UK HealthCare offers a program to treat pelvic floor disorders, providing up-to-date care and a better quality of life for women

The UK Urogynecology and Reconstructive Pelvic Surgery division is
(from left) Dr. Gerardo Heredia Melero; Briana Bell, advanced-practice
provider; and Dr. Johnnie Wright Jr. (UK photo by Carter Skaggs)

By Hilary Brown
University of Kentucky

A woman's pelvic floor, whether she realizes it or not, is constantly under stress. Pregnancy, obesity and physically demanding jobs can strain the pelvic-floor muscles, which are the network of tissues that support the intestines, bladder, urethra, rectum, cervix, uterus and vagina.

Those muscles are responsible for a number of functions, including controlling urination and bowel movements, as well as supporting the organs within the pelvis. A weak or dysfunctional pelvic floor can lead to a host of symptoms, ranging from occasional urinary incontinence to pelvic organ prolapse, which occurs when an organ in the pelvis slips down from its normal position.

UK HealthCare has a new subspecialty program to treat pelvic floor disorders called the Urognecology and Reconstructive Pelvic Surgery program. The providers are Dr. Gerardo Heredia Melero and Dr. Johnnie Wright Jr. and advance-practice provider Briana Bell. 

This team of experts in pelvic medicine and reconstructive surgery work with patients to develop a treatment plan; those treatments can be as simple as exercises or medications or as complex as robotic surgery.

“At UK HealthCare, we are among the few providers in Kentucky equipped to diagnose and treat common conditions that frequently go undiagnosed,” said Wright. He said the program offers "comprehensive and tailored treatments to women."

He said time is a factor because these disorders need to be addressed early before they are beyond the help of surgical intervention. “The majority of patients come to see us for the management of pelvic floor prolapse,” said Wright. “Probably 40 percent of them experience some degree of urinary dysfunction – either urgency, frequency or urge incontinence.”

Wright and Heredia identified a need for comprehensive care for patients who experienced complications during or after childbirth, both after delivery and years after the fact.

Many women experience urinary incontinence and other symptoms after having children but dismiss them as a normal aftereffect of pregnancy. Other risk factors, such as obesity and occupational hazards such as heavy lifting, can contribute pelvic floor stress. Over time, a weakened pelvic floor could lead to pelvic organ prolapse, which can involve a vaginal hernia. 

Other common symptoms of pelvic floor dysfunction include:

• A heavy dragging feeling in the vagina or lower back
• Feeling of a lump in the vagina or outside the vagina
• Urinary symptoms such as slow urinary stream, a feeling of incomplete bladder emptying, urinary frequency, urgency and urinary stress incontinence
• Bowel symptoms, such as difficulty moving the bowel or a feeling of not emptying properly
• Pain or discomfort during sexual intercourse

Those symptoms can lead to issues that go beyond the pelvic floor. Depression and anxiety are linked to urinary dysfunction; someone who feels they no longer can control their bladder may withdraw and become more socially isolated.

The first and arguably most important step in diagnosing and treating pelvic floor disorders is helping patients understand urinary incontinence is not normal, and that a better quality of life is possible, Wright said

“The greatest impact we can have is with education,” he said. “There’s a small subset, both in patients and referring providers, who believe that if there’s no pain and it’s not cancer, then there’s no reason to worry.”

Urogynecology has been a board-certified subspecialty for 11 years, but many providers have not had the opportunity to participate in a subspeciality fellowship or training. Additionally, Wright and Heredia say a number of patients they see have already had pelvic reconstruction surgery performed with materials and techniques that are no longer standard practice.

Wright and Heredia are working with referring providers throughout the state, spreading awareness of not just the specialized program at UK HealthCare, but about pelvic floor health in general. Surgery should be the last resort, Wright said; physical therapy, relaxation techniques, medication and targeted therapies can offer lasting relief.

“I call it ‘pelvic floor empowerment,’” said Wright. “We welcome anyone who is experiencing incontinence, discomfort or pain.”

Why millions are trying FDA-authorized alternatives to Big Pharma’s weight-loss drugs, exceedingly popular in Kentucky

Editor's note: Last year Kentucky led the nation in the percentage of population that had received these weight-loss druges by prescription.

By Arthur Allen

Britannica image

KFF Health News

Pharmacist Mark Mikhael has lost 50 pounds over the past 12 months. He no longer has diabetes and finds himself “at my ideal body weight,” with his cholesterol below 200 for the first time in 20 years. “I feel fantastic,” he said.

Like millions of others, Mikhael credits the new class of weight loss drugs. But he isn’t using brand-name Wegovy or Zepbound. Mikhael, CEO of Orlando, Florida-based Olympia Pharmaceuticals, has been getting by with his own supply: injecting himself with copies of the drugs formulated by his company.

He’s far from alone. Mikhael and other industry officials estimate that several large compounding pharmacies like his are provisioning up to 2 million American patients with regular doses of semaglutide, the scientific name for Novo Nordisk’s Wegovy, Ozempic, and Rybelsus formulations, or tirzepatide, the active ingredient in Eli Lilly’s Zepbound and Mounjaro.

The drug-making behemoths fiercely oppose that compounding business. Novo Nordisk and Lilly lump the compounders together with internet cowboys and unregulated medical spas peddling bogus semaglutide, and have high-powered legal teams trying to stop them. Novo Nordisk has filed at least 21 lawsuits nationwide against companies making purported copies of its drugs, said Brianna Kelley, a spokesperson for the company, and urges doctors to avoid them.

The U.S. Food and Drug Administration, too, has cautioned about the potential danger of the compounds, and leading obesity-medicine groups starkly warn patients against their use. But this isn’t an illegal black market, though it has shades of gray.

The FDA allows and even encourages compounding pharmacies to produce and sell copycats when a drug is in short supply, and the wildly popular GLP-1 drugs have enduring shortages — first reported in March 2022 for semaglutide and in December 2022 for tirzepatide. The drugs have registered unprecedented success in weight loss. They are also showing promise against heart, kidney, and liver diseases and are being tested against conditions as diverse as Alzheimer’s disease and drug addiction.

In recent years, the U.S. health-care system has come to depend on compounding pharmacies, many of which are run as nonprofits, to plug supply holes of crucial drugs like cancer medicines cisplatin, methotrexate, and 5-fluorouracil.

Most compounded drugs are old, cheap generics. Semaglutide and tirzepatide, on the other hand, are under patent, so they earn Novo Nordisk and Lilly billions of dollars a year. Sales of the diabetes and weight-loss drugs this year made Novo Nordisk Europe’s most valuable company and Lilly the world’s biggest pharmaceutical company.

While the companies can’t keep up with demand, they heatedly dispute the right of compounders to make and sell copies. Lilly spokesperson Kristiane Silva Bello said her company was “deeply concerned” about “serious health risks” from compounded drugs that “should not be on the market.”

Yet marketed they are. Even Hims & Hers Health — the telemedicine prescriber that got its start with erectile dysfunction drugs — is now peddling compounded semaglutide. It ran ads for the drugs during NBA playoff games. (According to a Hunterbrook Media report, Hims & Hers’ semaglutide supplier has faced legal scrutiny.)

The compounded forms are significantly cheaper than the branded drugs. Patients pay about $100 to $450 a month, compared with list prices of roughly $1,000 to $1,400 for Lilly and Novo Nordisk products.

Five compounders and distributors interviewed for this article said they conduct due diligence on every lot of semaglutide or tirzepatide they buy or produce, upholding standards of purity, sterility, and consistency similar to those practiced in the commercial drug industry. Compounders operate under strict federal and state standards, they noted.

However, the raw materials used in the compounded forms may differ from those produced for Novo Nordisk and Lilly, said GLP-1 co-inventor Jens Juul Holst, of the University of Copenhagen, adding that care must be taken in drug production lest it cause potentially harmful immune reactions.

To date, according to FDA spokespeople, reports of side effects from taking compounded versions haven’t raised major alarms. But everyone with knowledge of the industry, including the compounders themselves, worry that a single batch of a poorly made drug could kill or maim people and destroy confidence in their business.

“I liken the compounding industry to the airline industry,” Mikhael said. “When you have an airline crash, it hurts everybody.”

Warnings from the past

The industry endured just such a catastrophe in 2012, when the New England Compounding Center released a contaminated injectable steroid that killed at least 64 people and harmed hundreds more.

In response, Congress and the FDA had strengthened oversight. Mikhael’s company is an outsourcing facility, or 503B compounding pharmacy — so named for a section of the 2013 law that set new requirements for drug compounders. The companies are licensed to make slightly different versions of FDA-approved drugs in response to shortages or a patient’s special needs.

The law created two classes of compounding pharmacies: The FDA regulates the larger 503B compounders with standards like commercial drug companies, while 503A pharmacies make smaller lots of drugs and are largely overseen by state boards of pharmacy.

The 503A facilities also are producing compounded semaglutide and tirzepatide for hundreds of thousands of patients. Like the 503Bs, these operations take the active ingredient, produced as a powder in FDA-registered factories, mostly in China, then reconstitute it with sterile water and an antimicrobial in small glass vials.

Together, the compounding pharmacies may account for up to 30 percent of the semaglutide sold in the U.S., Mikhael said, although he cautions that is a “wild ballpark figure” since no one, including the FDA, is tracking sales in the industry.

The compounders say the companies should increase production if they’re worried about competition. Like the dozens of other drugs they produce for hospitals and medical practices, the compounders say, the two diet drugs are essential products.

“If you don’t want a 503B facility to make a copy, it’s pretty simple: Don’t go short,” said Lee Rosebush, chair of a trade association for 503B pharmacies. “FDA created this system because these are necessary drugs.”

Novo Nordisk hasn’t specified why it can’t keep up with demand, but the bottleneck apparently lies in the company’s inability to fill and sterilize enough of its special drug auto-injectors, said Evan Seigerman, a managing director at BMO Capital Markets.

The company announced June 24 that it was investing $4.1 billion in new production lines at its Clayton, N.C. site. The FDA last year issued a warning over procedural violations at the site and separate cautions at an Indiana facility that Novo Nordisk took over recently.

Compounding for dummies

At least 28 companies mostly in China, are registered with the FDA to produce or distribute semaglutide. At least half the companies have entered the market in the past 12 months, driving the raw material’s price down by 35%, according to Scott Welch, who runs a 503A pharmacy in Arlington, Va.

Compounders can buy powdered semaglutide from some U.S. distributors for less than $4,000 a gram, said Matthew Johnson, president and CEO of distributor Pharma Source Direct. That comes out to as little as $10 per weekly 2.5-microgram dose – not including overhead and other costs.

While Ozempic or Wegovy patients use a Novo Nordisk device to inject the drug, patients using compounded products draw them from a vial with a small needle, like the device diabetics use for insulin.

Some medical practices provide the compounded drug to patients as part of a weight loss package, with markups. Last July, Tabitha Ries, a single mother of six who works as a home health care aide in Garfield, Wash., found an online clinic that charged her $1,000 for three months of semaglutide along with counseling. She has lost 35 pounds.

She gets the drug from Mindful Weight Loss, a mostly telehealth-based operation led by physician Vivek Gupta of Manhattan Beach, Calif. Gupta said he’s prescribed the weight loss drugs to 1,500 patients, with about 60% using compounded versions from a 503A pharmacy.

He hasn’t seen any essential difference in patients using the branded and compounded forms, although “some people say the compounding is a little less effective,” Gupta said.

There’s some risk in using the non-FDA-approved product, he acknowledged, and he requires patients to sign an informed consent waiver.

“Nothing in life is without risk, but I would also argue that the status quo is not safe for people who need the medicine and can’t get it,” he said. “They’re constantly triggered by all this food that’s causing their weight to go up and their sugar to go high, increasing their insulin resistance and affecting their limbs and eyes.”

Compounding semaglutide is a helpful sideline for pharmacists like him, Welch said, especially given the pinch on drug sale revenue that has led many independents to close in recent years. He figures he earns 95% of his revenue from compounding drugs, rather than traditional prescriptions.

It’s important to distinguish compounded semaglutide from unregulated powders sold as “generic Ozempic” and the like, which may be contaminated or counterfeit, said FDA spokesperson Amanda Hils. But since compounded forms of the drug are not FDA-approved, those who make, prescribe, or use them also should have “an increased level of responsibility or awareness,” she said.

Corporate battles

Novo Nordisk and Lilly, in lawsuits each company has filed against competitors, say their own testing has found bacteria and other impurities in products made by compounding pharmacies. The companies also report patent infringement, but compounders, pointing to the FDA loophole for drugs in shortage, appear to have defeated that argument for now.

When the FDA removes the drugs from the shortage list, 503B compounders must immediately stop selling them. Smaller compounders may be able to produce their products for a reduced number of patients, said Scott Brunner, CEO of the Alliance for Pharmacy Compounding, which represents 503A compounders.

The evaporation of the compounded drug supply could come as a shock to patients.

“I dread it,” said David Wertheimer, an internist in Franklin Lakes, N.J., who prescribes compounded semaglutide to some patients. “People are not going to be able to plunk down a grand every month. A lot of people will go off the drug, and that’s a shame.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. 

Saint Joseph hospitals in Lexington, London and Mount Sterling seek applications for grants to improve well-being, health equity

By Melissa Patrick

Kentucky Health News

The CHI Saint Joseph Health hospitals in Kentucky are accepting applications for local nonprofit organizations to apply for grants aimed at supporting services to improve well-being and health equity in their service areas. 

The grants are part of the Community Health Improvement Grants program, which was created in 2019 when Catholic Health Initiatives and Dignity Health came together to create the national health system CommonSpirit Health.

Grants through Saint Joseph Hospital and Saint Joseph East in Lexington, and Saint Joseph London, can be as small as $20,000 and as large as $100,000. Grant opportunities are also available at Saint Joseph Mount Sterling to serve that area, ranging from $10,000 to $19,500.  Click here for the link to the application website. 

"Grant applications must include collaborating partner organizations helping to deliver services and not be solely about one agency’s work,” Michael Bilton, CommonSpirit Health's senior director for community health and benefit, said in a news release. 

The application period is open through Aug. 16. Grants are available to nonprofit organizations that address substance-use disorders, mental health, and issues involving weight, physical activity and nutrition. All projects must be planned for calendar year 2025. 

The priorities were identified in the hospitals' most recent community health needs assessment, which is conducted every three years. 

“We are deeply committed to the well-being of our community," Christy Spitser, interim market president of CHI Saint Joseph Health, said in the release. "Providing grants to local nonprofits is a vital part of our mission to give back and make a tangible difference in the lives of those we serve.” 

Interested organizations can learn more about the grant program, including eligibility criteria, how to apply, and a local contact for questions, by visiting https://www.commonspirit.org/communitygrants.

Curious about new, popular weight-loss drugs? Here's a lowdown

Axios Visuals map adapted by Ky. Health News; click to enlarge

Editor's note: At the end of 2023 Kentucky led the nation in the percentage of state residents, 2.1%, who had received the new class of diabetes and weight-loss drugs.

By Katelyn Jetelina
Your Local Epidemiologist

You’ve probably heard of Ozempic by now. It is everywhere. Sales are up more than 300% and research studies are coming out like a firehose, but future population-level implications are unknown. Here, we catch you up on the science and what it may mean for you.

Ozempic (one brand name for the substance semaglutide) is one of many medications under the umbrella of “GLP-1 receptor agonists.” Others are Trulicity (dulaglutide), Wegovy (semaglutide) and Mounjaro (tirzepatide).

GLP stands for glucagon-like peptide 1. GLP-1 is a hormone produced in the intestinal system and released when you eat food. It is a natural signal saying you have eaten enough food. Naturally occurring GLP-1 comes and goes in a few minutes.

These medications mimic this natural process but for longer. Ozempic, for example, stays in our system for an entire week. It also slows down gastric emptying, thereby slowing down digestion.

How effective are these drugs? Very. The original clinical trials that supported initial FDA approval for patients with diabetes blew expectations out of the water. It improved:

• Blood sugar control (A1c reduction)
• Weight loss (average 15 pounds)
• Unexpected positives, like reduced kidney disease (24% less likely to experience kidney failure and death due to kidney complications)

Since the first clinical trials, studies have tested its use in non-diabetic individuals, and its is effective in weight loss. A meta-analysis of eight studies found a significant decrease (about 10% of body weight). None saw an increase. Also, it has protective effects on the heart, such as reduced blood pressure and triglycerides.

 
What happens if you stop taking it? Unfortunately, weight (and other outcomes) rebound. As shown below, after the original clinical trial (68 weeks), people who stopped taking it regained their weight.

The use of GLP-1’s as a motivating tool for sustained change has been less studied. Will these be lifetime drugs like other medications (e.g., statin drugs for heart disease) or a tool to titer up or down in times of need? This is a big unanswered question.

While obesity often involves an energy imbalance where calories consumed exceed those expended, it’s influenced by genetics, socioeconomic status, environmental factors, and mental health. These factors contribute to a complex web of challenges that may extend beyond individual choices alone.

What about kids? Ozempic isn’t officially approved by the FDA for children (but can be used off-label), but Wegovy is approved. In 2023 alone, about 31,000 children aged 12 to 17 and 162,000 aged 18 to 25 used these medications.

A recent meta-analysis found treatments led to modest reductions in body weight and improved glycemic control in children with insulin resistance.

Ozempic babies? The term refers to a recent phenomenon where women are reporting unplanned pregnancies. This has sparked discussions on social media and in the medical community about the potential impact of these drugs on fertility. Why could this be happening? Two hypothesized pathways:

• 1. These drugs delay gastric emptying, which can impact the effectiveness of oral birth control by slowing down the rate of absorption
• 2. Weight loss enhances fertility, making it easier for women to become pregnant. This is particularly true for women with Polycystic Ovarian Syndrome, in which weight loss is known to boost fertility significantly.

However, it’s recommended to stop the medication two months before trying to get pregnant (see more below).

 

Datawrapper graph by YLE; data from Ghusn et al., JAMA

Are there downsides to the meds?

Like any medication, there are side effects and risks, some known and some theoretical, and many with mixed study results. Individuals must weigh the risks of obesity with the small but meaningful risks of the medication.

 
Many people experience side effects, particularly nausea and diarrhea. A recent analysis from an insurance agency found that 6 in 10 people who start the drugs quit before they see benefits because of side effects. These tend to go away after a few weeks, but they can substantially impact the quality of life until then.

Muscle loss: Most (60-75%) weight loss is from fat, but some is from non-fat, including muscle. This could lead to a rare condition called sarcopenia—loss of muscle mass and strength where you can’t do much because you’re physically weak. Research is mixed, though, on how often this happens, and it may be minimal when combined with exercise and adequate protein intake.

 
Increased risk of thyroid cancer. A small French case-control study found an elevated risk of thyroid cancers (58% elevated relative risk) and medullary thyroid cancer (78% elevated relative risk) after GLP-1’s. However, another study in Scandinavia with more than 400,000 people found no risk of thyroid cancer after 3 years. Regardless, the potential increase in absolute risk is very small.

Mental health. There is a big debate on what is happening in the brain. GLP-1 is not only produced in the gut but in the brain as well. Some evidence has correlated the usage of GLP-1 medications with suicidal ideation. However, recent evaluations by regulatory agencies found no substantial evidence after extensive review. Some studies have even suggested a potential decrease in the likelihood of anxiety and depression.

Eating disorders. It is a growing concern that GLP-1s may increase the risk of disordered eating, particularly among those who are high-risk (e.g., prior history of eating disorders).

 
Pregnancy. Pre-clinical trials on rats found GLP-1s are more likely to have offspring with birth deformities, so it’s not recommended to take during pregnancy.

While these new drugs have a strong safety profile based on available data, human studies are only about 5 years old. This means the long-term effects are not yet fully understood. However, we do have data from drugs in the same class that started testing in 2006, showing a consistent safety profile. Continued monitoring and research are essential to determine whether theoretical risks are real in light of new data.

This means decisions today must be made based on what is available and in the context of individual risk factors. For example, if you have a history of eating disorders, the risks of taking the medication may outweigh the benefits.

What does the future look like? After a century of fad diets and weight loss gimmicks, people are tired: some from fighting stigma and others from trying to lose weight unsuccessfully. These medications have proven to work, and the market shows it: GLP-1 prescriptions have increased by over 300% since 2020. A recent poll indicates that nearly half of adults express interest. But there’s no sugarcoating it: It’s expensive, about $1,000 per month without insurance. The price should decrease dramatically in about 8 years once the patent expires and the generic version comes to market.

On a population level, these drugs will likely have widespread impacts, just like the iPhone, which can be good or bad, depending on who you ask. Given the massive impact obesity has had on health in the past two decades, this could be extraordinary for lifespan and quality of life. It could also have ripple effects on the fast-food industry and save millions of dollars in health care costs.

But it could further widen health disparities, given the cost, and hurt body positivity, losing much ground gained. We also cannot ignore that these drugs benefit a billion-dollar pharmaceutical industry when underlying societal causes should be addressed for prevention. And, the fact there are numerous other benefits to a healthy lifestyle.
Bottom line

GLP-1 drugs offer much-needed hope to individuals, and a flood of studies show their effectiveness. However, there are both demonstrated and theoretical risks to consider. Regardless, obesity deserves compassion, and perhaps 21st-century tools can help foster a supportive environment that promotes lasting progress.

High cost of new diabetes drugs, more popular in Ky. than any other state, deprives low-income people of effective treatment

Photo by George Frey, Bloomberg, via iStock/Getty Images, KFF Health News

Editor's note: At the end of 2023 Kentucky led the nation in the percentage of state population, 2.1%, who had received the new class of diabetes and weight-loss drugs.

By Renuka Rayasam
KFF Health News

For the past year and a half, Tandra Cooper Harris and her husband, Marcus, who both have diabetes, have struggled to fill prescriptions for medications they need to control their blood sugar.

Without Ozempic or a similar drug, Cooper Harris suffers blackouts, becomes too tired to watch her grandchildren, and struggles to earn extra money braiding hair. Marcus Harris, who works as a Waffle House cook, needs Trulicity to keep his legs and feet from swelling and bruising.

The couple’s doctor has tried prescribing similar drugs, which mimic a hormone that suppresses appetite and controls blood sugar by boosting insulin production, but those are also often out of stock. Even if they are available, their Affordable Care Act insurance burdens the couple with a lengthy approval process or an out-of-pocket cost they can’t afford.

“It’s like, I’m having to jump through hoops to live,” said Cooper Harris, 46, a resident of Covington, Georgia, east of Atlanta.

Supply shortages and insurance hurdles for this powerful class of drugs, called GLP-1 agonists, have left many people who are suffering from diabetes and obesity without the medicines they need to stay healthy.

One root of the problem is the high prices set by drugmakers. About 54% of adults who had taken a GLP-1 drug, including those with insurance, said the cost was “difficult” to afford, according to KFF poll results released this month. Patients with the lowest disposable incomes who are hit the hardest; they have few resources and often struggle to see doctors and buy healthy foods.

In the United States, Novo Nordisk charges about $1,000 for a month’s supply of Ozempic, and Eli Lilly charges a similar amount for Mounjaro. Prices for a month’s supply of different GLP-1 drugs range from $936 to $1,349 before insurance coverage, according to the Peterson-KFF Health System Tracker. Medicare spending for three popular diabetes and weight loss drugs — Ozempic, Rybelsus, and Mounjaro — reached $5.7 billion in 2022, up from $57 million in 2018, according to research by KFF.

The “outrageously high” price has “the potential to bankrupt Medicare, Medicaid, and our entire health care system,” Sen. Bernie Sanders (I-Vt.), who chairs the U.S. Senate Committee on Health, Education, Labor and Pensions, told Novo Nordisk in April.

The high prices also mean that not everyone who needs the drugs can get them. “They’re kind of disadvantaged in multiple ways already and this is just one more way,” said Wedad Rahman, an endocrinologist with Piedmont Healthcare in Conyers, Georgia. Many of Rahman’s patients, including Cooper Harris, are underserved, have high-deductible health plans, or are on public assistance programs like Medicaid or Medicare.

Many drugmakers have programs that help patients get started and stay on medicines for little or no cost. But those programs have not been reliable for medicines like Ozempic and Trulicity because of the supply shortages. And many insurers’ requirements that patients receive prior authorization or first try less expensive drugs add to delays in care.

By the time many of Rahman’s patients see her, their diabetes has gone unmanaged for years and they’re suffering from severe complications like foot wounds or blindness. “And that’s the end of the road,” Rahman said. “I have to pick something else that’s more affordable and isn’t as good for them.”

GLP-1 agonists — the category of drugs that includes Ozempic, Trulicity, and Mounjaro — were first approved to treat diabetes. In the last three years, the Food and Drug Administration has approved rebranded versions of Mounjaro and Ozempic for weight loss, leading demand to skyrocket. And demand is only growing as more of the drugs’ benefits become apparent.

In March, the FDA approved the weight-loss drug Wegovy, a version of Ozempic, to treat heart problems, which will likely increase demand, and spending. Up to 30 million Americans, or 9% of the U.S. population, are expected to be on a GLP-1 agonist by 2030, the financial services company J.P. Morgan estimated.

As more patients try to get prescriptions for GLP-1 agonists, drugmakers struggle to make enough doses.

Eli Lilly is urging people to avoid using its drug Mounjaro for cosmetic weight loss to ensure enough supplies for people with medical conditions. But the drugs’ popularity continues to grow despite side effects such as nausea and constipation, driven by their effectiveness and celebrity endorsements. In March, Oprah Winfrey released an hourlong special on the medicines’ ability to help with weight loss.

It can seem like everyone in the world is taking this class of medication, said Jody Dushay, an assistant professor of medicine at Harvard Medical School and an endocrinologist at Beth Israel Deaconess Medical Center. “But it’s kind of not as many people as you think,” she said. “There just isn’t any.”

Even when the drugs are in stock, insurers are clamping down, leaving patients and health care providers to navigate a thicket of ever-changing coverage rules. State Medicaid plans vary in their coverage of the drugs for weight loss. (Kentucky's does not.) Medicare won’t cover the drugs if they are prescribed for obesity. And commercial insurers are tightening access due to the drugs’ cost.

Health-care providers cobble together care plans based on what’s available and what patients can afford. For example, Cooper Harris’s insurer covers Trulicity but not Ozempic, which she said she prefers because it has fewer side effects. When her pharmacy was out of Trulicity, she had to rely more on insulin instead of switching to Ozempic, Rahman said.

One day in March, Brandi Addison, an endocrinologist in Corpus Christi, Texas, had to adjust the prescriptions for all 18 of the patients she saw because of issues with drug availability and cost, she said. One patient, insured through a teacher-retirement health plan with a high deductible, couldn’t afford to be on a GLP-1 agonist, Addison said.

“Until she reaches that deductible, that’s just not a medication she can use,” Addison said. Instead, she put her patient on insulin, whose price is capped at a fraction of the cost of Ozempic, but which doesn’t have the same benefits. “Those patients who have a fixed income are going to be our more vulnerable patients.”

Raising Ky.'s health status has 'a ways to go,' hospital chief says; Chandler says people need to demand change in health policies

Ben Chandler, president and CEO of the Foundation for a Healthy Kentucky, and Christopher Roty, president of Baptist Health Lexington, spoke at the April 4 Lexington Forum. (Photo by Melissa Patrick)

By Melissa Patrick
Kentucky Health News

A discussion on health care at the April 4 Lexington Forum led to information about the many challenges Kentucky faces when it comes to improving the health of its people, and a few solutions.

At several points, Ben Chandler, president and CEO of the Foundation for a Healthy Kentucky, said little will be done to improve health care and health-care costs as long as people don't demand change from their lawmakers in Frankfort and Washington.

"Apparently, it's OK with you guys," Chandler told the Lexington business-and-civic group. "That's all I can say, is that apparently it's OK with you guys because you are not demanding that it change. We can change it through public policy if the citizens of this country wants to do it - and apparently, we don't."

Chandler, 64 and a Democrat, was state auditor and attorney general before losing the 2003 governor's race and representing the 6th District in Congress from 2004 through 2012.

'Kentucky uglies'

Asked about what then-University of Kentucky President Lee Todd called "the Kentucky uglies," referencing the state's most troubling and chronic health issues, Chandler said we don't pay enough attention to them.

"Kentucky's numbers are abysmal," he said. "We have some of the worst health numbers in the United States in almost any health indicator that you can think of, starting with cancer. We lead the nation in cancer . . . and in cancer mortality."

Kentucky ranked No. 41 in the America's Health Rankings 2023 report. Kentucky has found itself among the bottom 10 states in health status since the rankings began in 1990, except in 2008, when it ranked 39th.

Chandler said many Kentuckians work on this problem from a health-care standpoint every day, but "a long, long way to go" remains toward improvement. 

"I think there are some solutions," he said. "But we as a society, at least right now, are not prepared to deal with" them. 

Christopher Roty, president of Baptist Health Lexington, agreed that health-care providers are working on these Kentucky uglies, like obesity, diabetes and lung cancer. 

One way, he said, is by employing new technology, pointing to new protocols for lung-cancer screening that include low-dose CT scans and remote monitoring tools that reduce hospital readmissions. But when it comes to prevention, which involves things like education and poverty, he said, "We've got a ways to go." 

Opioid epidemic

Asked about the opioid epidemic in Kentucky, Roty noted that the hospital has instituted new pain-medication protocols that send people home with just enough medicine for a few days, with instructions to call their doctor if they need more. Also, an addiction nurse at the hospital is available to patients. 

"Lots and lots of progress, but then, we've got a ways to go with that," he said. 

Chandler said the prescription-monitoring system that was created out of a task force he created while serving as state attorney general worked to stop the "proliferation of the pills on the street," heroin quickly followed and "it has been a significant problem ever since." 

Further, he said that despite all of the "really good work" being done to deal with opioid addiction, we haven't figured out how to effectively treat it. 

"We have yet as a society, not gotten the tools to deal with this dreadful addiction," he said. "It's just dreadful. My own brother died of a fentanyl overdose a couple of years ago. . . . There are very few people who have not been affected by this." Chandler was speaking of his brother, Matthew Chandler. 

He added, "We're pouring a whole lot of money into well-intentioned efforts to try to fix people who are already addicted. And we're not doing enough on the preventive side to stop the addiction in the first place. And that's where the money. We need to see what we can do to go upstream to try to deal with some of these things."

That would include, he said, addressing what are often called the social determinants of health, or the social drivers of health status. These include things like education, housing, transportation, food insecurity, education, access to health care, employment and poverty.

'As important as health care is, and it's very, very important, it's only a piece of the problem," he said. "If we want people in our society to be well and to live healthy lives, we've got to work on these social determinants," the biggest of which is poverty. 

"People who don't have resources are less healthy and they live less long," he said, adding later, "It's a problem of equity in our society and quite frankly, I think we ought to be deeply concerned about it." 

The state's latest annual Overdose Fatality Report shows that  2,135 Kentuckians died from overdoses in 2022, with opioids involved in 90% of those deaths, led by fentanyl, which was involved in 72.5% of the deaths. 

Health worker shortage

Roty said a shortage of health-care workers continues to be a problem, saying about 5% of his nurses are "agency" workers for outside firms. Another challenge is that they see a lot of first-year turnover among the nurses, who he said leave for various reasons, including a dislike of shift work. 

Asked how they are addressing this issue, Roty said they are doing what many hospitals are doing, offering all kinds of bonuses and loan forgiveness programs. 

He said some of the schools that produce health-care workers aren't graduating enough students to take care of the shortages: "We've got a new class of nurses coming in this spring, but it's not going to . . . get rid of all the agency workers," who are generally paid more.

Roty noted that Baptist Health is opening a second Lexington hospital, on Interstate 75, in phases. He said the outpatient facility, with a freestanding emergency department, cancer center, surgery center and medical office building will open first, followed by a hospital bed tower.

The hospital's site was selected party to serve rural areas south and east of Lexington. Chandler noted, "The people in rural areas don't have the same services. . . . It's just an urban/rural problem." 

This led to him talking about the "institutional problems" in health care, including the fact that the U.S. spends about twice as much per capita on health care as any other industrialized country in the world, while ranking near the bottom for health outcomes.

"Now, something is wrong institutionally with a system that spends twice as much per capita on a problem and ends up with the 60th best result," he said, adding that any other business with such results would surmise that "something has got to give."  

"People in this country are dying because we can't fix this issue," he said. "They are dying and their quality of life is much poorer than it ought to be. And again, I go back to the social determinants of health. One of the reasons that other societies are doing better than we are . . . is that they do a better job on the social determinants."  

Health-care costs

Roty said they do their best to work with people challenged by the costs of health care, whether that is getting them signed up for Medicaid or a financial assistance program. "It's a broken system when it comes right down to it," he said. 

Chandler added, "There are a lot of citizens who are going bankrupt because they can't pay for their health care." 

Further, he said, the health-care system is hard to navigate, while agreeing with Roty that the system is "incredibly complex" for patients and providers. 

"And for a country as strong and capable as we are, it's just amazing to me that we can't come together and find the answers to these problems," he said. " We actually have an idea about what the answers are, we're just unwilling to implement them. And it's because, as you can imagine, there are interests that are not interested in seeing that implemented. " 

Legislative priorities

Chandler opened this segment of the conversation by saying, "The legislature is not easy to work with, we have found, particularly on these kinds of issues." 

This year, he said the foundation's priority was creation of an "all-payers claims database," which would track all health-care insurance claims (including Medicaid and Medicare) in Kentucky to improve the transparaency of health-care costs in the state. He said 22 states already have this in place. 

"We were unsuccessful in that effort, " he said. "And that's not surprising because it's a complicated thing and it's not really sexy." He added, "At some point, we're going to need to get to the bottom of where all the money is going." 

Other priorities, he said, revolved around the social determinants of health and adverse childhood experiences, which he called "childhood trauma." He added, "We're trying to address those things, but we can't seem to get the legislature to invest in the solutions."

The foundation funds Kentucky Health News but does not control its content.

Drugs for weight loss

Asked about the use of the new weight-loss drugs, like Ozempic and Wegovy, in which Kentucky leads the nation, Roty said Baptist Health would no longer cover them for weight loss because they are too expensive, effective May 1. He said they would only cover it for the treatment of diabetes. Roty said the company, Kentucky's largest hospital chain, has spent $24 million on this drug this year in its employee health plan. 

"We are not going to reimburse for that anymore . . . for weight loss purposes, obesity," Roty said. He acknowledged that "A lot of people are seeing results," but "The expense to us, so to speak, is incredible."

"Baptist Health’s employee health plan has seen significant growth in usage of both these medications since they were introduced, with Wegovy alone seeing a 600% increase in users over the past 13 months," according to a statement provided by Baptist Health. 

Chandler suggested that tackling obesity would ultimately result in overall health-care savings, since so many health conditions are caused by or worsened by obesity. 

"If they are working and they are healthy and they are not hurting people, then ultimately in the long run, while the short-term expense may be very high, in the long term the expenses ought to go down for the society in general in savings on health care." 

The 20th annual State of Obesity report from Trust for America’s Health says 37.7% of Kentucky adults are obese and nearly 72% of the state’s adults are either obese or overweight, tied for sixth place with Delaware. Among the state’s high-school students, 19.6% are obese and 16.2% are overweight.

Anthem is among health insurers now covering anti-obesity drug if it is prescribed to reduce the risk of heart attack and stroke

One of Kentucky's major health insurers is among the first that have "agreed to start paying for the popular anti-obesity drug Wegovy for certain people on Medicare with heart-related conditions," The Wall Street Journal reports. Kentucky has the highest share (about 2.1%) of a state's population that have prescriptions for the new class of weight-loss drugs.

Elevance Health, the corporate parent of Anthem, joined CVS Health and Kaiser Permanente in covering Wegovy to reduce the risk of heart attacks and strokes in beneficiaries "who have cardiovascular disease, meet body-weight criteria and are covered by a Medicare drug-benefit plan," report the Journal's Peter Loftus and Anna Wilde Mathews.

State table shows Medicaid coverage numbers for March. FFS
means "fee for service," which is separate from managed care.

"Elevance, which operates many Blue Cross and Blue Shield health plans, also said it would extend coverage to people insured by a commercial plan" and would make the change in the next few weeks. "A committee of outside advisers to Elevance Health’s CarelonRx unit, which manages pharmacy benefits, has approved the use of Wegovy to reduce the risk of major cardiovascular events. . . . The company also is working with state-government agencies to determine Medicaid coverage of Wegovy." Anthem manages the Medicaid care of about 172,000 Kentuckians; county-level numbers are available.

"The insurers’ moves open up reimbursement of the coveted but costly class of weight-loss drugs, which had previously been excluded from Medicare coverage by a U.S. law and which many private health plans had resisted reimbursing because of the expense," the Journal notes. "The decisions will ease the financial burden on people who had been paying more than $1,000 out of pocket each month because their health plan wouldn’t cover the medicines, and spur use among people who couldn’t afford the heavy cost or didn’t want to pay for it. Other Medicare and commercial health plans might now feel pressure to follow suit and begin coverage. But the widening coverage could result in billions of dollars in additional drug spending by health insurers that have struggled to keep a lid on rising health costs. Wegovy lists for about $1,349 a month."

U.S. Sen. Bernie Sanders (I-Vt.), chair of the Senate's health committee, this week called on insurers to charge Americans no more than they charge in Canada for the drugs. That would lower their prices by about two-thirds.

"The insurers’ decisions arose from new guidance issued last week by the Centers for Medicare and Medicaid Services," the Journal notes. Medicare Part D plans, "which are administered by private insurers, might cover anti-obesity medications if the drugs receive approval for an additional use. Their use for weight-loss alone would still be excluded from coverage. That new guidance applies to Wegovy because the Food and Drug Administration this month approved the weight-loss drug’s use reducing the risk of heart attacks and strokes in people with a history of heart disease, and who have a body-mass index above certain thresholds. A study showed Wegovy reduced cardiovascular risk by about 20% versus a placebo."

Kentucky-based Humana, which manages the care of 155,000 Kentuckians on Medicaid and has a broad paying-customer base in the state, said it is reviewing the CMS guidance. UnitedHealth Group, which covers more than 91,000 Kentucky Medicaid beneficiaries and has many paying customers in the state, declined the Journal's request for comment.

Chair of U.S. Senate health committee demands maker of weight-loss drugs, most popular in Kentucky, cut their prices by two-thirds

Axios Visuals map, adapted by Kentucky Health News; click it to enlarge.

Sen. Bernie Sanders of Vermont, who chairs the U.S. Senate's Health, Education, Labor and Pensions Committee says the maker of two popular diabetes and weight-loss drugs Ozempic and Wegovy should lower their list prices of “to no more than what they charge for this drug in Canada,” The Washington Post reports.

Sanders, an independent who votes with Democrats, "is demanding that Novo Nordisk slash the prices of its blockbuster drugs Ozempic and Wegovy, citing a new study on the manufacturing costs of the diabetes and weight-loss medications," the Post reports.

Kentucky leads the nation in the percentage (about 2.1%) of residemts who have received a prescription for one of the new drugs created to fight obesity and diabetes, which can also aid weight loss.

"Researchers found that a month’s supply of semaglutide — the active ingredient in both drugs — could be manufactured for an estimated 89 cents to $4.73," the Post reports, but "Novo Nordisk charges $935.77 for four weekly injections of Ozempic in the United States, while it costs about $300 per month out-of-pocket in Canada."

In response, a Novo Nordisk spokesperson didn’t address manufacturing costs but said the Danish company offers several ways to help patients and "supports changes in policy to improve patient affordability and access for those living with chronic diseases," the Post reports.

State health chief says measles risk stems from pandemic's anti-vaccine 'ideologies'; discusses how to lose weight, need for sleep

WKYT news anchor Bill Bryant, left, interviews state Health Commissioner Steven Stack, M.D.

This story has been updated.

By Al Cross
Kentucky Health News

In a wide-ranging TV interview, state Health Commissioner Steven Stack warned Kentuckians that not enough of them are vaccinated for measles, which he said is an outgrowth of reaction to the Covid-19 pandemic and the measures taken against it.

Stack reflected on his work in the pandemic and talked about other health concerns, including the opioid epidemic, weight-loss drugs and the need for Kentuckians to get more sleep, in an interview that aired Sunday, March 10, on WKYT's "Kentucky Newsmakers" with Bill Bryant.

As of March 7, the Centers for Disease Control and Prevention had recorded 45 cases of measles in 17 states: Arizona, California, Florida, Georgia, Illinois, Indiana, Louisiana, Maryland, Michigan, Minnesota, Missouri, New Jersey, New York, Ohio, Pennsylvania, Virginia and Washington.

Stack said measles was declared elimiated in the U.S. in 2000, but it has returned because vaccination rates have dropped to 90 percent. The disease may be the most contagious, and epidemiologists say 95 percent of a population needs to be vaccinated to protect those who can't or won't get the shot.

Stack said the measles-mumps-rubella (German measles) vaccine has been used since 1971, and is very effective. "We’ve got to get the public I hope, to accept that these tools help to prevent us from having far worse problems, like little babies who can't get vaccinated getting seriously ill." Children younger than 6 months are ineligible for vaccination.

Pew Research Center graph, based on Pew polling by party

Why have vaccination rates for contagious diseases dropped? "It's all gotten caught up in the Covid pandemic, in the narrative, in the ideologies that have unfortunately become associated with public health and medical science," said Stack, a physician.

Asked if he and Gov. Andy Beshear made the right calls in the pandemic, he said "I think we did the best we could with what we knew at the time." He said Kentucky outperformed most other states, considering its lower health status, which made it more vulnerable.

Stack said he and Beshear "balanced saving the most poeple [with] other harms that are worse than what you're trying to prevent." He said Kentucky's death toll of 20,000 was "far from what it would have been had we not intervened," noting that an intiial estimate was it could lose 1 to 2 percent of its population: 45,000 to 90,000 people.

Looking ahead, Stack said people 65 and older and those with other risk factors should get a Covid-19 booster this spring, and everyone should get an annual booster, much like has long been done for influenza.

Other health issues

Kentucky leads the nation in the percentage (about 2.1%) of population that has received a prescription for one of the new drugs created to fight obesity and diabetes, which can also aid weight loss.

"Overweight and obesity is a big problem in Kentucky," Stack said, noting that 38% of Kentuckians weigh too much. "That leads to diabetes, it increased your risk of cancer and cardiovasculat disease, like stroke and heart disease. It's really a major issue for us to address."

As for the drugs, "People are understandably desperate to find ways to get it under control," he said. "It's really too early to say what the long-term outcome of those medications will be. Some people have had wonderful benefits from it, have lost a lot of weight and improved their overall performance. Some individuals have had a difficult time tolerating it: persistent nausea, vomiting, or an unlucky small number with pancreatitis, so time will tell on those.

"Right now I think what we really need to do is try to think about ways to improve our environment so it's easier to eat healthier -- fresh fruits and vegetables -- and do mild things, like just go for a walk three or four days a week for 35 to 45 minutes; if you could do simple things like that, most of us could actually lose the small weight that we have to avoid becoming diabetic."

Kentucky is also one of the states most affected by the opioid epidemic. Stack said it has evolved because "The criminals keep getting more creative in the cocktails they put together and they're becomeing more and more lethal for people."

Speaking on the weekend that the nation moved its clocks to daylight saving time, Stack said lack of sleep is also a major health issue, especially for teens, who need more of it.

He said teens and adults "disrupt our sleep" with big and small screens, on TVs and smartphones. "We’ve got to get better sleep hygiene," he said, "and set out the time we need to get that eight hours of sleep."

Kentucky leads the nation in use of new class of drugs that fight diabetes and obesity; more than 2% of Kentuckians use them

Kentucky Health News

This story has been updated, as underlined.

Kentucky has the nation's highest rate of dispensed prescriptions for a new class of diabetes and obesity medications, according to the analytics company PurpleLab and published by Axios.

"For every 1,000 people in Kentucky, roughly 21 were prescribed a drug that belongs to a buzzy class of diabetes and anti-obesity medications last year," Tina Reed of Axios reports.

The drugs are GLP-1 agonists, which mimic a hormone that triggers the release of insulin, which lowers blood sugar; slows digestion; and increases the feeling of fullness after eating. They were developed to treat diabetes but have become popular in treating obesity, in which Kentucky ranks high.

"GLP-1 agonists alone can’t treat Type 2 diabetes or obesity," the Cleveland Clinic cautions. "Both conditions require other treatment strategies, like lifestyle and dietary changes." The drugs are costly, running between $900 and $1,300 a month, and most must be injected into fatty tissue.

Axios reports that after Kentucky, West Virginia had the next highest prescribing rate, at 18.9 prescriptions dispensed per 1,000 residents. That was followed by Alaska (17.5), Mississippi (16.1) and Louisiana (15.4). Rhode Island had the lowest rate (3.7), and Massachusetts was second lowest (4), followed by Wisconsin (4.3) and Hawai'i (4.3.)

The figures come from a collection of 1.9 billion claims to private insurers, Medicare (which only covers GLP-1s to treat diabetes) and Medicaid. "The data lumps the prescriptions together, so it's not possible to tease out how often these drugs are being prescribed for obesity versus diabetes," Axios notes. Kentucky Medicaid does not cover the drugs, but health insurance for state workers does.

In another story Reed reports, "Doctors are getting inundated with patients' requests . . . including from many who don't really need them. Primary-care doctors in particular, who typically have little training in obesity, have found themselves as gatekeepers for a class of injection drugs, including Novo Nordisk's Ozempic and Wegovy, that are effective but still face questions about who should take them."

'SMART' ways to make those New Year’s resolutions stick

SMART goals concept
(Wikipedia graphic)

By Shorus Minella

University of Kentucky

If you’re looking for ways to make those New Year’s resolutions stick, try finding something you are really motivated to do. You are more likely to want to work toward a goal if you enjoy the activity. 

For example, if you want to start exercising but hate exercise equipment at the gym, find a dance or aerobic class instead.

After you’ve identified something you want to work towards, be realistic and set a specific goal. 

Instead of a broad goal like “I want to eat healthy,” instead, try “I want to eat two cups of vegetables every day.” You’re more likely to accomplish and stick to a specific goal.

Following the SMART goals concept is a great guide to setting and sticking to goals. Here’s what to keep in mind when making your goals:

 

Specific – Giving yourself a very specific goal makes it easier to achieve. For example, instead of setting a goal to lose weight, aim for a specific number, such as five pounds. When you reach that goal, aim for another five pounds.
Measurable – Set yourself up for success by tracking your progress. Seeing how far you’ve come is an excellent motivator!
Achievable – If you’ve never run a step in your life, vowing to run a marathon might be a difficult goal to stick to. Start small by running around the block, then a mile, then try signing up for a community 5K.
Relevant – Your goals should be in line with your values and passions. You’re more likely to achieve your goal if you are enjoying it!
Time-Based – Give yourself a realistic time frame to complete your goal.

Most importantly, give yourself grace during your journey. Celebrate your successes but don’t get discouraged by any setbacks. Talk to your doctor or check in with the local health department for resources and programs to help you meet your goals.

Shorus Minella is a dietitian and patient education coordinator at UK HealthCare’s Gill Heart & Vascular Institute.

At upcoming holiday celebrations, focus on social connections, not on the food; eat mindfully to avoid celebration guilt

Photo by iStock from "How to eat healthy during a holiday celebration," by Hola 

By Patty Craig
Beech Tree News, Morgantown

We will soon enter the holiday celebration season. Our culture promotes celebrating with food – despite staggering obesity statistics. Anticipating those celebrations, how might health-minded people celebrate?

First, carrying extra weight is a real problem. The Centers for Disease Control and Prevention website reports: “The obesity prevalence was 39.8% among adults aged 20 to 39 years, 44.3% among adults aged 40 to 59 years, and 41.5% among adults aged 60 and older.”

Obese children may have to deal with psychological problems such as anxiety and depression, low self-esteem and lower self-reported quality of life, social problems such as bullying and stigma, and obesity as adults.

Obese adults face high blood pressure and high cholesterol, Type 2 diabetes, breathing problems, joint problems, gallstones and gallbladder disease. Additionally, “adults with obesity have higher risks for stroke, many types of cancer, premature death, and mental illness such as clinical depression and anxiety.”

Patty Craig

Why, then, is food a part of life’s celebrations? The Cultural Awareness International website says: “Conceivably it (food) is the most significant commonality that humanity shares. Whatever shape, form, flavor, or seasoning food may take around the world, people eat. More than that, across the world, people enjoy eating.”

Food is a way to show hospitality, and it provides an opportunity to make connections. Food is generally provided with celebrations throughout the life cycle – from birth to death, including many holidays.

How can we find a healthy balance? In a Film Daily article by Samantha Williams ("Healthy Celebrations: Striking a Balance between Indulgence and Wellness"), the author discussed how to be mindful and still savor a celebration. Two of her points resonated with me:

“Set Realistic Expectations: Understand that celebrations are exceptions, not the norm. Don’t expect to maintain your usual dietary and fitness routines during every celebration. Instead, aim for balance over time.

“Focus on Social Connection: Celebrations are about connecting with others and making memories. Shift your focus from food to the people and experiences around you.”

By eating mindfully, a balance between indulgence and wellness can be achieved, ridding us of celebration guilt.

I’ve read that health is an investment, not an expense. The Roman poet Virgil said, “The greatest wealth is health.” And I agree.

So what about those holiday celebrations on the horizon? I say yes, let’s provide the food, but not push anyone to eat or drink what’s being served. After all, we may not understand their situation, and we don’t want to be stumbling blocks to their health goals.

Patty Craig of Morgantown is a mother, grandmother and retired educator.