Holistic Health Advisor

Exercise: The Miracle Gro of Our Neurological Landscape

2009-04-01T10:38:00.000-07:00

How Does Exercise Improve Brain Function?

We all know that exercise is good for us. We know that it tones, builds muscle, increases strength and stamina. For many of us though, exercise is the medicine one swallows while holding our noses. Its drudgery, monotonous and we often don’t see the results we envision or expect. If physical attributes weren’t enough to get you to exercise routinely, if your desired results aren’t being realized, here’s some exciting information that just might inspire you to commit to exercising and it has nothing to do with transforming yourself into Adonis.

Allen Bowling, MD, PhD has been researching the relationship between exercise and neurological function. More and more research is now showing that it plays an important if not essential role in treating neurological conditions. We can grasp how exercise helps strengthen muscle which protects our bones, improving fatigue seems reasonable; intuitively these make sense, but what about depression and neurological conditions? How can exercise directly and positively affect the brain? Until recently I thought it was simply mind over matter. You get yourself up and get going and by doing so you get your mind going in a more positive thinking pattern. Although this cognitive approach to exercise is helpful there is a lot more going on here than we ever imagined. In fact, Dr. Bowling says that if exercise were a medication it would be the number one prescription he would write.

If you’re anything like me, you are not satisfied with what you should do. You ask why and soon to follow is how does it work? The following information is based on ground-breaking research and should be taken seriously by everyone, not just those with neurological conditions. You will see that it is beneficial for overall neurological health.

The Proof is in the Pudding or in This Case the Brain.

There are important proteins found in the brain and the spinal cord known as Nerve Growth Factors (NGF). There are multiple NGF’s that have been identified over the years. NGF was the first. Another commonly studied NGF is Brain Derived Neurotrophic Factor (BDNF). NGF’s do exactly as their name implies, they stimulate nerve cells to grow. They’re the Miracle Gro of the neurological landscape. They have the following characteristics:

1) Nerve-regenerating Effects: BDNF significantly change the structure and function of the nervous system

2) Nerve Protecting Effects: Protect nerve cells from various types of injury

3) Anti-inflammatory Effect: Affect immune system in such a way that they decrease inflammation

Hardwired vs Plasticity

Hardwired, inflexible and undeviating view of brain function is outdated dogma. Our brain is capable of adapting quite well and efficiently. It was once believed to have specific areas which performed specific functions and although this is true, it is not written in stone as it was once thought. This process of adaptation is called plasticity.

MRI’s of some cadaver’s brains have been found to contain multiple plaques. Based on the location of these plaques one would expect that the individual in question would have had symptoms during their lifetime and in fact in many cases there is no correlation with MRI results post-mortem and clinical symptoms when the person was alive. We now know that it is possible for the brain to regain previously lost function through the process of plasticity. It is able to duplicate that lost ability, at times on the opposite side of the brain.

Exercise stimulates the production of various growth factors; it causes brain levels of growth factors to increase. Not only does it improve physical function, these studies show that it also improves non-physical function such as sensation or thinking processes. Thirty minutes of exercise was shown to increase the blood levels of BDNF.

I find when I understand the evidence; I can more easily commit myself to a challenge. I no longer walk aimlessly hoping for positive change but rather with a purpose and clear goal and expectation. Beyond faith, I now have the vision of a truly powerful healing experience. Every step I take I add a bit more miracle gro.

Dangerous Plastics (Bisphenol A): Endocrine Disrupters

2008-06-04T08:31:00.000-07:00

".............bisphenol A, a compound detected in the urine of 93% of Americans recently tested. An overwhelming majority of these studies show that the chemical is harmful----causing breast cancer, testicular cancer, diabetes, hyperactivity, obesity, low sperm counts, miscarriage and a host of other reproductive failures in laboratory animals."

Susanne Rust at the Milwaukee Journal Sentinel ( http://www.jsonline.com/ ) and staff researched 258 scientific studies from around the world concerning the safety of bisphenol A. It is used to make polycarbonate, the plastic most commonly used to make baby bottles and much more. It is ubiquitous in our environment and a serious threat to our health. The government of Canada has already banned the substance completely. This article is thorough and comprehensive. I would highly recommend that you read it if your looking for more information on what this is and where it is found.

In addition, I am including a link below to a handout that clearly lists harmful plastics and the various ways you can identify them. In the meantime a good rule of thumb would be to avoid plastic containers, NEVER heat food in plastic of any kind, including plastic wraps and be especially vigilant with your infants and young children. Some scientists are comparing this to the lead and asbestos crisis of this generation!

http://www.healthobservatory.org/library.cfm?refid=77083

Credentials

2008-05-30T08:36:00.000-07:00

EDUCATION

Bachelor of Science in PharmacyCollege of Pharmacy
University of Rhode Island
September 1984-May 1989

Masters of Education in CounselingProvidence College
Providence, RI
1998-2002

Psychodynamic/Pastoral Psychotherapy Residency
Interfaith Counseling Center
Providence, RI
January-September 2002

Reiki Master TrainingRichard Curtin, PhD
Cambridge, Massachusetts
April and May 2003
EXPERIENCE

Staff Pharmacist
Dartmouth Hitchcock Medical Center
Lebanon, NH
Drug information consultant for physicians and other healthcare professionals.
Poison center consultant for emergency room physicians and the general public.
Pharmacokinetic analysis of drug levels, drug and dose recommendations.
Evaluation and review of adverse drug reaction reports submitted by physicians, nurses, pharmacists and the clinical review services department.
Interfaith Counseling Residency: Included Psychodynamic, Family Theory with a spiritual integration. Background in Cognitive-Behavior, Person-Centered, and Gestalt Therapy at Providence College and Salve Regina University.

Pharmacist for CVS pharmacy

Reiki training at Center for Change in Cambridge, Massachussetts

PROFESSIONAL ASSOCIATIONS AND LICENSES

Certified Reiki Master

Registered Pharmacist

American Counseling Association

American Holistic Health Association

International Center for Reiki

Pharmacogenomics: A Tailored Approach to Therapy

2008-03-14T06:24:00.000-07:00

Pharmacogenomics is a new scientific discipline made possible by the genome project. The mapping of the human genome has opened up enormous possibility for the identification and treatment of disease. Pharmacogenomic research focuses on the relationship between genes and drugs. One such example is a look at drug side effects and adverse reactions. We are beginning to identify why some individuals experience side effects to some drugs while others respond favorably with no adverse reaction to the very same drug. Some side effects can be life threatening, in fact, adverse drug reactions are a major cause of hospitalizations.

Stevens-Johnson syndrome (toxic epidermal necrolysis) is a severe and potentially life threatening reaction. It is now known that individuals of Asian descent have a gene referred to as HLA-B 1502. HLA's are human leukocyte antigens, proteins on white blood cells, that are responsible for recognizing foreign invaders. Some HLA subtypes see a particular drug as harmful and start an immune reaction. In the case of HLA-B 1502 it perceives carbamazepine (a popular seizure medication) as a foreign invader. Five percent of individuals that test positive for this gene will develop Stevens-Johnson Syndrome. It is recommended that individuals of Asian descent be offered other alternatives until genetic testing is made available to all and becomes more affordable.

The following drugs have a higher rate of causing hypersensitivity reactions: allopurinol, sulfonamides, hydralazine and others. Their HLA substypes are also being identified. In addition, HIV guidelines also urge screening for HLA-B5701 before starting abacavir to avoid a hypersensitivity reaction.

This is an exciting area of research, one which promises a tailored approach to therapy, in this case drug therapy.

Milk Thistle: Liver Regenerator

2008-02-04T17:34:00.000-08:00

Silymarin is the active constituent of the milk thistle seed. It consists of flavonolignans called: silibinin, silicrystin, and silidianin. Silibinin (also known as Silybin) makes up about 70% of Silymarin. Silymarin undergoes enterohepatic recirculation and has higher concentrations in liver cells. It is a potent inhibitor of tumor necrosis factor (TNF). TNF induces cytotoxicity, inflammation and apoptosis (cell death). These are effectively blocked by Silymarin. TNF is involved in the body's normal inflammation response. However, in certain diseases TNF is working overtime, causing cell death and damages healthy cells. This disregulation often occurs in diseases such as, Rheumatoid Arthritis. The way Silymarin works is unclear, it appears to work by facilitating cellular communication (intracellular signaling).

Silybin is an antioxidant, a free radical scavenger, and an inhibitor of lipid peroxidation. When an oxygen atom loses an electron, that electron floats around the body damaging tissues, cells or anything it comes in contact with. When an appliance, like a computer is plugged in and not grounded, and a power surge occurs, your computer is toast. Similarly, these electrons referred to as free radicals, damage cells and cause cell death.

In vitro, Silybin shows affinity for binding to P-glycoprotein. This protein is thought to be involved in the drug resistance of cancer cells. So by binding to this protein, which in essence protects cancer cells from being affected by drugs, it improves the efficacy of these drugs.
With respect to liver disease, Silymarin seems to cause an alteration of the outer hepatocyte (liver cell) cell membrane, preventing toxin penetration. It increases a protein called ribosomal protein synthesis, which stimulates liver regeneration and the formation of new hepatocytes. Silymarin might have antifibrotic, anti-inflammatory, and immunomodulating effects that could also be beneficial in liver disease.

Silymarin might protect against kidney damage. In vitro, it has been shown to protect the kidney cells from nephrotoxic drugs such as, acetaminophen, cisplatin, and vincristin. Silybin and Silicristin also appear to have a regenerative effect on kidney cells, similar to that on hepatic cells. It also seems to decrease insulin resistance, which in turn reduces blood glucose and lipid levels in patients with diabetes. Some research suggests that oxidative stress can contribute to pancreatic beta-cell dysfunction (these cells are responsible for producing insulin), reduced insulin secretion and insulin resistance. Silymarin is thought to reduce this oxidative stress.

Since so many drugs are metabolized by the liver, it has been a concern that this metabolism might be affected by Silymarin. Although it does seem to be an inhibitor of some liver enzymes, this inhibition does not so far seem significant with respect to drug metabolism.
In review, Silymarin is effective for liver disease, diabetes, and dyspepsia (acid reflux/heartburn). Normal dose is ranges from 100mg to 200mg of Silymarin 2-3 times a day.

In Charge of Morale: SAMe Improves Health and Mood)

2008-02-02T14:42:00.000-08:00

Research is finding more and more a correlation with various health conditions, including heart disease, and depression. Low levels of SAMe may have something to do with these disease states. Perhaps it is the common thread. SAMe is a naturally occurring molecule distributed throughout all body tissues and fluids. The concentration of SAMe is highest in childhood, decreasing with age. It plays an essential role in more than one hundred chemical reactions (involving enzymatic transmethylation). It contributes to the synthesis, activation, and/or metabolism of hormones, neurotransmitters, nucleic acid, proteins, phospholipids, and some drugs.

SAMe is produced endogenously by adenosine triphosphate (ATP) activation of methionine that is synthesized in the body or obtained from metabolism of dietary protein (e.g. meat). SAMe synthesis is closely linked to Vitamin B12 and Folate (also known as folic acid) metabolism. Deficiency of these vitamins can decrease SAMe concentrations in the Central Nervous System (CNS).

Although it seems to have antidepressant properties, its actual mechanism of action is unknown. It is associated however, with an increase in serotonin turnover (facilitates higher levels of serotonin to be found and used outside the cell) and elevated dopamine and norepinephrine levels. These are three major neurotransmitters that are related to mood. By altering cellular membrane fluidity (improves traffic in and out of the cell), it facilitates signal transduction across membranes and consequently increases the efficiency of receptor effector coupling (the neurotransmitter finds a parking space). Neuroimaging studies indicate that SAMe affects the brain similarly to conventional antidepressants.

There appears to be hepatic SAMe deficiency in liver disease. Exogenously, it may act as an essential nutrient by restoring biochemical factors that are depleted in people with liver dysfunction. People with acute or chronic liver disease lose the ability to synthesize SAMe from methionine. This might be due to low activity of methionine adenosyl transferase (MAT), the enzyme that converts methionine to SAMe. As a result, this can lead to deficiencies in cysteine and choline, as well as depletion of glutathione, which plays a major role in liver detoxification and antioxidant reactions (gets rid of free radicals which harm cells and ultimately kills cells). This depletion in turn, exacerbates liver disease. SAMe also has a gastric cytoprotective effect (protects the cells of the stomach).

As was mentioned there are over one hundred chemical reactions in which SAMe is involved in; the following is one of the more important reactions and one that is well understood:

SAMe-------->Homocysteine---->---(remethylated,via folate and B12)---->Methionine

Methionine coverts back to-------->SAMe

Or

Through transulfuration converts to-------->Glutathione

If these reactions are uninterrupted the result is the production of more SAMe and Glutathionine (antioxidant). However, if for example, an individual is deficient in Vitamin B12, Folate or Vitamin B6 (pyridoxine); SAMe will be converted to homocysteine and the reaction ends there. This outcome is unwelcome since high levels of homocyteine are associated with renal and cardiovascular disease. Recent studies show no significant increases however under normal circumstances, to the contrary, adequate levels of SAMe seems to promote the formation of glutathione by converting homocysteine. Low levels of SAMe have actually been correlated with coronary artery disease. Doses of 1200mg per day are used in people with liver disease.

SAMe taken orally has low bioavailability (isn’t absorbed well) because of first pass effect (liver metabolism). That is why higher doses are required and should be taken on an empty stomach. Levels peak 3 to 5 hours post ingestion. Although well tolerated, common side effects may be: flatulence, nausea, vomiting, diarrhea, constipation, dry mouth, and headache. But these are rare and usually seen with higher doses. Clinical trials used a dose of 1600mg/day, but the normal range is between 400mg-1600mg/day in divided doses. People with fibromyalgia take 800mg/day. It is available intravenously, but seldom used, for depression.
Not recommended for bipolar disorder since it can at times exacerbate the mania part of this condition. It should not be used concomitantly with antidepressants. It could potentiate serotonergic effects and serotonin syndrome like effects. Avoid if you have Parkinson’s. It may reduce effectiveness of levodopa given for this disease. Also avoid taking dextromethorphan (cough syrups), meperidine and DO NOT USE with MAO inhibitors. The body must be clear of MAOs for at least 2 weeks. Also avoid tramadol.

Physician Heal Thyself

2008-01-30T16:10:00.000-08:00

As a pharmacist I walk a thin line. Morally I feel obligated to offer information to patients about alternative therapies when appropriate. At the same time I feel I hold back for fear of being reprimanded by the board of pharmacy or admonished by disgruntled physicians who may not appreciate my suggestions. "First do no harm", has at times become; first protect yourself legally; and that's unfortunate.We have been forced to practice defensive medicine. Our medical system, as technologically advanced as it is, is in disarray. Thousands of MRI's, CAT scans, X-rays, blood work are being performed every day; many needlessly. Prescriptions are being handed out like candy; at times just to pacify the patient. Unfortunately these patients soon realize just how expensive the piece of paper they hold in their hands really is.

At the pharmacy I'm approached by patients all the time with various questions. In an attempt to more effectively provide them with helpful information, I usually ask brief questions about their conditions and if they had discussed their concerns with their physicians. Often time the answer is no. Excuses may range from, "I could see that he was busy, so I didn't want to bother him" or "We did discuss it, but I'm not sure I understand" or "I'm concerned about any side effects or drug interactions" or "Isn't there anything else I could take that's over the counter" or "This is too expensive, I can't afford it". In addition, many patients are seeing several doctors and often times each doctor is unaware of what the others are prescribing. In an attempt to save money the patient frequents several pharmacies in order to get the best price. All of this leads to a disorganized medical system which leaves the patient in a vulnerable position as well as their health care providers. If Dr. X isn't aware that Mrs. Smith is taking diazepam, he may write for another sedative, alprazolam. If her primary care physician prescribed the diazepam for muscle spasms and her psychiatrist prescribed alprazolam for anxiety, the patient may believe that these two drugs have nothing in common and it doesn't even occur to her to mention it to either doctor.

Time and again I see that physicians are not aware of their patient's complete drug history and even less aware of what they take over the counter. It is our responsibility as pharmacists to bring this to the doctor's awareness, but we are hindered by not having access to the patient's complete medical history, which includes other pharmacies that they go to. In these cases it seems obvious that the person most capable of resolving these issues is the patient herself, by being forthcoming with the information. I'm all for patient responsibility, but what do you do with an elderly population that has a difficult time remembering and understanding medical jargon?And what of individuals whose English is their second language and have difficulty understanding as well? By no means are these the only patients that we have to be concerned with. The population at large still sees the physician as a patriarchal figure, an expert when it comes to their health. They mistakenly assume that practitioners have an ongoing dialogue amongst each other, in which they routinely partake in conversations regarding their patients. This naive understanding of the medical system, contributes to a patient's vulnerability and less than optimal medical care. I am a strong supporter of patient responsibility--to a certain extent. They are responsible for communicating openly with all their health care practitioners and asking questions, until they are satisfied that they understand all options regarding therapy they are receiving.

However how is it possible for someone outside the medical field, to understand completely what is best for them? It seems that every nightly news show is full of contradictory research conclusions. Part of the problem is sensational headlines, whose only purpose it to captivate the audience's attention. Viewers are left with the misleading headline in their minds and aren't aware of the details in the research, which offers a more comprehensive analysis. Of course we are taking for granted that the study itself was well designed and accurate. Patients are bombarded with contradicting information on a regular basis. Even if they want to take an active role in their healing process, they are overwhelmed with questions that seem to have no end. To make matters worse, according to Dr. John Abramson of Harvard Medical School, many popular studies that have been done in the recent past have had significant flaws at best and outright fraudulent at worst. How are patients to know the difference if practitioners themselves have a hard time deciphering the good ones from the bad?

What I once thought to be research that was done impeccably, with the highest scientific standards, published in trustworthy peer reviewed journals, is no longer true. I went to college in the eighties, a time in which I was made to believe that scientific research was almost sacred in nature. Scientists were seen as objective individuals who would above all else do everything within their power to avoid any bias toward a particular outcome. Dr. Abramson explains in his book Overdosed America that we are standing on shaky ground. Research that once was done by nonprofit organizations, such as universities and hospitals, is now being done by drug companies. Our regulatory agencies which once were forbidden to take money from drug companies are now being subsidies by them. The journals that once had my full confidence, are now receiving millions of dollars from drug companies in exchange for advertisements. Physician's prescribing habits are not only being monitored by insurance companies but also by drug companies and their sales people, in order to more efficiently target marketing. In addition, practicing physicians have routinely been recruited to participate in clinical studies. They were modestly reimbursed for their time if at all; now participating in clinical research means big dollars. Not only are the drug companies doing their own research, but they are hiring their own doctors to do the follow-up clinical studies. This does not mean that all results are unreliable, but one has to question the validity of studies financed through private companies. Where are the safeguards against bias?

Practitioners that are hesitant to recommend or merely tolerate the idea of alternative medicine should consider the issues that have arisen over the last few decades within our own medical system. Healthy skepticism is necessary when evaluating any therapy now more than ever before. Fortunately many physicians have the capacity and aptitude to thoroughly evaluate a study. Statistical analysis is now taught at most medical schools. Unfortunately, evaluating alternative therapies is a bit more complex, only because their knowledge base in these therapies is minimal. Most medical schools don't have these courses available.There are some medical school curriculums which offer courses on alternative and complimentary approaches. These are few and are most often offered as electives within the required curriculum. Some schools are on the cutting edge of training their physicians in a more comprehensive fashion. Often these opportunities are available to medical school graduates when they finish their standard training. These already established physicians chose to do a fellowship in integrative medicine. One such school is the University of Arizona Integrative Medicine Program. This program was founded by Dr. Andrew Weil a foremost expert in the field. In an attempt to educate the practitioner at large, the program also offers continuing education courses on various therapies in complimentary and alternative medicine (CAM). Educational institutions such as this one are at the forefront of a changing paradigm in medicine. They are doing much to dispel the negative stereotype that CAM approaches have received over the last forty years or so. They have taken a hard look at CAM therapies and identified those that are efficacious and beneficial.

Although the number of clinical trials being conducted on CAM therapies are growing in number, there is an undercurrent of disapproval in order to show that most of these therapies are ineffective at best and harmful at worst. It is logical that given the number of therapies available to the consumer, some will be shown not to work and some may prove to be unsafe, but the amount of negative reports in the media suggest a negative bias. There was a news report a few years ago whose headline read "Study proves that St. John's Wort is no better than placebo". In that same study they also compared the efficacy of a popular antidepressant medication. What the media didn't convey was that this antidepressant, which was widely used, was shown to be less effective than placebo. What would it mean to the drug companies if an herb was found to be effective in mild depression? Millions of dollars would be lost.It is difficult to discern credible reporting from what amounts to be agenda driven advertisement.

It is essential that we understand the obstacles that we are faced with and take it upon ourselves to unscrupulously assess the reliability and credibility of the report, whether it be conventional or alternative. We need the support and guidance of respected institutions to help us lead the way to a more holistic model of medicine. At the same time we need comprehensive resources to be easily accessible. Having these support systems in place would not only afford us the ability of providing quality care, but would simultaneously reduce our exposure to liability. According to the University of Arizona Program in Integrative Medicine (PIM), the legal issues that health care providers face when recommending or discussing complementary and alternative medicine modalities in their office are as follows:

Malpractice liability for inadequate informed consent

Licensure and credentialing

Scope of practice (the legally authorized practice boundaries for providers)

Professional discipline (discipline for professional misconduct)

These concerns are valid and one can understand the hesitancy that many practitioners have. From their perspective they would be jumping in a fire hoping to avoid getting burned. In the midst of these obstacles there are seeds of hope. We as patients and as healthcare providers must not capitulate to this challenge. We must avoid complacency and strive for a healthcare environment that is open to new thought and offers more options. PIM offers suggestions and guidelines to follow which will help in traversing these murky waters. When a patient asks about alternative therapies the following should be considered:

What is the curability rate with conventional care?

Weigh quality of evidence, invasiveness, and toxicities of each therapy.
Patient clearly understands the risks and benefits of each option and accepts those risks.It is also important to familiarize yourself with organizations that have been established, in order to demystify CAM therapies. The Consortium of Academic Health Centers for Integrative Medicine (CAHCIM) is an organization responsible for performing rigorous studies on various medical therapies in order to create new models of clinical care, these models would integrate biomedicine, the complexity of human beings, the innate nature of healing, with the diversity of therapeutic systems from all over the world. It understands that the western medical model, although superb at treating many diseases and conditions, also has limitations. At the same time it acknowledges that for millennia there have been effective medical models from around the world. Some of the academic medical centers that are members of CAHCIM include: University of Arizona, Harvard, Georgetown, Duke, and Columbia University to name a few. The following is a list of resources that are also a good place to start:

American Botanical Council

American Herbal Pharmacopoeia

Consumer Labs: Randomly test dietary supplements and release their finding to the public

http://www.drweil.com/: Extensive website with information pertaining to both conventional and CAM treatments.

FDA Food Manufacturing Practices (GMP): Sporadically monitors products off the shelf

Independent Drug Information Service (iDiS)

National Center for Complimentary and Alternative Medicine (NCCAM)

National Institute of Health

National Sanitation Foundation (NSF): Dietary supplement quality verification, they use GMP
compliance standards

Overdosed America, Dr. John Abramson

Powerful Medicines, Dr. Jeffrey Avron

The Association of Official Analytical Chemists (AOAC)

The Compendium of Asian Patent Medicines

University of Arizona Integrative Medicine Program

United States Pharmacopoeia (USP): Dietary supplement quality verification they use GMP compliance standards

World Health OrganizationGiven the available resources and I'm sure there will be more to come, a practitioner who has a sincere interest in offering his patients more options, can feel more comfortable with the use of alternative medicine. It saddens me to think how the western medical community has so often disparaged and looked upon other medical models with disdain and total disregard. We don't have all the answers, far from it. All medical traditions have blind spots, strengths and weaknesses. Western medicine would benefit from a visit to the therapist, there it would hopefully have a revelation, and it would realize that it is not omnipotent. Could it be projecting onto other medical models what it is afraid to accept of itself? We bare and share the same responsibility, which is to provide the best medical care available to our patients.

Guiding You Through the Supplement Labyrinth

2008-01-28T08:37:00.000-08:00

The word vitamin comes from the Latin words, vital (life) and amine (building blocks of DNA). Most vitamins we take in from dietary sources. In an ideal situation (when we're young, disease free, healthy diet), our body receives and manufactures all the essential vitamins and minerals that it requires for maintaining physical, emotional and mental health. However, for various reasons vitamin deficiency has been a significant problem, mostly due to poor diet. Although agricultural practices have increased the world's food capacity, there are still to this day many areas of the world in which food is not readily available. Thus, these societies do not receive important nutrients simply due to starvation. In addition to present day famines , western cultures have developed unhealthy lifestyles, specifically with respect to diet and exercise.

The fact that we are becoming obese and live sedentary lifestyles is not earth shattering news. What has not been emphasized enough however, is that while we are taking in more calories, they are not necessarily healthy ones; in fact the opposite seems to be true. Less than a century ago, we were more active. Having to walk to where ever it was we had to go, exposed us to the outdoors, which in turn increased our bodies ability to produce its own vitamin D; a vitamin that research is looking more and more into and finding benefits for use in various diseases. The point is this: yes it's true that if (and in this day and age, it's a big if), you are a healthy person, with a healthy lifestyle, most likely you don't require supplements of any kind. But if you fall into the group of people, who have not been able to maintain a healthy diet regimen due to long hours at work, busy schedule at home and overall lack of knowledge on what it constitutes to eat healthy, then more than likely you could benefit from some supplements added to your diet.

Which supplements to consider, will be age specific and also dependent on your physical, emotional, and mental condition. Are you looking for supplementing overall health? Or do you have specific illnesses and symptoms you want to target? Supplement selection should be carefully researched on an individual basis and discussed with your physician or health practitioner. What I see most often in the pharmacy are clients who come to the counter and ask about a particular supplement in which someone they know has recommended. There is nothing wrong with listening to suggestions as long as you do the follow up which is to ask if that particular supplement would be of benefit to you. Supplements can be expensive, especially if your personal physical condition warrants that you take more than one, so it becomes imperative from a health stand point but also a financial stand point that you take the time to educate yourself thoroughly about which supplements would be of most benefit to you.

There are many places to educate yourself. The internet is a great source if you know where to look. You can ask your doctor or a pharmacist. A pharmacist who specializes in Integrative Medicine would be especially appropriate. They can guide you through what can be at times an overwhelming plethora of information. This is a fairly new field of medicine, but an invaluable one. The role of an Integrative Pharmacist is to evaluate your circumstances and educate you as to what options you might have or would be most appropriate for your condition and your financial situation. It may be as simple as making you aware of less expensive alternatives. For example, I have had several clients who have been switched from antidepressant to antidepressant, it isn't unusual for someone to be on two at a time, only to be switched yet again to a more expensive drug new to the market. In frustration, they tell me they can't afford the medication and that as soon as the doctor finishes handing out his samples, they will have to stop taking it. I explain that very often patients who don’t respond well to antidepressants, especially if they have already tried several, might have low levels of folate or folic acid. More often than not folic acid supplementation along with vitamin B6 (pyrodoxine) and vitamin B12 (cyanocobalamin) significantly improves their response to a less expensive generic drug. This is merely one example of how supplements, in this case vitamins, can make a significant impact on therapy response and effectiveness.

Contemporary medicine is more and more complex. Physicians are finding it necessary to specialize more and more, being able to keep up with the most recent research, and understanding in depth what therapy will be most effective for each individual can be an overwhelming if not impossible task. The benefit of this specialized approach to medicine would seem to be obvious. A physician is able to be an expert in his field. But this has also created a problem in our medical system. So many medical students today are specializing, that we are losing the glue that holds it all together. This glue that I'm referring to, which is essential to practicing good medicine, is our front line doctors and practitioners. The family physicians and pediatricians for example, who are responsible for practicing preventive medicine (educating the patient on staying healthy), identifying and treating diseases when they arise, but they are also the ones responsible for collecting all the data and reports that are being produced by the specialists that their patients have been referred to. If this seems like a mouthful, it's more than that, it's more than a handful. Because of the increase in rate of physicians who become specialists, there are less and less front line physicians. The ones that remain are overworked and at times overwhelmed.

There is a medical crisis in this country for various reasons, but substandard communication between health professionals and their patients is of major concern, in part because there is so much information to keep track of. We need an integrative approach to medicine. Dr. Andrew Weil is a physician who has developed an Integrative Medicine program at the University of Arizona Medical School and there are other universities across the country that have begun to incorporate this idea into their medical schools. The basic philosophy is this: you treat the body as a whole and you treat the patient with a team of physicians that work closely together. Their clinic works with family practitioners, specialists, as well as alternative practitioners; acupuncturists, massage therapists, physical therapists, psychotherapists, pharmacists, nutritionists, etc. Although integrative medicine is becoming prevalent, it is by no means a part of mainstream medicine.

In the meantime, patients need to do the best with what they have available to them. Towards that goal is familiarizing yourself with what types of therapies are available and being able to decide which ones are credible and which ones aren't and that most certainly includes supplements. Knowledge is power. It is not enough to explain the benefits and risks of taking supplements. We are people first and patients second and we are responsible for our own health. In order to make informed decisions we need to understand why vitamins are necessary or "essential" to good health and how they work. The words essential and non-essential are often used to describe vitamins. These terms can be misleading. An essential vitamin is one that can only be found in the diet. A non-essential vitamin is also necessary for good health, but it can be manufactured by the body through other biochemical reactions. This however does not mean that non-essential vitamins are less important or that additional supplementation is never required. There are conditions in which the pathways in which these non-essential vitamins are formed are inefficient. Under these circumstances additional supplementation would be necessary. For example, a supplement and vitamin-like substance called Coenzyme Q is necessary for the proper cell function. The levels of CoQ diminish with age and are also diminished in people who take cholesterol lowering drugs called statins. In this case and there are others, external supplementation could be helpful in maintaining overall health. It is not possible to explain in detail all of the various vitamins, supplements, and vitamin-like substances in the scope of this article. I have thus focused on the most important and effective supplements; supplements that also are backed with a significant amount of credible research.

Vitamin D: No Longer Calcium's SideKick, Essential in its Own Right!

2008-01-28T08:31:00.000-08:00

Vitamin D is a fat soluble vitamin and exists in two forms: ergocalciferol, vitamin D2 and cholecalciferol, vitamin D3. Ergocalciferol (VitD2) comes from ergosterol, a plant sterol and yeast. Cholecalciferol VitD3, is synthesized in the skin via 7-dehydrocholesterol, a cholesterol precursor. Both forms are biologically inert (inactive) until they are hydroxylated (converted) in the body to Calcitriol.
Hydroxylation (conversion) of Vitamin D to calcitriol occurs in the kidneys. People with kidney failure may require Vitamin D in its active form. Vitamin D3 is significantly more potent and effective in humans.

Few foods naturally contain Vitamin D and the ones that do have been fortified. Brief exposure to sunlight is the best way to get Vitamin D. Skin exposure to the sun provides as much as 80% to 90% of the body's Vitamin D stores. In northern latitudes sun exposure particularly in the winter months may not be sufficient to cause Vitamin D synthesis in the skin. Sunlight intensity depends on latitude, altitude, season, cloud cover, ozone levels, etc. The capacity of UVB mediated Vitamin D synthesis is huge. Six days of casual sunlight exposure without sunscreen can make up for 49 days of no sunlight exposure. Skin pigmentation affects Vitamin D synthesis. A light-skinned person in northern latitudes wearing a bathing suit receives about 10-20,000 units of cholecaliferol in 10-12 minutes of peak July sun. A darker skinned person would require 30 minutes and an African-American 120 minutes for their skin to produce the same amount of Vitamin D.

African-American infants who are exclusively breast fed are at higher risk for Vitamin D deficiency and Rickets. Sun exposure three times a week for a period of time ( 25% of that which would cause a mild sunburn) will produce adequate amounts of Vitamin D.

Factors that affect Vitamin D levels:

Insufficient sun exposure
Reduced skin synthesis
Lower dietary intake
Impaired intestinal absorption
Decreased metabolism by the kidneys to active form of Vitamin D
(this condition increases with aging)
Vitamin D receptors decrease with age (serious concern for the elderly)
Obese people may have reduced serum Vitamin D levels and reduced
bioavailability. It seems the Vitamin D is sequestered into body fat
and unavailable.

Vitamin D regulates serum calcium and phosphorus concentrations. It enhances the efficiency of the intestinal absorption of calcium. Calcitriol (active form of Vitamin D), also has effects in the brain, heart pancreas mononuclear cells, activated lymphocytes, and skin.

Vitamin D increases muscle strength and neuromuscular function in addition to strengthening bone. It increase protein synthesis (700-800 units/day).

Vitamin D seems to have immunosuppressant activity, beneficial in autoimmune disorders like Rheumatoid Arthritis and Multiple Sclerosis. Evidence suggests that it improves respiratory disorders. There is an association between levels of 25-hydroxy vitamin D serum levels and pulmonary function. It might be involved in remodeling lung tissue. It could also decrease immune mediated inflammation in the airway.

Vitamin D deficiency is linked to an increase risk of falls. Taking Vitamin D supplements reduces falls by 22% in the elderly. Some studies showed that this benefit is independent of calcium supplementation.

A dose of 800units or higher is necessary for it to be effective. Interestingly, researchers believe that Vit D prevents falls by decreasing body sway and decreasing systolic blood pressure rather than increasing bone mass strength. Until now Vitamin D has been seen as a mere adjunct to calcium supplementation, but it is necessary and effective in it's own right.

Studies show that individuals with higher levels of vitamin D serum levels (25mol/L) concentrations have a significantly lower incidence of ceratin cancers, particularly gastrointestinal. In clinical trials, women taking calcium (400-1500mg/day with 1,100units of vit D3 had a 60% lower risk for developing cancers of various types.

Long term vit D supplementation decreases the risk of Multiple Sclerosis in women by 40%. Again the effect is dose dependent in this case a minimal dose of 400units/day. In addition, when vit D levels were measured in the general population the higher the level the lower the chances of developing Multiple Sclerosis (50nmol/L). Scientists suspect that this may be one of the reasons why the rate of MS is higher the further you are from the equator.

A large trial showed that women with lower levels of vit D have a higher risk of being obese, yet another reason to take vit D. When combined with calcium it helps maintain a healthy weight baseline. Effective doses are between 800-2000units/day.

Cautions: If you are using topical vitamin D creams you must consult your physician before taking vitamin D orally. Topical vitamin D is absorbed. Cimetidine (Tagamet) can decrease active vitamin D levels, particularly in patients with liver or renal insufficiency.

Omega-3: "An Omega a Day Helps Keep the Doctor Away"

2008-01-28T08:30:00.000-08:00

There are several Omega-3 fatty acids. The two most commonly taken are DHA(docosahexaenoic acid) and EPA(eicosopentaenoic acid).

DHA is a polyunsaturated fatty acid that is found in tissues of marine animals. It is converted to EPA in humans. DHA competes with arachidonic acid for inclusion in cyclooxygenase and lipoxygenase pathways (substances responsible for inflammation). This competition may be responsible for its anti-inflammatory effect.

It reduces serum triglycerides (important in coronary artery disease). Increases fasting insulin and glucose concentrations(important for diabetes). It increases HDL (good cholesterol) by about 12 percent. It has an additive affect in reducing symptoms associated with schizophrenia and recurrent unipolar depressive disorder. The ethyl form of EPA is especially effective in depression (1gm twice a day). It slows weight loss in cachectic cancer patients. There is some evidence that suggests it to be helpful in prostate cancer.

It plays a key role in neural and synaptic membranes. These functions play a key role in learning and memory function. It is essential in healthy neurological development of infants. It is found in breast milk but not in standard infant formula. Supplementation is recommended for pregnant women beginning at week 15 (1.2gm-2gms/day).

It has been recommended for age-related macular degeneration, coronary disease, psoriasis(as an IV injection), hyperlipidemia, ADD, Alzheimer's. May also be beneficial in Multiple Sclerosis for its anti-inflammatory activity as well as its role in healthy neurological function.

The standard total Omega-3 fatty acid dose is 1800mg per day. It usually comes as a combination of EPA 350mg/DHA 200mg.

It is now well known that many of our diseases are in part a result of or are exacerbated by inflammation. Poor diets (high in saturated fatty acids and high glycemic index foods) as well as lack of adequate exercise play a significant role in the increase in inflammation in our bodies. Inflammation is a healthy response of the body to injury, but is problematic when it becomes chronic inflammation artificially produced by poor diet and a sedentary lifestyle. This inflammation affects our muscles, our vascular system and our neurological system, as well as our organs. Omega-3 fatty acids seem to block the inflammation pathway and help minimize subsequent damage. In addition to taking Omega-3's you should also minimize high glycemic foods in your diet. These include processed foods such as white sugar, white bread, pasta, etc. When we ingest high glycemic foods our pancreases release insulin and insulin is involved in a wide range of hormonal cascades which in turn cause inflammation.

CoEnzyme Q: "The Little Engine That Can"

2008-01-28T08:27:00.000-08:00

Coenzyme Q (CoQ) is a staple for cardiovascular disease therapy in Japan, Europe and Russia. It is a vitamin like compound that is present in most cells of the body. The heart, liver, kidney and pancreas have especially high concentrations of CoQ. It is fat soluble and is a potent antioxidant. It is a membrane stabilizer (keeps the cell healthy and intact), it's a cofactor in metabolic pathways (a necessary enzyme in biochemical reactions in the cell) particularly in the production of adenosine triphosphate (ATP) in oxidative respiration (basically it plays an essential role in cell energy production).

The CoQ that is formulated in soybean oil appears to have superior bioavailability(easily absorbed by the body) compared to other formulations. Coenzyme Q increases HDL (good cholesterol), vitamin E, vitamin C, and actually decreases LDL (bad cholesterol).

So why and when do we need to supplement CoQ? Well the why is pretty evident. It is essential for overall good health. Coenzyme Q levels decline with age, declines with certain diseases(Congestive Heart Failure, Hypertension, Periodontal disease, certain muscular diseases and AIDS), and declines when taking certain drugs(such as beta-blockers and statins which are cholesterol lowering drugs; these drugs block the synthesis of cholesterol as well as CoQ).

In addition to the diseases already mentioned, CoQ supplementation may be beneficial in the following diseases as well: Parkinson's and Huntington's. It appears that these diseases might be caused by impaired function of the mitochondrial electron transport chain and particularly the mitochondrial enzymes, Complex I and Complex II (the mitochondria is like the cell's engine, the place where all the energy is produced).

CoQ might also prevent cardiotoxicity caused by phenothiazines (certain antipsychotics), tricyclicantidepressants, doxorubicin (chemotherapy). Some studies show that it may have some immunostimulatory activity in breast cancer.

It may also help in reducing migraine severity and increase exercise tolerance as well as helping with fatigue in Multiple Sclerosis.

As you can see there are various scenarios in which serum levels of CoQ are reduced and you can also see how important and essential it is to overall health. Every reaction in our body requires energy and CoQ is an essential part of that process. Dosing varies depending on which condition is being treated. Generally it is dosed at 100-200mg per day.

Folic Acid as Cinderella and Homocysteine as the Evil Stepmother

2008-01-28T08:16:00.000-08:00

Folic Acid as Cinderella and Homocysteine as the Evil Stepmother
By: Cristina Berard, RPh, MEd

Folic acid or folate as it is also called, is found in green leafy vegetables. Folate from vegetables is about 40-50% less bioavailable than synthetic folic acid, which is almost 100% bioavailable. After it is absorbed by the body it is converted into tetrahydrofolate. Tetrahydrofolate based coenzymes play a major role in intracellular(within the cell) metabolism. Folic acid reduces errors to DNA and prevents replication errors. Folate deficiency disturbs the cycling of the cells and induces and increases the rate ofcell aptopsis (cell death). It is involved in the metabolism of homocysteine (high levels cause inflammation). Low levels of Folate are associated with an increase plasma homocysteine levels. High levels of homocysteine (hyperhomocysteinemia) is a risk factor for coronary, cerebral, and peripheral atherosclerosis; recurrent thromboembolism; deep vein thrombosis; myocardial infarction; and ischemic stroke.

Why are high homocysteine plasma levels a risk factor for certain diseases? The mechanism of action isn't fully understood, but it might include vascular endothelial cell damage(deterioration of the blood vessels), impaired endothelium dependent vasodilation (blood vessels don't dilate properly) due to reduced nitric oxide activity, arterial stiffening due to increase in oxidation(arteries become stiff) and arterial deposition of low density lipoproteins (LDL cholesterol deposits in the lining of the artery), increase of platelet adhessiveness (blood thickens becomes less viscous), and activation of the clotting cascade (increase in clots formed in the vessels).

All vitamins are essential and play important roles in metabolic pathways. Folic acid is an especially important vitamin. The following description of it's role may at times be a bit technical, but it is important in helping you to understand just how imperative it is to ensure that you are not deficient in folic acid or in any steps along the way.

Homocysteine is metabolized via two pathways. One is called "remethylation" the other "transsulfuration".

remethylated
Homocystein-----------------------> methionine

This reaction is facilitated by folate and Vitamin B12 (cofactors). Without these two cofactors, this processes would not take place and homocystein would remain in tact, thus increase homocystein levels in blood stream. There is another factor that can impede this process. Some people homozygous fo the mutations of the gene MTHFR(5,10 methyltetrahydrofolate reductase). This is an enzyme involved in the conversion of homocysteine to methionine. When you are homozygous for this gene most often you need to take higher doses of folate, usually 1mg per day.

Transsulfuration usually occurs after an individual ingests a meal high in animal protein (a methionine load).
via pyrodoxine(vit B6)
Homocystein-------------------------->cystathionine------------------------------->cysteine

Deficiency of pyrodoxine impairs the pathway raising homocysteine levels as well. In addition to folic acid, vitamin B12 and B6 are important for successful conversion of homocysteine.

What does all of this mean and why is it important to health? Well plays an important role in pregnancy and the healthy development of the fetus. Low levels are associated with neural tube defects in the fetus.

Low levels might play a role in Alzeihmers Disease. It seems to be associated with atrophy of the cerebral cortex.

Homocysteine is thought to be neurotoxic, causing DNA damage and cell apoptosis which is associated with functional and mental deterioration in the elderly.

Folic acid deficiency is common in people with depression. Low levels have been linked to poor response to antidepressant treatment.

Folic acid is required for the conversion of homocysteine------->SAMe. SAMe in turn is associated with an increase in serotonin turnover, increase in dopamine, and norepinephrine levels. All of these play a role in mood.

When you go to the pharmacy, you will find that there are individual B vitamins and then there are products that provide a combination of all B vitamins. The previous pathways might have given you a clue as to why these B vitamin complexes are so popular. Various B vitamins played a key role in these homocysteine conversion pathways. Where folic acid is the work horse, the other B vitamins are its helpers. Just like Cinderella was the hard worker of the family she couldn't have made it to the ball without her little helpers. By working together they were able to stop the evil stepmother (homocysteine) from getting her way.

Folic acid supplementation is helpful in treating and or preventing the following conditions: End-stage renal disease, hyperhomocysteinemia (11 micromoles/L or higher), methotrexate toxicity, neural tube defects, breast cancer, colorectal cancer, depression, Alzheirmers, risk of cervical cancer, cognitive function, infertility, and restless leg syndrome.

Typical doses are: 250mcg-1000mcg/Day
Severe disorders and under medical supervision(1000-5000mcg/Day)

A Summer Night's Breeze

2007-10-21T12:42:00.000-07:00

Wicked games, tempered lies
Win or lose something dies

The aches that come
Forever glide like streams
And rivers

****
Breezes, blow gently
Through the night
Calm your heart, display it
Feel the wisdom from up above
Gentle kisses, calling love

****
Caress my skin a gentle touch
So pure and clean
Innocence in the ruff
Hypnotic it’s beauty
A wondrous site

****
Send me, send me
Far along the broken path
Carry me with gentle strength
Courage and tenderness
Wake me from this dreadful sleep
I love the scent of your simplicity
Remind me of times
Glasses of lemonade and those hot summer days

****
I love the way
You caress my skin
You exist, but I forget

You are quiet and I forget
Gently you caress and once again
I remember……I am alive
and you are there
and never left.

--Ana Cristina Berard

Vulnerable

2007-10-21T12:38:00.000-07:00

Do not judge me
You do not know
The sharpness of this blade
You do not bleed my blood
Or taste the salt of my tears.
***
Rays of sunlight
Have warmed me now
Gentle breezes pass softly by
Once again replenished, nourished
As the beauty of a deepest love.
***
Longing for sun-filled days
Grayness banished
My skin once again alive
I tingle, I breathe inside
***
More deeply than the darkest night

Moonlight brightens
The darkest recess of my soul
***
So do not judge me
For now I breathe
My soul alive
Stirring inside of me

--Ana Cristina Berard

Lifting the Veil

2007-10-21T12:36:00.000-07:00

Through the maze of confusion
Our minds emerge
A blissful sweetness.

--Ana Cristina Berard

Passion

2007-10-21T11:50:00.000-07:00

Passion, our soul’s longing
to be expressed.
Fulfill its desire
Listen…Believe….and Manifest.

--Ana Cristina Berard

A Tribute to Family

2007-10-20T15:12:00.000-07:00

A Letter and a Tribute to My Great-grandparents

Dear Avo Ze and Avo Rita,

“Saudade” is a Portuguese word for which I have yet to find an accurate English translation. They say this word only exists in the Portuguese language. It describes a deep seated longing for a place or family. It is beyond missing someone. There must exist a deep visceral connection to whatever is longed for—a soulful bond. I feel this for the place I was born and for the ancestors that were a part of creating that environment. It is not easily put into words, it is something to be experienced. When I walk into your home I feel as though my thirst has been finally quenched. From time to time, I might feel out of place in the world, but in your home I just AM. I belong to a place and to a people that have lived here from generation to generation. It is an anchor, a type of umbilical cord that reminds me; no matter where I am in the world, I am grounded in you and those that came before you. Even though you and I never met, I feel as if I know you.

Throughout my life my mother Violeta, your granddaughter, shared many family stories. The ancestors are so many that at times it’s difficult to keep up with her. Today she was telling us under what circumstances, you and Avo Rita were married. In her own animated way she vividly recounts how you and Rita fell in love, and that your own family disapproved of the relationship. They were so disappointed in the girl you were courting that they threatened to disinherit you completely, if you married Rita. They considered themselves high-class members of society; land owners and businessmen. The Almeidas were successful in their own right, they also owned businesses; but in the Amaral’s eyes they didn’t compare. Your parents wanted more for you. They wanted you to follow in the family tradition of pursuing higher education, but you chose to stay in Penalva and follow your heart--in more ways than one.
You had always been good with your hands; and you wanted to have a career in which you could use them and develop your own talents. Being sure of yourself and your love for Vovo Rita, you married her knowing full well you could lose everything. Not long after you were married, your parents changed their minds. You inherited the house I was to be born in, the one your granddaughter, Virita now owns, and several parcels of land; each with its own distinct name. To this day my mother speaks of them with nostalgia (as Borrocas, as Belgas, a Vinha das Canas). She reminisces about the lush vineyards, the fragrant orchards, and various abundant fields of vegetables. The house itself had an interesting history. In the eighteen hundreds it was used as a local “chapel”. The priests used it as their home and a place to say mass. The confessional window still exists today.

Your first year of marriage started off with a bang! No sooner did you get your business up and running (today we would call it a taxi service/UPS couriers/mechanic shop), another challenge was laid at your door. Avo Rita had a cousin whose husband left her with three children to raise and one on the way. She later died while giving birth. The children were placed in a type of orphanage. Shortly after you were married, you and Vovo decided to raise those children as your own. Knowing that the baby would die without someone to nurse her, you took the baby to a woman in a nearby town; who you knew had had a stillbirth and would be able to breastfeed the baby girl. In that one action you did two wonderful things. First, you gave the baby a chance for life and secondly you filled the heart of a woman who was mourning her own child. The little girl was lovingly raised by her with your financial assistance; and on the weekends she would come and stay with you. This little girl was Celeste’s mother.

Not long after that, you and Avo started a family of your own. There were nine children in all: Pedro, Rosalia, Antonia, Afonso, Albano, Armanda, Joao, Maria (Tia Miquitas). One of the children died very young. Add that to your adopted children, you had thirteen children all together to support. Perhaps the home had been blessed after so many years of prayers being said inside its walls or perhaps it was your love and commitment to each other that created a safe haven for all those that were to pass through those doors. Your spirit, your compassion and your sense of perseverance are still palpable to this day. You have left behind a legacy of compassion and kindness.

Although, Vovo (Rita), I hear that when one of your kids misbehaved, you would slap them so fast their heads would spin and if they were beyond your reach, the tools near the fireplace would do just fine. Later you would tenderly call them back upstairs and offer them comfort. You led a strict household with a firm hand and a kind heart. Your children and grandchildren respected you, cared for you deeply and lovingly spoke of you. There is one particular story my mother tells and I never tire of hearing it. My grandmother Rosalia, one of your daughters, moved into your home after you passed away. Now and again she would get strangers knocking at the door looking for “the house of the poor”. Individuals they had come across along their travels, told them of some folks that lived in a town called Castendo. They will feed you and clothe you and give you a place to rest. It was known as a safe haven for the poor.
You touched the lives of many in need; you had them bathe, gave them clean clothes, warmed them by the fire, offered them a meal and allowed them to stay until they could get back on their feet. Often they would beg you for a job and although you didn’t need help, you hired them anyway. You knew that aside from feeding them, they needed to feel a sense of worth; you gave them back their pride and dignity. You fed their stomachs and as well as their souls.

My mother describes you as an “open hand” (uma mao aberta), you always had something to offer someone in need. Times were tough for everyone, luxuries were not to be found, but you did your very best to feed your family, and somehow always had some to spare. You kept them safe and secure in your love and commitment. Your love for your wife only grew stronger over the years, as did your respect for her. You saved the best of what you had and offered it to her first. If she were sick, you made sure she was cared for and that no one was to disturb her. “Your mother needs her rest”, you would say.

Although we never met, stories like these keep you alive in our hearts. Each one of your children and their children have given us, in this generation, a direct connection to you. There are many in this world who don’t have extended family ties; the stories are never told; their heritage has been lost. In light of this, I feel blessed that I am your descendent, your great granddaughter; because your perseverance, loyalty, compassion, and devotion to the human spirit now runs through my veins and in those of this generation of Amarals and Almeidas; and so I am humbled to say that I am the great-granddaughter of Ze Pina Amaral and Rita Almeida. In a world where positive role models are hard to find, you are both exemplary; and a tough act to follow.