The postings on this site are my own and don’t necessarily represent the positions, strategies or opinions of The Kroger Company family of stores.
An elderly lady was at the pharmacy window picking up prescriptions and needed help finding a OTC product. She had been taking something for memory, but could not remember its name. If it wasn’t so sad, it would be funny. The culprit here was Prevagen and I was able to point her in a more reasonable direction. This was made easier by the exorbitant price of Prevagen.
I recently asked a student pharmacist, Thuy “Tina” Ngan Vo, to look into some of the “brain boosting” products that we offer. Although I have posted about Prevagen previously, I felt that her research added new facets to the discussion and bolstered the argument against spending money on these products. I was especially pleased to see Tina take a close look at the “clinical studies” used to market these expensive products. Her original paper is on this site, but I’d like to put my two cents in also.
I’ve already called out Prevagen as snake oil and not worth a dime, let alone more than a buck a pill. The only study that purportedly showed any action at all showed that apoaequorin (active ingredient in Prevagen) infused directly to rat brains may have slowed ischemic cell death. The study was totally funded by the manufacturer, not peer reviewed and the claims of memory enhancement are total bullshit. Though the manufacturer cites many clinical trials, actual peer reviewed trials are non-existent. So, to be clear, when you take a Prevagen pill, any apoaequorin present (if any) will be destroyed by your digestive tract, you may get a peptide or two or some amino acids, but the rest will be tomorrow’s poop. Shame on Quincy Bioscience.
Maybe the patient should try Natrol’s Cognium, that sounds pretty science-y, right? Here we find silk protein hydrolysate. Wow! That sounds impressive! But, digging a little deeper we find more bad science, and in this case a set of six trials by the same author. One published manuscript was retracted due to data fabrication and falsification by the authors. Even the best of these “studies” claims a meager 1.7% improvement in cognition. Save your money!
So maybe one the many herbal supplements would be a good choice. Have a look at Healthy Brain All-Day Focus. This has some vitamins, ginkgo, some roots and other crap (see Tina’s paper) none of which, if present, will help. One ingredient, Rhodiola Rosea root was shown in one study on intern nurses on shift work to actually worsen fatigue! Stop wasting your money! Don’t have a brain fart!
So what can this patient do to help sustain and possibly improve her memory and brain function? As Tina points out, higher homocysteine levels have been associated with Alzheimer’s as well as an increased risk of heart attacks and strokes. Homocysteine is an amino acid that is a by product of protein digestion, particularly methionine, which most of us consume as animal protein. I would suggest this patient start with a reputable B-complex vitamin supplement, with good representation of vitamins B-9 (folic acid), B-6, and B-12, just in case her diet is lacking in these vitamins which help to detoxify homocysteine.
Notice that I said “reputable.” These products are unregulated and what is stated on the label may not truly represent the contents. I look for the US Pharmacopeia symbol to be sure that we have a product that meets scientific standards.
Beyond a good B-Complex supplement, I also recommend:
Try new things that require learning. Make it real, the FTC warns that these brain game apps overstate their usefulness. Working a crossword or finishing a puzzle is good but learning new things is even better.
Be physical. Stay active. Walking is the easiest and requires no special equipment. Swim.
Avoid nicotine. Limit consumption of caffeine and alcohol.
Maintain a healthy blood pressure to avoid strain on your cardiovascular system and avoid accelerated organ damage and strokes.
Besides, ginkgo, there is no proof that vitamin E, ginseng, or mass quantities of fish oil are of much benefit.
Modify your diet to eliminate as many processed foods as possible and limit your consumption of animal protein other than fish. Although there is that worrisome connection between methionine and homocysteine, we do need methionine (it is an essential amino acid) so do not try to completely eliminate if from your diet. Moderation is key.
Socialize to improve your mood and engagement. Love your loved ones and live and act for others when you can.
He was always willing to help out, covering an extra shift here and there, offering to work till closing alone, and always just so darn helpful. It wasn’t long before I began to notice the dark side, however. The nervous reaction when a pharmacist or tech approached him while he was working alone, escalating offers that would allow him to be alone in the pharmacy, and an underlying sense of dishonesty, all led to suspicions of misbehavior. Then product started disappearing. When alerting management of my suspicions,I was advised not to schedule this pharmacist for coverage shifts any longer, effectively terminating his part-time employment with us. I know now that this was the wrong thing to do. He was never allowed back in that pharmacy.
Months later he started showing up at the clinic and the pharmacy. He brought treats for the nurses and the pharmacy staff. He tried so hard to ingratiate himself into our good graces. I could still see the dark side, however. The offers to send myself or the staff pharmacist home early and he would close up for us, resumed. Even off the clock! I detected the furtive glances trying to see how much hydrocodone we had on the shelf. I could feel the desperation.
Despite what management had told me, I felt that I must intervene, so I took this young pharmacist to my office and discussed his obvious substance problem. At first he denied it all, of course, but as I expressed empathy and pointed out the obvious addictive behaviors, he told me the whole story. Like many patients with substance abuse disorders, it began with a legitimate prescription for pain management of an acute injury. This pharmacist had be in a grievous accident, involving multiple fractures and significant pain. The slippery slope was too much for him to overcome. In a familiar progression of events, he started augmenting his regular prescriptions with Rxs from other prescribers, taking a tablet or two during his works shifts at one of his three part-time jobs, to eventually stealing entire stock bottles as his addiction took control of his life.
Fortunately, he was able to break the cycle of addiction and get the help he needed. He admitted his addiction to his parents and referred himself to the board of pharmacy and into the PAPA program. All of this happened over a decade ago and that pharmacist is now rehabilitated and working in the profession.
Over the years I have had more opportunities to see the scope of this problem. It has many different faces. A doctor friend whom I played racquetball with on a regular basis, had been ordering a hydrocodone cough syrup at increasing frequency from our pharmacy “for office use,” a former student was caught on tape accessing the narcotic cabinet during non-business hours and removing product, I was asked to go to a pharmacy as quickly as possible because there would be no pharmacist there and arrived in time to see the pharmacist being “perp walked” out of the facility, I was nearly physically assaulted when a call from a technician required me to go and ask the pharmacist for his keys and terminate his employment as he was obviously drunk, and belligerent, on duty. The scary stories are endless.
Most of us enjoy the thrills we get from a scary movie, whether it be an evil clown peeking out of a sewer or mysterious creatures from an upside-down world right next to ours. In real life, not only our patients are affected, the problems of substance abuse permeate our profession. Pharmacists are not unlike our patients and have substance abuse disorders at about the same rate as the general population, somewhere around 12%. The problem is scary and all too real.
This is why I became a part of the Arizona Pharmacy Foundation which provides critical support for the PAPA program as well as providing education for pharmacists and the community to prevent, recognize and understand treatments of substance abuse disorders. It’s rewarding to be a small part of an effective solution.
This is what I sent to my Senators:
The Graham-Cassidy bill threatens the health of anyone who is sick, has ever been sick, or who will become sick in the future. This bill is disastrous and will result in coverage being prohibitively expensive for those most in need of it. This bill serves to maximize profits to the corporations that indirectly manipulate health care, at the expense of patients and those of us that provide direct patient care.
The bill would decimate Medicaid, endangering access for millions of Americans. This would have a huge negative impact on low-income individuals and families affected by diabetes and other chronic diseases. Adults with diabetes are disproportionately covered by Medicaid. In Medicaid expansion states, more individuals are being screened for and diagnosed with diabetes than in the states that did not expand. As a pharmacist, I play a key role in helping people manage this insidious disease. Diabetes and its complications can be managed but patients need help to overcome the outrageous drug costs made possible by our Congress. I have had enough of health care executives pulling down multi-million dollar compensation with bonuses that are essentially based on denial of care to those that need it.
I also can see that the strategy of providing block grants will lead to diminished care and programs for special needs patients of all ages, with many good programs that provide pathways for these special people to contribute to society at risk of being eliminated.
I strongly urge you to focus on bipartisan efforts like market stabilization, taking an unbiased look at a modest “safety-net’ Medicare expansion that eventually reaches all Americans, while leaving plenty of viable marketplace options for non-catastrophic coverage. I believe it can be done.
For now, please vote NO on the Graham-Cassidy bill.
I thank you for your service and your desire to do the right thing for your constituents.
I am happy to discuss any facet of health care, because, I believe that through mutual understanding and similar ideals, we may reach a consensus.
(thanks for the form letter seed from American Diabetes Association)
Spiders, more specifically their venom, are the next enticing source of pharmaceuticals. Many of the peptides found in various species of spiders’ venom are pharmacologically active. We are acutely aware of the nasty neurotoxic effects but other components of venom demonstrate a variety of drug-like effects, including analgesic, antimicrobial, hemolytic, antiarrhythmic, and even enzyme inhibition. The possibilities for drug discovery are enormous.
Spiders are the most prevalent venomous species on the planet. Since most spider venoms are actually a complex mixture (a toxtail, if you will), of mostly peptides along with some other organic compounds. It is estimated that there could be over 12 million unique peptides produced by the venomous portion of our 100,000+ species. So far, we have just scratched the surface, with the latest total on the ArachnoServer listing over 1500 toxins from just 100 species. This database curates data from UniProt, a scientific consortium, with a mission to “provide the scientific community with a comprehensive, high-quality and freely accessible resource of protein sequence and functional information.” The ArachnoServer itself also uses the World Spider Catalog for its taxonomy identification. No mention of radioactice spiders here.
Most peptides do not make for good drugs because of their innate instability and limited human absorption. But here is where spider venom gets really cool. It turns out that in most spider toxins the biologically active peptide is “packaged” in what is called a “inhibitor cystine knot (ICK),” which essentially embrace the peptide to create a very stable mini-protein. Crazy shtuff. Without getting too deep into this science, suffice it to say that new studies are looking at oral dosage forms for humans. The ICK peptides are resistant to pH extremes, proteolytic enzymes, and high temperatures.
The most exciting area of spider venom research is in the area of treatment of chronic pain. In light of our current opioid dilemma, the possibility that we could have a non-addictive pain reliever is exciting. Our growing knowledge of certain neural ion channels playing a role in the inception and perception of pain, coupled with our growing knowledge of these spider peptides, may lead to some new effective remedies. A group of researchers in Australia is studying the peptide toxin – known as ProTx-II – that inhibits pain signals by binding to the membranes of nerve cells. This toxin is found in the venom of the Green Velvet Tarantula.
We already have pharmaceuticals derived from venom found in the animal kingdom. Pharmacists will know the drug the venom-derived drug approved by the FDA, exenatide (a glucagon-like peptide-1 agonist), which helps treat type 2 diabetes. It was originally isolated from the saliva of the Gila monster, a venomous lizard.
There is a pretty good article from the British Journal of Pain here at the NIH.
Remember the days when being anxious had a more appealing connotation? We enjoyed being anxious for that first date, graduation, getting a license to drive, and so many more of life’s milestones that made us excitedly anxious. The DSM-5 now lists no less than 9 categories of anxiety. It seems to me that we have ratcheted up the level of anxiety in the world today with the fast pace, climate change, terrorism, and the continual barrage of fear mongering from the media. But much of it seems self inflicted too.
One of my pet peeves is how we are our own worst enemy. I see this in the rise of obesity and type 2 diabetes, depression, and the incredible increase in anxiety disorders. Take a look at these graphs and you can see what I mean when I say we cause much of our own problems. We buy on both sides of the problem, the cause and the treatment. Great for the economy (and my job), but dumb.
Pretty wild huh? I swear that most people fail to see the connection! Energy drink sales are climbing and the sales of anti-anxiety meds are soaring right along with them. Energy drinks are also contributing to a dramatic rise in emergency room visits, as seen here:
I’m sure you could look at sleep meds and see the same sort of correlation. People seem to think that these drinks supply some sort of magical “energy” without consequence but the outcomes prove them wrong. These drinks supply caffeine and other sympathomimetics (think, speed) that put a tremendous burden on the cardiovascular system and hence, all organs.
It all gets back to the basics; eat right, exercise, enjoy life. Stop and think before you buy!
New light is being shed on the pet food business, so here is some food for thought on feed for your pet.
Recently, a couple batches of dog and cat food were found to contain pentobarbital, sickening many dogs and cats with one verified dead dog. The product was labeled as containing beef but actually contained apparently euthanized horse. Of course, pet owners are righteously alarmed.
Pet owners speak out most effectively with their wallets, but, in truth, the $26 billion per year pet food market is mostly unregulated. One of the problems is that pet food is considered animal feed and so its labeling is not directly controlled by the FDA. The standards for animal feed, pet food included, are established by the Association of American Feed Control Officials (AAFCO). You can check that web site youself and see that their board of directors seems like a pretty appropriate bunch of folks, mostly from state agencies and academia. Where things get interesting is when you realize that AAFCO merely sets standards for animal feed. As it states: “AAFCO does not regulate, test, approve or certify pet foods in any way.” That leaves it up to pet food manufacturers to formulate products up to those minimum standards.
So who does regulate pet food, if anybody? Again quoting AAFCO: “It is the state feed control official’s responsibility in regulating pet food to ensure that the laws and rules established for the protection of companion animals and their custodians are complied with so that only unadulterated, correctly and uniformly labeled pet food products are distributed in the marketplace and a structure for orderly commerce.” In Arizona, our statutes for animal feed are in Title 3, Chapter 15 (3-2610 covers labeling and 3-2611 covers adulteration).
The problem is that many pet food manufacturers are simply not being held accountable and are essentially self-regulating. In my research I came across a website that takes issue with improper labeling and adulteration of some prominent pet foods, asking folks to contact their AZ representatives. Specifically the sample letter provided mentions: “Pedigree Dog Food, Hill’s Science Diet Crafted Pet Food, and FreshPet Pet Food show grilled meat or roasted meat on the label, however there is no grilled or roasted meat in the pet food.” The site also provides some great information on what to avoid and how to find good pet food.
There are many other issues too. Remember the AAFCO sets standards, minimum standards, and some nutrition may be inadequate for your dog or cat. I would also worry about adulteration, such as the pentobarbital case and concerns of previous reports of contamination such as the Chinese gluten debacle of 2007 (the wheat gluten contained melamine, an industrial chemical used in the making of plastics.) You may recall (get it?) that melamine has resulted in baby formula recalls also.
So far in 2017, there have been FDA recalls of pet foods containing pentobarbital, metal fragments, salmonella, listeria, high levels of thyroid hormone, excess copper, and my favorite, Cesar Filet Mignon dog food with plastic filler. Puppies usually get enough plastic in their diet by chewing up your personal belongings! Obviously, we have a lot of work to do. Considering the current administration’s love for lack of regulation the need to speak out is greater than ever. So check out the sample letter that was linked above and let your voice be heard.
In the meantime, it’s buyer beware. Always, buyer beware!
In 2008 the Nobel Prize in chemistry was awarded to Americans Martin Chalfie and Roger Tsien and Japan’s Osamu Shimomura for their discovery and isolation of Green Fluorescent Protein from jellyfish. Shimomura first isolated GFP from a jellyfish found off the west coast of the US in 1962 and demostrated that it glowed bright green under ultraviolet light. The Nobel Prize recognized the value of a luminescent protein in use as a “tag” or “marker” for tracking various physiological processes in the body. Shiomura collected the outer rings of Aequorea victoria and squeezed the juice out of them to get the bioluminescent protein. Roger Tsien was able to change out various amino acids in this complex protein to alter the color, intensity, and duration of the fluorescence. Marty Chalfie and others were able to insert the gene that coded for GFP and therefore use it as a marker to track production of various biologically active molecules. They were able to insert the GFP gene between the gene for the target protein and the “stop” codon, making a bioluminescent version of the target protein that could be easily monitored. Read more about that science here.
Notice that none of these scientists thought it would be a good idea to eat the stuff. The value of GFP is in its use as a biological tool for scientific study. The promoters and manufacturer of apoaequorin protein, the synthetic version of GFP, would have you believe that it improves memory function. Others have made even more fantastic claims such as holding Alzeiheimer’s at bay, battling delusions, and augmenting dream-awareness. Great. I happen to believe we have a huge placebo effect happening here. Oh, before I forget, Quincy Bioscience, the manufacturer, was able to grant Prevagen GRAS (Generally Recognized As Safe) status for itself, simply by gathering opinions and sending a letter off to the FDA. Prevagen does not have to be independently tested for safety nor efficacy because it is marketed as a “food.” A very expensive food at forty bucks for a bottle of 30 capsules.
Intersetingly, Prevagen is harvested from GMOs. Yep, genetically modified e. Coli are grown in vats, after have their genes tinkered with, and the apoaequorin is extracted from the fermentation broth. There is no valid, peer reviewed study to support the claims of improved memory or any of the other claims made on the packaging.
But here’s the rub. We are talking about a protein made of of about 80 amino acids. One of the main functions of our digestive tract is to digest proteins. You may recall some of this process: Chewing begins to break down the protein, physically creating more surface area, next stomach acid start to “unfold” these complex molecules exposing them to the action of the enzyme pepsin. By now the protein molecule has started to fall apart into “peptides.” As this acidic broth of peptides enters the small intestine, a bicarbonate buffer from the pancreas neutralizes the acid. The neutral environment of this portion of your gut encourages the activity of more protein-digesting enzymes, such as trypsin and chymotrypsin, originating from both your pancreas and the cells lining your small intestine. Essentially, this process results in individual amino acids that can then be absorbed and distributed throughout the body. So when you eat a Prevagen capsule, the wonderful jellyfish protein they love to brag about is DECONTRUCTED into amino acids! At best you are getting some very expensive amino acids. So although, this may be a unique protein for us humans, the amino acids that go into that e. Coli broth are not. I feel we are spending a lot of time and money feeding amino acid building blocks to pampered e. Coli, extracting, encapsulating, and packaging a product that we will simply digest back to the amino acids that we fed to the e. Coli.
So the only benefit from this stuff has to come from the amino acids, right? There is no need to spend $40 a month. If you are concerned that you are missing some nutrient that is harming your memory, improve your nutrition. I just suggested to our new vegan employee that she add some whey to her diet to ensure that she is getting the essential amino acids needed by the human body. I have written about whey before. The FDA and the FTC both have objected to the marketing practices for Prevagen and Quincy Bioscience has, so far, been able to stonewall any impact on their marketing.
Stop wasting your money !
Oh When I was pondering a title for this piece the old song “Jam Up and Jelly Tight” came to mind even though I hadn’t heard or thought about it for many years. I guess I do not need Prevagen either. Anyway, in 1968, this Tommy Roe song was too sexy for a lot of folks as it seemed to be pressuring a perfectly nice girl to say yes to sex. You can check it out for yourself. It is pretty tame by today’s standards. Hey, at least he asked:
“You’ve got a sweet disposition
So come on and give me permission”
There are some pretty nifty developments in the realm of women’s health. We have come a long way from the days when I had the rather unique opportunity to learn how to install an IUD. Not too many pharmacists get an opportunity like that! Over a decade ago, as Pharmacy Director at ASU Campus Health, our wonderful Ortho rep set up a training class on-site and I was invited to attend along with several doctors and nurse practitioners. We sat in front of life-sized pelvic models similar to one seen here and did not have benefit of ultrasound or other technology, so using just sight and touch, used a small device to carefully place the Paragard IUD. On our models, there was a little trap door in place of pubic hair that we could lift open to see if we had properly placed the IUD. A training session that I will never forget! Yes, I got right the first time! I still have my stunningly stylish Paragard tie tack!
Speaking of vaginas, I came across a bit of trivia. The Walt Disney company is credited with releasing the first film to use the word vagina! Apparently working with funding from Kotex, the animators got to work on explaining menstruation. A ten minute restoration of this animated classic can be seen here on YouTube. I do find it hard to believe that the scary STD films they showed to our boys heading off for WWII didn’t mention vaginas, but maybe not.
Fast forward to modern times and we find that researchers at Northwestern Medicine have developed a miniature, functioning version of the female reproductive system. It is a small cube that can fit on the palm of you hand. This 3-D model is made with human tissue and uses artificial “blood” to allow transport of hormones and other secretions throughout the system. This technology, EVATAR, will enable the testing of new drugs without risk to patients. Imagine having a drug tested on this model, made from YOUR tissue! Ultimately the long term goal is a “body on a chip” which would use your stem cells to create tiny models for testing of various treatments for highly personalized therapies. You can take a few minutes to learn more about EVATAR here on YouTube. Someday, your doctor will harvest some of your stem cells, grow out a heart, a lung, liver, or an ovary and then test dozens of drugs and doses to see which best would treat whatever ails you. Creating a pancreas via this process may someday lead to a cure for diabetes! There is a male version on the way called ADATAR and another focused on the testicles and prostate with the working name Dude Kube.
In the meantime, as we see more and more young people opting for more natural food and drink, it is no surprise that modern women are looking for alternatives to the mass-produced, artificial menstruation products. Many women rightfully worry about exposure to bleaches and pesticides. Several new products are being marketed with moderate success, from natural sea sponges to reusable fiber products like “Glad Rags” or Thinx panties. There are also menstrual cups like the Soft Cup or the Diva cup (these cups may be referred to as catamenia cups in some literature – from the Greek, cat (pussy) -menia (blood) sorry, just kidding, although catamenia is a real word). From what I have read they require a short learning curve as well as the ability to become more intimate with your monthly visitor as well as your vag. If you want to read about one woman’s journey of discovery as she “test drives” these products visit Rachel Krantz. Considering that one woman can have about 450 periods in a lifetime and may use 16,000 tampons, pads, liners and such, its obvious that this is a big market not to mention more “stuff” in our landfills. Having reusable options seems like a good idea to me.
In world news, in Italy, the parliament is debating a measure that would have employers offer “menstrual leave” of up to 3 days per month for women with painful periods. Italy would follow in the footsteps of countries like Japan and Indonesia already offering some form of menstrual time off. It seems like a sticky wicket to me.
More world news. In a response to Donald Trump’s pussy grabbing quote, the Russian girl Punk Band, Pussy Riot, released the English language version of “Straight Outta Vagina,” which reminds us, “Don’t play stupid, don’t play dumb, vagina’s where you’re really from.” These ladies spent 16 months in a Russian jail so they definitely have street cred as fearless feminists.
And now: If your vag feels or looks a little worn out, and needs a little rejuvenation, and you can afford the procedure, and several days off work, you might consider an “Aussie makeover.” It’s suggested for a well-used or stretched out vag, or if it doesn’t match up to partner’s penis size. You can even have your labial lips sculpted! I would never have known about this, but I have the tendency to read anything I can get my hands on, especially in a waiting room.
That’s all for now, my final word is, support Planned Parenthood!
I rode in my second Tour de Cure bicycle ride last week with over a thousand local riders, including many colleagues from pharmacy. I raised over $300 which might cover the cost of a box of insulin pens for one patient and that might last a month or more. Diabetes is an expensive disease. I signed up to ride 25 miles but the final course was just over 28 miles. That’s one mile for every million Americans with type two diabetes. Diabetes is a prevalent disease. The Tour de Cure raises money to aid diabetes research. We can only hope that we find a cure soon.
I fervently hope that a cure, when found, is not suppressed. It costs Americans, all of us, either directly or indirectly, about $200 billion per year to treat diabetes. You can bet the medical-industrial complex does not want to see that money dwindle away. I’ve been hearing rumors about this sort of thing ever since pharmacy school, so many years ago. Rumors of drugs that were so effective that they essentially fixed the problem, but the company owning the rights would manipulate the molecule so as to cripple its effect or limit its effectiveness, thereby requiring repeated dosing to hold the problem or condition at bay.
It’s our new business model, after all. We are encouraged, or forced, to “subscribe” to so many of our modern conveniences, lease our cars and gadgets, and constantly renew our prescriptions. Let’s not allow this to happen with diabetes or any other of the diseases or conditions that we all walk for, run for, bike for, or otherwise donate our time, energy and money. I dream that part of our ideal national health care policy is to be sure that basic research, funded by tax dollars or donations, reveals all results to we the people. I know, naive and I didn’t really intend to stray down that path of negativity.
As I pedaled those miles, I took time to ponder some other facets of diabetes, beyond the staggering cost of treatment. There is lost productivity, as well, of course, but it seems that few of the players devote serious energies to managing type two diabetes without coming to me for drugs. Take a pill! If my corporate overlords allowed it, I could spend more time with these patients. Being in a supermarket presents a tremendous opportunity to do some coaching on buying habits and encourage smarter choices. We would spend most of outr time going around the perimeter of the market, limiting exposure to the center which is mostly stocked with processed foods. It does not have to be myself or even one of my staff pharmacists, I’d love to see an appointment system set up to have our at risk patients go shopping with an expert in nutrition. Unfortunately, without a significant charge to the patient, there is no return on investment. In fact, if some of these folks got healthier, we might fill fewer prescriptions. Ye gods, NO!
The baby step here is for patients and their loved ones to start small, by adding some fresh produce to every day’s menu, eliminating soda, whether sugary or artificially sweetened, and slowly sneaking in some exercise. It could happen. It might start with a friendly nudge.
To learn more about diabetes, you must start at the American Diabetes Association! Check it out! I invite you to ride with me next year.
My Tour de Cure 2017: