Triage Your Health Efforts: The Good, The Bad & The Ugly
by Jeff Novick, MS, RD on Thursday, May 24, 2012 at 11:46am •
Everyday in the news, there is another breaking story telling us how bad something is for us. From problems with the food we eat, the air we breath, the water we drink, to problems with the methods of how we cook, to the chemicals in plastics, cans, cookware, toiletries and to the impact of cellphones, microwaves, etc etc. By the time we are done listening to all the the news, it seems like there is nothing safe anymore. So, how do we handle all this overwhelming information? What actions should we take, if any? How do we determine what, if anything, matters most?
The answer, lies in a simple process called "Triage."
Triage: The determination of priorities for action in an emergency; A process in which things are ranked in terms of importance or priority
Now for the good, the bad and the ugly.
The Good:
EPIC is a large study of diet and health having recruited over half a million (520,000) people in ten European countries: Denmark, France, Germany, Greece, Italy, The Netherlands, Norway, Spain, Sweden and the United Kingdom.EPIC was designed to investigate the relationships between diet, nutritional status, lifestyle and environmental factors and the incidence of cancer and other chronic diseases. Many studies have come out of this database but 2 important ones are..
1) They followed 25,663 Adults, Aged 45-79 Years Since 1993-2006
They found
- Eating 5 servings of fruit & veggies a Day Gives You the Life Expectancy of
Someone 3 Years Younger.
- Not smoking turned the clock back by 4-5 years.
- Increasing exercise by a moderate amount takes up to three years off.
Following these three simple changes was the equivalent of adding 10 more healthy years to your life expectancy
Khaw KT, Bingham S, Welch A, Luben R, Wareham N, et al. (2001) Relation between plasma ascorbic acid & mortality in men and women in EPIC-Norfolk prospective study: a prospective population study. European Prospective Investigation into Cancer and Nutrition. Lancet 357: 657–663. Find this article online Khaw KT, Jakes R, Bingham S, Welch A, Luben R, et al. (2006) Work and leisure time physical activity assessed using a simple, pragmatic, validated questionnaire and incident cardiovascular disease and all-cause mortality in men and women: The European Prospective Investigation into Cancer in Norfolk prospective population study. Int J Epidemiol 35: 1034–1043
2) In a separate study that came out about a year later, they added in alcohol intake and found if someone followed the three behaviors above and limited alcohol intake, it was the equivalent of adding up to 14 more healthy years to your life expectancy.
Khaw KT, Wareham N, Bingham S, Welch A, Luben R, et al. (2008) Combined Impact of Health Behaviours and Mortality in Men and Women: The EPIC-Norfolk Prospective Population Study . PLoS Med 5(1): e12 doi:10.1371/journal.pmed.0050012
In the WHO report, 'Preventing Chronic Diseases: A Vital Investment' 06/06/2005
They found that of the 35 million deaths from chronic disease each year, three most important modifiable risk factors are:
- unhealthy diet and excessive energy intake;
- physical inactivity;
- tobacco use.
And, that these 3 modifiable risk factors cause/lead to the intermediate risk factors of raised blood pressure, raised glucose levels, abnormal blood lipids (particularly low density lipoprotein-LDL cholesterol), and overweight (body mass index 25- 29.9 kg/m2) and obesity (body mass index > 30 kg/m2).
They Estimated that of the 3 most important modifiable risk factors,
-4.9 Mil Die As a Result of Tobacco Use,
-2.7 Mil Die As a Result of Low Fruit/Vegetable Intake,
-1.9 Mil Die As a Result of Physical Inactivity
Added together, these 3 simple lifestyle behaviors themselves account for over 40% of the lifestyle related premature deaths.
In addition, they estimated that
-2.6 million people die as a result of Excess Weight
-7.1 million people die as a result of raised blood pressure;
-4.4 million people die as a result of raised total cholesterol levels
These add up to almost 24 million deaths per year, which is 65% of the 35 million people who die prematurely from chronic diseases that can easily be prevented by a few simple lifestyle behaviors.
And, as the WHO says that the first 3 cause the second 3, then we can then also say that the first 3 simple lifestyle behaviors themselves could prevent over 65% of the premature death from chronic disease.
They also said, "the major causes of chronic diseases are known, and if these risk factors were eliminated, at least 80% of all heart disease, stroke and type 2 diabetes would be prevented; over 40% of cancer would be prevented."
While these are worldwide figures, lets apply this to just the USA..
In The USA right now
• 652,000 die from heart disease
• 559000 die from cancers
• 143000 die from stoke
• 75000 die from diabetes
• That equals 1,429,000
If we can prevent 80% of heart disease, stroke and diabetes and 40% of the cancer, we can prevent about 928,000 of the 1,429,000. That's over 65%.
(NOTE: The WHO believes their figures are underestimates of the impact and the real impact would be much higher than just 65% And, these are minimums. What if we looked at 9-12 servings of fruits & veggies, a BMI of 18.5-22, exercising 30-60 minutes 5-6 days per week, and being smoke free. Also, in 2011, the WHO raised the number of deaths from chronic disease from 35 million deaths to 51 million deaths per year.)
That is the good news.
Now, The bad news..
In their report the WHO identified 10 misunderstandings that were obstacles to changing these modifiable risk factors. A few were relevant
1) Chronic diseases are often viewed as primarily affecting old people.One quarter of all chronic disease deaths occur in people under 60 years of age.
2) The solutions for chronic disease prevention and control are too expensive to be feasible for low and middle income countries (populations).
In reality, a full range of chronic disease interventions are very cost- effective for all regions of the world. Many of these solutions are also inexpensive to implement.
3) Half Truths and kernels of truth. In these cases, the kernels of truth are distorted to become sweeping statements that are not true. Because they are based on the truth, such half-truths are among the most ubiquitous and persistent misunderstandings. Two principal half-truths are refuted below.
“ My grandfather smoked and was overweight and he lived to 96”.
Answer: In any population, there will be a certain number of people who do not demonstrate the typical patterns seen in the vast majority. For chronic diseases, there are two major types: 1) people with many chronic disease risk factors, who nonetheless live a healthy and long life; 2) people with no or few chronic disease risk factors, who nonetheless develop chronic disease and/or die from complications at a young age.
These people undeniably exist, but they are rare. The vast majority of chronic disease can be traced back to the common risk factors, and can be prevented by eliminating these risks.
4) ”Everyone has to die of something"
Answer: Certainly everyone has to die of something, but death does not need to be slow, painful, or premature. Most chronic diseases do not result in sudden death. Rather, they are likely to cause people to become progressively ill and debilitated, especially if their illness is not managed correctly. Death is inevitable, but a life of protracted ill-health is not. Chronic disease prevention and control helps people to live longer and healthier lives.
And more of the "bad"
In 2005, a study was published in the Archives of Internal Medicine, looked at how many Americans actually engage in these healthy lifestyle factors that are known to prevent most of the chronic diseases we die from.
Healthy Lifestyle Characteristics Among Adults in the United States, 2000. ARCH INTERN MED/VOL 165, APR 25, 2005
The surveyed over 153,000 Adults, age range from 18 to 74, through the
Behavioral Risk Factor Surveillance System, of the CDC.
The four Healthy Lifestyle Characteristics (HLC) were
1) Healthy Weight defined as a BMI 18.5- 25 2) consumed the minimum of 5 Fruits & Vegetables Per Day
3) Engaged in Regular Physical Activity, defined as 30 Minutes, 5x/week 4) Did Not Smoke
For each individual HLC, the numbers were,
Not smoking was about 76%, healthy weight was about 40%, engaging in adequate exercise was 23% as was consuming the minimum fruits and veggies (22%).
However, when you put all 4 together, only 3% (2.8%) of Adults Followed All 4 HLC's.
The highest subgroup (well educated, upper income) was 5%
This study confirms the above.
They monitored 42 847 men in the Health Professionals Follow-up Study, 40 to 75 years of age and free of disease in 1986 for the following 5 healthy characteristics.
- Not currently smoking
- Diet score top 40%
- Exercise ≥30 min/d
- BMI
- Moderate alcohol (5–30 g/d) or less
Only 32% practiced any two of the above Only 28% practiced any three of the above
Only 14% practiced any four of the above and Only 4% practiced all 5 Healthy Lifestyle Characteristics
Circulation. 2006 Jul 11;114(2):160-7. Epub 2006 Jul 3.Healthy lifestyle factors in the primary prevention of coronary heart disease among men: benefits among users and nonusers of lipid-lowering and antihypertensive medications.
As does this study, which also confirms the above.
They followed 84,129 women participating in the Nurses' Health Study, 30 to 55 years of age, from 1980-1994 for the following 5 healthy characteristics.
-
Not currently smoking
- Diet score top 40%
- Exercise ≥30 min/d
- BMI
- Moderate alcohol (< 5g/d)
Only 12.7% practiced any three of the above Only 7.2% practiced any four of the above
and Only 3.1% practiced all 5 Healthy Lifestyle Characteristics
Socioeconomic status had no substantial effect on the estimates
Stampfer MJ, Hu FB, Manson JE, Rimm EB, Willett WC. Primary prevention of coronary heart disease in women through diet and lifestyle. N Engl J Med. 2000; 343: 16–22
In 2010, the American Heart Association identified 7 criteria “to guide people toward ideal cardiovascular health." The called these, Life’s Simple Seven and here are the criteria.
- 150 Minutes of Moderate Activity per week
- BMI < 25
- Non Smoker > 1 yr
- Healthy Diet (As defined by the AHA)
- Cholesterol < 200
- BP < 120/
- Blood Sugar < 100
Later that year, a study looked at 17,820 Adults to see how many met this criteria.
- Only 213 met the criteria for 6 of the 7 (~1%)
- Only two (2) met the criteria for all seven.
And, when we look specifically at diet, only .5% of those surveyed met the criteria for healthy diet.
Think about that. Only 2 met the criteria for all seven and only .5% met the criteria for a healthy diet.
(And, these criteria are the strictest to meet).
That is the bad. Now for the Ugly
In the article, Adherence to Healthy Lifestyle Habits in US Adults, 1988-2006.American Journal of Medicine Volume 122, Issue 6, June 2009, Page 528-34.) they looked at the difference in the percent of Americans who were adhering to the 5 Healthy Lifestyle Characteristics between 1988 and 2006. The data from the National Health & Nutrition
Examination Survey was used for the analysis.
- The % of Americans with a BMI > 30 (which is the classification for obese) Increased From 28% to 36%
- The % of Americans who meet the minimum requirements for exercise decreased From 53% to 46%
- The% of Americans who met the minimum criteria of a healthy diet decreased From 42% to 26%
- The % of Americans who met the criteria for all 5 Healthy Lifestyle Behaviors dropped 47%
So, as you can see, we are not getting better, we are getting worse.
In addition, in a article published in the NEJM in 2005,
Olshansky, Butler,, NEJM, March 17, 2005
The authors predicted that For The First Time in US History Average Adult Life Expectancy May Be Decreasing. And that Obesity May Shorten Average Life Spans More Than Accidents, Homicides and Suicides Combined
Their famous quote from the study was
"Unless effective population-level interventions to reduce obesity are developed, the steady rise in life expectancy observed in the modern era may soon come to an end and the youth of today may, on average, live less healthy and possibly even shorter lives than their parents."
In January of 2008, a study came out confirming that this is already beginning to happen.
Ezzati M, Friedman AB, Kulkarni SC, Murray CJL (2008) The reversal of fortunes: Trends in county mortality and cross-county mortality disparities in the United States. Plos Med 5(4): e66. Doi:10. 1371/journal.pmed.0050066
This study, looked at 3141 Counties in the USA and Grouped then together Into 2068 of what they called, County Units (CU). They did this to even out populations in the counties groups and ratios of male to females
Between 1983 and 1999 Life Expectancies:
Declined Significantly In 11 CU For Males,
Declined Significantly In 180 CU For Females
Average Decline was 1.3 Yrs
Also, Life Expectancies
Declined In 48 Counties For Males
Declined In 783 Counties For Females
Average Decline Was .5 (Women) and .4 (Men)
This was most prevalent in the Deep South, Mississippi River, Appalachia, Midwest, Texas
The main reasons were Smoking, Poor Diet, Weight, Blood Pressure, & Inactivity.
We can prevent and/or stop about 70% of this by simply not smoking, being at a healthy weight, engaging in regular exercise and eating the minimum recommendations of a healthy diet. Yet only about 3-4% of Americans, at best, do this.
Think about it. Especially in regard to triaging, or prioritizing, our efforts to improve our health and lifestyle behaviors.
What matters most is what matters most.
In Health
Jeff
Thanks Jeff Don Porter
Triage Your Health Efforts: The Good, The Bad & The Ugly
by Jeff Novick, MS, RD on Thursday, May 24, 2012 at 11:46am •
Everyday in the news, there is another breaking story telling us how bad something is for us. From problems with the food we eat, the air we breath, the water we drink, to problems with the methods of how we cook, to the chemicals in plastics, cans, cookware, toiletries and to the impact of cellphones, microwaves, etc etc. By the time we are done listening to all the the news, it seems like there is nothing safe anymore. So, how do we handle all this overwhelming information? What actions should we take, if any? How do we determine what, if anything, matters most?
The answer, lies in a simple process called "Triage."
Triage: The determination of priorities for action in an emergency; A process in which things are ranked in terms of importance or priority
Now for the good, the bad and the ugly.
The Good:
EPIC is a large study of diet and health having recruited over half a million (520,000) people in ten European countries: Denmark, France, Germany, Greece, Italy, The Netherlands, Norway, Spain, Sweden and the United Kingdom.EPIC was designed to investigate the relationships between diet, nutritional status, lifestyle and environmental factors and the incidence of cancer and other chronic diseases. Many studies have come out of this database but 2 important ones are..
1) They followed 25,663 Adults, Aged 45-79 Years Since 1993-2006
They found
- Eating 5 servings of fruit & veggies a Day Gives You the Life Expectancy of
Someone 3 Years Younger.
- Not smoking turned the clock back by 4-5 years.
- Increasing exercise by a moderate amount takes up to three years off.
Following these three simple changes was the equivalent of adding 10 more healthy years to your life expectancy
Khaw KT, Bingham S, Welch A, Luben R, Wareham N, et al. (2001) Relation between plasma ascorbic acid & mortality in men and women in EPIC-Norfolk prospective study: a prospective population study. European Prospective Investigation into Cancer and Nutrition. Lancet 357: 657–663. Find this article online Khaw KT, Jakes R, Bingham S, Welch A, Luben R, et al. (2006) Work and leisure time physical activity assessed using a simple, pragmatic, validated questionnaire and incident cardiovascular disease and all-cause mortality in men and women: The European Prospective Investigation into Cancer in Norfolk prospective population study. Int J Epidemiol 35: 1034–1043
2) In a separate study that came out about a year later, they added in alcohol intake and found if someone followed the three behaviors above and limited alcohol intake, it was the equivalent of adding up to 14 more healthy years to your life expectancy.
Khaw KT, Wareham N, Bingham S, Welch A, Luben R, et al. (2008) Combined Impact of Health Behaviours and Mortality in Men and Women: The EPIC-Norfolk Prospective Population Study . PLoS Med 5(1): e12 doi:10.1371/journal.pmed.0050012
In the WHO report, 'Preventing Chronic Diseases: A Vital Investment' 06/06/2005
They found that of the 35 million deaths from chronic disease each year, three most important modifiable risk factors are:
- unhealthy diet and excessive energy intake;
- physical inactivity;
- tobacco use.
And, that these 3 modifiable risk factors cause/lead to the intermediate risk factors of raised blood pressure, raised glucose levels, abnormal blood lipids (particularly low density lipoprotein-LDL cholesterol), and overweight (body mass index 25- 29.9 kg/m2) and obesity (body mass index > 30 kg/m2).
They Estimated that of the 3 most important modifiable risk factors,
-4.9 Mil Die As a Result of Tobacco Use,
-2.7 Mil Die As a Result of Low Fruit/Vegetable Intake,
-1.9 Mil Die As a Result of Physical Inactivity
Added together, these 3 simple lifestyle behaviors themselves account for over 40% of the lifestyle related premature deaths.
In addition, they estimated that
-2.6 million people die as a result of Excess Weight
-7.1 million people die as a result of raised blood pressure;
-4.4 million people die as a result of raised total cholesterol levels
These add up to almost 24 million deaths per year, which is 65% of the 35 million people who die prematurely from chronic diseases that can easily be prevented by a few simple lifestyle behaviors.
And, as the WHO says that the first 3 cause the second 3, then we can then also say that the first 3 simple lifestyle behaviors themselves could prevent over 65% of the premature death from chronic disease.
They also said, "the major causes of chronic diseases are known, and if these risk factors were eliminated, at least 80% of all heart disease, stroke and type 2 diabetes would be prevented; over 40% of cancer would be prevented."
While these are worldwide figures, lets apply this to just the USA..
In The USA right now
• 652,000 die from heart disease
• 559000 die from cancers
• 143000 die from stoke
• 75000 die from diabetes
• That equals 1,429,000
If we can prevent 80% of heart disease, stroke and diabetes and 40% of the cancer, we can prevent about 928,000 of the 1,429,000. That's over 65%.
(NOTE: The WHO believes their figures are underestimates of the impact and the real impact would be much higher than just 65% And, these are minimums. What if we looked at 9-12 servings of fruits & veggies, a BMI of 18.5-22, exercising 30-60 minutes 5-6 days per week, and being smoke free. Also, in 2011, the WHO raised the number of deaths from chronic disease from 35 million deaths to 51 million deaths per year.)
That is the good news.
Now, The bad news..
In their report the WHO identified 10 misunderstandings that were obstacles to changing these modifiable risk factors. A few were relevant
1) Chronic diseases are often viewed as primarily affecting old people.One quarter of all chronic disease deaths occur in people under 60 years of age.
2) The solutions for chronic disease prevention and control are too expensive to be feasible for low and middle income countries (populations).
In reality, a full range of chronic disease interventions are very cost- effective for all regions of the world. Many of these solutions are also inexpensive to implement.
3) Half Truths and kernels of truth. In these cases, the kernels of truth are distorted to become sweeping statements that are not true. Because they are based on the truth, such half-truths are among the most ubiquitous and persistent misunderstandings. Two principal half-truths are refuted below.
“ My grandfather smoked and was overweight and he lived to 96”.
Answer: In any population, there will be a certain number of people who do not demonstrate the typical patterns seen in the vast majority. For chronic diseases, there are two major types: 1) people with many chronic disease risk factors, who nonetheless live a healthy and long life; 2) people with no or few chronic disease risk factors, who nonetheless develop chronic disease and/or die from complications at a young age.
These people undeniably exist, but they are rare. The vast majority of chronic disease can be traced back to the common risk factors, and can be prevented by eliminating these risks.
4) ”Everyone has to die of something"
Answer: Certainly everyone has to die of something, but death does not need to be slow, painful, or premature. Most chronic diseases do not result in sudden death. Rather, they are likely to cause people to become progressively ill and debilitated, especially if their illness is not managed correctly. Death is inevitable, but a life of protracted ill-health is not. Chronic disease prevention and control helps people to live longer and healthier lives.
And more of the "bad"
In 2005, a study was published in the Archives of Internal Medicine, looked at how many Americans actually engage in these healthy lifestyle factors that are known to prevent most of the chronic diseases we die from.
Healthy Lifestyle Characteristics Among Adults in the United States, 2000. ARCH INTERN MED/VOL 165, APR 25, 2005
The surveyed over 153,000 Adults, age range from 18 to 74, through the
Behavioral Risk Factor Surveillance System, of the CDC.
The four Healthy Lifestyle Characteristics (HLC) were
1) Healthy Weight defined as a BMI 18.5- 25 2) consumed the minimum of 5 Fruits & Vegetables Per Day
3) Engaged in Regular Physical Activity, defined as 30 Minutes, 5x/week 4) Did Not Smoke
For each individual HLC, the numbers were,
Not smoking was about 76%, healthy weight was about 40%, engaging in adequate exercise was 23% as was consuming the minimum fruits and veggies (22%).
However, when you put all 4 together, only 3% (2.8%) of Adults Followed All 4 HLC's.
The highest subgroup (well educated, upper income) was 5%
This study confirms the above.
They monitored 42 847 men in the Health Professionals Follow-up Study, 40 to 75 years of age and free of disease in 1986 for the following 5 healthy characteristics.
- Not currently smoking
- Diet score top 40%
- Exercise ≥30 min/d
- BMI
- Moderate alcohol (5–30 g/d) or less
Only 32% practiced any two of the above Only 28% practiced any three of the above
Only 14% practiced any four of the above and Only 4% practiced all 5 Healthy Lifestyle Characteristics
Circulation. 2006 Jul 11;114(2):160-7. Epub 2006 Jul 3.Healthy lifestyle factors in the primary prevention of coronary heart disease among men: benefits among users and nonusers of lipid-lowering and antihypertensive medications.
As does this study, which also confirms the above.
They followed 84,129 women participating in the Nurses' Health Study, 30 to 55 years of age, from 1980-1994 for the following 5 healthy characteristics.
-
Not currently smoking
- Diet score top 40%
- Exercise ≥30 min/d
- BMI
- Moderate alcohol (< 5g/d)
Only 12.7% practiced any three of the above Only 7.2% practiced any four of the above
and Only 3.1% practiced all 5 Healthy Lifestyle Characteristics
Socioeconomic status had no substantial effect on the estimates
Stampfer MJ, Hu FB, Manson JE, Rimm EB, Willett WC. Primary prevention of coronary heart disease in women through diet and lifestyle. N Engl J Med. 2000; 343: 16–22
In 2010, the American Heart Association identified 7 criteria “to guide people toward ideal cardiovascular health." The called these, Life’s Simple Seven and here are the criteria.
- 150 Minutes of Moderate Activity per week
- BMI < 25
- Non Smoker > 1 yr
- Healthy Diet (As defined by the AHA)
- Cholesterol < 200
- BP < 120/
- Blood Sugar < 100
Later that year, a study looked at 17,820 Adults to see how many met this criteria.
- Only 213 met the criteria for 6 of the 7 (~1%)
- Only two (2) met the criteria for all seven.
And, when we look specifically at diet, only .5% of those surveyed met the criteria for healthy diet.
Think about that. Only 2 met the criteria for all seven and only .5% met the criteria for a healthy diet.
(And, these criteria are the strictest to meet).
That is the bad. Now for the Ugly
In the article, Adherence to Healthy Lifestyle Habits in US Adults, 1988-2006.American Journal of Medicine Volume 122, Issue 6, June 2009, Page 528-34.) they looked at the difference in the percent of Americans who were adhering to the 5 Healthy Lifestyle Characteristics between 1988 and 2006. The data from the National Health & Nutrition
Examination Survey was used for the analysis.
- The % of Americans with a BMI > 30 (which is the classification for obese) Increased From 28% to 36%
- The % of Americans who meet the minimum requirements for exercise decreased From 53% to 46%
- The% of Americans who met the minimum criteria of a healthy diet decreased From 42% to 26%
- The % of Americans who met the criteria for all 5 Healthy Lifestyle Behaviors dropped 47%
So, as you can see, we are not getting better, we are getting worse.
In addition, in a article published in the NEJM in 2005,
Olshansky, Butler,, NEJM, March 17, 2005
The authors predicted that For The First Time in US History Average Adult Life Expectancy May Be Decreasing. And that Obesity May Shorten Average Life Spans More Than Accidents, Homicides and Suicides Combined
Their famous quote from the study was
"Unless effective population-level interventions to reduce obesity are developed, the steady rise in life expectancy observed in the modern era may soon come to an end and the youth of today may, on average, live less healthy and possibly even shorter lives than their parents."
In January of 2008, a study came out confirming that this is already beginning to happen.
Ezzati M, Friedman AB, Kulkarni SC, Murray CJL (2008) The reversal of fortunes: Trends in county mortality and cross-county mortality disparities in the United States. Plos Med 5(4): e66. Doi:10. 1371/journal.pmed.0050066
This study, looked at 3141 Counties in the USA and Grouped then together Into 2068 of what they called, County Units (CU). They did this to even out populations in the counties groups and ratios of male to females
Between 1983 and 1999 Life Expectancies:
Declined Significantly In 11 CU For Males,
Declined Significantly In 180 CU For Females
Average Decline was 1.3 Yrs
Also, Life Expectancies
Declined In 48 Counties For Males
Declined In 783 Counties For Females
Average Decline Was .5 (Women) and .4 (Men)
This was most prevalent in the Deep South, Mississippi River, Appalachia, Midwest, Texas
The main reasons were Smoking, Poor Diet, Weight, Blood Pressure, & Inactivity.
We can prevent and/or stop about 70% of this by simply not smoking, being at a healthy weight, engaging in regular exercise and eating the minimum recommendations of a healthy diet. Yet only about 3-4% of Americans, at best, do this.
Think about it. Especially in regard to triaging, or prioritizing, our efforts to improve our health and lifestyle behaviors.
What matters most is what matters most.
In Health
Jeff
Thanks Jeff Don Porter
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