PTW: June 2017

HEALTH | EDUCATION

David Senoner Former Skiing Professional and Previous Athlete in the Italian Winter Sports Team

GLOBAL DEVELOPMENT | VOLUNTEERING Edition 5 Volume 3

CONTENTS FEATURE INTERVIEW

David Senoner Former Skiing Professional and Previous Athlete in the Italian Winter Sports Team

The Nine New Postures

For every condition, symptom or disease that impacts our health and wellbeing, a medication is more than likely what we will turn to. Although not all of us will experience different medical conditions or illnesses, almost every person who has access, will use a medication occasionally or in their daily lives.

Whilst the process of taking medications is globally a common phenomenon, medication errors occur very often. A “medication error” is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer.

A medication is a drug or other form of medicine that is used to treat or prevent disease. Even herbal remedies, vitamins, supplements, tablets, patches, vaccinations, pills, inhalants, injections, creams, pastes and other substances are medicines if its function and purpose of use is to treat or prevent disease. This doesn’t mean that everything claiming to be a medicine does treat or prevent disease, it simply means that any drug or substance that does treat or prevent disease can be considered as a medicine.

At a glance, most people would think that medications are not a big issue; right? If so, the World Health Organization (WHO) decision this year to prioritize Medication Safety with aims “to reduce medication errors by 50% in the next five years” seems quite unnecessary.

The practice of taking medication is so old that Ancient Mesopotamian artefacts illustrate the practice and use of medicine from the 18th century BCE, and today modern medications have become part of our modern lifestyles with the potential to extend our life expectancy by decades and drastically improve our quality of life. If you’re wondering just how much medications play a role in daily life, a research study of 500 random seniors above 70 years of age in the United States found that:

take 4-or-more prescription medications

take 6-or-more prescription medications

Well, last year the WHO released a document of data addressing the Global Challenge of Medication Safety which outlined: “Unsafe medication practices and medication errors are a leading cause of patient safety incidents...” [more in next page]

Unsafe medication practices and medication errors are a leading cause of patient safety incidents in countries across the world.

In the United States alone, it is estimated that as many as 1.5 million patients are harmed and hundreds of thousands are killed every year because of the medication safety issue. The incidence is similar in Europe. Statistics in low- and middle-income countries are limited and vary widely, indicating that the true burden of unsafe medication practices is grossly underestimated.

Worldwide, the cost associated with medication errors has been estimated at US$42 billion annually. This is almost 1% of total global health expenditure.

Another report shows that ‘Medication Errors’ are the eighth leading cause of death in the US with more than 98,000 mortalities annually, exceeding those from car accidents, breast cancer, or AIDS. We’ve all seen a lot of much-needed public awareness for these issues, but why not medication errors?

WHO EUROPE REPORT THAT IN EUROPE: •

medical errors and health-care related adverse events occur in 8% to 12% of hospitalizations

•

23% of European Union citizens claim to have been directly affected by medication error

•

18% claim to have experienced a serious medication error in a hospital

•

11% claim to have been prescribed the wrong medication

•

50% to 70.2% of medication errors can be prevented

THE BODY COCHRANE REVIEWED MULTIPLE STUDIES TO FIND THAT: •

20% of geriatric (senior) patients were readmitted to hospital within 6 months of a previous admission to hospital due to drug-related incidences

•

10.6% of admissions to Intensive-Care-Units in hospitals were found to be drug-related

The issue of medication safety is a genuine issue impacting every person and even many animals, our hospitals, communities and homes; and the WHO believes that the full cost and severity of medication safety errors is much larger than what they have calculate.

WHERE ARE THE MEDICATIONS COMING FROM? Medication errors come from every step in the chain of obtaining a medication to taking a medication.

When we put all of this onpaper, the issue becomes very complex:

THE 2 KEY AREAS: PRESCRIPTION MEDICATIONS

OVER-THE-COUNTER AND NONPRESCRIPTION MEDICATIONS:

A medication ‘prescriber’ is a person who has legal authority to authorize the use of a medicine or treatment. A ‘prescription’ is the instructions by a prescriber for a treatment or medicine. Different medications can be prescribed by a range of health professionals around the world depending on the national laws. The majority of prescribing globally is by doctors but other health professionals like dentists, optometrists and pharmacists have certain prescribing capabilities in different countries.

Globally, ‘prescription medications’ can only be legally supplied by a pharmacist after consent from a legal prescriber.

Not all medications require a prescription and these are typically known as an ‘over-thecounter medications’ (OTC). Common OTCs include certain pain medications, vitamins and supplements. These OTCs will be available in pharmacies, but depending on the national laws, some OTCs will be available from supermarkets, health food stores, online stores and other commercial vendors. Herbal medicines and health products are also becoming increasingly popular that don’t need a prescription or medical authority to prescribe or a pharmacist to sell.

PROBLEMS WITH PRESCRIBING: ‘Prescribing errors’ are a major part of medication errors. By this, we mean one of two things: 1. prescribers making mistakes in their choice of medication 2. prescribers making mistakes in writing the prescription A study published in the British Journal of Clinical Pharmacology last year found that 36.1% of patient’s medication charts within UK hospitals had errors.

In the European Journal of General Practice studies looking at GP doctors in the community found that: •

Of 3,948 prescriptions reviewed in Europe, 12.4% contained one or more errors

•

Of 8,686 medication items reviewed in Europe, 6.2% contained one or more errors

Multiple studies around the world have found common reasons for why prescribing errors occur globally and what causes medications to be given incorrectly. The most universal reasons globally are:

• • • • •

Staff shortages Heavy workloads Time pressures Distractions from having to multi-task Misinterpretation of the prescriptions and medication charts

Some countries are struggling more than others.

According to the WHO, the average density of the health workforce in Southeast Asia is 4.3 per 1000 population, far less than that of Europe and the United States. Countries like Vietnam, Myanmar, Laos and Cambodia fail to meet the WHO’s basic healthcare standard of 2.28 skilled health workers per 1000 population. Indonesia and Thailand barely reach this target; whilst Malaysia and Singapore are exceptions.

Even countries that do meet the WHO basic standard are struggling. Unbalanced staff-topatient ratios due to high population growth and shortages in healthcare professionals lead to long working hours without breaks, multitasking, an uncongenial environment and sleeplessness; all of which are serious causes of accidents, skipping or violation of procedural steps leading to prescribing errors.

UNNECESSARY PRESCRIBING: Another issue is unnecessary prescribing. This means, the prescribing of medications that were not required and did not result in beneficial health outcomes; or medications prescribed that would have other evidence-based non-medication treatments that might be more effective.

Last year it was published by JAMA and the Centres

for Disease Control and Prevention that at least 30% of antibiotics prescribed in the United States in 2016 were unnecessarily prescribed, and of those that were necessary, many still had prescribing errors. This included both hospital and community doctor prescriptions. The issue of unnecessary prescribing is not just an issue for antibiotics, but the whole gamut of medications in general.

PRESSURE ON TAKING MEDICATIONS: One of the most controversial areas of prescribing is the influence of pharmaceutical companies on the habits of prescribers. In many countries, it is legal for pharmaceutical companies to form publicrelations with doctors, and this has been criticized for causing unnecessary and poor prescribing. A systematic review of the influence of pharmaceutical companies on prescribers found that exposure to information from pharmaceutical companies was associated with either lower prescribing quality or no other detectable connection. Similarly, exposure to information from pharmaceutical companies was associated with either an increase in prescribing frequency or no other detectable connection.

Another controversial reason for unnecessary prescribing in some studies has come from patients

themselves demanding medications. Findings from a survey by General practitioners across the United States showed that some patients are not satisfied unless they leave the medical clinic with a prescription for a medication. The studies found many patients would rather take a medication to manage their condition rather than looking to non-medication approaches such as exercise, other physical therapies or lifestyle modifications such as changing their diets. Part of this pressure has been linked to advertising pressures from pharmaceutical companies to the patients directly. Medical advertising pressures directly to consumers. An American study in 2013 showed that patients who requested advertised drugs were nearly 17 times more likely to receive one or more new prescriptions than patients who did not request any drugs.

PRESSURED TO SELL MEDICATIONS: Even pharmacies, health shops and supermarkets that do marketing and advertising have contributed to unnecessary prescribing, with studies suggesting that pharmacists and pharmacy workers feel pressured to sell patients a medications or health

products such as OTCs even if they don’t feel it is necessary, and many health shops advertise and push product sales that have no evidence for their product’s use, value or even safety.

THE DISPENSING OF MEDICATIONS: In most countries, pharmacists are the ‘gatekeepers’ to medications. ‘Dispensing’ is the term used to describe the reviewing and then supplying of medications to a patient or customer. Whilst doctors can prescribe medications as much as they want, it is the responsibility of pharmacists to ensure medications are safe and the right choice for patients. Sometimes an error occurs in this process.

• • • • • • • •

Several studies across America, Australia, Europe and South-East-Asia and Finland have found several main categories of potential causes of dispensing errors by pharmacists:

•

Being too busy Being short-staffed Being under time pressures and stress Being subject to time constraints Fatigue of providers Interruptions during dispensing Look-alike/sound-alike medicines Lack of knowledge of the patients medical and medication history Lack of resources

TAKING MATTERS INTO OUR OWN HANDS Prescribing errors by the professionals is a concern, but does that mean we should take matters into our own hands and bypass them?

If you developed a headache, it would be safe to assume that you would probably take some sort of tablet, pill, herbal liquid or other product to supress

this headache pain. In fact, a study by the Journal of Pakistan Medical Association researched 248 individuals above the age of 18 to find that 81.7% of them would self-manage their headache. Of this group, 95.5% of the population would turn to a type of medication to treat their headache.

HIGHLY RISKY EASE OF ACCESS Some OTC medications such as pain relief medications and vitamins can be bought in supermarkets and stores without a pharmacist, and depending on the country you live in, herbal remedies, supplements and some other medications can be marketed, advertised and sold claiming health benefits but without any substantial evidence to support their claims. Even more concerning is that through the internet, people are finding ways of buying prescription medications through online stores without any health professional advice or recommendation or legal prescription.

Before you think that OTC medications can’t lead to serious health implications, consider a study by The International Journal of Drug Safety reporting that: •

from 6,887 patients admitted to hospital with adverse drug events (ADR), 53.8% of admissions were due to OTC medications.

ADRs are harmful and unintended responses to medications that occurs in, what is considered, normal doses for a human. So just because you’re following the instructions on the box, it doesn’t mean it is safe for you or that you have all the information you need to take it safely.

One group of medications that has led to hospital admissions globally due to ADR are non-steroidalanti-inflammatories (nsaids) such as ibuprofen.

Ibuprofen can be obtained without any medical input in many countries. Yet, Ibuprofen cannot be taken by certain people with certain medical conditions, needs to be taken with food and should only be taken for a certain duration before a doctor’s input is needed. Yet, this product can be purchased at supermarkets or online in large quantities without any professional advice and guidance.

POOR EDUCATION, POOR HEALTH Part of the issue with the ‘self-prescribing’ is where we get our information from. A study by an Australian medical school reviewed magazines with the word “health” in their title which were portrayed to be giving good health advice. The study found that these magazines had poor use of evidence and the advice wasn’t based on reliable evidence or medical guidelines. There was also a lot of health product placement and push to take certain products, particularly vitamins and minerals and supplements that were paying for their product to be in the magazine.

A similar issue exists in mainstream media, TV commercials, internet sites and, well, almost anywhere that a product or health topic can be discussed. Product placements and advertisements are very good at persuading people into thinking their product is not only the best for you, but

also convincing you that you need the product or should try it. Unfortunately, even some health professionals have used their degrees to market health products for their own profit interest. It was only a few magazines ago that we looked at how Dr Oz was taken to court in America for marketing a weight-loss pill that had no evidence for its effect and made false claims about the product.

Journalism, internet groups and mainstream media have often misrepresented medications and in doing so, mislead the public in the attempts of creating a big story. Some of these stories create misleading fear around medications which lead people to stopping the medications which they genuinely need to take, or convince people to take medications or health products unnecessarily, prematurely promising ‘cures’ or ‘the future of treatment’.

THE MANAGEMENT OF THE MEDICATIONS: Even if the right medication is prescribed correctly and dispensed properly, this doesn’t mean people are taking medications properly. The word ‘adherence’ refers to the extent to which a person’s behaviour—taking medication, following a diet, and/or executing lifestyle changes—corresponds with agreed recommendations from a health care provider.

Taking medications incorrectly leads to an increase in poor health and possibly death, with an approximated cost of $100 billion per year globally. This issue has major implications for global health, such as the research showing how Tuberculosis medications have developed resistance due to poor adherence to antibiotics.

Research over the past decade by the WHO found:

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•

WHAT IS RESISTANCE?

approximately 50% of patients with chronic illnesses do not take their medications as prescribed.

PTW: AUGUST 2016, PAGE 58

Some of the reasons for poor compliance and adherence by patients include: Lack of understanding of their disease: It makes sense that patients who don’t understand their disease, they won’t see the need or benefit of taking their medications or what the objectives are for managing their condition.

Lack of concordance: Some people refuse or ignore the doctor’s or pharmacist’s advice because they felt it was an order or forced command without discussion of their comfort and willingness to take the medication.

Lack of explanation as to the benefits and expected side effects of medications: If the person doesn’t understand the value of the medication or what to expect, they’re unlikely to continue taking it; especially in the case of medications which don’t always have obvious positive effects and can often have unpleasant side effects.

Lack of ability to take medications: Some people have swallowing difficulties, making it hard for them to take tablets or capsules, and some people have physical difficulties like arthritis that makes it hard to open medication containers or use asthma pumps and other medication devices.

Cognitive difficulties of the patient: If a person has issues remembering when and how to take medications, then they’re at high risk of take them incorrectly or inconsistently .

Unaffordable medication regimes for patients: Simply put, if you don’t have the money, you can’t have the medication. This was an issue that made headlines in America, where Turing Pharmaceuticals increased the cost of their lifesaving AIDS drug by 5000% which thousands of people depend on to live but could not afford after the price-hike .

POLYPHARMACY: One of the biggest issue is complex drug regimens and polypharmacy. This involves taking multiple medications, often for multiple conditions.

In an American study: •

nearly 20% of surveyed seniors either taking five or more prescription medications or above the age of 65 have reportedly experienced challenges in managing their medication regimen, including keeping track of which medications they have taken and when, opening medication containers, using medication devices, reading and understanding directions and remembering to order refills on medications when they had run out

•

10% of surveyed seniors had unintentionally made a mistake when taking medications, which could have resulted in devastating effects

As both age and the number of prescribed medications increased, so too did the risk of errors occurring with medication management.

The American Centres for Disease Control and Prevention reports that over 100,000 senior adults end up in the hospital each year because of an adverse drug event.

POOR COMMUNICATION In many cases, poor communication might be a big link between poor prescribing and poor adherence of medications. A study in Adelaide, Australia found 24% of patients admitted to hospital were taking herbal remedies but only 4.2% of the patients taking a herbal preparation had its use documented.

For the most part, herbal preparations had not been specifically investigated by a health professional, nor did the patient associate this with being a medication. Many herbal medications caused problems for patients including toxicity from the herbal remedy itself, and also impacted on the effect of other prescribed medications that resulted in poor health outcomes for the patient.

Whilst the patients may not communicate enough to health professionals, sometimes health professionals may not communicate enough to patients. A study in Dubai UAE reviewed 1600 patients and over 700 pharmacist-patient

encounters and reviewed the counselling (the education and information) given to patients from the pharmacists.

•

72.1% of patient counselling interactions were considered brief, basic and nonindividualised

•

Less than 1% reached a stage considered detailed, interactive and a collaborative discussion.

Despite this, the overall satisfaction score of this counselling from patients was 4.71 out of 5.

Within the same study of 1600 patients: •

41.8% of patients who were coming to get a medication they have been taking for a long time, believed that they needed counselling but did not receive any from the pharmacist

•

manage access to medications and health products obtained through new age technology and ensure they are being taken under health professional supervision

•

work with pharmaceutical companies to ensure that medications are affordable and accessible for everyone who needs them

•

manage and regulate medication prices

•

implement and provide the technology that connects all healthcare providers with realtime patient medical and medication history

•

resourcing and supporting pharmacies to provide better medication management services

•

recognizing and promoting medications as a matter of healthcare and service to patient health management rather than a matter of business and products sales

TIME TO CHANGE CULTURE All these studies have highlighted several wellknown reasons for medication errors. It’s easy to start a global blame-game, but the reality is that it is no individual, or group’s fault. In many cases, the issues reside in the global culture around medications. This includes how we think about medications and how we see medications and their priorities in our life. Whilst every country is at a different stage, globally there are a few uniform areas that need changing by global leaders and governments including the need to: •

manage pressure on healthcare workers by funding appropriate staffing and resources

•

implement better regulations and restrictions on the advertising of all medications and products marketed for health by pharmaceutical companies, health product producers and suppliers

•

implement better regulations on the influence of health product producers and suppliers in mainstream media

HOW YOU CAN MAKE ALL THE DIFFERENCE: Whilst governments and medical bodies around the world have a significant role in meeting the 5 year WHO Challenge, even you can make an enormous difference. Here are a few key points that you can use in your own life to make medication use safer.

DEVELOP GOOD CULTURE FOR YOURSELF AND OTHERS AROUND MEDICATIONS Develop a culture for yourself and others that promotes safety around medications by: •

Accepting that medications and health conditions are a normal part of modern society

•

Removing embarrassment, taboo or shame about having a health condition or needing to take a medication

•

Learning and thinking more about your medications and your health

•

•

•

When any medication is prescribed, there are a few questions the health professional needs to know to make sure the medication is safe and effective.

Each of these details is specific to each of us and will change person-to-person.

What your friend takes for a headache will not necessarily be the same as what you can take. This is because there are multiple factors that control what the right medication is for you including: •

Your age - some medications are not suitable for people in certain age groups

•

Accept that it is normal for people to struggle with taking medications and seek help in managing medications

Your medical history - some medications cannot be taken if you have certain medical conditions or a history of certain medical conditions

•

Keep a written or electronic diary about your consistency with taking medications

Your weight - certain medications have to adjust for your weight

•

Your general health and body functions some medications need to be adjusted for the way your body works including your metabolism, whether you are pregnant or breastfeeding

•

Other medications you are taking regularly or even occasionally - some medications cannot be taken with other medications and some medications have to be adjusted around your other medications including vitamins, supplements and herbal medications you might be taking

•

Your medication adherence - if you do have troubles with taking medications, don’t be afraid to tell your healthcare providers because it will impact their understanding of your health

Talking to your family members about your medications and theirs so you can help and support each other

•

Use alarm clocks or prompts to remind you to take medications at the right times

•

Be comfortable with asking your pharmacy or doctor for education and support with your medications

•

Keeping your medications organized and always check for expired medications or regular medications that are running out

•

Organize your medications in advance of traveling and talk to your doctor and pharmacist about your medications before traveling Think of medication safety not as avoiding errors, but making medications simple, safer and easier to use so you can spend more time doing the things you enjoy doing!

•

HELPING YOUR HEALTHCARE PROVIDERS

KEEPING PREPARED AND UP-TODATE Keeping a good record of your health is not only important for yourself, but also important in emergencies. Some of the details about your own health and medications you should always have accessible to you are: •

All the medications including vitamins, supplements, herbal medications and anything else medicinal that you take regularly and occasionally including: - the dose or strength of the medication (e.g. I take a 500mg tablet) - frequency (e.g. I take the tablet four times a day) - purpose of the medication (e.g. I take the tablet to manage my arthritic pain)

•

Vaccinations you’ve had in your lifetime

•

Allergies and reactions you’ve experienced to medications and foods

•

Medical conditions you currently have or have had in the past

•

Procedures and surgeries you have undergone

•

Medical tests you have had and their results

•

Family medical history

•

The contact details of your regular doctor

•

The contact details of your regular pharmacy

This information is essential to carry with you whenever you are admitted to a hospital, visiting a new doctor, going to a new pharmacy or other health professional so that they can make better decisions for you and your health. Your regular doctor and pharmacist should also have a copy of all this information and it’s important to update both if ever you make a change.

DEVELOP A GOOD RELATIONSHIP WITH A DOCTOR It’s important to find one regular doctor, rather than going to different doctors regularly. Having one doctor helps to build repour and trust between yourself and the doctor, makes it easier for the doctor to keep up-to-date with your health and your medications; which reduces the risk of medication errors, both short-term and long-term.

Discuss with your doctor that you want someone who: •

you are comfortable with

•

is willing to spend quality time discussing your medications with you

•

explains your medical conditions and the purpose of the medications that they prescribe

•

discusses non-medication options for your health conditions

•

reviews your health and need for medications regularly even if you’ve been taking the same medications for a long time

•

Is open to answering any of your questions no matter how ‘small’ or ‘simple’ you think they might be

If your doctor doesn’t do these things routinely, you have the right to ask the doctor to do these at each visit and any good doctor should be willing and open to doing so. If you think of a question or issue about your medications, write them down and take them with you next time you see your doctor.

DEVELOP A GOOD RELATIONSHIP WITH A PHARMACIST Building a good rapport with a regular pharmacist is just as important as building a good repour with a doctor. It is also important to build that relationship with an individual pharmacist, rather than the pharmacy shop itself. Pharmacists are easy-toaccess because you don’t need an appointment to see one, so they are a good first point-of-contact for general health and medicinal queries.

Each time you get a new medication from the pharmacist, even OTC or supplement, make sure your pharmacist has your full medical and medication history. Ensure that you give the pharmacist enough time to properly review your prescription and able to prepare the medications without rushing the pharmacist to reduce the risk of a medication error.

When a pharmacist recommends a medication or dispenses a doctor’s prescription, prompt the pharmacist to explain the treatment by asking the questions: a.

What is the purpose of this medication and how does it work?

b.

Can I take this medication with my medical conditions and allergies?

c.

Does this medication impact my other medications in any way?

d.

How should I be taking this medication and how frequently?

e.

Is this medication affected by food?

f.

How should I be storing this medication?

g.

What signs should I look for to know that I am getting the positive effects of the medication?

h.

What side-effects should I look out for and what should I do if I develop any?

i.

How long should I be taking this medication for?

j.

Under what circumstances should I be stopping this medication?

k.

When should I get this medication reviewed with my doctor?

Always ask to have information about your medications in writing when leaving a pharmacy.

It’s also useful to write down a list of questions and issues you have about your health or medications as they come to you, so that you are prepared to discuss them with the pharmacist at your next visit. Ask your pharmacist to go through your usual medications with you regularly and see if any changes or adjustments are needed or if there are better ways of managing your medications. Much like a doctor, if you don’t trust the pharmacist or the pharmacist isn’t taking time to discuss your medications with you, you can always go to another pharmacist!

BE CAREFUL WHERE YOU GET YOUR INFORMATION FROM Whenever you hear or read about health, medications or health products on the internet, in the media or in your social circles, it would be a good idea to discuss what you’re reading and hearing with your pharmacist and doctor before acting on the information. Advertisers, journalists, internet bloggers and magazines don’t know you or your health the way your doctor does and aren’t trained to make personalised medical diagnoses and treatment choices like a doctor. Similarly, supermarkets, health shops and online shops don’t have the knowledge or experience to check the safety of the medication for you or able to make a judgement on the appropriateness of a medication for you the way your pharmacist can. Of course, if you don’t trust one doctor or pharmacist, get a second opinion from another general practitioner or pharmacist!

When a pregnant mother goes into labour, medications are given to help the process. From the time of birth, the infant will be injected with several

medicines to develop the infant’s immune system and protect it against life-threatening illnesses. As the infant grows into a child and then teenager, medications will be used occasionally to help manage pain, headache, nausea, vomiting, infections, and acne. As the child grows into a parent, they may experience new health conditions such as diabetes, heart disease, depression, cancer and start taking 1 or 2 medications every day.

When the parent becomes a grandparent, they may now have multiple health conditions, taking 6 or 7 medications every day that can increase their life expectancy by another 10 years. Finally, at the end of this grandparent’s life, medications will be used to help give comfort and relieve this person of pain and discomfort in the last days of their lives. Medications play a silent role from birth to death at our most emotional life moments and most challenging times. As something that can save lives when used properly, or take lives when used incorrectly, they should be viewed seriously by all.

Nikki

Zahk

Chirag Lodhia, Editor-InChief PTW Magazine Clinical Hospital Pharmacist

Nikki is a 23 years old graduate from UNH May 2016 who was on the women’s varsity swimming and diving team there starting her sophomore year, and that’s when she really started getting into fitness and nutrition. Nikki has become a social-mediasensation for her fitness transformation and now created her own personal online fitness coach program. She creates custom fitness and meal plans to help people transform and live a happier, healthier lifestyles and so PTW talked to her about this transformation in health.

ka

Tell us about the transformation that has inspired and motivated many others to do the same: Although I was never obese, I was never comfortable or confident in myown body.

I always had a good amount of ‘chub’. My most insecure body part was always my stomach. I had “the pooch” all my life.

That chub roll along the bottom of my belly, around my waist for a good little muffin top. I would look in the mirror, grabbing what I didn’t like and pick myself apart of everything that was wrong and that I hated but for some reason I would turn to food for comfort which would only make it worse.

One day about 4 years ago now, something clicked and I decided to stop wishing I looked different and actually do something about it. I researched diets and exercises for months and committed my free time to reaching my new goals. Along the process I became more confident in myself not only from reaching goals of how I looked but the fact I was now aware I could set high goals for myself and reach them. Fitness and nutrition became an outlet for me and a sense of empowerment. It saved me.

I lost about 25 pounds within that first 6 months and after that I have been making new goals for myself and trying to build my strength and endurance to continue progressing.

What were your first steps and what were your first goals?

My first goal was to be comfortable in my own skin. I honestly just wanted to look in the mirror and be able to pick things I loved about my body instead of picking myself apart. A major goal was a flat stomach, I was always so self conscious about that bottom role and how my stomach had random bulges and rolls. Since I had already started to work out significantly more than I used to, my focus was improving my nutrition as well. I started doing my own research online and speaking with differentnutritionists and trying new recipes and diets. The best way to find out what works best for you and your body is to experiment! Yes, it takes a while and it can be frustrating, but it’s how you get those long term results.

During the transformation, did you have to try a lot of different exercise regimes before you found the one that worked for you?

To be honest I was lucky. I got thrown into a workout regime I loved right away. Since I walked onto a D1 sports team we had practice everyday, lifting 3 times a week, and additional workouts that were expected of us. I got to experiment with lifting with my team and our lifting coaches and find what exercises I liked and didn’t like, what I was good at, what needed to be improved, where my strengths and weaknesses were for my body. It was an eyeopening experience.

‘It’s similar to dealing with the passage of age. I’m just present with what I do and don’t worry about the time that is passing’.

How did your motivation change throughout your transformation?

When you’re first getting started you’re so motivated to reach those goals and just keep going.

As time goes on if you don’t see results right away it’s natural to get a little discouraged. I still have my on and off days, it’s work just to be motivated each day. But you have to remind yourself why you started and where you want to be in a few months.

Once you start seeing even the slightest results it’s that motivation burst all over again. Just keep working hard, it takes patience but you’ll get there.

How has your diet changed with the transformation?

The hardest part of the diet was definitely trying to cut out simple carbs. I would eat full loafs of bread and was one of those freshman who mix every type of sugary cereal in the dining hall. Being conscious of what you’re putting into your body and eating consciously helped tremendously. Having a food journal and tracking what I’m eating was the biggest help I think; actually inputting your meals and seeing the different macros and how much fat, calories etcetera, you’re having is a shock when you are so used to eating whatever youwant whenever you want.

What’s your favourite and most effective types of ways to stay healthy and fit?

Lifting is still my favourite workout days. I lift 3 days a week still and try to switch up my routine every few weeks to continue progressing and seeing results.

That is also part of my changing goals once you reach your initial goal it is far from over. Keep making harder goals and improving yourself each day! On the other days I like to mix up HIIT, Circuit training, yoga and different cardio.

Cardio is not my strong suit and I will most likely never love to run, but you can find so many other ways to be active and live a healthy lifestyle. Whether you love playing different sports, hiking, water activities like paddle boarding or rowing; switch it up! Keep it interesting and your body guessing, then you’ll never get bored.

How much of your transformation was about changing?

Transforming your body and your lifestyle is about 90% mental I’d say. In order to change your physical appearance your mental state needs to change first.

It’s a different way of thinking completely with everything you do. You have to motivate yourself to be active, to have self control, to make healthier choices each day. Whatever your mind believes, your body achieves. If you’re in the middle of a workout thinking “I can’t go any further”, “I can’t do this”... you won’t.

This is embarrassing but I often give myself pep talks in my head during

workouts. You have to motivate yourself to keep going somehow! I’ll make little goals during each workout too, like getting a certain number of meters, or minutes on the rowing machine, 2 additional reps in squats with the same weight as last week, 5 or 10 added pounds in a set; things like that. Getting there is a little victory. I give myself a “good girl” proud moment after each.

Once you went through your transformation, how did you change your lifestyle to maintain your transformation?

It’s continuing to make more goals. Don’t stop at that first goal no matter what it is, weight loss, muscle gain, toning, endurance, etc. Once you reach that goal, think about the next thing you want to accomplish. It’s a never ending cycle, that’s why they call it a lifestyle change not some quick fix.

With social media today, a lot of people focus on their looks to decide if they are healthy; what do you feel about this and people comparing themselves to the‘fitspiration’ photos out there?

Just be conscious of what you’re viewing. I heavily relied on social media accounts to get myself motivated when I first started, and I didn’t understand most of those people do not look that way 24/7. It’s often unrealistic goals. I try to post every once in a while, just to show how different poses or flexing can tremendously effect a photo. You are often seeing fitness leaders posting pictures of themselves flexing, in good lighting, or the right pose to look a certain way.

We all have our off days, feeling bloated, unmotivated, self conscious, or uncomfortable. It’s human nature, it’s natural. What you see on social media isn’t always what meets the eye and you need to remember that. It’s great to follow fitspiration accounts and there are so many amazing influencers who make it a point to advertise real beauty and show both sides too.

What positive transformations do you want for yourself, and the world in 2017?

I would like to continue my own transformation both mentally and physically and I’d love to be a part of other people’s journeys. What keeps me motivated now is hearing from people saying I have helped motivate them live a healthier lifestyle and find confidence like I did. Ultimately I want to inspire other people who are going through the same struggle as me and help people everywhere realize they are beautiful the way they are, but a healthy lifestyle will not only change your body but improve your self esteem, confidence, and respect for yourself.

You are capable of making any change you desire and I’d love to be a part of your journey and help along the way. ■

David

Senoner

David Senoner is a former Skiing Professional and previous athlete in the Italian Winter Sports team.

Battling multiple injuries and difficulties through his career at a young age, David talked to us about how he overcame obstacles and difficulties through his career and how we adapted to his situations to make the best out of every opportunity that came his way.

What motivated you to become a ski athlete?

I grew up in the north of Italy in an area called the Dolomites. My hometown has roughly 2,500 people living there so you can imagine it being a place where nature is the predominant factor.

Skiing was something that came naturally to me. I just remember it being the thing I loved the most. In high school I went to a school which has the best winter sport programme in Italy. It was where I tried to pursue my goal of becoming a professional alpine ski racer the best way I could.

What was the process of getting into the Italian Ski Team?

I made it into a junior national team selection at a very young age, when I was 15. It was a way of showing that the national team was considering you as a potential future member of the team. To me, this was a great experience.

I remember setting my main goal that particular year on entering the national team selection and it was all decided in one single race. The top 4 were able to make the team. I ended up 4th, and I remember the 8th being only four hundredth of a second behind me. This was one of the closest ski races I ever skied and the luck was certainly on my side.

How much training did you have to undergo and how important was it for you to mainTAin your own fItness and health ?

In summer I would ski roughly 40 days on Europeans glaciers, depending on the snow conditions, to prepare for the winter season. The rest of the time I would build up my physical strength with dryland training. I would train 6 days a week and on 5 days both morning and afternoon.

It was pretty intense but I was in a great shape. Skiing is a very complex sport. One needs endurance, strength, coordination, agility, speed. On top of this, as probably in most of the individual sports, the mental strength plays the biggest role I believe. In my opinion you can train this ability to a certain extent only, but the athletes that are the most successful, usually have a certain hunger for victory that is much stronger than anything else.

What did the training involve especially in the snow?

Alpine ski racing includes five different disciplines. Slalom, Giant Slalom, Super G, Downhill and combination.

Slalom is the slowest and most technical, downhill the fastest, where you reach speeds of up to 145 km/h.

So depending on the calendar and the competitions, I would train a different disciplines. My strength though was in slalom and giant slalom, the most technical disciplines.

Was training in the cold hard for the athletes and how did you overcome this mentally?

This might sound odd but most of the times it didn’t feel cold at all. I have experienced ski races with -28 degrees Celsius and that was really cold,

considering all you have on is a woollen sweater, long underwear and a very thin ski racing suit. But in Europe the driest season is winter, so it is usually very sunny. The sun reflects on the snow and often with minus 5-10 degrees it felt warmer than what it feels in Melbourne during winter. I believe the difference in humidity is the biggest factor in how someone perceives the cold.

During a ski race, one is so focused on being fast, that you can’t feel the cold. Everything happens really quickly, if you turn a tenth of a second too early it can make you crash and your race is over.

What was your most memorable experience of working with the Italian Ski Team?

Well, definitely the fact of being part of a group of young athletes that represent my country. That is a great joy, it was something

very uplifting and rewarding for the efforts that I put in every day. It makes you feel like you are a step closer to your final goal of becoming a professional athlete.

You then joined the U.S.A ski team in a coaching role; how important was it to maintain your health and Fitness even as a coach?

Soon after joining the Italian Team for some competitions I had several injuries. I had two surgeries on my knees, surgery on my hip and shoulder as well. All this within two years. I lost a lot of ground, also in the world rankings which made it quite hard for me to get back to where I was. This was also during a key moment of my career, when I was 17 years old and should have established myself in the national team. After having overcome the injuries I was almost 20 years old and considered “old” for a national team. I then was granted a scholarship in the United States and raced in the NCAA circuit which is the college league in the US. After one season I had another injury on my shoulder and decided to quit my career and move to Australia.

While in Melbourne, I was contacted by the TCRA, an American private ski team, which is one of the most prominent private ski teams in the world. They offered me to coach them for 2-3 months in New Zealand during their training camp. I accepted the offer and worked along with them and also in close contact with some national teams that were there in Wanaka and Queenstown. It was a great time which I might consider to experience again one day but at that time I felt like returning to Melbourne and trying to establish myself in Australia. For now I enjoy my life outside of the skiing industry.

What is a positively transforming world to you?

PTW to me is a dynamic movement towards a better future. It is a change that starts within us and once that happened it is able to manifest itself also on the outside by using the power of the collective.

PTW is a modern approach to transform and ennable the world we live in now. I would like to see an organization like PTW that is led by the youth with strong values succeeding in positively transforming the world.

Much love â–

Stand together,

Keep Safe Together Here are a few ways to keep you and your community safer in public and at home.

1

Be VIGILENT Keep your eyes and ears open to suspicious behaviour

Be PROACTIVE

2

If you suspect it, report it to your local authority immediately

3

BE SUPPORTIVE

“Above all, Spread acts and words of kindness and love to everyone around you Stand Together. Stand Safer.

Source: West Midlands Police UK

If you know a friend or family member who is vulnerable to radicalisation and acts of violence, help them seek support from local community bodies.

Some signs of vulnerability include: - peer pressure - bullying - change of appearance or behaviour - crime and anti-social behaviour - family tensions - race hate/crime - lack of self-esteem or identity - personal or political grievances

ptworld.org

SANTONASTASSO

NICK Nick Santonastasso was born with Hanhart syndrome.

People affected by this condition are often born with a short, incompletely developed tongue; absent or partially missing fingers and, or, toes; abnormalities of the arms and, or, legs; and an extremely small jaw. The severity of these physical abnormalities varies greatly among affected people. In Nick’s case, he was born without legs and with only one arm.

Despite his physical differences, it’s hard to think of Nick as any different to anyone else in capability or ambitions in life. He learnt how to play the drums and the piano, has mastered two types of skateboards and is learning how to swim. Nick was honoured at New Jersey governor's mansion for a poster he drew in a state-wide competition intended to promote family values. He grew online fame from his string of online videos playing pranks and jokes making light of his differences. Now Nick has turned to goals focusing around his own health

How did you look at sports and fitness growing up?

As a kid, I didn’t really see myself different until middle school but sports I would always try everything and anything to see if I could do it. as I got older it was a bit difficult to accept that some sports I just couldn’t play.

Did people ever tell you that you should re-think what you wanted to become at a young age?

At a young age I’m not sure if I aspired to be anything. I was just being me and trying new things as well as being a kid. as I got into high school and I was deciding my future and I then started doing pranks on Vine and YouTube where I became one of the most popular vine pranksters with over a million followers.

Some people thought that was the career for me and others didn’t agree. When I decided to become a fitness model and bodybuilder people thought I was crazy and laughed but that’s all strictly motivation.

Have you ever felt significantly limited by your difference?

I never felt super limited to be honest. I feel as if its helped me tremendously in gaining notoriety because everything I do or attempt, people love watching, because I’m extremely different. So, I only look towards the positives.

What methods and training styles do you use to keep healthy and fit?

I take my fitness and lifting very seriously because I have a lot of fitness goals I want to achieve. I have my meal prep sponsor Nutrition Solutions who sends me all my preps every week and I’m training 6 days a week.

Do you often find people underestimate you?

The people who underestimate me just give me motivation and if people are underestimating me those are the types of people that I would never surround myself with anyway.

People do often underestimate their own potential which stops so many dreams from coming true because people simply don’t even believe in themselves.

How do you motivate people to becomes more healthy and fit?

If they don’t have motivation to look after their health then it’s simple, but may come off a bit aggressive, but the bottom line is that health is wealth...you don’t want to take care of your body then you’ll die sooner. You have one body and if you don’t have the respect for yourself and your body then it won’t support you in life. People take so much for granted that others who can’t do what others have the opportunity to do, would switch places in a second.

What goals do you have for yourself this year?

To finish my business website, land several speaking gigs this year, have a smooth move to Tampa, land a magazine cover, and start grinding to be in a position where I can have complete financial freedom.

What is health to you?

Health is everything to me. Especially in my condition I feel as if I would be hurting and so

uncomfortable if I let my body go and didn’t care about my weight, my joints and all of that. I am just keeping my body healthy so I don’t have to suffer when I’m in my early 30’s because I neglected my health and I love to motivate people through fitness.

What is a positively transforming world to you?

Where people aren’t so judgmental- everyone is so scared of being judged or what the other person think of them; or people can just stop caring about others opinions. ■

Follow Nick on his various social media outlets. ( Click to be redirected )

The Nine New Postures

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