BCNH March 2019 Newsletter

April 2019 NEWSLETTER DON'T miss our UPCOMING WEBINAR . Click here for more information Page 3: BCNH Course Webinar Information & BCNH News Page 4: Feature Article - Stress & Therapeutic Foods Page 8: Adrenal Stress Profile Testing Page 10: An Interview With: Sephora Xuereb Page 12: Overcoming Multiple Sclerosis Retreat Page 14: Stress Themed Quiz GET INVOLVED WELCOME Dear Readers, Welcome to our latest edition of the BCNH newsletter, focusing on stress to coincide with Stress Awareness month, which takes place every April. Modern, non-stop lifestyles mean that stress is a huge issue for many people, and something which is very hard to avoid. This issue includes features on the physiological pathways of stress, therapeutic foods and the value of an Adrenal Stress Profile Test. I hope that you find them informative and helpful. If you’re contemplating a career change into nutritional therapy, but are worried about not having a scientific background, turn to page 10 for an interview with our Science Foundation Course (SFC) lecturer and tutor Sephora Xuereb, which may help address your concerns. Finally, turn to page 12 for an inspiring read about BCNH graduate Sam Josephs' trip to Yarra Valley, Australia for an Overcoming Multiple Sclerosis retreat. Text We aspire to be famous for our excellent academic standards and the quality of graduates who enter the Nutritional Therapy Practice Text CONTENTS Text To sign up to our mailing list and receive details of Open Days, new courses and the BCNH Newsletter, please click here and make sure you check the 'Email' box to give us permission to contact you. We promise we’ll never share your details with a third party and we will try to send you only things you’re really interested in. Gemma ??????????????????????????? bcnh news upcoming OPEN EVENTS The best way to get a feel for BCNH is to join one of our Open Events, in person or online. This will give you the chance to find out more about the academic and clinical work you will experience at BCNH, in addition to the career options that will be open to you as a graduate of our college. We hold regular webinars, designed to inform potential students who are not able to travel to London in person. We also run regular Open Evenings in Central London, where you will have the opportunity to learn more about the courses we offer, experience the UCL campus and facilities (where BCNH lectures and seminars take place) and also ask questions of staff members, current students and graduates. UPCOMING DATES: WEBINAR: Weds 24th April 6.00-7.30pm OPEN EVENING: Thurs 16th May, 6-8pm    REGISTER NOW! You can register for all our events via our Eventbrite page. Please note that places are on a first come, first served basis. You can also book an interview / friendly chat with a member of our team via Skype or in person at our offices in NW3. Veronica Lim New Academic Staff Member We are delighted to welcome a new tutor to Year 2. Veronica Lim holds the BCNH Diploma in Nutritional Therapy with Clinical Practice (with Distinction) and is due to complete her BSc with the University of Greenwich this year. She is also a volunteer for BANT, a Master NLP Practitioner, and the UK’s first Functional Medicine Certified Health Coach. Throughout her time studying at BCNH, Veronica impressed us with her technical knowledge and ability and her calm, helpful manner and we are confident she will be a much appreciated member of the Academic team. Feature article : stress By Beverley Shergold, BCNH Head of Education, BA, DipBCNH, mBANT, CNHC April is Stress Awareness Month, therefore now seems like the perfect time to put stress under the microscope. What is stress? Stress’ is a common everyday term, however there is no universally accepted definition of stress. Hans Selye, a pioneering endocrinologist, defined stress in 1936 as “the non-specific response of the body to any demand for change”1 and over the years, contributed greatly to our understanding of the biological processes underpinning the stress response, now recognised to contribute to ageing and the development of disease when chronically stimulated. Perhaps a more relevant definition for the average individual, however, is that offered by the UK Health and Safety Executive (HSE), as “the adverse reaction people have to excessive pressures or other types of demand placed on them”2. But is stress always bad? Arguably a degree of stress can be motivating and helpful – but only to a point, and each one of us perceives, processes and copes with stress differently3, therefore early recognition of the signs and symptoms of stress is vital, before it gets out of control. The physiological response to stress The initial phase of the stress response is known as the fight-flight response, mediated by the hormones adrenaline and noradrenaline, released from the adrenal medulla in response to nervous system stimulation4. The fight-flight response is a rapid reaction, designed to mobilise the body’s resources for immediate physical activity i.e. fight or flight; it enhances immune protection and prepares vital systems such as the cardiovascular, musculoskeletal, and neuroendocrine systems to deal with challenges such as wound healing or infection that may be imposed by a stressor5. However, adrenaline and noradrenaline are not the only hormones involved in the stress response. In addition to fight-flight, stress will also activate the hypothalamic-pituitary-adrenal (HPA) axis4. The HPA axis is a complex set of stimulatory signals and feedback loops among three endocrine glands: the hypothalamus, the pituitary and the adrenal glands6. When activated, the end result is the secretion of glucocorticoid hormones (e.g. cortisol) from the adrenal glands, which have a diverse array of effects in almost all tissues and organs6. Cortisol is the predominant hormone associated with chronic stress and is a catabolic steroid hormone synthesized from cholesterol in the adrenal cortex4. Although cortisol is well-known for its immuno-suppressive effects6, it is also involved in the metabolism of fats, protein, and carbohydrate7. Normally, cortisol levels will follow a strong diurnal rhythm through the day, surging to a peak shortly after waking and then dropping (rapidly at first, followed by a more gradual decline), and reaching a low point around bedtime8. This diurnal variation has an important regulatory effect on many body processes, impacting upon energy levels and arousal, immune and inflammatory function, as well as mood and cognitive processes9. However, there are individual differences in this rhythm of cortisol secretion, which may be influenced not just by genetic and developmental factors, but also by the psychosocial environment8. For example, prolonged stress can result in overactivity of the HPA axis, manifesting in excessive cortisol secretion10. Should this overactivity continue without sufficient time for recovery, it may eventually result in low cortisol, manifesting in symptoms such as exhaustion and fatigue (or ‘burnout’)11. Consequences of stress Whilst acute responses to stress may be evident from changes in behaviour (e.g. becoming withdrawn, aggressive), emotions (e.g. anxiety, irritability) and even physical symptoms (e.g. headaches, palpitations, gastrointestinal distress)12, chronic stress has been directly implicated in the aetiology and prognosis of a number of diseases and disorders including (but not limited to) cardiovascular disease13, diabetes and metabolic syndrome6, musculoskeletal disorders14, common mental disorders, such as anxiety and depression15, cognitive decline and dementia16 and gastrointestinal conditions such as IBS17 and Crohn’s disease18. Much of the damaging effects of chronic stress are thought to be due to the prolonged effects of the major effector molecules of the stressor system (e.g. cortisol and noradrenaline)6, with cortisol in particular thought to play a major role in mediating associations between stress exposure and health outcomes8. How can nutrition help with your stress control? One of the fundamental ways to balance stress hormones is balancing blood glucose levels by avoiding excessive alcohol, refined carbohydrates and stimulants (e.g. coffee, tea, cigarettes, etc.). As refined carbohydrates are rapidly absorbed and quickly raise blood glucose levels, this can result in an exaggerated insulin response, the end result of which can be low blood glucose concentration (with blood glucose falling below the fasting levels19, which the body perceives as stress), producing symptoms of hypoglycaemia such as fatigue, irritability, anxiety and craving stimulants and carbohydrates. Stress hormones are released to address falling blood glucose levels, stimulating breakdown of glycogen in the liver (glucose storage) and creating insulin resistance at the cell membrane to reduce the flow of glucose from the blood into the cells20. Having regular meals containing complex carbohydrates, fats and protein will ensure slower entry of glucose into the small intestine and therefore slower glucose absorption provoking a more balanced insulin response and removing the unnecessary stress of subsequent low blood glucose levels. The adrenal glands play a central role in the stress response Feature article Chronic stress is implicated in a number of conditions, including diabetes & metabolic syndrome Cortisol is the predominant hormone associated with chronic stress feature article supporting stress with therapeutic foods Magnesium (Mg) Magnesium is a co-factor for more than 300 metabolic reactions in the body, including those involved in energy production and protein synthesis, and plays a pivotal role in nerve transmission, cardiac excitability, blood pressure and blood glucose management; making it susceptible to depletion by stressors26. Prolonged stress is recognised to considerably increase magnesium elimination in the urine27. Studies in mice have demonstrated that magnesium deficiency increases HPA axis activity, dysregulation of which have been suggested to contribute to conditions such as anxiety and depression28. Although the magnesium content of foods is declining, increasing our risk of deficiency, the foods highest in magnesium include wholegrains, nuts, legumes, leafy green vegetables and potatoes29. Vitamin C Humans, unlike most animals, cannot synthesize vitamin C and must therefore obtain it from the diet21. Vitamin C is found in high concentrations in the adrenal glands22, where it is necessary for stress hormone synthesis23 . Stress also increases urinary excretion of vitamin C24, hence additional vitamin C may be required during stressful periods. Fruit and vegetables are rich sources of vitamin C, particularly peppers, citrus fruit and broccoli, however the content is decreased by storage and the cooking process25. REFERENCES Fermented foods Foods which have undergone microbial fermentation are a source of gamma-Aminobutyric acid (GABA ), an inhibitory neurotransmitter in the central nervous system associated with calmness and involved in the management of stress32. Lactic acid bacteria produce GABA as a metabolic by-product whilst also preventing food spoilage pathogens to grow. Kimchi, a traditional Korean vegetable dish, is a particularly good source of GABA33. Research has suggested that people who regularly consume fermented foods have a reduced incident of anxiety and stress34. supporting stress with therapeutic foods Green tea Green tea contains the amino acid theanine, which is a natural relaxant with anti-stress properties34. Research has shown that those who consume regular cups of this beverage experience less stress symptoms. Be sure to select a low caffeine version though, as this has been demonstrated to block the actions of theanine35. Vitamin B5 – pantothenic acid Vitamin B5 is needed in the maintenance of adrenal structure as well as for the production of cortisol30. B5 is a component of coenzyme A (CoA)31 required for cholesterol synthesis, which adrenal steroid hormones are derived from. Vitamin B5 is ubiquitous in foods of plant and animal origin, with fish, eggs, dairy products and legumes being particularly rich sources. The Adrenal Stress Profile The Adrenal Stress Profile is one of our most popular profiles and can be helpful for patients with a range of disorders such as anxiety, depression, chronic fatigue, insomnia and difficulty losing weight. We measure salivary cortisol at four points over the day in order to assess the diurnal rhythm. The natural cortisol diurnal rhythm shows a peak within the first hour after awakening, a rapid decline over morning hours and then tapering through the rest of the day before reaching its lowest point at night. A low slope may represent chronic stress burden or lack of HPA axis resiliency whereas a high slope may indicate response to a major stressor. Salivary DHEA is also measured as part of the profile. A low DHEA can be an indicator of long term stress. DHEA is the precursor to testosterone, so low DHEA may have implications on sex hormone balance. Cortisol Awakening Response The Adrenal stress profile has recently been updated with the option to add the Cortisol Awakening Response (CAR). The CAR is measured by assessing cortisol on awakening and then again 30 minutes later to give a % rise in cortisol. A value of at least 50% is expected. The cortisol awakening response is a physiological response to awakening and an independent marker of central biological clock function and overall HPA axis resiliency – so it represents the patient’s ability to prepare for a daily stressor, anticipation of stressor and resiliency. An elevated CAR maybe due to exacerbated anticipation of daily stressor, whereas a low CAR may be due to burnout, depression, PTSD, chronic fatigue or early loss experience. Who might the Adrenal Stress Profile be particularly useful for and what patterns might you see?  Adrenal Stress Profile can be helpful for patients with a range of disorders such as anxiety, depression, chronic fatigue, insomnia and difficulty losing weight. It is not always easy to link a pattern of results to a particular condition as stress responses are so individual. For example, chronic fatigue patients may show lower levels of cortisol throughout the day, but this is not exclusively so. We fairly often see patterns of elevated morning cortisol with a huge drop in the 2nd, 3rd and 4th samples which we usually consider to be ‘Wired and Tired’. The patient can produce cortisol, but seemingly is unable to maintain it throughout the day. Elevated late evening cortisol may be connected with poor sleep and the patient may find it helpful to look at improving sleep hygiene and introducing relaxation techniques. What about more unusual patterns such as a low morning cortisol with a mid-afternoon peak and remaining elevated into the evening? When we see more unusual patterns we recommend checking with the patient for possible causes of elevated cortisol. These can include exercise, infections, pain and inflammation, sleeping in the afternoon, hypoglycemia or acute stress. We also encourage patients to complete the test on what they would consider a ‘typical day’ so that results are representative of their current state of health. If these have all been ruled out then we usually discuss starting with lifestyle changes, balancing blood sugar, making sure that there is optimal supply of nutrients that nourish the adrenal glands through diet and supplementation, and then considering adaptogenic herbs or adrenal glandulars as appropriate. What nutrients would you consider for adrenal support?  Specific supplement protocols are not our area of particular expertise but a high-grade multi-vitamin or mineral can provide baseline nutrients, additional vitamin C, B5, B6, magnesium and zinc can be useful. For elevated cortisol, phosphatidyl serine may resensitise the hypothalamus and pituitary to cortisol negative feedback. Adaptogenic herbs can also be very helpful for both hyper and hypocortisol results. Are there any supplements or medications which can impact on the results?  Any steroid-based medication, including nasal sprays, inhalers or eye drops will directly impact cortisol levels and we sometimes see results that are skewed very high. Nutritional supplements should not directly impact these test results. We cannot be certain of the impact that glandular support would have on these test results. Kate Osborne graduated from BCNH in 2006 with a Diploma in Nutritional Therapy and went on to run a clinic in Islington. She then studied for an MSc in Person Centred Nutrition which she completed in 2015. Kate joined Genova Diagnostics Clinical Education Team in 2016 where she educates clinicians on how to use functional testing. This involves lecturing for colleges and for BANT, running webinars and giving clinicians one-to-one support over the phone. She is also part of Calmer Clinics, a multi-disciplinary clinic based in Pimlico where she specialises in gut health and hormone health. adrenal stress profile testing adrenal stress profile testing What is your regular 'day' job? I am a qualified secondary school teacher and have been teaching for last 15 years. I specialise in science and have taught all three areas at various point (Biology, Chemistry and Physics) for students up to 16 years of age as well Biology and Chemistry at A-level. I am currently the Head of Biology at a lovely 6th form college. How long have you been teaching the SFC at BCNH? Since September 2011. In that time, I have thoroughly enjoyed working with BCNH to hone and deliver a course that will enable students to be well prepared for accessing the nutrition courses. How does your style of teaching on the SFC teaching adults compare to that when teaching school students? Teaching on the SFC is quite a unique experience. The course is designed to deliver a fairly large volume of content within a limited time-frame. For this reason, the lessons need to be delivered in a mostly lecture style which is different . However, lecturing to a small audience on the SFC enables me to utilise elements of secondary school teaching for assisting students to assimilate their learning. Such techniques include asking the audience questions to check their understanding, inviting the students to ask questions, issuing exercise tasks to rehearse the knowledge being discussed and speaking at a similar pace as to when teaching teenagers. What would you say to somebody who has a completely non-scientific background and is contemplating a career change into nutrition? With any career change, new sets of skills and knowledges need to be learned and this is no different when moving into science related professions. If you are enthusiastic in learning about nutrition and motivated to work at it, this will be a totally achievable dream. I want to study nutritional therapy, not biology and chemistry, do I really need to study the SFC first? Nutritional therapy is a science. A nutritional therapist requires a thorough understanding of how body systems operate, the biochemical reactions that take place within cells and be able to relate these to active chemical ingredients within foods and supplements in order to work with a client to tackle a health issue. The nutritional therapy courses focus on the structure and function of the biological molecules and how they interact with one another. Diploma lecturers will assume that students have prior knowledge of the concepts that underpin the molecules discussed. For example, the fundamental ideas regarding atoms, molecules and bonding will be assumed knowledge and the SFC teaches these. Furthermore, the diploma will require student to research and read technical scientific papers and the SFC is an introduction to scientific terminology to help with making these more accessible. I haven’t sat a formal exam for many years and I’m out of practice studying, will I be able to cope? You certainly will be able to cope particularly if learning is spread out across the year. The advantage of the SFC formal exam over standard secondary school exams is that the questions asked are straight forward 'describe' and 'explain' questions and students will more easily be able to pick out the ideas present within the lecture notes to answer these. The pressure of having to work out what a question is actually asking or applying knowledge to unfamiliar situations is removed. This frees up students to use their study time to memorise the content without having to also cope with learning to cut through exam jargon. This style of examination favours SFC students who are juggling very busy lifestyles whilst studying. What makes a successful SFC student? The most successful SFC students follow the lecturer’s advice to watch the videos, make their own notes, complete the online quizzes, homework and practice exam questions. Those that score the most highly make use of the online platform to ask me plenty questions and to clarify their understanding. What is the best piece of advice you can offer a potential SFC student? The key is to be patient with yourself, learn ideas at your own pace and have the belief that you can do it. Finally, has working at BCNH influenced your own diet and lifestyle choices? As a teenager, I became quite overweight and my motivation to achieve a healthy weight and sculpt a shape that I can be happy with has fuelled my strong interest in diet and lifestyle. For many years, I believed that avoiding fat was important in weight loss. However, working at BCNH has provided me with an opportunity to have a consultation with a 4th year student completing her clinical practice year. I learned that fats are an essential component of a healthy diet and eaten in the correct quantities would not make me gain weight and have many benefits such as controlling inflammation and maintaining healthy skin. This was music to my ears and as a result, I now enjoy a more varied diet. AN INTERVIEW WITH: SEPHORA XUEREB Sephora studied a general Bachelor of Science degree followed by a graduate diploma in Education at the University of Melbourne, Australia. Driven to explore the UK and Europe, she moved to England in 2004 and has lived here since. Sephora works as a secondary school teacher and is the lecturer and tutor on the Science Foundation Course (SFC) with BCNH. She strongly believes that the key to health and vitality is totally within the control of the individual and as such is mindful of fuelling the body with nutritious food and exercise bcnh SCIENCE FOUNDATION COURSES AN INTERVIEW WITH : sephora xuereb Option 1: STANDARD SFC (ONLINE) This course can be started at any time during the year with options to take the Science Foundation Course exam in May or June (or even later with a prior arrangement). The online SFC requires no attendance. All course materials will be provided on our VLE, Moodle, including lecture notes, lecture audio and video recordings and tutorial support. The course tutor also holds regular webinars with students which are also recorded. The aim of these webinars is to discuss revision questions and the content from the previous lecture weekend. Option 2: REFRESHER SFC The Refresher SFC is designed for those candidates who have completed their Chemistry / Biochemistry A – level (or an equivalent) within 10 years of enrolment on BCNH Level 6 Diploma course. The course covers the same syllabus as Standard SFC, however, there is no formal examination for this course I first heard about Dr George Jelenik and his evidence-based approach to MS in 2011. I was really inspired and motivated by the excellent collation of studies published on diet and lifestyle factors for both preventing and addressing progression in MS. The latest edition of the book draws on over 1200 studies and has spawned the 7-step approach to MS recovery (yes, a brave word to be using when discussing chronic illness!), which is being promoted through the work of the charitable organisation OMS – Overcoming Multiple Sclerosis, www.overcomingms.org. Part of the support OMS provides is running retreats – both in Europe and in George’s native Australia. This February, I flew to Melbourne to work as a facilitator for OMS at one of their Australian 5-day retreats. Twice a year, at the beautiful Yarra Valley Living Centre they host 40 participants (a mix of pwMS and some supporters/partners) guiding them through the evidence-based principles of the program and giving practical instruction in all areas. We did a practical session on food which involved navigating fat content of foods and learning to decipher food labels. Participants explored different meditation techniques such as body scans, meditative movement and breath awareness. Qi Qong was the main exercise practised which was a treat for me as I had never done it before. There were also sessions exploring the emotional impact of a diagnosis like MS for both pwMS and their supporters/families. Participants responded really well to being given so much information, despite much of it biochemistry! It really underlines the point that ‘knowledge is power’, and educating pwMS exactly how and why the certain foods exacerbate or calm symptoms and disease progression almost guarantees compliance. We specifically looked at a number of studies around using vitamin D to prevent onset, reduce relapse rate and limit progression of MS. It was tough to encourage an Australian audience to see the sun as a positive source of health, rather than a vehicle for delivering melanoma. George Jelenik now heads up the Neuroepidemiology Unit at Melbourne University, and his HOLISM study and STOP-MS study have been published in world renowned journals, with the HOLISM study still spawning further papers. HOLISM reports on over 2,500 pwMS in over 57 countries examining the impact of lifestyle factors on MS, the results confirming the 7-step program approach. The STOP-MS study specifically looks at the impact of the OMS retreats on pwMS, concluding that people who attend the retreat experience improved mental and physical health, fewer relapses and disability stabilizing three years on – pretty impressive when you consider MS is a ‘progressive’ disease. Before heading up to the Yarra valley, I was invited to lunch at George Jelenik’s house in Melbourne along with my colleagues Phil Startin (UK facilitator and expert in meditation and mindfulness who has Primary Progressive MS, and Gary McMahon, the CEO of OMS). Sandy, George’s wife, cooked us the most delicious OMS-friendly meal – dips, olives and stuffed vine leaves to start; tiger prawns, artichoke, bean and vegan-pesto pasta salad and a tomato and pomegranate salad; and to finish a baked plum tart with cashew nut cream. George is extremely down to earth and so knowledgeable, he didn’t mind at all sharing latest research and letting us quiz him on the minutiae of the program. He himself was diagnosed with MS in 1999 but remains relatively symptom-free due to the OMS program. I look forward to meeting George again this June when he hosts the OMS Edinburgh Conference. I will be there presenting on Diet and MS. If you know anyone affected by MS, or newly diagnosed, then I strongly recommend this event as a point of introduction to the program and the first step on a possible road to real recovery. The OMS charity also sends out free copies of George’s book to the newly diagnosed. The 7-step Approach Step 1 – Diet (low saturated fat, plant-based, whole food diet – with fish & seafood) Step 2 – Sunlight & Vitamin D Step 3 – Exercise Step 4 – Meditation Step 5 – Medication Step 6 – Prevention for family members Step 7 – Do whatever it takes Phil Startin, another UK faciliator (left) and George Jelenik (middle). Me on the right! About me: My husband was diagnosed with MS in 2002 and despite being told by neurologists that diet and lifestyle interventions were unfounded, we quickly found evidence in medical literature to make some drastic dietary changes. I qualified from BCNH in 2008, and at first resisted the world of MS patients as it was so all-consuming in our home life. However, word spread, and now I am invited to speak at many MS groups, was on the panel of experts at the MSLife Expo 2016, work as a retreat and conference facilitator for the Overcoming Multiple Sclerosis charity and teach the MS modules at both BCNH and ION as well as seeing many MS clients in my own North London practice. a trip to a multiple sclerosis retreat By Samantha Josephs,DipBCNH a trip to a multiple sclerosis retreat A delicious OMS-friendly lunch! 7. Stress can contribute to high blood pressure. a) True b) False 5. Stress can make us fat: a) True b) False 3. Stress can inhibit thyroid hormone secretion, slowing down metabolism: a) True b) False 10. Long-term yoga training improves stress-related psychological symptoms  a) True b) False Click here for answers 8. Long-term stress can enhance immunity: a) True b) False 6. Which of the following B vitamins is required for cortisol synthesis, vital during the periods of stress? a) Vitamin B1 b) Vitamin B3 c) Vitamin B5 d) Vitamin B6 e) Vitamin B12 2. Which of the following is not a stress hormone? a) Adrenaline b) Noradrenaline c) Cortisol d) DHEA e) Oestrogen 4. Which of the following nutrients is found in high concentrations in the adrenal glands, where stress hormones are produced? a) vitamin C b) Vitamin D c) Vitamin C & B5 d) Vitamin B5 e) Mg 1. Activation of the fight-flight response always has negative consequences for health:    a) True b) False 9. Which of the following are associated with chronic stress? a) Constipation or diarrhoea b) Depression c) Gastric ulcer d) Hypoglycaemia e) Psoriasis f) All of the above   QUIZ 1. The American Institute of Stress. What is Stress? [Internet]. Available from: https://www.stress.org/what-is-stress 2. Health and Safety Executive. Work-related stress and how to tackle it [Internet]. Available from: http://www.hse.gov.uk/stress/what-to-do.htm 3. Gunnar M, Quevedo K. The Neurobiology of Stress and Development. Annu Rev Psychol [Internet]. 2007 Jan [cited 2019 Feb 27];58(1):145–73. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16903808 4. Tortora G. Principles of Anatomy and Physiology. 15th ed. Wiley; 2017. 5. Dhabhar FS. Effects of stress on immune function: the good, the bad, and the beautiful. Immunol Res [Internet]. 2014 May 6 [cited 2019 Feb 27];58(2–3):193–210. Available from: http://link.springer.com/10.1007/s12026-014-8517-0 6. Nicolaides NC, Kyratzi E, Lamprokostopoulou A, Chrousos GP, Charmandari E. Stress, the Stress System and the Role of Glucocorticoids. Neuroimmunomodulation [Internet]. 2015 [cited 2019 Feb 27];22(1–2):6–19. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25227402 7. Hoehn K, Marieb E. Human Anatomy & Physiology. San Francisco: Benjamin Cummings; 2010. 8. Adam EK, Quinn ME, Tavernier R, McQuillan MT, Dahlke KA, Gilbert KE. Diurnal cortisol slopes and mental and physical health outcomes: A systematic review and meta-analysis. Psychoneuroendocrinology [Internet]. 2017 Sep [cited 2019 Feb 27];83:25–41. Available from: http://www.ncbi.nlm.nih.gov/pubmed/28578301 9. Sapolsky RM, Romero LM, Munck AU. How Do Glucocorticoids Influence Stress Responses? Integrating Permissive, Suppressive, Stimulatory, and Preparative Actions 1. Endocr Rev [Internet]. 2000 Feb [cited 2019 Feb 27];21(1):55–89. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10696570 10. Stokes PE. The potential role of excessive cortisol induced by HPA hyperfunction in the pathogenesis of depression. Eur Neuropsychopharmacol [Internet]. 1995 [cited 2017 Oct 31];5 Suppl:77–82. Available from: http://www.ncbi.nlm.nih.gov/pubmed/8775763 11. Lennartsson A-K, Sjörs A, Währborg P, Ljung T, Jonsdottir IH. Burnout and Hypocortisolism - A Matter of Severity? A Study on ACTH and Cortisol Responses to Acute Psychosocial Stress. Front psychiatry [Internet]. 2015 [cited 2019 Feb 27];6:8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25698980 12. Michie S. Causes and management of stress at work. Occup Environ Med [Internet]. 2002 Jan 1 [cited 2018 Dec 30];59(1):67–72. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11836475 13. Fishta A, Backé E-M. Psychosocial stress at work and cardiovascular diseases: an overview of systematic reviews. Int Arch Occup Environ Health [Internet]. 2015 Nov [cited 2018 Dec 23];88(8):997–1014. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25687981 14. Bongers PM, de Winter CR, Kompier MA, Hildebrandt VH. Psychosocial factors at work and musculoskeletal disease. Scand J Work Environ Health [Internet]. 1993 Oct [cited 2019 Jan 4];19(5):297–312. Available from: http://www.ncbi.nlm.nih.gov/pubmed/8296178 15. Stansfeld S, Candy B. Psychosocial work environment and mental health--a meta-analytic review. Scand J Work Environ Health [Internet]. 2006 Dec [cited 2018 Nov 9];32(6):443–62. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17173201 16. Nilsen C, Andel R, Fors S, Meinow B, Darin Mattsson A, Kåreholt I. Associations between work-related stress in late midlife, educational attainment, and serious health problems in old age: a longitudinal study with over 20 years of follow-up. BMC Public Health [Internet]. 2014 Aug 27 [cited 2018 Dec 29];14:878. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25159829 17. 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We would love to hear your comments, suggestion and questions, which we aim to incorporate in future editions.  Simply get in touch: gemma@bcnh.co.uk   We look forward to hearing from you all! Breda & Gemma 1) b) False The fight-flight response is necessary to cope with the challenges of everyday life. Problems start when the stress response is inappropriate to the intensity of the challenge 2) e) Oestrogen 3) a) True 4) a) vitamin C 5) a) True  6) c) Vitamin B5 7) a) True Stress raises blood pressure via adrenal stress hormones output, which increase heart rate, sodium retention and blood vessel constriction. 8) b) False While chronic stress has profound immunosuppressive effects, short-term stress (i.e. lasting for minutes to hours) can enhance our first line of defense against invading organisms and is considered one of the nature's fundamental survival mechanisms. 9) f) All of the above 10) a) True Studies have shown that long-term yoga training improves stress-related psychological symptoms, such as perceived stress by lowering the levels of anxiety and anger, which can ultimately help reduce cortisol levels.