Terry A. Rondberg, DC | Wellness for Mind and Body

Vitamins and calcium supplements appear to reduce the risk of breast cancer, according to findings presented at the American Association for Cancer Research 101st Annual Meeting 2010.

“It is not an immediate effect. You don’t take a vitamin today and your breast cancer risk is reduced tomorrow,” said Jaime Matta, PhD, professor in the Ponce School of Medicine in Puerto Rico. “However, we did see a long-term effect in terms of breast cancer reduction.”

Matta said the findings suggest that the calcium supplements are acting to enhance DNA repair capacity, a complex biological process involving more than 200 proteins that, if disrupted, can lead to cancer.

“This process involves at least five separate pathways and is critical for maintaining genomic stability,” said Matta. “When the DNA is not repaired, it leads to mutation that leads to cancer.”

The study included 268 women with breast cancer and 457 healthy controls. Women were more likely to have breast cancer if they were older, had a family history of breast cancer, had no history of breastfeeding, and had lower DNA repair capacity.

The risk of breast cancer appeared to be reduced by about 30% in the case of vitamin supplements, 40% with calcium supplements. After controlling for the level of DNA repair capacity, calcium supplements were no longer as protective, but the link between vitamin supplements and breast cancer reduction remained.

“We’re not talking about mega doses of these vitamins and calcium supplements, so this is definitely one way to reduce risk,” said Matta.

Allopathic medicine has a long history of “inventing” diseases and giving them fancy Latin names — all in order to come up with a pill or treatment to “cure” it.

But this one gets the absurdus maximus award — a Californian doctor, Steven Bratman, has “medicalized” a strong conscious desire to eat healthy, nutritional foods as a mental disorder! And, of course, he’s given it a name: orthorexia nervosa.

These poor demented souls are, as reported in The Guardian, “solely concerned with the quality of the food they put in their bodies, refining and restricting their diets according to their personal understanding of which foods are truly ‘pure’.”

They follow crazy behavior, like trying to eliminate refined sugar, salt, caffeine, alcohol, or other food groups from their diet. And they rebuff foods that have been in contact with pesticides, herbicides or contain artificial additives.

Granted, there are people who get a bit neurotic about food safety and base their dietary choices on fear rather than good sense. But the idea of turning food concerns into a mental health disease is just one more instance of medical manipulation.

While an anti-orthorexia drug hasn’t been developed — yet — Bratman quickly cashed in on his “disease” by writing a book called, “Health Food Junkies.”  I’m gratified to see it didn’t make much of a blip on the sales lists and got a dismal review score on Amazon.com (just 3 stars out of 5, with one person echoing my own feelings, saying, “So it is now a fixation to ‘obsess’ about healthy food? This is the most stupid, irresponsible drivel I have ever heard of. Ok, let’s NOT obsess about food, let’s keep eating meat, and dairy, and preservatives, and chemicals, let’s eat genetically modified food, let’s NOT read labels, let’s NOT think about what’s in our food, let’s keep getting diabetes, cancer and heart disease which NO DOCTOR has ANY CURE FOR!!! Just treatment, NO CURE. Let’s do that. Because doctors are so good at curing diseases. That’s why we are such a healthy nation! Mind-numbingly irresponsible, for a physician to write this.” I swear, I didn’t write that (but wish I had!). Here’s the Amazon page, just so you can read some of the other scathing reviews!

Not surprisingly, Bratman’s ideas have been picked up by the British medical community, which seems intent on destroying everything that isn’t totally aligned with the allopathic paradigm, be it homeopathy or, now, healthy eating!

Ursula Philpot, chair of the British Dietetic Association’s mental health group, told The Guardian: “The issues underlying orthorexia are often the same as anorexia and the two conditions can overlap but orthorexia is very definitely a distinct disorder. Those most susceptible are middle-class, well-educated people who read about food scares in the papers, research them on the internet, and have the time and money to source what they believe to be purer alternatives.”

(Interestingly, the main goal of the association appears to be acceptance by the medical profession, and, in the group’s words to “act as a specialist within a multi-disciplinary team … (and) act as a consultant to other health professionals advising on nutritional aspects of care.” Sounds much like those chiropractors and other alternative health providers who used to be willing to medicalize their professions in order to gain the approval of MDs. By now, most of them realize that’s not going to happen!)

Getting back to the dread “orthorexia nervosa” disease, Wikipedia further explains: “The subject may avoid certain unhealthy foods, such as those containing fats, preservatives, man-made food-additives, animal products, or other ingredients considered by the subject to be unhealthy; if the sufferer does not eat appropriately, malnutrition can ensue. Orthorexia sufferers have specific preferences about the foods they are eating and avoiding. Products that are preserved with additives can be considered dangerous. Industrial products can be seen as artificial, whereas biological fruits and vegetables can be seen as healthy.”

So, unless you relish an apple with a thick coating of pesticide residue, a fast food burger with 80 grams of saturated fat, or a TV dinner with a list of unpronounceable (and unidentifiable) ingredients, you may want to make an appointment with the nearest shrink. You could be a very sick mind (although chances are, you’ll have a heck of a lot healthier body than most!).

The friend who sent me this information — a guy who has a PhD in molecular biology and is finishing his last year interning as a psychiatrist — had a novel suggestion: “How about we come up with a term for a syndrome where certain sciences over-classify and are slaves of the pharmaceutical industry? Maybe inservio supervacuus (superfluous slave).”

When DD Palmer called our profession “chiropractic” — combining the Greek words cheir (hand) and praxis (action) — he couldn’t have chosen a better name. While there are a few doctors who substitute mechanical devices for their hands, even those practitioners have some hands-on work with patients — palpation, adjusting or just placing the hands on affected areas.

We, and our patients, have always known that the success of chiropractic has a great deal to do with the “personal touch” we provide (metaphorically as well as literally). Surveys on patient satisfaction almost always emphasize the influence of our personal involvement with those under our care, particularly when compared to the cold, impersonal treatment received from many medical providers.

A recent research study, sponsored by the National Cancer Institute and presented at the 6th International Conference of the Society for Integrative Oncology, reinforces our understanding of the importance of true “by hand” practice, whether it’s provided by a health care practitioner or a caretaker.

Researchers found that touch — particularly massage — administered by care partners significantly reduces the effects of cancer and the side-effects from its treatment while providing comfort and improvement in the quality of life.

In the study, 97 family caregivers learned touch and massage techniques from a 78-minute instructional DVD, called “Touch, Caring, and Cancer: Simple Instruction for Family and Friends.” They then used these touch techniques to safely care for people living with cancer. “The magnitude of the impact of family members was unexpected. Our research found significant reductions of pain, anxiety, fatigue, depression and nausea when massage was routinely administered at home by family and caregivers,” lead researcher William Collinge, PhD, revealed.

The study found massage by family members reduced stress/anxiety (44% reduction), pain (34%), fatigue (32%), depression (31%), and nausea (29%).

“The discovery that family members can learn and administer simple massage techniques that can consistently reduce stress is significant. Stress is a constant that negatively impacts the lives and wellbeing of cancer patients,” Collinge wrote. “Both cancer patients and caregivers benefit because massage appears to strengthen the relationship bond. Massage provides the caregiver a way to make a difference.”

This research not only reminds us of the significance of personal touch between doctor and patient, but might be a good incentive to bring a massage therapist into your practice. The synergistic effect of the two disciplines would no doubt benefit many patients and might increase patient volume.

You may even want to provide certain patients with the video used to train the participants in the study (it’s available from Amazon.com). I believe strongly that the “hands on” approach works for all people, regardless of the state of their health. Since it reduces stress — the primary cause of most health issues — it would be effective on most people, not just those with cancer.

By Terry A. Rondberg

A new study published by JAMA shows that among patients age 65 years and older, rosiglitazone (a medication for treating Type 2 diabetes) is associated with an increased risk of stroke, heart failure, and all-cause mortality (death) when compared with pioglitazone (another medication for diabetes).

In their conclusion, the authors wrote: “…in a population of more than 227,000 patients 65 years or older who initiated treatment with a thiazolidinedione, we found that, compared with pioglitazone, rosiglitazone was associated with an increased risk of stroke, heart failure, and death and the composite of AMI (heart attack), stroke, heart failure or death.” (JAMA.doi:10.1001/jama.2010.954)

Despite trying to put rosiglitazone in the most “favorable” light possible, researchers had to admit that “analysis showed no differences in the risk for heart attack between rosiglitazone and pioglitazone,” even though the study found that rosiglitazone was associated with a 1.25-fold increase in risk of heart failure compared with pioglitazone.

Obviously, BOTH medications have serious negative side effects, but the report’s wording seems somewhat biased to me so I delved a little deeper. Within the past five years, the study’s head researcher, Steven E. Nissen, MD, has received research support from numerous drug companies, including AstraZeneca, Atherogenics, Novartis, Pfizer, Resverlogix, Daiichi-Sankyo, Sanofi-Aventis and — most importantly — Eli Lilly and Takeda.

The drug that fared better in this study (branded name Actos) is manufactured by Eli Lilly and Takeda. Avandia, the branded version of rosiglitazone, is made by GlaxoSmithKline, a name curiously absent from the list of Nissen’s financial benefactors.

Probably just a coincidence, right? Yet, only this month, the BMJ (which used to be called British Medical Journal) published a report that explored a possible link between authors’ financial conflicts of interest and their position on the association of rosiglitazone with increased risk of myocardial infarction in patients with diabetes.

The research abstract noted: “Of the 202 included articles, 108 (53%) had a conflict of interest statement. Ninety authors (45%) had financial conflicts of interest. Authors who had a favourable view of the risk of myocardial infarction with rosiglitazone were more likely to have financial conflicts of interest with manufacturers of antihyperglycaemic agents in general, and with rosiglitazone manufacturers in particular, than authors who had an unfavourable view (rate ratio 3.38, 95% CI 2.26 to 5.06 and 4.29, 2.63 to 7.02, respectively). There was likewise a strong association between favourable recommendations on the use of rosiglitazone and financial conflicts of interest (3.36, 1.94 to 5.83)” (BMJ 2010;340:c1344)

In another, even more chilling report (also published in BMJ), the author writes: “Casually following the fortunes of the blockbuster diabetes drug rosiglitazone (Avandia), you can’t help but imagine a Hollywood thriller. There is the scene where a leading scientist secretly records a meeting with drug company executives, a high powered congressional investigation, and a bitter legal battle waiting in the wings. Yet when you look more closely, the facts are even stranger than fiction. An expensive new drug shown to raise the risk of heart failure and suspected of increasing the chance of heart attacks has been taken by millions of people around the world and is being kept on the market by an industry funded regulatory system, despite calls from senior safety experts to withdraw it.” (BMJ 2010;340:c1848)

I took a look at one other factor as well: pricing. The most common price I could find for Avandia — the drug touted as “safer” by the research paper — was $3.32 per pill (for 30 pills of 8mg, which is considered the normal dose). For Actos, the price was $1.34 per pill (for 30 pills of 30mg, again, considered the normal dose).

When it comes to this type of medical drug research, the saying “follow the money” seems to apply. Perhaps it’s also time to follow the advice of “X-Files” character Fox Mulder: TRUST NO ONE.

About Terry A. Rondberg, DC
Terry A. Rondberg is founder and CEO of the World Chiropractic Alliance. He is an ardent advocate for drug-free chiropractic care not just for back pain, but total body wellness. He has spoken globally on the issue of alternative care and the abuses of our current “health care” system.

By Terry A. Rondberg

Like many wellness practitioners, I don’t believe in the traditional “germ theory.” Of course I know germs exist, but I don’t think they “cause” illness. The true cause is the inability of the human body to deal with germs and counter their effects. After all, if germs were the actual root cause of illness, everyone who came into contact with them would be ill — that is, ALL of us!

Having said that, most of the people we see in our offices have impaired immune systems, to some degree or another. The existence of subluxations; the lack of proper diet or exercise; the overuse of antibiotics; and even physical, mental or emotional stress can all weaken the immune system to the point where the body is vulnerable to the impact of germs and viruses.

That’s why proper infection control procedures are critical in any wellness office. Unfortunately, this basic tenet of hygiene is often overlooked in medical settings. In fact, a report published in the June 9 issue of JAMA found that such lapses were common in many of the 70 ambulatory surgical centers studied. These centers are rapidly becoming the primary facility for a wide variety of medical and surgical procedures that don’t require hospitalization. In 2007, these facilities performed more than 6 million procedures including endoscopy, pain injections, and dental procedures.

The problem is, these places are often germ breeding environments where medical personnel don’t adhere to basic infection control procedures such as washing their hands.

Melissa K. Schaefer, MD, of the Centers for Disease Control and Prevention, Atlanta, and colleagues conducted the study and assessed procedures in five different categories: hand hygiene, injection safety and medication handling, equipment reprocessing, environmental cleaning, and handling of blood glucose monitoring equipment.

More than half of the facilities (67.6%) studied had at least one lapse in infection control noted by surveyors and 17.6% of the facilities had lapses identified in three or more categories.

Nearly one in five facilities (19.4%) didn’t properly apply “hand hygiene” (a euphemism for washing hands!) or use proper personal protective equipment such as gloves. More than one quarter of them (28.4%) had deficiencies related to injection practices or medication handling, primarily through use of single-dose vials for more than one patient.

Another 28.4% of these facilities failed to adhere to recommended practices regarding reprocessing of surgical equipment; and 18.8% didn’t properly clean high-touch surfaces in patient care areas.

Thankfully, chiropractors don’t have to be concerned with the high risk procedures involving injections and drugs, but tables and other high-touch surfaces need to be kept clean and disinfected.

The recommendations given by researchers from Parker Chiropractic College — published in Chiropractic & Osteopathy in 2007 — are excellent. They stated:

“Pathogenic microbes may be present on chiropractic treatment tables and can be effectively killed with proper disinfecting. Hand washing/sanitizing is an important measure in infection control as is table disinfecting. Rudimentary behavioral changes to improve chiropractic clinic infection control are needed. More comprehensive behavioral models are needed. All teaching clinics and private chiropractic offices should adopt infection control practices including routine table disinfecting and hand sanitizing. Effective measures can be put in place at minimal costs.”

References: JAMA. 2010;303[22]:2273-2279 — Abstract

“Assessment and risk reduction of infectious pathogens on chiropractic treatment tables,” Chiropractic & Osteopathy 2007

In a study published in the Journal of Patient Safety, non-medical therapies were shown to relieve pain among a wide range of hospitalized patients as much as 50 percent. However, chiropractic was not among the approaches tested. Instead, researchers focused only on acupuncture, acupressure, massage therapy, healing touch, music therapy, aromatherapy, and reflexology.

The study showed that allowing patients to have access to drug-free care that reduces stress can have a significant impact on pain major challenge and eliminate the risk of negative side effects associated with the drugs normally given to patients.

“Roughly 80 percent of patients report moderate to severe pain levels after surgery,” said Gregory Plotnikoff, MD, one of the study’s authors and medical director of the Penny George Institute for Health and Healing at Abbott Northwestern Hospital.

“We struggle to provide effective pain control while trying to avoid the adverse effects of opioid medications, such as respiratory depression, nausea, constipation, dizziness, and falls.”

The study included 1,837 cardiovascular, medical, surgical, orthopedic, spine, rehabilitation, oncology, and women’s health patients between January 1, 2008, and June 30, 2009. They scored their pain verbally on a zero-to-ten scale before and after treatments.

“Earlier studies narrowly focused on whether specific integrative therapies manage pain in either cancer or surgical patients,” said Jeffery A. Dusek, PhD, research director for the George Institute. “Our real-world study broadly shows that these therapies effectively reduce pain by over 50 percent across numerous patient populations. Furthermore, they can be clinically implemented in real time, across, and under the operational and financial constraints within an acute care hospital.”

Lori Knutson, RN, BSN, HN-BC, executive director of the George Institute stated: “I think we will find that integrative approaches to pain management during the hospital stay will improve patient satisfaction and outcomes, and we will see cost savings from patients using fewer drugs and experiencing fewer adverse events.”

SOURCE: “The Impact of Integrative Medicine on Pain Management in a Tertiary Care Hospital,” March 5, 2010. Journal of Patient Safety.

By Terry A. Rondberg

For years, I’ve been railing against the over-use, misuse and outright abuse of antibiotics. Time and again, I’ve reported on the evolution of “superbugs” that have built up a resistance to traditional antibiotics.

Plants as medicine?

Recently, I heard some good news about the topic. Researchers have found that inexpensive plant-derived essential oils might be a natural alternative to many chemical antibiotics.

According to research presented at the Society for General Microbiology’s spring meeting in Edinburgh in May, the essential oils of thyme and cinnamon were found to be particularly efficient antibacterial agents against a range of Staphylococcus species.

Strains of these bacteria are common inhabitants of the skin and some may cause infection in immunocompromised individuals. Drug-resistant strains, such as meticillin-resistant Staphylococcus aureus (MRSA) are extremely difficult to treat.

“Not only are essential oils a cheap and effective treatment option for antibiotic-resistant strains, but decreased use of antibiotics will help minimise the risk of new strains of antibiotic resistant micro-organisms emerging,” said lead researcher Professor Yiannis Samaras of the Technological Educational Institute of Ionian Islands, in Greece.

Dr. Samaras and colleague, Dr. Effimia Eriotou, tested the antimicrobial activity of eight plant essential oils. They found that thyme essential oil was the most effective and was able to almost completely eliminate bacteria within 60 minutes.

The Society’s announcement about the research provided additional information on essential oils, which have been recognized for hundreds of years for their therapeutic properties, although very little is still known about how they exert their antimicrobial effects in humans.

Australian aborigines used tea tree oil to treat colds, sore throats, skin infections and insect bites, and the remedy was sold commercially as a medicinal antiseptic from the early 20th century. Various scientific studies have demonstrated that essential oils are not only well tolerated, but are effective against a range of bacterial and fungal species. Their therapeutic value has been shown for the treatment of a variety of conditions, including acne, dandruff, head lice and oral infections.

The Greek team believes essential oils could have diverse medical and industrial applications. “The oils — or their active ingredients — could be easily incorporated into antimicrobial creams or gels for external application. In the food industry the impregnation of food packaging with essential oils has already been successfully trialled. They could also be included in food stuffs to replace synthetic chemicals that act as preservatives,” the researchers added.

I have mixed feelings about this report. Of course I’d like to see more attention paid to health care that doesn’t rely on chemical drugs. But I think this type of report only goes half way to the goal of changing the prevalent mindset about health.

It isn’t enough to switch to phytochemical substances as “treatments” for disease. We need to get to the point where we’re balancing the human system and optimizing its own ability to counteract any environmental stresses it encounters. As long as researchers keep thinking of plants and foods as “medicine” we aren’t making the fundamental changes that are vital for true wellness.

While pharmaceutical companies have boasted for decades that their pills and potions are “approved by the FDA,” does that really mean anything? Apparently, very little, if the story of how one drug — Multaq (dronedarone) — “earned” its approval is any indication.

Drug maker Sanofi-Aventis touts Multaq on its website as “a prescription medicine used to lower the chance you would need to go into the hospital for heart problems.” The FDA’s decision to approve the drug was based primarily on a study conducted last year by Richard Page, chairman of the department of medicine at the University of Wisconsin School of Medicine and Public Health. The paper was published in The New England Journal of Medicine.

However, it turns out that Page was pretty much “bought and paid for” by Sanofi-Aventis. The drug company PAID for the research, collected data, and performed the analysis without an external audit. Page put his name on the paper, never having seen the raw data. He simply trusted the company to be honest and ignored the fact that the major financial experts, including Morgan Stanley, estimated the drug could reach nearly $3 billion in revenues.

In addition, Page and four co-authors were Sanofi-Aventis paid consultants and/or speakers, and two co-authors worked directly for Sanofi-Aventis, and owned stock in the company.

Despite all that, Page shrugged it off with a glib, “There is a sense of trust that they won’t falsify data.” Either he’s incredibly naïve, or he thinks the rest of us are.

To add injury to insult, the Multaq branded pill was selling for 47 times as much as its generic equivalent — in Britain Sanofi was selling the drug for £2.25 pounds per day, compared to 5 pence a day for a generic competitor, amiodarone. That equates to $3.30 compared to 7¢!

But wait … it gets better. Another research study (this one, by researchers at the Cedars-Sinai Heart Institute — Journal of the American College of Cardiology, 2010; 55: 1569-76) has concluded that the branded drug is far less effective than the current standard drug, Cordarone (amiodarone) for atrial fibrillation, and has no safety benefits.

That’s pretty much what was known back in 2003, when a drug trial was actually stopped because patients receiving Multaq were dying in greater numbers than those getting a placebo.

Still, the drug was “approved” by the FDA. You have to ask yourself — what would it take for a drug to be rejected?

In recent years, chiropractors have once more turned their attention to the neurological component of the subluxation. After decades of concentrating on musculoskeletal aspects, it’s a move that is as timely as it is important. In the years to come, our understanding of how we impact the brain will be the key to becoming the leader in the wellness revolution.

It’s a trend we’re seeing in other non-medical fields as well. In fact, a British research study published earlier this year in the journal Brain Research revealed that acupuncture has a significant effect on specific neural structures.

The researchers explained that when a patient receives acupuncture, it triggers a sensation called deqi (literally, the arrival of chi, pronounced duh-chi). Scientific analysis shows that this energy impulse deactivates areas within the brain that are associated with the processing of pain.

Dr. Hugh MacPherson, of the Complementary Medicine Research Group in the University of York’s Department of Health Sciences, noted: “These results provide objective scientific evidence that acupuncture has specific effects within the brain which hopefully will lead to a better understanding of how acupuncture works.”

Neuroscientist Dr. Aziz Asghar, of the York Neuroimaging Centre and the Hull York Medical School, added: “The results are fascinating. Whether such brain deactivations constitute a mechanism which underlies or contributes to the therapeutic effect of acupuncture is an intriguing possibility which requires further research.”

Last summer, following research conducted in York, acupuncture was recommended for the first time by the National Institute for Health and Clinical Excellence (NICE) as a treatment option for NHS patients with lower back pain. NICE guidelines now state that GPs should “consider offering a course of acupuncture comprising a maximum of 10 sessions over a period of up to 12 weeks” for patients with this common condition.

Current clinical trials at the University of York are investigating the effectiveness and cost-effectiveness of acupuncture for Irritable Bowel Syndrome (IBS) and for depression. Recent studies in the US have also shown that acupuncture can be an effective treatment for migraines and osteoarthritis of the knee.

The York team believes that the new research could help to clear the way for acupuncture to be more broadly accepted as a treatment option on the NHS for a number of medical conditions. “Our results show the importance of collecting and accounting for needle sensation data in neuroimaging studies of acupuncture,” researchers concluded.

There’s an equally important need to collect information on the neurological impact of chiropractic adjustments, such as that being collected by doctors who use the NeuroInfiniti equipment.

ABSTRACT:  “Acupuncture needling sensation: The neural correlates of deqi using fMRI.” Brain Research, Vol. 1315, 22 February 2010, Pages 111-118.

AUDIO: Dr. Hugh Macpherson, from the University of York, discusses new research into the effects of acupuncture on the brain published in Brain Research.

By Terry A. Rondberg, DC

For years, chiropractors and other non-medical wellness professionals have advocated taking nutritional supplements to make up for the deficiencies in our modern diets. Vitamin A has always been among the most recommended, since it’s critical to maternal health and child survival.

Recently, researchers at The Johns Hopkins Bloomberg School of Public Health have found a link between a newborn’s lung function and the vitamin A supplementation the mother has taken. The results were published in the May 13, 2010, issue of the New England Journal of Medicine.

“Children of mothers who received vitamin A supplementation before, during and after pregnancy had significantly improved lung function when compared to those whose mothers received beta-carotene supplementation or placebo,” said lead author of the study, William Checkley, MD, PhD, assistant professor in the Division of Pulmonary and Critical Care of the Johns Hopkins School of Medicine with a joint appointment in the Bloomberg School’s Department of International Health. “Lung function of offspring in mothers who received maternal vitamin A supplementation improved by about 40 ml versus those whose mothers received a placebo. This represents an approximately 3 percent increase in lung function. Furthermore, the magnitude of effect observed in this study is slightly greater than that associated with preventing exposure to parental smoking in school-age children.”

Vitamin A deficiency isn’t as widespread in the US as it is in some developing countries, where nearly 190 million pre-school age children worldwide don’t get enough vitamin A — the underlying cause of night blindness among children, as well as 650,000 early childhood deaths annually. But since the main sources of natural vitamin A are raw vegetables like carrots, sweet potatoes, winter squash, spinach, and cantaloupe, many people in America and Europe are not getting enough A either.

The new study emphasizes the need to eat nutritional, wholesome meals including plenty of vegetables, or to take supplementation as a safeguard. Since medical doctors receive little or no training in nutrition, this is where chiropractors and other wellness professionals can really make a difference. By educating patients and even providing access to nutritional supplements, we can make profound differences in the lives of all the people we serve.