by Anne S. Boyd, MD, FAAFP, FACSM

You might know the fastest car or even the fastest athlete, but did you know that melanoma is the most common and the most rapidly growing cancer in the United States? Imagine you’re sitting in a room of 50 people. Now, look around…the person sitting next to you could be that one-in-50 Americans at risk for developing melanoma in their lifetime…or, it could be you.

May is National Skin Cancer Detection and Prevention month, but there’s another reason I chose this topic for the newsletter. Recently, a particularly reluctant patient was coaxed by her husband to come in for a routine physical. I found a new mole that she’d never noticed or would have been able to see. I removed it, sent it for biopsy and the report came back as a malignant melanoma. Her longevity and lifetime changed in that one instant.

In its early stages, melanoma can be successfully removed and monitored by regular skin screenings. In fact, survival rates can exceed 90 to 95 percent. However, in its most advanced stages, melanoma can be deadly as few treatment options exist. Survival rates drop to less than 20 percent when melanoma has spread to other organs.

Early detection is the key!!! That’s why a careful monthly self exam is so important. Remember, this includes close inspection of any moles including those in the hairline, behind your ears, between your toes, under your nails, around the genital areas and even within the mouth. Wherever there is skin, there is a potential for melanoma. If you can’t see or reach areas to be examined, ask a partner or utilize mirrors. If there is a family or personal history, a regular skin exam every 6 to 12 months by a trained medical professional is recommended.

“How do I know what I am looking for?” Well…like your mama’ told you…use your ABC’s. Actually, when it comes to distinguishing between benign or malignant moles use your ABCD and sometimes E’s:

• Asymmetry. Benign lesions generally have a round, symmetric border (if you folded one in half, the 2 halves would match). Melanomas are often asymmetric.
• Borders. Benign lesions have regular borders while melanomas are often irregular and less well defined.
• Color. Benign lesions are uniform in color, while melanomas often have various colors within one lesion.
• Diameter. Most benign lesions are < 6mm (the size of a pencil eraser).
• Evolution. Benign lesions tend to remain unchanged for prolonged periods of time.

How do you protect yourself and help prevent melanoma? We know that genetics is one risk factor and, at least for now, we can’t influence genetics. However, there are several things we can all do to reduce the risk of this ever increasing, deadly disease:

• Use sunscreen daily and repeatedly. Sunscreen should block both UVA and UVB rays and should be at least SPF 30. Regardless of any product claims, there is no sunscreen that lasts all day. And don’t forget your ears, hands, feet and scalp.
• Wear protective clothing. Sleeves, pants, wide-brimmed hats and sunglasses.
• Avoid unnecessary exposure to natural light, particularly from 10am-4pm.
• Avoid tanning salons; there is no occasion worth the risk.

To learn about this insidious form of cancer, read our latest blog, Melanoma—Just the Facts!

As for our ‘reluctant’ melanoma patient, you’ll be happy to know that she is now doing well. She has had a second, wider excision of her melanoma and, fortunately, it was detected early enough, when it was still superficial and localized. She will be fine. And both she and I are exceedingly glad she came in for her executive physical.

Mediterranean-Style Dieting: It really is too good to be true!

by Sabrina Zaslov, MS, RD, CDE

Ah, the Mediterranean… sunny climate, amazing blue sea, stunning beaches, and now also famous for its extremely healthy diet. While there may be no such thing as an “official” Mediterranean diet, consuming a Mediterranean-style diet has been linked to lower risks of coronary artery disease, stroke, diabetes, metabolic syndrome, certain cancers, as well as better eye health and an increased lifespan.

What makes this diet so beneficial? A major factor may be its influence on inflammation and oxidative stress which both tend to be the root of chronic disease and, as recent research is showing, cognitive disorders.

A study done at the University of Miami Miller School of Medicine found that people whose diets followed a Mediterranean-style eating pattern had lower white matter hyperintensity volume, indicating less brain damage. For those of us without a neurology degree, white matter hyperintensities can indicate small-vessel damage in the brain foreshadowing an increased risk of dementia and a faster decline in cognitive performance.

While it might be nice to move to the Mediterranean and simply adapt their diet, here are some practical tips for eating “Mediterranean-Style” right at home.
The primary diet is plant-based:

• 7-10 servings a day of fruits and vegetables
• Whole grains such as whole wheat, oats, brown rice, quinoa, & barley (nothing processed)
• Protein sources such as fish, nuts, beans and legumes
• Snack on nuts and seeds daily

Rules to live by (whatever your diet):

• Don’t overdo alcohol
• Replace saturated fats such as butter and animal fats with olive oil, avocado & almonds
• Use herbs & spices instead of salt to flavor foods
• Limit red meat to no more than a few times a month and consume in ‘petite’ portions
• Eat fish at least 2-3 times a week

Remember, individual components of the Mediterranean-style diet are healthy, but it’s the entire dietary pattern which has been associated with decreased chronic disease risk and overall better health.

However, if you aren’t ready or willing to fully adopt the Mediterranean-style diet pattern, try starting here:

• Include fruits and vegetables at each meal
• Substitute processed grains with whole grains
• Decrease consumption of saturated fats

The benefit of the diet comes from not only what you are eating, but what you are NOT eating.

Buon Appetito!

An Alternative to Sleeping Pills: Cognitive Behavioral Treatment for Insomnia (CBTI)

by Derek Loewy, PhD, DABSM, CBSM
Insomnia Program Director
Integrative Insomnia & Sleep Health Center

We’ve all lived through the occasional bad night’s sleep. Such intermittent bouts of insomnia are often due to some short-term malady like a head cold or acute stress. Perhaps the culprit is an external nuisance like a snoring bed-partner or a disruptive family pet roaming the bed. For most of us, a poor night’s sleep is a transient thing and not a big deal. Not so for a large segment of the population. It’s estimated that up to 10% of adults suffer with severe insomnia, meaning that for them it occurs most nights of the week. The condition is deemed chronic if it persists for at least three months. In reality, most chronic insomniacs have dealt with their sleep problem for years!

Insomnia is defined as any of the following: difficulty with falling asleep, difficulty staying asleep, waking up too early in the morning, or waking up feeling unrefreshed. Research has shown that chronic sleeplessness is more than a mere annoyance. Insomnia has been associated with decreased quality of life, increased risk for hypertension and heart attack, increased risk for accidents, and increased risk for the development of psychiatric illness, most notably depression.

A comprehensive review of available scientific evidence on insomnia treatment led the National Institute of Mental Health, in 2005, to conclude that only two validated treatments existed for the effective management of chronic insomnia:

(1) Benzodiazepine hypnotic medications, such as Ambien and Lunesta, and
(2) Cognitive Behavioral Therapy for Insomnia (CBTI).

Sleep medications, both prescription and over-the-counter, constitute the most widely employed form of insomnia intervention.

In a recent, widely popularized, yet controversial, study published by a renowned San Diego sleep physician, Daniel Kripke, the safety of sleep medication use was seriously called into question. (See Dr. Lee Rice’s article on the subject, Sleeping Pills and Early Death.) The study found that sleep medication use, even for brief durations, was associated with significantly greater risk of premature death and elevated cancer risk. While the study did not demonstrate a causal connection between hypnotic use and mortality, the findings rekindled concern felt by many healthcare providers and insomnia sufferers alike about the long-term use of hypnotic drugs.

By contrast, CBTI is a treatment intervention with origins in behavioral and cognitive psychology, hence the name “cognitive-behavioral”. CBTI is a constellation of validated treatment strategies aimed at improving sleep through non-pharmacological means.

The first step in CBTI is to conduct a functional analysis of the problem by identifying all active contributing factors. Medically-based causes are treated through medical channels. CBTI then addresses the remaining so called “primary” insomnia factors which include such things as conditioned arousal at night, circadian rhythm disturbance, sleep fragmentation, problematic sleep-wake behaviors, and anxiety-provoking thoughts and beliefs about sleep. This subset of perpetuating factors is remarkably common among most insomnia sufferers and consequently can be addressed through a structured program that is deliverable in individual or small group formats. The typical CBTI program is comprised of a number of weekly or bi-monthly treatment sessions conducted over the course of 5 to 8 weeks.

Controlled, randomized studies on the efficacy of CBTI versus hypnotic drugs have shown that after about six weeks of therapy both groups show improvement and to about the same extent. Long term follow-up (1 year post-treatment) data however consistently show that only the CBTI-treated patients retain their treatment gains.

It is believed that CBTI yields longer lasting sleep improvement because, unlike sleep medication, CBTI targets the causes of insomnia not just its symptoms. The drawbacks to CBTI are that it takes longer to “kick in” than does a sleeping pill and, as with any lifestyle change program, success is largely dependent on the patient’s level of commitment and follow through with the treatment recommendations. One of CBTI’s biggest strengths is that it has no known side effects!

Dr. Derek Loewy is the Director of the Insomnia Program at The Integrative Insomnia & Sleep Health in San Diego. He is a licensed clinical psychologist and board-certified sleep specialist and certified behavioral sleep specialist. Dr. Loewy earned his doctoral degree at the University of Ottawa, Canada in 1996 and completed his sleep medicine fellowship at the Stanford Sleep Disorders Center in 2001 where he co-founded the Stanford Insomnia Program.

• Melanoma is the fastest growing cancer in the United States and worldwide.
• One-in-50 Americans has a risk of developing melanoma over their lifetime.
• Although the mean age at diagnosis is age 50, this is a cancer that affects a younger population than most cancers.  Melanoma is the most common cancer for young adults (ages 25-29) and the second most common cancer in adolescents and young adults (ages 15-29).
• The incidence in people under 30 developing melanoma is increasing at a faster rate than any other age group.  For young women, the rate has risen by 50% since 1980!
• According to the National Cancer Institute, it’s predicted that in 2012 76,250 people will be diagnosed with melanoma, causing 9,180 deaths and that’s just in the United States.
• This means that every eight minutes, someone in the US will be given a diagnosis of melanoma…and that every hour someone will die from the disease.

Risk Factors

Genetics and exposure to UV rays from natural sunlight or artificial sources (tanning salons) are the two greatest contributors to melanoma.  Individuals with a family history of melanoma or a prior personal history of any type of skin cancer have a higher lifetime incidence of melanoma.  The use of tanning beds before the age of 30 may increases your risk of melanoma by 75% percent.  Even occasionally using tanning beds can triple your chances.

The risk of unnecessary exposure to natural or artificial light has been well established.  And although it is common sense to avoid exposure to these light sources, it is important to note that melanoma may occur anywhere—even where the skin is not exposed to light.

Melanoma can occur in the eye, the mucous membranes (such as the mouth) and even underneath the nails.  While melanoma does occur more frequently in people who have fair skin, light hair, and light eye color, darkly pigmented skin does not eliminate the risk of melanoma.

Having numerous moles (> 50), particularly if they are ‘dysplastic’ or abnormal appearing, puts you at an increased risk of developing melanoma.

For more information, read our newsletter article Fastest Car, Fastest Athlete…Fastest Growing Cancer in the US?  To see illustrations of common moles check out the National Cancer Institute’s Melanoma FactSheet.

About the Author: Anne Boyd, M.D., FACSM brings over 17 years of both family and sports medicine experience to Lifewellness Institute. She has been recognized as a “Top Doctor” by Pittsburgh Magazine 4 years in a row, and has published countless research articles and presentations.

Flash forward to modern day.  Proponents of colon cleansing, colonics and colon irrigation believe that toxins from the gastrointestinal tract can cause a variety of health problems such as allergies, arthritis and asthma. They believe that colon cleansing can help cure these diseases.  There are claims by practitioners of colonics and manufacturers of colon cleansing products that state weight loss, treatment of irritable bowel syndrome (IBS), and detoxification are the results of their product or service.  The reality is that none of these claims is supported by sound evidence.  Studies have concluded that these claims mislead patients.

The digestive system and bowel naturally eliminate waste and bacteria; colon cleansing may disrupt the balance between bacteria and natural chemicals in the bowel.  Some colonics and cleansing supplements can be dangerous.  They can increase risk of dehydration, and of bowel perforation.  Some herbal cleansing programs can cause an imbalance of electrolytes in the body that can be very dangerous, possibly leading to kidney failure or heart disease if used incorrectly.  People with a history of gastrointestinal disease, such as diverticulitis, Crohn’s disease or ulcerative colitis, are at higher risk for complication.

If you choose to participate in colon cleansing for purposes other than as a preparation for a medical procedure, such as a colonoscopy, please check with a traditional medical practitioner first, showing him or her a list of specific products to be used.  Stay well hydrated with oral fluids and make sure that any colon cleansing practitioner uses disposable equipment so as not to spread infection.

Although most medical providers prescribe colon cleansing in preparation for procedures, most do not recommend using colon cleansing for detoxification or treatment for disease.  The best way to take care of your colon is to drink plenty of fluids, eat a diet high in fiber and get regular exercise.

Groupon (and the like).  If you’ve considered hot yoga but didn’t want to commit, online coupons may be for you.  From gyrotonics to piloxing, ballroom dancing to crossfit, you can find great local discounts on classes or training sessions that you’d never try out at full price.

REI.  Absolutely one of my favorite stores for exploring outdoor activities, your local REI will often put on introductory classes & outings for activities like paddling, backpacking, climbing, etc.  They even have classes for GPS navigation, digital photography and stewardship.

Act Like a Tourist.  Sometimes, as a local, we get too used to our environment (I’ve lived in San Diego for 10+ years and still have not been in Sea World).  After finding your local tourist page, check out what’s recommended under sports and recreations.  Things that you haven’t thought about for years will come bounding forward; kayaking, golfing, places to hike and skateboard parks are all waiting for your rediscovery.

Remember – keep your exercise fun and you’re more likely to stick with it!

About the Author: Quan Campbell MBA, MS, RCEP is President and Clinical Director for Lifewellness Institute. Her field expertise in athletic training, injury rehabilitation and team coaching serve as a launching point for designing effective wellness programs for individuals, corporations and athletes.

Here are a couple things to keep in mind:

• Training Routine.  Provide an option for a training program.  Too many people injure themselves or just get turned off by exercising too much at too high of a pace… a proper training program allows people to gradually ramp up and helps them succeed.

• Talk to the experts.  Prevention is key when it comes to sports injuries.  Have the local running store come in and talk about proper shoe fit & socks.   If you can organize it, maybe take the team to an expert… your local bike shop would most likely be happy to put together a quick presentation on bike fit, if it gets a good handful of people in their store.
• RICE.  Most mild aches, pain, bumps, strains & sprains can be handles with RICE.  That’s Rest, Ice, Compression, Elevation.  Injuries that persist should be seen by a medical professional – but the RICE method is great for immediate minor injuries.
• Stretch.  Provide a sport-specific stretching routine for your team; flexibility is just as important as strength.  Consider posting the stretches at shared printers or copiers so that people can do just one or two while they wait!

About the Author: Quan Campbell MBA, MS, RCEP is President and Clinical Director for Lifewellness Institute. Her field expertise in athletic training, injury rehabilitation and team coaching serve as a launching point for designing effective wellness programs for individuals, corporations and athletes.

The idea is that each of the 461 main points has a very specific physiological effect upon the body.  Recently, a study at Loma Linda Hospital using advanced PET scans of the brain validated this; a scan of the visual cortex within the brain was mapped before and after points correlating to eye problems were needled.  After stimulation of these points, there was a clear effect within the visual cortex, providing acupuncture with vital scientific validation.

Acupuncture was introduced into the United States in 1970 when President Nixon visited China.  His press secretary had an emergency appendectomy in which only acupuncture was used as anesthesia. This procedure was so effective that doctors from UCLA visited China and began using acupuncture in their pain clinic in conjunction with conventional therapies.  These procedures continue to this day.

In the last twenty years, acupuncture has seen an explosion in use and recognition.  Most notably, its ability to reduce pain has been documented time and again.  Scientifically, this phenomenon has been explained by studies in which acupuncture caused the brain to release powerful neurotransmitter substances called endorphins. These chemicals are believed to be more powerful than morphine in controlling pain.  Recent studies have also shown acupuncture to have strong anti-inflammatory effects on traumatic injuries while improving circulation to injured areas.  For many years, acupuncture with its pain reducing ability was thought to be appropriate only for short-term symptomatic relief.  However, with these new properties coming to light, it is now accepted that acupuncture can help speed up the healing process with traumatic injuries such as neck and back strain, tendonitis and chronic headache.

With scientific studies finally shedding light on acupuncture’s healing potential, Western doctors are beginning to integrate this non-drug therapy into their patients’ treatment plans.  Most major insurance companies are also seeing the benefits with increased coverage of acupuncture for structural problems. As of 2007, acupuncture is also part of California workers compensation law, allowing injured workers to utilize this modality as part of their healing process.

The future of acupuncture is incredibly bright as new studies are showing benefits in many other medical conditions such as digestive, gynecological and infertility problems.  Others are using acupuncture for stress relief and immune system enhancement with great success.  As Western medical research uncovers more about the uses of acupuncture, this traditional method of healing will undoubtedly continue to grow in popularity.

About the Author, Linda Codianni: After attending the University of Connecticut, Linda began working in computer operations in Connecticut.  Her move to California in 1983 was also the beginning of a new career in technical communications.  Over 20 years in publications for a software company prepared her for writing and editing corporate collateral, newsletter articles and blogs for Lifewellness Institute.

Hair loss can occur in both men and women, and is usually a consequence of aging.  That being said, there are some medical conditions and medications that can cause hair loss and balding.  Most of the products that are sold “over the counter” have no proven effect, but there are two prescription medications that have been proven, with clinical trials, to slow hair loss.

Minoxidil, or Rogaine as it is commonly known, had an interesting beginning.  It was originally introduced to lower blood pressure.  It worked well but patients reported the unusual side effect of preventing or reducing hair loss.  During subsequent clinical trials, it was discovered that rubbing a 2% solution on the scalp actually was effective.  In 1988 the FDA approved Rogaine as the first safe and effective pharmaceutical to prevent hair loss.  There is also an extra strength version that is a 5% solution.   This medication is approved for use by women as well.  The drawback to this treatment is that it must be used regularly and when stopped, the hair loss will resume within a few weeks.  It also doesn’t work for everyone, some people show no increased hair growth, some a peach fuzz effect and for the lucky cohort, moderate hair growth.

Finasteride (Propecia) is the only other drug approved by the FDA to treat hair loss.  This medication was initially approved for treatment of enlarged prostate glands and for treatment of prostate cancer.  It is not approved for use in women and should not be handled at all by pregnant women as it may harm the fetus.  Side effects can be a reduction of libido but that is not very common.

There are some current treatments in development, including gene therapy, to reduce hair loss and laser treatments.  There are also some natural treatments, such as taking Saw Palmetto, but these therapies have no medically proven results at this time.

Hair loss can also occur in women and has two common origins.  First, thinning hair is common after age 50 due to decreasing estrogen levels, in essence leaving too much testosterone.  This is called Androgenic Alopecia.  Treatments for this can range from using Rogaine, to estrogen replacement, oral contraceptives or the medication, Aldactone.  The second cause of hair loss is called Alopecia Areata, which is an autoimmune disease where hair loss is in discrete areas of the scalp, but can spread to the entire scalp.  The usual treatment for this is steroid therapy.

Certain medical conditions such as hypothyroidism can also cause hair loss.  This is easily reversible with thyroid replacement medications.   Several medications have also been linked to hair loss.  With the exclusion of agents used to treat cancers, the occurrence of this side effect is quite rare.  Some of the reported medications include: Accutane, Warfarin, Allopurinal, Acyclovir,  amphetamines, androgens, antifungals, and ACE inhibitors.

In short, there is no permanent solution to counteract baldness at this time.  The good news is there are treatments such as hair transplantation available as well as some new research being done on therapies.  Most importantly, thanks to movie stars like Bruce Willis and Vin Diesel, athletes like Kelly Slater and even female actresses shaving their heads to appear bald…..think Demi Moore and Natalie Portman…  bald is beautiful!

About the author: Cheryl Lee, FNP received her bachelor’s degree from UCSD and her Master’s degree in Nursing from USD. She is certified as a Family Nurse Practitioner and is an active member of the American Academy of Nurse Practitioners.

Tylenol:

The active drug in Tylenol is acetaminophen, which can readily be found in its generic form at most stores.  It’s safe & effective for pain & fever relief in all ages.  Tylenol is also safe to take in all trimesters of pregnancy.

Advil (or Motrin):

The active drug in these brands is ibuprofen, also available in its generic form.  In addition to providing pain & fever relief, this drug also has anti-inflammatory aspects.  So if you’re in pain from a swollen ankle, this drug is likely to be a better option than Tylenol.  Unfortunately, Advil is NOT advised for those that are pregnant.

Aspirin:

Finally, the active drug in Aspirin is acetylsalicylic acid.  Aspirin provides fever & pain relief, some anti-inflammatory help and acts a blood thinner.  This drug is not advised for some children who have viral illnesses.  Aspirin is relatively safe in small doses during the 1^st & 2^nd trimesters of pregnancy.

Dosage:

As always, follow the dosage recommended on the medication.  More does NOT mean better; as there are often side effects such as stomach upset, ulcers and bleeding, especially when people mega-dose.

About the Author: Quan Campbell MBA, MS, RCEP is President and Clinical Director for Lifewellness Institute. Her field expertise in athletic training, injury rehabilitation and team coaching serve as a launching point for designing effective wellness programs for individuals, corporations and athletes.

Cell Phones: The World Health Organization (WHO) announced on May 31, 2011 that it considers the radio frequency electromagnetic fields emitted from cell phones as “possibly carcinogenic”.  Research has shown that cell phone usage directly affects brain glucose metabolism.  Using a cell phone has been shown to increase glucose metabolism, which is a marker of brain function.  Areas of the brain that were closest to the antenna of the phone were affected, showing some amount of radiation uptake.  Cell phones weren’t widely used until the last 10-15 years so it may be too early to accurately predict how the effects of cell phone usage will be linked to brain cancer in the future.  The research results are somewhat inconsistent currently but should not be ignored.  Interestingly, there is current thought and potential research projects involving the use of cell phones as therapy for patients who require brain stimulation.  There is evidence that the father away the phone is from the brain, the less the brain is affected.  So, use your speakerphone, blue tooth and headset.

Microwave Ovens: Microwave ovens are operated by high frequency electromagnetic waves that permeate food, causing molecules to vibrate, causing heat.  It is known that microwave radiation can heat body tissue in the same way it heats food.  The FDA states that a person can be exposed to radiation if microwaves don’t completely seal.   Although this sounds frightening, we don’t need to give up the convenience of the microwave oven. Modern microwaves are built to protect against leakage.  Faulty door seals are the most common cause of leakage.  Slamming the door repeatedly, build up of dirt or general wear and tear are the top offenders.  The FDA advises that the door be checked for cracks or misalignment often and don’t stand directly in front of the oven when operating.

X-rays and CT Scans: X-rays and CT’s are powerful and indispensible diagnostic tools for clinicians.  They do, however, emit radiation and should be used judiciously.  The average dose of radiation with an x-ray or CT scan is low but the effect is cumulative.  Research to measure a direct link from these diagnostic tools to developing cancer is difficult to measure as the latency period can be up to 20 years before a tumor develops.  Common sense dictates using these diagnostic tools when needed, while at the same time only when needed.  As an aside, MRI uses a different technology.  It uses a powerful magnetic field and radio waves.  It does not use ionizing radiation like x-ray.  Radio waves can be considered radiation, but the amount is much less than x-ray or CT.

Using techniques to minimize exposure to radiation makes sense; wearing sunscreen when outside, and sitting in the aisle seat rather than the window when flying is a good idea.  Use a headset, Bluetooth or speakerphone when using your cell phone. Check your microwave door on a regular basis and repair any defects immediately. Lastly, do your best to minimize optional x-rays and CT scans.  That being said, if these diagnostic studies are recommended by your health care provider, know that the benefit has been determined to outweigh the risk.

About the Author: Cheryl Lee, FNP received her bachelor’s degree from UCSD and her Master’s degree in Nursing from USD. She is certified as a Family Nurse Practitioner and is an active member of the American Academy of Nurse Practitioners.

We have more power than we realize to heal ourselves by making choices that move us in the direction of better health.  The key is recognizing those opportunities to improve our health and wellness.

While thousands of years have passed since Hippocrates’ days, his beliefs are still relevant today.  It can be easy to blame external factors for our illnesses (“well my mother and sister are overweight and have diabetes, so it’s in my genes” or “my spouse really likes fried food, so I can’t really give that up” or “my job is so demanding, and exercising is impossible, so being in better shape isn’t an option for me”).  Statements like these point a finger at these situations as if they are “supernatural” forces.  Just like the ancient Greeks, we can still fall into the same trap of not taking responsibility for our health.

The good news is that regardless of our individual wellness “realities”, we can help determine the outcome for ourselves. With that in mind, what kinds of opportunities have you taken lately or, would like to take, to move you towards better health?

About the Author:  Kelly Rice, MFA is a Master Coach and has extensive experience coaching people towards a better lifestyle.  She coaches both in English & Spanish here in the United States and England.