider first. 2) If melatonin is used for insomnia, generally the dose should be within the 0.3 mg to 1 mg range. 3) The dose should be taken 90 minutes before bedtime, if possible. Melatonin can cause drowsiness if taken during the day. 4) If drowsiness occurs the morning after taking melatonin, try taking a lower dose. 5) Pregnant or nursing women should not take melatonin because it can interfere with fertility and pregnancy. 6) Melatonin use should be avoided in children.
By: Dr. Shanna Ndong

By Shanna Ndong
In part one of this series on epigenetics (“Fundamentals”) we reviewed some general definitions and concepts and gave an overview of the topic. Epigenetics is the study of inherited changes in gene expression that, unlike mutations, are not caused by changes in the sequence of DNA. These are mechanisms that help to turn genes off and on, and include DNA methylation and acetylation, respectively.

Cancer is caused by an imbalance in the mechanisms that control cell reproduction. Loss of reproductive control in cancer cells can occur due to random gene mutations, exposure to high-risk environmental and lifestyle factors (e.g. poor diet, smoking, alcohol, obesity), or rare inherited cancer syndromes (e.g. BRCA mutations and increased risk for breast/ovarian cancers).

The loss of control of cell proliferation can be due to genetic mutations and epigenetic abnormalities. Epigenetic changes are potentially reversible and are targets for the development of future nutritional, drug, or dietary interventions to treat or prevent genetic conditions including cancer.

Nutrition can potentially affect epigenetic processes at multiple points in DNA methylation. Nutrients are the main source of methyl groups or act as coenzymes for methyl transfer and DNA synthesis. A number of phytochemicals found in plant foods and in dietary supplements alter epigenetic processes by interfering with the activities of methylation enzymes. I will review some of the foods that have been shown to have cancer preventative and therapeutic properties with epigenetic targets below.

Folate

Folate is one of the B vitamins and is obtained solely from food (green vegetables, beans, grains, and pasta). Folate regulates the biosynthesis, repair and methylation of DNA, whereas deficiencies in folate can initiate cancer due to disruptions of these processes. Low folate intake is reported to contribute to the development of several different cancers, including breast, cervix, ovary, brain, lung and colon.

Green Tea (EGCG)

EGCG, the major polyphenol in green tea, has been extensively studied as a potential demethylating agent. In cell culture and animal models of lung, colon, bladder, liver, prostate, breast and skin cancers, the most commonly observed anti-cancer mechanisms of EGCG include inhibition of proliferation and induction of programmed cell death.

Soybeans (Genistein)

Genistein is one of the many phytoestrogens contained in soybeans and is a demethylating agent. Several epidemiologic studies showed a relationship between a soy-rich diet and cancer prevention. These studies arose from observations that in Asian countries, such as Japan and China, where diets are high in soy products, the incidence of breast and prostate cancers is relatively lower. Furthermore, migration studies showed an increase in prostate and breast cancer incidence in Asians after immigration to the United States, suggesting that environmental factors and changes in lifestyle, particularly in dietary practices, affect these types of cancer.

Berries (Resveratrol)

Resveratrol is a polyphenol found in grapes, peanuts, and berries. It is concentrated in the skin of grapes, so the process of crushing and mashing grapes for winemaking results in high levels of resveratrol in wine. It has anti-cancer, anti-inflammatory, blood-sugar-lowering and other beneficial cardiovascular effects. It has been found to have anti-cancer activity against colon cancer in human clinical trials. Several studies using animal models for non-melanoma skin cancer, breast cancer, prostate cancer, liver cancer, pancreatic cancer, lung cancer, and stomach cancer all showed anti-tumor effects.

Cruciferous vegetables

Members of the Brassicaceae family include broccoli, cauliflower, brussels sprouts, kale, and cabbage. They have anti-inflammatory properties and contain chemicals that stop cancer cell growth and stimulate programmed cell death. High rates of cruciferous vegetable consumption have been associated with lower risk for bladder cancer. Laboratory studies on human prostate, colon, and breast cancer cells have all shown positive anti-cancer effects of cruciferous vegetables and their metabolites.

Additional foods that have been shown to prevent cancer through epigenetic mechanisms are human breast milk, extra-virgin olive oil, garlic, selenium, curcumin (turmeric), and caffeic acid (thyme, sage).

It’s important to keep in mind that much of this research is in its infancy and many of these studies have been performed in the laboratory or on animals. In general, most of the foods listed are healthful and would be a great addition to your diet, but I suggest that you speak to your doctor before beginning any supplements as they may interact with medications you are already taking. Stay tuned for part three of this series called “Behavioral Epigenetics” where I review evidence that experiences can cause epigenetic changes, and psychological and behavioral tendencies are inherited.
By: Dr. Shanna Ndong

By: Dr. Caroline Leaf
We all have to eat to live, as redundant as that statement may sound. Yet the act of eating is not just a biological function of survival. The consumption of food, as normal as it is, is in fact a highly emotional and metacognitive event. Indeed, this should come as no surprise to us: throughout human history, gathering around a table and eating food has been a way for us to celebrate or commemorate notable seasons, individuals and events. Meals are a focal point for social gatherings, and sharing food is a powerful medium of communication both in-between cultures and among different peoples. I certainly believe that the joy of preparing a meal and sharing it with people is incredibly powerful, and incredibly therapeutic. As my daughter likes to say, one seasoning every cook should use is the pleasure of a hearty gathering, which should be sprinkled generously on every plate. Who needs a handful of digestive supplements when you have good, real food and good, real company?

Yet, like all things, meals can have either positive or negative emotional “seasonings,” both of which affect the way our body digests food. Our gastrointestinal tract (GI tract) is very sensitive to our emotions, since it is connected to the brain’s hypothalamus, which controls both the feelings of satiety and hunger, and deals with our emotional state of mind. The mind and the gut are acutely interconnected, and thus happiness, joy, and pleasure, as well as anger, anxiety, sadness, and bitterness, for example, trigger a physical reaction in you digestive system. The large and small intestines are densely lined with neurons, neuropeptides and receptors (the “doorways” into cells), which are all rapidly exchanging information laden with emotional content. Indeed, we have all experienced this gurgling emotional activity in our guts, colloquially known as a being “sick to your stomach,” a “gut-feeling” or having “butterflies in your stomach.”

Unless we are aware of what our digestive system is telling us, we may fall into the trap of overeating. The pancreas releases at least 20 different emotionally-laden peptides, which regulate the assimilation and storage of nutrients, and carry information about satiety and hunger. Do not ignore the information these peptides provide. Just as eating when you are angry or trying to bury another unpleasant emotion will affect the way that the nutrients in your food are assimilated, eating when you are not hungry will upset your digestive system. Overeating will make the food you eat or drink less beneficial, since the emotions generated by toxic thinking interfere with the proper workings of your body. Eating when you are in a distressed emotional state, or not hungry, is essentially like adding every spice and herb in your cupboard to your meal. All these seasonings will destroy the balance of flavors among the meal’s components. Emotionally-driven food consumption literally adds a flood of chemical, emotional “seasonings” to your food: your digestive system, like your palate, will not know how to interpret such a conflicting range of signals.

When we react incorrectly to the events and circumstances of life, we actually move into toxic stress, or stages two and three of stress. Toxic stress keeps your “fight or flight” response activated, which inhibits gastrointestinal secretion and reduces blood flow to the gut, thereby decreasing metabolism and affecting your body’s ability to digest food. In fact, toxic thinking and emotions, which lead to toxic stress, can affect the movement and contractions of the GI tract, cause inflammation, make you more susceptible to infection, decrease nutrient absorption and enzymatic output, upset the regenerative capacity of gastrointestinal mucosa and mucosal blood flow, irritate intestinal microflora, cause your esophagus to go into spasms, give you indigestion and heartburn by increasing the acid in your stomach, make you feel nauseous, cause existing digestive issues such as stomach ulcers to worsen, and agitate your colon in a way that gives you diarrhea, constipation and/or extreme bloating. To say that you should not eat food when you are stressed, unhappy, angry or any other negative emotion is most certainly an understatement.

A HEALTHY GUT IS A HAPPY MIND

Yet thinking good thoughts cannot excuse an unhealthy diet. The digestive system itself is a rich source of neurotransmitters, which carry signals inside the brain and body. In fact, 95% of the serotonin and half the dopamine in the body are produced in the gut. Considering these neurotransmitters are famous for their mood-calming and reward effects respectively, we should be paying a lot more attention to what we are putting in our gut—what you eat affects the way these neurotransmitters function. Indeed, beneficial symbiotic gut bacteria produce benzodiazepine-like substances, which are naturally occurring anti-anxiety neurochemicals. A healthy gut promotes a calm, satisfied and happy mind.

For more on the history and research of the gut-brain connection, get the book, “Think and Eat Yourself Smart,” or the “63-days to Think and Eat Yourself Smart” online program.
By: Dr. Caroline Leaf

By: Dr. Shanna Ndong
The analogy I often use for genetics is that DNA is the cookbook for the human body, residing inside the nucleus of every cell. RNA transcribes the genes (recipes) to make whatever proteins the cell needs. The human genome contains approximately 20,000 genes. DNA is made up of billions of repeating nucleotide molecules and is organized and condensed with proteins into chromosomes in the nucleus in preparation for cell division.

This article is the first in a three-part series that explores the exciting and rapidly evolving field of epigenetics. Epigenetics is the study of inherited processes that can alter gene expression. In the 1970s, it was discovered that mechanisms other than the DNA sequence itself are important in determining the expression of genetic traits and can be passed to offspring. DNA methylation and acetylation are two such mechanisms. Methyl groups can become permanently attached to cytosine, one of the chemical bases in DNA, and can replicate with it through generations. The attachment of methyl groups significantly alters the gene it binds, inhibiting its transcription. Other molecules, called acetyl groups, were found to play the opposite role, unwinding DNA and making it easier for RNA to transcribe a given gene.

An important concept to mention when discussing epigenetics is genomic imprinting. We inherit two working copies of most genes, (one from each parent) but with imprinted genes, we utilize only one working copy. Depending on the gene, either the copy from mom or the copy from dad is epigenetically silenced through the addition of methyl groups during egg or sperm formation. Uniparental disomy (UPD) occurs when a person receives two copies of a chromosome, or part of a chromosome, from one parent and no copies from the other parent. UPD can occur as a random event during the formation of egg or sperm cells or may happen in early fetal development.

In many cases, UPD has no effect on health or development because most genes are not imprinted. However, one of several genetic disorders can result from UPD if imprinted genes are involved. The most well-known conditions include Prader-Willi syndrome, which is characterized by uncontrolled eating and obesity, and Angelman syndrome, which causes intellectual disability and impaired speech. Both of these disorders can be caused by UPD or other errors in imprinting involving genes on the long arm of chromosome 15.

A number of important conditions may result from external or environmental factors.

It is now well accepted that conditions in the womb can determine later risk for a number of diseases through epigenetic mechanisms, including obesity, diabetes, allergies, asthma, and heart disease. The mother’s nutrition, including vitamin levels (particularly folate, B vitamins, and choline) and blood glucose, as well as mental health and substance abuse history, have all been shown to influence the methylation patterns of key genes in her offspring.

Since DNA methylation is a common mechanism for inactivation of genes, diets high in methyl-donating nutrients may help to alter gene expression, particularly during early development. A mother’s diet during pregnancy (and conception) and an infant’s diet can affect the epigenome (and health) in long-lasting ways. Diets that are rich in folate and choline are essential during these periods. In adulthood, too little of these nutrients can result in hypermethylation, but it is typically reversible with changes in diet.

A number of dietary supplements are of particular interest in the field of epigenetics. Many of these compounds display anticancer properties and may play a role in cancer prevention. I will discuss this topic further in the next article in this series (The Epigenetic Diet and Cancer).

Heavy metals are widespread environmental contaminants and have been associated with a number of diseases, such as cancer, cardiovascular diseases, neurological disorders and autoimmune diseases. Several studies have established an association between DNA methylation and environmental metals, including arsenic, nickel, and cadmium. Various other environmental pollutants that have been linked to disease through epigenetic mechanisms include pesticides (testes and ovarian dysfunction), air pollution (heart and lung disease), and bisphenol A, BPA: hormone disruptor (increased cancer risk).

There is strong evidence that experiences can cause epigenetic changes and that psychological and behavioral tendencies are inherited. A parent’s or grandparent’s exposure to emotional trauma may not only impact their mental health, but animal studies have shown changes in methylation patterns in the brains of their children and grandchildren. This field of research is called behavioral epigenetics, and it will be the subject of the third article in this series.
By: Dr. Shanna Ndong

In the United States, there are 4 different types of midwives with a varied range of training, scope of practice, and experience. Of those, 3 hold national certifications and credentials. The history of the word midwife is derived from two Middle English elements: mid meaning with, and wife meaning woman. Therefore, it simply means being “with woman,” specifically during childbearing.

Traditional/Lay Midwives (TMs)
According to the Midwives Alliance of North America (MANA), TMs are those who for various reasons choose not to hold certifications and/or licenses. They may or may not have training (formal or informal) in the art and science of midwifery. Many believe that they are responsible to their communities, midwifery is a contract between a woman and her midwife, the practice of midwifery should not be legislated at all, or women have the right to choose their care provider irrespective of legal status. They practice solely in out-of-hospital settings.

Midwives have been the traditional attendants of birth dating all the way back to Biblical days in Exodus. In colonial America, many were charged as witches and executed in the Salem Witch Trials. In the South during the 19th and 20th centuries, TMs were referred to as “Granny midwives.” Most were of African Americans or Appalachian descent. The title was given them by the government and was derogatory, suggesting ignorance. However, some referred to themselves in this way to redeem the offensive term, making it one of honor as a “granny” is someone whose age and wisdom are to be revered. They were regarded as elder healers, not just midwives. They had a certain spiritual authority, and considered midwifery a deep calling, just as many of today’s midwives do.

As doctors specializing in obstetrics and gynecology gained popularity in the20th century, the campaign against midwives (especially the African American/granny midwives of the South) began to impose various restrictions on TMs’ practice through legislation. In the South, Jim Crow laws further outlawed midwifery.

Women like Onnie Lee Logan and Margaret Charles Smith from Alabama have long since died, taking many of the secrets of traditional midwifery with them. I recently read a letter of one midwife who is returning to the roots of traditional midwifery. Though it is not the path I or many others would choose, her story brought tears to my eyes while deepening my commitment to become a midwife and promote the instinctive nature of birth again. There are some traditional midwives left, however they are becoming fewer and further between.

Certified Professional Midwives (CPMs)
According to MANA, this a type of direct entry midwife (one who does not have prior education as a nurse) trained in out-of-hospital settings. CPMs are credentialed by the North American Registry of Midwives (NARM) and trained in the midwifery model of care, practicing in freestanding birth centers and homes. One desiring to pursue this path obtains an experienced CPM as a mentor/preceptor with whom they will work side-by-side to learn the skills necessary for practice. Some who obtain this credential have degrees from schools accredited by the Midwifery Education Accreditation Council (MEAC) while others do not and have been trained via self-study of the same books and materials as Certified Midwives (CMs) and Certified Nurse Midwives (CNMs).

These midwives complete an extensive apprenticeship (even if they attend a MEAC accredited school) similar to what other healthcare professionals call clinical internships. Apprenticeships generally last 3-5 years, sometimes longer. When the necessary requirements are complete and both student and preceptor have agreed that she is ready, the application is submitted to NARM. Upon review, the certification exam is scheduled, along with a skills validation. If both are passed, the CPM credential is awarded.

As of 2017, Alabama joined a growing number of states who license and regulate the practice of CPMs. Prior to this, CPMs could be prosecuted and convicted of a class C misdemeanor, incurring fees and jail time. Women wanting the option of home birth were (and are) forced to drive out of state for this type of midwifery care. Though the law has been passed, it will take time to set up a state midwifery board and begin issuing licenses.

Certified Midwives (CMs)
This is another type of direct entry midwife who has a bachelor’s degree in a health-related field who attends graduate school, obtaining a master’s degree. The training is similar to that of a CNM. Practice standards are also similar but without the nursing component. They can practice in any setting (hospital, freestanding birth center, or home). These types of midwives are still relatively rare and not utilized in many states.

Certified Nurse Midwives (CNMs)
Certified Nurse Midwives are midwives trained in the disciplines of both nursing and midwifery. They hold a bachelor’s degree in nursing and a master’s degree in midwifery. They are mostly trained in hospitals, and most CNMs practice there; however, their scope of practice allows for practice in any setting. They care for women across the lifespan, from puberty to menopause and beyond. They are classified as primary care providers, specifically in the realm of women’s health. Many hold a dual certification as a Women’s Health Nurse Practitioner (WHNP). WHNPs function essentially the same as CNMs, but are not trained in labor, birth, or newborn care. CNMs are legal to practice in all 50 US states, as well as many other countries due to the vast scope of their training.

In spite of the recent passage of the CPM law, CNMs in Alabama are not currently able to practice in out-of-hospital settings due to the Alabama laws governing advanced practice nurses. Very few in the state are able to practice to the full scope of their training, even in the hospital. It is my hope as a CNM student that this too will soon change.
By: Rachel Clark, RN, BSN

No group of medications is more controversial in my practice than the ‘statins.’ The statins or hydroxymethylglutaryl (HMG) CoA reductase inhibitors are a group of medications that are used to treat elevated cholesterol levels and lower risk of heart attack and stroke. They include medications like Crestor (rosuvastatin), Lipitor (atorvastatin), Zocor (simvastatin), and Pravachol (pravastatin) to name a few. They act to block the last step in cholesterol production in the liver and lower LDL by 30-60%.

Statins and the Liver
When statins were introduced in the 1990s, regular lab monitoring was recommended to screen for elevations in liver enzymes. The FDA changed the safety labeling after it became apparent that significant elevations in liver enzymes in patients taking statins are relatively rare (0.1%). Routine monitoring of liver function is no longer needed.

Statins and Muscle Pain & Injury

Statins can cause varying degrees of muscle pain and injury that occurs in approximately 4-8% of users. Symptoms can range from myalgia, which is characterized by mild muscle aches and soreness with normal muscle enzymes, to the severe condition known as rhabdomyolysis, which is a combination of kidney failure, very elevated muscle enzymes, and proteins in the urine.

Muscle injury is more likely to occur on higher doses of statin, with concurrent use of other cholesterol medications like Niaspan (niacin) or Zetia (ezetimibe), and in patients with conditions like ALS, hypothyroidism, or renal failure. The onset of muscle symptoms is usually within weeks to months of starting the statin, but may occur at any time. If muscle pain is experienced while taking a statin, an assessment for elevations in muscle enzymes, hypothyroidism, drug interactions, or low vitamin D can be performed. A decrease in dosage or a switch in the statin may be made if muscle enzyme levels are normal.

Statins and Vitamin D
Research is ongoing, but patients taking statins tend to have higher vitamin D levels. However, patients with low vitamin D are more likely to experience statin-related muscle pain. Thus, a vitamin D level should be measured prior to initiating a statin.

Statins and Coenzyme Q10
Coenzyme Q10 (CoQ10, ubiquinone) is an antioxidant that helps to make energy in the muscle cell. Research has been inconsistent on the matter, but some studies have found that statins decrease CoQ10 levels in the muscle and blood. It has been speculated that a reduction in CoQ10 levels in muscle may contribute to statin-induced muscle injury.

Some researchers have suggested that supplementation with ubiquinone or ubiquinol (a more expensive form) can reduce the risk of muscle aches. A meta-analysis of randomized trials concluded that existing trials do not suggest a benefit of CoQ10 for statin myopathy, but larger trials are needed to confirm this lack of benefit.

Statins and Diabetes
Statins have been associated with an increased risk of diabetes that is most significant with high-potency statins like Lipitor and Crestor. A 2016 analysis estimated that high-dose therapy would lead to 50 to 100 new cases of diabetes in 10,000 treated individuals. However, statins have been shown to reduce heart attacks and strokes in known diabetics. Both randomized trials and observational studies suggest that the benefits of statins on reduction of cardiovascular events outweigh the risk of development of diabetes in many.

Statins and Memory Loss

The FDA released a warning in 2012 after it compiled several reports it received through its Adverse Event Reporting System (AERS) of memory loss associated with statin use. Systematic reviews of randomized trials since that time have failed to find an association between statin use and memory loss; however, randomized trials may not detect rare medication side effects. In contrast to the reports above, several studies have even shown a reduced risk of dementia with statin use.

Statins and Cancer Risk

There is no evidence that statins increase or decrease risk for cancer.

Summary

In summary, the statins have had their fair share of controversies, but every medical intervention has risks and benefits. People who benefit most from statin use are patients who already have cardiovascular disease. This includes individuals who have had a heart attack, coronary artery stenting or bypass, angina, or stroke. I want to emphasize that treatment with statins is not about number goals. The ultimate goal of statin treatment is reduction in risk for cardiovascular events like heart attack or stroke, and prevention of death. I believe that the statins can greatly benefit certain high-risk patients and are invaluable drugs for anyone with cardiovascular disease.
By: Shanna Ndong

Several weeks ago, I saw a Facebook post about how secrets can be dangerous things. Webster’s Dictionary defines a secret as something we keep hidden from the knowledge of others. Teaching children about secrets is an important part of keeping them safe from the long-term effects that can be caused by abuse.

According to a sexual abuse prevention workshop called “Parenting Safe Children,” secrecy is a key element to childhood sexual abuse. A Denver mom wrote a blog post about her experience with teaching her son an alternative to secret keeping. In her home, she teaches her children about surprises instead. She recounts the story of a friend who gave her son a cookie and said “shhh…it’s a secret.” To the mom’s utter delight, the son told the woman that in his home, they don’t do “secrets,” but instead they do “surprises.”

The mom explains “Surprises are something we keep quiet about temporarily; then you share the surprise and people are happy. But secrets are meant to be kept quiet forever and they are often protecting something that would make people unhappy.” Surprises are things like a birthday party or a gift. Secrets like sexual abuse leave long-lasting scars on everyone involved.

Often times, sexual predators will test children by asking them to keep smaller secrets (like cookies or other treats), building up to bigger and bigger secrets about what is happening to them. By teaching her children different terminology, she is bypassing this common method of trapping children in the abuse cycle. This little boy was bold enough to say that he doesn’t keep secrets. He is no longer a vulnerable target because of the wisdom of his mother in teaching him about body safety.
It is vital to start early teaching children about their bodies and which parts are ok to touch and which parts aren’t. If these important lessons are instilled in them early on, they are less likely to experience abuse, and the devastating effects it can lead to in the future such as anxiety, depression, and suicidal ideation/attempts.

Body Safety Rules include the following (adapted from Parenting Safe Children Workshop developed by Sandy Wertele, Ph.D. and Feather Berkower, MSW):

1.No one is allowed to touch your private parts
2.You should not touch someone else’s private parts
3.No one is allowed to take pictures of your private parts
4.If someone tries to touch your private parts, say “NO!”
5.When playing friends, play with your clothes on
6.You are allowed to have privacy when bathing, dressing and using the toilet
7.You have permission to say “No” and get away if someone tries to touch your private parts or breaks any of your body safety rules
8.We don’t keep secrets in our family. If someone tells you to keep a secret, tell an adult.

Also, educate children that doctors and nurses sometimes have to examine these private parts of their bodies and that is ok, because Mommy or Daddy is with them. Begin to teach your children these rules now to eliminate them as targets later. If you don’t yet have children, adopt the practice now of not keeping “secrets” so that it will be easier to instill in them these principles when you do.
By: Rachel Clark, RN, BSN

Few of us are aware of the connection between nutrition and depression, despite the fact that we understand to some extent the relationship between nutritional deficiencies and physical illnesses. Depression is still thought by many to be a biochemical or emotional based issue, however nutrition can determine the extent and duration of depressive symptoms.

Neuroscience research conducted by clinicians like Dr. Caroline Leaf and others suggests that nutritional factors are very much intertwined with emotions, cognition, and behaviors. Some of the most common mental health issues include obsessive compulsive disorder, depression, schizophrenia, bipolar disorder, anxiety disorders, and ADD/ADHD.

Numerous studies show that the dietary intake pattern of most American and Asian populations as opposed to Mediterranean countries are often deficient in nutrients such as essential vitamins, minerals, and omega-3 fatty acids. Also, evidence now suggests that the pathology of Major Depressive Disorder (MDD) may be rooted either primarily or secondarily to oxidative stress in the body (A. Sarandol, ET AL.).

Our brains are more sensitive to oxidative stress and free radicals than other tissues. The brain is only about 2% of the weight of the human body, yet it uses approximately 20% of its energy. MDD is also distinguished by the activation of an inflammatory response system, thus increasing free radical production.

What is interesting is that inflammation shows up in different people as different symptoms. Some people may exhibit cardiovascular disease, others diabetes, or an autoimmune disorder. Still yet others manifest depression, anxiety and mental illness. It is no surprise that these things are often listed as comorbidities (the presence of two or more chronic diseases) since they have the same root: inflammation. What was interesting in the study relating MDD to oxidative stress was the conclusion: the drug combination used had no effect on measurable oxidative stress markers in the body at the end of 6 weeks.

So what is the solution? Many people think vitamins will help their nutrient deficiencies, but according to a study done at John Hopkins University, vitamins are at best a waste of money, providing no clear benefit. At worst, they can do more harm than good, with high concentrations of isolated and fractionated vitamins E and A, as well as beta carotene, could increase the risk of death in certain individuals. Therefore, use vitamin supplements judiciously, or avoid them altogether.

This still leaves the question as to how to nourish our bodies, and therefore our brains. The solution is a diet that is high in the various micronutrients we need to keep our bodies functioning such as vitamin C, vitamin E, vitamin B6, vitamin B12, folate (or vitamin B9), zinc, and omega-3 fatty acids (EPH/DHA). The Mediterranean Dietary Pattern (MDP) which is high in fruits, vegetables, olive oil, and oily fish is now thought to reduce inflammation due to its richness in antioxidants that come from these whole foods.

“Optimizing our nutrition is a safe and viable way to help avoid, treat, or lessen the symptoms of mental illness. Poor nutrition is a significant and modifiable risk factor for the development of mental illness,” said Julia Rucklidge, a PhD professor of clinical psychology in Christchurch, New Zealand, who has studied the treatment of ADD/ADHD and other mental health issues with micronutrients for the last 10 years.

We rely on medications, but honestly we need to stop visiting the “pharmacy” and start visiting the “farm” to decrease the prevalence of mental illness. I am not dismissing the effectiveness of medications on some severe forms of mental illness, nor advocating that you should stop treatments prescribed by your healthcare practitioner without first consulting them. They can be very effective for some people in the short term, but on a long term basis have lasting effects on our bodies. Despite our reliance on these drugs, our outcomes are no better than they were 50 years ago.

The research is clear: the well nourished brain is better able to withstand stress and recover from illness. Sixty to eighty percent of people will respond to better nutrition. Let’s get serious about the role nutrition plays not only in our physical health, but also our mental health.
By: Rachel Clark, RN, BSN