NewsMakers
Health disparities among patients with diabetes can be improved by new approaches, insights
Patient- and clinician-focused mobile technology improves outcomes; patient support programs utilizing community health workers had positive impact on care; and new insights indicate racial/ethnic differences that impact the development of type 1 diabetes.
Health disparities in the U.S., including inequalities in the delivery of care and access to care across various racial, ethnic and socioeconomic groups, are of widespread concern, particularly in people with diabetes who require continuous, regular health care to effectively manage their disease.
Such disparities can greatly impact patients’ overall well-being and may lead to serious complications. Three studies that assessed ways to potentially decrease health disparities among people with diabetes were presented today at the American Diabetes Association’s 77th Scientific Sessions at the San Diego Convention Center.
Mobile health technology and Community Health Workers (CHWs) are two emerging strategies increasingly being used throughout the U.S. by health care teams. In the study, “Community Health Workers, Mobile Health, or Both for Management of Medicaid Patients with Diabetes” (365-OR), these approaches were evaluated to determine potential methods to improve diabetes management outcomes among minority patients. CHWs and the use of a mobile health technology app (mHealth) were tested both separately and together among 166 Medicaid patients with type 2 diabetes who receive care in Internal Medicine practices or diabetes clinics at three medical centers in Washington, D.C. At baseline, the patients had an average HbA1c level of 10.5 percent, and they were not meeting three or more of 13 wellness goals established by the study.
Patients in the 12-month study were randomly assigned to three different groups. Group 1 consisted of 56 patients who used an app—the Voxiva Care4Life (C4L) mHealth system. The C4L app helped patients manage their health with features that kept track of frequent measurements of blood sugar and blood pressure levels; provided alerts to remind them to take medications and keep doctor appointments; and offered tips on nutrition and exercise. Group 2 included 56 patients who were assigned CHWs. The CHWs were either educators or lay people who were integrated with the medical teams at each center and helped patients by providing services such as connecting them with primary care doctors and visits to see them; making home visits to help coordinate care and access to food resources and medications; providing language interpretation; helping to identify and address barriers to care; and advocating to ensure the patients received appropriate and culturally tailored health care services. Group 3 had 54 patients who were assigned both a CHW and the use of the C4L mHealth system/app.
Study endpoints included wellness/clinical goals, HbA1c levels, self-care behavior and diabetes distress. Prior to completion of the study, just 6 percent (n=11) of patients withdrew from the program.
Results indicated that within the 12 months, patients in all three groups had achieved on average 1.3 additional wellness/clinical goals from when they enrolled in the study. Additionally, HbA1c levels improved across all of the groups, and data showed that patients decreased their HbA1c levels by an average of 1.3 percent (p<0.0001). Overall, 30 percent of the patients achieved HbA1c levels of less than 8 percent—17 percent of Group 1 patients met that goal; 29 percent of the Group 2 patients; and 43 percent of the Group 3 patients; (p=0.02 vs. C4L alone). Significant improvements were also observed in all three groups of patients for numbers of hospitalizations (p=0.02); and numbers of urgent care visits (p=0.03). Diabetes distress also decreased in all groups (p<0.0001; NS between groups).
“Diabetes self-care is complex and can be a burden for many patients,” said study author Michelle Magee, MD, associate professor of medicine at Georgetown University, and the Director of the MedStar Diabetes Institute. “When we provided the support of a CHW or a mobile health application, patients with type 2 diabetes experiencing challenges with their self-care were able to achieve important improvement in health measures and a reduction in distress secondary to living with this chronic condition. Evidence to show both the potential impact of CHWs and the potential use of mobile health applications to improve health outcomes, as detailed in this study, are needed in order for health care systems to comfortably invest dollars to these new patient support approaches. Our study shows that these two strategies can significantly improve patient health. In fact, the reduction in A1C levels in our study was as positive a change as what we typically see with the addition of another antihyperglycemic medication to patients’ treatment regimens. Additionally, the resulting increase in meeting wellness goals is important for patients’ daily health and for preventing long-term diabetes complications. And, reducing hospital admissions and acute care visits are important outcomes from both the patient and health economics perspectives.”
While the approach of combining a community health worker and mobile health technology was successful in this population of Medicaid patients, the strategies developed were designed to be adaptable for use by health care teams and the patients they care for at multiple locations. The study team recommends additional research into which programs are most successful and how best to expand them for broad implementation.
Teaching clinicians how best to assist patients with diabetes and their caregivers is an important aspect of continuing medical education. While many research studies and courses explain how clinical factors influence glycemic control, translating that knowledge into a patient care setting is often challenging. This study, “A Social Media Learning Collaborative Approach to Competency-Based Training in Diabetes” (368-OR), emphasized personalizing therapeutic options to fit the individual needs of patients by developing an online, case-based, interactive training toolkit. The study aimed to facilitate the interpretation of research results and to determine how patient-centered factors such as age, gender, socio-economic status, education, race and ethnicity, body weight and current glycemic control can impact the effectiveness of various diabetes treatments.
The study investigators pooled data from 19 clinical trials with a total of 6,954 patients on 38 diabetes regimens from 1,002 clinics, in addition to using Electronic Health Records from 233,627 diabetes patients, to estimate the odds that a particular patient would achieve good glycemic control with different treatment regimens, based upon individual personal characteristics.
Subsequently, eight of the 19 randomized clinical trials contained full quality-of-life and patient satisfaction data from 2,927 patients from 413 clinics. Researchers modeled the probability of achieving HbA1c levels of less than 8 percent and less than 7 percent using 12 regimens of insulin and oral agents alone or in combination during a 24 to 52 week period. Of the 2,927 patients analyzed, 22.6 percent had type 1 diabetes and an average HbA1c level of 8.0; and 77.4 percent of the patients had type 2 diabetes and an average HbA1C level of 9.2 percent.
The primary endpoint at 52 weeks (one year) was HbA1c levels of 7.7 percent. Patients’ socio-demographic information was assessed, and treatment satisfaction questionnaires and quality of life assessments were completed throughout the study. Outcomes of HbA1c levels of less than 8 percent and less than 7 percent were modeled with logistic regression, and resulting estimators were used to develop benchmarking calculators using WebOS, Android, iOS and Windows compatible WordPress software. Calculators were then tested and optimized within case-based learning exercises. During the exercises, the clinician could simultaneously modify patient characteristics to explore and visualize how individual patient profiles might influence the probability of reaching target glycemic goals.
The study determined that the interactive learning collaboratives tested could be beneficial in translating diabetes research findings into clinical practice, while providing a novel approach to competency-based training that meets both the American Diabetes Association’s and the American Association of Clinical Endocrinologists’ clinical care guidelines.
“Relying on the published literature and more passive online courses to translate research findings into concepts that can be applied in practice is not sufficient, and often does not result in knowledge retention or a change in behavior,” said study author Donald C. Simonson, MD, MPH, ScD of the Division of Endocrinology, Diabetes and Hypertension at Brigham and Women’s Hospital and Harvard Medical School in Boston. “Additionally, data on the effectiveness of various diabetes treatments are typically based upon the average effect estimated for a specific group of individuals in randomized clinical trials. However, there is large variability in treatment response that is not well quantified. Some patients respond very well to particular therapies, while others patient do not; and much of this variability can be explained by the personal characteristics of the patients. Our research emphasizes personalizing therapeutic options to fit the individual needs of patients so that clinicians can be made aware of how patients differ in their response to the same treatment based on various patient-centered demographic, socio-economic, behavioral and quality-of-life characteristics.”
The study group plans to continue refining the predictive models and intends to help communicate, disseminate and implement their findings and toolkit into practice by extending the social media learning collaborative to additional practitioners.
Type 1 diabetes (T1D) is now recognized by scientists to be heterogeneous, meaning it can be caused by varying factors and different genes. Understanding the differences in its causes among individuals of different racial/ethnic groups can help researchers and clinicians design improved prevention strategies and treatments. The study, “Ethnic Differences in Progression to Type 1 Diabetes in Relatives at Risk,” (285-OR) examined if there are racial/ethnic differences in how T1D develops by comparing the progression of islet autoimmunity and T1D among races/ethnicities in at-risk individuals.
Researchers used data from TrialNet’s Pathway to Prevention Study screening program, which offers screening for relatives of patients with T1D in the hopes of identifying the risk for type 1 diabetes up to 10 years before symptoms actually appear.
The trial evaluated data of 4,227 TrialNet Pathway to Prevention participants between 1 and 49 years old who did not have diabetes and were autoantibody [Ab] positive relatives of patients with T1D, and followed them prospectively. The trial participants consisted of the following racial/ethnic groups: 12 percent were Hispanic/Latino; 3 percent were African American of non-Hispanic origin; 1.4 percent were Asian/Pacific Islanders of non-Hispanic origin; 79.3 percent were white of non-Hispanic origin; and 4.3 percent were “other,” non-Hispanic origin.
The analysis indicates that race and ethnicity play a role in how T1D develops, and the study specifically demonstrated that the detrimental effect of obesity on T1D risk may differ by race/ethnicity. T1D develops in stages, where individuals first progress from having a single autoantibody (i.e. marker of T1D) to having multiple autoantibodies, and later develop symptoms of T1D. The participants of Hispanic/Latino origin had a 40 percent lower risk of progressing from single to multiple diabetes autoantibodies, compared to the non-Hispanic white participants (HR=0.59, 95% CI=0.40-0.88, p=0.01). Among lean children younger than 12 years of age with multiple positive autoantibodies, the Hispanic/Latino group had half the risk of developing T1D compared to the non-Hispanic white group (HR=0.50, 95% CI=0.27-0.93, p=0.028). However, in this age group, Hispanic/Latino children were more susceptible to the effect of overweight and obesity, which increased the risk of developing T1D by 34 percent among non-Hispanic whites (HR=1.34, 95% CI=1.01-1.79, p=0.046), but quadrupled the risk in the Hispanic/Latino (HR=2.03, 95% CI: 1.25-3.31, p=0.004).
“The differences in type 1 diabetes development among races/ethnicities discovered in this study are striking,” said Mustafa Tosur, MD, a fellow in the pediatric diabetes and endocrinology division of Texas Children’s Hospital at Baylor College of Medicine. “Especially of interest is the dramatic differential effect of being overweight/obese for Hispanic/Latino children younger than 12 years of age, compared to non-Hispanic white children in the same age group. The research demonstrates that racial and ethnic differences should be taken into consideration when counseling family members who are at-risk of developing type 1 diabetes, and when designing preventive care and treatment options. Considering the obesity epidemic in children, which is more prevalent among minorities, and the frequency of type 1 diabetes is growing most in Hispanics in the U.S., these findings have important public health implications.”
Tosur noted that because the study participants were autoantibody-positive relatives of patients, the results of the study are not necessarily representative of the general population. The study team plans to conduct further research on possible reasons for the differences among the various racial/ethnic groups.
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Coffee and heart health: How many cups of caffeinated coffee are safe to drink each day?
For most adults, consuming up to 400 mg of caffeine/day (or up to 5, 8-ounce cups of caffeinated coffee per day) is safe and appears to be linked to a lower risk of cardiovascular disease for some individuals.
Previous studies have found that caffeine is the world’s most popular stimulant and psychoactive substance, and coffee is the most common way people consume caffeine. The latest research supports the conclusion that for most adults, consuming up to 400 mg of caffeine/day (or up to 5, 8-ounce cups of caffeinated coffee per day) is safe and appears to be linked to a lower risk of cardiovascular disease for some individuals.
However, higher doses of caffeine, such as levels found in energy drinks including energy shots, may cause cardiovascular harm, according to a new American Heart Association scientific statement, “Caffeine and Cardiovascular Disease,” published in the American Heart Association’s flagship peer-reviewed scientific journal Circulation.
“Caffeine consumed in coffee is a key part of daily life for millions of people, and in our review of the most recent research, for most adults, intake of up to 400 mg of caffeine/day, the equivalent of up to 5 cups of caffeinated coffee per day without added sugars or fillers, is safe and does not increase cardiovascular risk,” said Chair of the scientific statement volunteer writing group Gregory M. Marcus, M.D., M.A.S., FAHA, a professor of medicine at the University of California, San Francisco School of Medicine and the associate chief of Cardiology for Research at the University of California, San Francisco Health. “However, high doses of caffeine, such as those found in energy drinks including energy shots, may have harmful effects on the heart and should be avoided.”
The statement authors note that studying the effects of caffeine on the cardiovascular system is challenging. Coffee is the main source of caffeine in most research studies, and the observed cardiovascular effects may be due to other compounds in coffee. For example, experimental studies suggest that the bioactive compounds in coffee may have antioxidant and anti-inflammatory properties, which may help explain some health benefits. It’s also difficult to separate the effects of caffeine from other ingredients usually added to coffee, such as milk, cream, flavored syrups and/or sugar. In addition, most studies on caffeine are observational, meaning they cannot prove cause and effect.
Although coffee is the main source of caffeine for most adults, tea, chocolate, soda and energy drinks, as well as over-the-counter and prescription medications, also contribute to overall caffeine intake. More research is needed about other products with caffeine in order to understand caffeine content and caffeine’s impact on cardiovascular health.
The new scientific statement details the most recent research primarily on caffeinated coffee and the potential impact of caffeine in coffee on high blood pressure, cholesterol, Type 2 diabetes, coronary heart disease, stroke, heart failure, atrial fibrillation, other arrhythmias and other cardiovascular conditions.
Caffeine and cardiovascular health: key things to know
- Based on the results of the latest research studies reviewed, consuming up to 400 mg of caffeine per day, or no more than 3 to 5, 8-ounce cups of regular black caffeinated coffee per day (without sugars, sweeteners, flavors or added fillers), is considered safe for most adults. A regular brewed, non-specialty, caffeinated coffee typically contains 9.4-20.6 mg of caffeine per fluid ounce.
- Consuming caffeinated coffee without added sugars, flavors or cream was linked to a lower risk of Type 2 diabetes, heart disease, stroke, heart failure and some irregular heart rhythms.
- Randomized trials, the most rigorous and reliable type of study design, have shown that caffeine consumption in coffee is associated with a lower risk of atrial fibrillation but also a higher risk of premature ventricular contractions.
- Adding sugar, flavored syrups, milk and/or cream to coffee likely reduces its potential health benefits, and more research is needed to understand the impact of these additives.
- Higher caffeine intake, such as levels found in energy drinks including energy shots, was associated with cardiovascular harm, such as increased risk of high blood pressure and irregular heart rhythm. Energy drink shots may contain 40-69 mg of caffeine per fluid ounce, 3-4 times more caffeine than regular caffeinated coffee.
How does caffeine affect the body?
Caffeine consumed in coffee is metabolized by the liver and generally reaches peak concentration for most people within an hour. However, how quickly individuals process caffeine depends on their genetics, metabolism, age and past caffeine use. When more caffeinated coffee is consumed regularly, some people may develop a tolerance to higher levels of caffeine.
Other people may feel stronger effects from the same amount of caffeine. Short-term effects of caffeine may include temporary increases in blood pressure, heart rate, blood sugar and alertness. Some people may experience heart palpitations and/or sleep disruption.
Specific health impacts of caffeine
- Effects on blood pressure: Studies have found that caffeinated coffee consumption may affect blood pressure differently depending on how much is consumed. In people with optimal blood pressure, drinking 1–3 cups a day was associated with an increased risk of developing high blood pressure, while drinking more than 3 cups per day was associated with a lower risk. High doses of caffeine (such as those from energy drinks or energy shots) can significantly increase blood pressure, especially in people who already have high blood pressure.
- Effects on Type 2 diabetes: Research suggests that caffeinated coffee may reduce insulin sensitivity in the short term. In addition, drinking black, caffeinated coffee (no additives, flavors or sweeteners) regularly was linked to a lower risk of developing Type 2 diabetes. However, this benefit may be due to compounds in coffee other than caffeine. More research is needed to clarify the impact on Type 2 diabetes of caffeinated coffee vs. various compounds in coffee.
- Effects on cholesterol: Data from randomized clinical trials indicate cafestol, a component in both caffeinated and decaffeinated coffee, was associated with higher levels of low-density lipoprotein (also known as “bad” cholesterol). Cafestol is present in unfiltered coffee (such as espresso, French press, Turkish coffee or boiled coffee) but not present in coffee brewed with paper filters or instant coffee. More research is needed to understand which products have higher levels of cafestol and their mechanisms.
- Effects on heart rhythm: The most recent analyses of health measures with self-reported information from participants have found that drinking 1-3 cups of caffeinated coffee per day was not associated with an increased risk of atrial fibrillation or abnormal heart rhythm. However, caffeinated coffee at that same level may be associated with more early beats from the lower chamber of the heart, called premature ventricular contractions (or PVCs). Very high doses of caffeine (such as those in caffeinated energy drinks or energy shots) have been linked to abnormal heart rhythm in people usually considered to have low cardiovascular disease risk, such as healthy adults younger than age 30.
- Effects on heart disease and stroke: Drinking 2-4 cups of caffeinated coffee per day was linked to a lower risk of heart disease, heart failure and stroke. However, drinking more than 4 cups of caffeinated coffee a day may increase the risk of heart failure.
Not all sources of caffeine are the same
More research is necessary to investigate the different health impacts of various types of caffeinated coffee and other products with caffeine, such as tea, soda, energy drinks and energy shots, and foods. There have been fewer studies focused on tea vs. coffee; however, tea has been associated with reduced risk of atrial fibrillation, heart failure and stroke, similar to caffeinated coffee. Energy drinks, bars, gels and caffeine-based supplements often contain other added ingredients that may increase the absorption of caffeine, may accelerate its effects on the body, may raise blood pressure and increase the risk of cardiovascular harm.
More randomized controlled trials investigating the effects of caffeine in coffee and other products that have caffeine on cardiovascular health are needed to better understand how caffeine affects different people and how different sources of caffeine impact heart health. The writing group emphasized that there is also a need for research focused on caffeinated energy drinks and other popular products containing caffeine. Due to the lack of sufficient, rigorous data to develop guidance on recommendations for caffeine intake, caffeine was not referenced in the Association’s 2026 Dietary Guidance to Improve Cardiovascular Health.
“Although research suggests that caffeine consumption may be associated with certain cardiovascular benefits for some people, it’s important to remember that there is no ‘one-size-fits-all’ strategy for safe caffeine consumption. People can respond very differently to caffeine based on various factors, such as age, medications, underlying health conditions, genetics and how quickly their bodies metabolize it. What may be a reasonable amount for one person could cause unwanted effects, such as heart palpitations, anxiety or sleep disruption, in another. That’s why it’s important to pay attention to how your body responds to caffeine and talk with your healthcare team about what is right for you,” Marcus said.
Co-authors are Vice Chair Frank B. Hu, M.D., M.P.H., Ph.D., FAHA; Rob M. van Dam, Ph.D.; Marilyn C. Cornelis, Ph.D.; Thomas A. Dewland, M.D.; JungHee Kang, Ph.D., M.P.H., R.N.; Susanna C. Larsson, Ph.D.; Robert L. Page II, Pharm.D., M.S.P.H., FAHA; and Niyati Parekh, Ph.D., FAHA. Authors’ disclosures are listed in the manuscript.
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Loneliness strongly linked to poorer mental health and wellbeing, study finds
Loneliness was found to be linked with worse general health, including experiencing multiple health conditions. Social isolation is associated with lower wellbeing, too.
People who feel lonely are much more likely to experience poorer mental health and lower wellbeing, a collaborative study led by the University of Bristol, Nesta and Amsterdam UMC has found. Loneliness was also found to be linked with worse general health, including experiencing multiple health conditions. Social isolation is associated with lower wellbeing, too.
Loneliness is increasingly recognised as a major public health issue, with growing evidence connecting it to poorer health. However, it is unclear whether loneliness itself contributes to poor health or whether these links are driven by other factors.
The study, in association with the universities of Oxford and Manchester, combined evidence from three different research methods, including observational analysis, sibling comparisons, and Mendelian randomisation, a genetics-based approach, to build a clearer understanding of these relationships.
Using data from the UK Biobank and large-scale genome-wide association studies, the researchers investigated how both loneliness – the quality of a person’s social relationships; and social isolation – the number of social connections, relate to health and wellbeing. The study is published in Nature Communications.
The research team found that loneliness and social isolation are linked to poorer mental health and reduced wellbeing, with loneliness also associated with worse general health. While the study found no clear evidence of effects on specific physical health conditions, these potential impacts cannot be ruled out.
The findings suggest that loneliness, and potentially social isolation, remain important public health issues, particularly because of their links with mental health, wellbeing and overall health.
As loneliness becomes an increasingly important public health challenge, tackling it could bring benefits for both individuals and society.
Dr Zoe Reed, Research Fellow in the School of Psychology and Neuroscience at the University of Bristol, and corresponding author, said: “Our findings suggest that loneliness, and possibly social isolation, are still important public health concerns, especially for mental health and general health. Supporting people who feel lonely or socially isolated could help improve mental health, wellbeing and overall health.”
Lauren Bowes Byatt, Director of Nesta’s healthy life mission, added: “This research underlines that loneliness is likely to have a detrimental impact on our mental health and wellbeing. While this link may seem obvious, the topic has long been understudied. Studies like this can help to bridge this research gap and by understanding how loneliness or social isolation may be contributing to ill-health, we can get closer to new and more effective solutions.”
The researchers suggest more research is needed to understand exactly how loneliness and social isolation affect health and to develop the most effective ways to reduce their impact.
As the study focused on middle-aged and older adults, future studies should explore whether these patterns are similar in younger people. It will also be important to investigate the effects of persistent or long-term loneliness, as the study measured loneliness at a single point in time.
The paper’s findings add to growing evidence that loneliness and social isolation are not just social issues, they are important public health concerns with wide-ranging implications for wellbeing and mental and physical health. The research reinforces the importance of addressing these issues as part of public health policy and practice.
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Weight loss drugs could help with binge eating disorder
Drugs commonly used for weight loss, known as GLP-1 receptor agonists, have been found to reduce the key symptoms of binge eating disorder
Drugs commonly used for weight loss, known as GLP-1 receptor agonists, have been found to reduce the key symptoms of binge eating disorder, in a new review of evidence led by University College London (UCL) researchers.
The systematic review and meta-analysis, published in eClinicalMedicine, found that weight loss drugs can reduce binge eating episodes, loss-of-control eating and emotional eating, and highlights its potential role to treat binge eating disorder as well as obesity.
Lead author Dr Ilaria Costantini (UCL Psychiatry) said: “Binge eating disorder, where people regularly eat an excessive amount of food while feeling they have lost control, is common and highly impairing, affecting over 17 million people worldwide.
“But treatment options are limited and there are currently no approved medications, so there remains a need for better ways to help people living with this condition. We found evidence that weight loss drugs may help to manage some key symptoms of binge eating disorder.”
In the largest study to date on the subject, the researchers pulled together evidence from 25 randomised controlled trials that took place in 12 countries on four continents, including data from 8,069 participants.
The studies were testing the effects of drugs targeting the appetite-regulating hormone GLP-1 such as semaglutide (often marketed under brand names Ozempic or Wegovy), tirzepatide (also known as Mounjaro) or liraglutide.
These drugs can suppress appetite by targeting the central nervous system and insulin secretion, and they can delay stomach emptying, while also potentially influencing brain processes of reward and impulse control.
The researchers found that the drugs yielded benefits beyond weight loss, including reducing binge eating, loss of control eating and emotional eating.
Participants also reported increased cognitive or dietary restraint (which relates to how much people intentionally limit their eating), but the researchers say more research is needed to understand this link.
The study’s first author, PhD candidate Izzy Emptage (UCL Psychiatry), said: “From the evidence available, we cannot say whether the increase in dietary restraint reflects a positive and helpful form of self-regulation or if it is a more dysfunctional pattern of eating. We hope that future research can clarify whether or not taking weight loss drugs might contribute to more pathological forms of eating restriction such as meal skipping.”
The researchers say their findings demonstrate that weight loss drugs could be an important part of treatment plans for people with binge eating disorder, alongside psychological therapies and social support.
Izzy Emptage added: “Many people with binge eating disorder cannot access weight loss drugs through their public healthcare providers, so many have to seek treatment privately at considerable personal cost.
“We hope that by highlighting the potential of weight loss drugs to help with binge eating symptoms, our findings will lead to further funding of larger high-quality studies in this area, to better understand how this medication could be used in practice and improve treatment options.”
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