Employee Health Screening

Type 1 Diabetes

Type 1 diabetes is generally a genetic disease passed on through generations of a family. It can affect kids and adults alike, but most often begins in childhood and is carried through adulthood. The body produces only a small amount of insulin, if any at all. Consuming excessive amounts of sugar can worsen the natural disruption caused by this specific classification.

Type 2 Diabetes

Type 2 diabetes often occurs because of a poor diet combined with lack of exercise. This classification most often occurs in adults over the age of 35, but the number of children getting this disease is rising because of poor food options and lack of exercise. A handful of people who contract type 2 diabetes are predisposed to it because of genetics.

Gestational Diabetes

Pregnant women sometimes experience a brief interaction with diabetes during pregnancy. This is called gestational diabetes. It happens in the second trimester and, in most cases, disappears after the baby is born. It is very important for a woman to keep in close contact with her obstetrician when this disease occurs. Gestational diabetes puts an expectant mother at higher risk for developing permanent type 2 diabetes. The risk for gestational diabetes in future pregnancies is higher, as well. The cause of gestational diabetes isn’t completely known, but there is a theory. Hormones from the placenta may be blocking the insulin that is being produced, causing the insulin not to be able to do its job properly.

What Are the Symptoms?

Symptoms of diabetes can be unnoticeable or mild in the early stages. Often, diabetes isn’t diagnosed until blood tests confirm the results. Symptoms of diabetes might include one or more of the following:

o  Frequent urination

o  Excessive thirst

o  Nausea

o  Blurred vision

o  Fatigue

o  Excessive weight loss, even if eating a normal amount of food

o  Tingling of the hands and/or feet

o  Ulcers (skin sores) that don’t heal

o  Acquiring frequent infections

When to Seek Specialist Help

If you experience any of the symptoms listed above, you ought to contact your physician as soon as possible. Even if you do not have diabetes, these can be symptomatic of other potential diseases. You should have blood tests performed on a regular basis if diabetes runs in your family. Sugar levels are something that doctors check on a each year basis, so getting a regular physical is something everybody should do.

Many of us suffer from our blood sugar level being out of balance. If you have high blood sugar levels (diabetes), then you will hopefully be under the supervision of a medical practitioner. This article is about low blood sugar levels, sometimes referred to as hypoglycaemia.

There are many causes of low blood sugar, including stress, food allergies and nutritional deficiencies. However, here we are focusing on three ways in which we can all make changes to our habits to greatly reduce the likelihood of suffering low blood sugar – our intake of sugar, coffee and tobacco.

Sugar

Refined grains and refined white sugar are probably the most significant factors involved in hypoglycaemia. As well as the sugar we ourselves add to drinks and food, surprisingly large quantities of sugar are added to many processed foods and drinks, even savoury ready meals. Refined grains are stripped of their nutrients and only a few are replaced. E.g. up to 98% of chromium is lost and 78% of zinc. These two minerals are critical for blood glucose control. Refined grains are not only depleted of nutrients, but they use up your body stores of nutrients in the process of trying to deal with them.

Solution –  Purchase only natural ingredients and resist the temptation to add sugar to your food and drinks!

Coffee

Coffee can drastically lower your blood sugar level. Coffee stimulates the adrenal glands, which encourages the liver to breakdown its glycogen stores, and release it back into the bloodstream as glucose. The dependable quick fix of a cup of coffee with sugar is like a double â..whammy’. The body is flooded with an immediate source of sugar into the bloodstream, while coffee adds to the total sugar load by acting through the adrenal glands and liver.

Solution –  Try to cut back your coffee consumption, and gradually reduce the amount of sugar you take with it.

Tobacco

Studies have shown that nicotine rapidly increases glucose levels by as much as 36 percent, followed by a rapid drop shortly after the cigarette is put out. This sudden drop in blood sugar level after a cigarette helps to explain the addictive nature of nicotine and the craving for the next cigarette soon after. Although the mechanism isn’t clearly understood, tobacco use can cause a severe deficiency of vitamin C. This vitamin has many roles in the body and a deficiency is associated with many degenerative diseases.

Solution –  Quit smoking if you can. If you can’t, bettering your diet by eating more fruits and vegetables can help to reduce cravings, thus making it easier to quit smoking in the long run.

Advantages of Fitness Plans

Exercise reduces weight, reduces risks of heart attack and stroke, helps to control blood pressure (BP) and diabetes, and improves mood. Studies increasingly show that exercise might also help reduce the occurrence of certain types of cancer.

Researchers at the Centers for Disease Control and Avoidance (CDC) lately documented another major advantage –  exercise improves the health of the nation’s medical care expenditures.3 As reported by the CDC, physically active individuals incur $865 less annually in medical costs than inactive people .

Dr. Michael Moore, vice president and chief medical director at Nationwide Insurance in Columbus, maintains that exercise is the most effective tool in health maintenance. “If you may prescribe exercise in a pill, it’d be the number-one prescribed treatment in the world,” he said.

In step with Dr. Moore’s prescription, almost one-third of United States companies help staff pay for fitness club memberships, as reported by an Associated Press report. Subsidizing fitness club memberships is just one way companies encourage active life choices.

Popular fitness-forward initiatives -

o  Start a corporation softball or volleyball league.

o  Compile and distribute information about opportunities to join athletic groups in your community.

o  Offer partial or complete reimbursement for fitness facility memberships.

o  Hold aerobics, karate, yoga or other types of fitness classes on-site.

o  Provide extended lunch hours for personnel who commit to lunchtime exercise plans.

o  Introduce an on-site fitness facility that is free, or available at a nominal cost, to staff and their families.

o  Conduct on-site wellness fairs that include fitness demonstrations and promote fitness activities and resources.

There are 17 million diabetics in the United States and 80 million more who are in some stage of insulin resistance. A diet high in carbohydrates and lack of nutrition are the two main factors in creating insulin resistance. Insulin resistance is a “pre-diabetic” condition, which, when it gets extreme, becomes type 2 diabetes. Below are two doctors clarifying how this condition develops and its effects on the body:

When cells become resistant to insulin, the receptors on their surfaces designed to respond to insulin have begun to malfunction.

It simply means that the receptors require more insulin to make them work properly in removing sugar from the blood. Whereas before they needed just a touch to lower it, now they need a continuous supply of excess insulin to keep blood sugar within normal range.

As time goes by, blood sugar rises higher and stays up longer after the carbohydrate meal despite the immense amount of insulin mustered to lower it. Bear in mind that were your doctor to check blood sugar during this stage of developing insulin resistance, your blood sugar would be perfectly normal. The major silent change taking place is the ever-growing quantity of insulin needed to keep it that way.

excerpted from Protein Power by Doctors Michael and Mary Eades

“The liver becomes resistant first, then the muscle tissue, then the fat. What’s the effect of insulin on the liver? It is to suppress the production of sugar by the liver.

The sugar floating around in your body at any one time is the result of two things, the sugar that you have eaten and how much sugar your liver has made. When you wake up in the morning it’s more of a reflection of how much sugar your liver has made. If your liver is listening to insulin properly it won’t make much sugar in the middle of the night. If your liver is resistant, those brakes are lifted and your liver starts making a bunch of sugar so you wake up with a bunch of sugar.”

“The next tissue to become resistant is the muscle tissue. What’s the action of insulin in muscles? It allows your muscles to burn sugar for one thing. So if your muscles become resistant to insulin it can’t burn that sugar that was just manufactured by the liver. So the liver is producing too much, the muscles can’t burn it, and this raises your blood sugar.

Well the fat cells become resistant, but not for a while. It is only after a while that they become resistant. It takes them longer. Liver first, muscle second, and then your fat cells.”

“So for a while your fat cells retain their sensitivity. What’s the action of insulin on your fat cells? To store that fat. It takes sugar and it stores it as fat. So until your fat cells become resistant you get fat, and that is what you see. As people become more and more insulin resistant, they get fat and their weight goes up.

But eventually they plateau. They could plateau at three hundred pounds, two hundred and twenty pounds, one hundred and fifty pounds, but they will eventually plateau as the fat cells protect themselves and become insulin resistant.”

“As all these major tissues, this massive body becomes resistant, your liver, muscles and fat, your pancreas is putting out more insulin to compensate, so you are hyperinsulinemic [having an abnormally high level of insulin in the blood] and you’ve got insulin floating around all the time.

Insulin floating around in the blood causes a plaque build up. Insulin causes the blood to clot too readily. Insulin causes cells that accumulate fatty deposits. Every step of the way, insulin’s got its fingers in it and is causing cardiovascular disease. It fills it with plaque, it constricts the arteries, it increases platelet adhesiveness and ability of the blood to coagulate [clot]. Any known cause of cardiovascular disease, insulin is a part of.”"”

If you want to know if insulin sensitivity can be restored to its original state, well, perhaps not to its original state, but you can restore it to the state of about a ten year old.

You can increase sensitivity by diet and a lot of supplements.

The next question perhaps would be – What’s blood sugar testing? – It is mainly a test of the amount of glucose in one’s system. It will show whether one has below or above normal levels of sugar in his blood. Correspondingly, conditions of hypoglycemia or hyperglycemia may become more obvious after such tests.

If asked, what is blood sugar testing frequency appropriate for one? It’ll all depend on your current situation and your doctor’s advise. If one has pre-diabetes, the doctor may require testing on regular intervals. If you are a known diabetic however, you may be asked to closely monitor your glucose levels several times a day – prompting you to do self-checks at home, with the use of blood sugar meters. A hemoglobin A1c test might also be ordered by your doctor along with blood sugar testing for a better monitoring of glucose over a period of time.

Blood sugar testing may however be done to healthy, asymptomatic individuals for screening of diabetes. As one may know, diabetes starts with a few symptoms and thru such tests – one will be able to find concrete results of his true health standing.

In emergency settings – perhaps where symptoms of fainting and unconsciousness are seen, blood sugar testing may also have to be administered. Such tests would determine whether an abnormal glucose level – low or high – is contributing to the symptoms of the patient.

In workplace health programs, an information drive is usually done to answer –  ”what is blood sugar and blood sugar testing?” – And actual blood sugar testing is also being done here. Public health fairs also have this.

In routine physical exams, blood glucose testing may form part of the tests one has to undergo. It’ll help screen and diagnose diabetes. The sooner one knows his true condition, the earlier the appropriate treatment can be administered to him – and preventive measures can be taken to control one’s glucose levels to normal.

Wellness program means different things to different corporations. Effective wellness programs could be as simple as bringing bushel baskets of fresh fruit into break rooms to encourage better eating. They could be as comprehensive as building fitness facilities on-site or paying for obesity treatments.

A driving factor behind the push toward wellness spans corporations of all types, sizes and cultures –  that is, health care costs are spilling over the corporate belt buckle.

The annual cost of medical services in the U.S. is rising at seven times the rate of inflation.  And the rise in health care costs is one boom pundits expect our economy to sustain.1

This trend makes it increasingly challenging for employers to maintain current levels of insurance coverage. In 2003, health care inflation forced 65 percent of businesses to raise employees’ share of healthcare costs.

Seventy-nine percent of large firms said they will increase workers’ share of health care costs in 2004.2 But with lost benefits and increased financial burdens come lost morale and productivity.

Companys are searching for another way. While corporations cannot control many of the supply-side elements contributing to rising health care costsâ.”malpractice insurance rates, the nursing shortageâ.”they can help curb demand. That’s why efforts are being redirected from disease to wellness.

The case for wellness is supported by an ever growing body of evidence demonstrating the high costs associated with controllable health risks -

o  One study reports that obesity raises healthcare costs by 36% and medication costs by 77%.

o  Michigan officials estimate lack of exercise cost the state almost $8.9 billion in 2002, a cost estimated to be largely borne by corporations through insurance premiums and lost productivity.

o  The not-for-profit National Committee for Quality Assurance reports that the estimated typical cost for postnatal care for women who did not receive prenatal care was $2,341 more than for women who had.  And the indirect costs of unhealthful behavior can be just as high.

Data shows that healthier staff members are more productive, spending more time at work and showing increased “presenteeism,” or productivity, while there. Further, healthier staff members use fewer medical services.

The five leading causes of death in the U.S. â.” heart disease, cancer, stroke, chronic obstructive pulmonary disease and diabetes â.”  are directly linked to unhealthful life choices. Obviously, encouraging healthful habits presents an opportunity to improve employees’ well being, reduce the need for healthcare services and help control costs.

Offering worker wellness benefits â.” large or small â.” represents an intersection between corporate social responsibility and responsibility to stakeholders. Between worker health and corporate health. It is often the right thing to do for workers and corporations.

Research by Traveler’s Corp. shows a $3.40 return for every dollar invested in Wellness Programs. for many corporations, the choice to offer employee wellness benefits is easyâ.”one where conscience and pragmatism align.

The challenge arises in selecting  the health promotion programs that’ll deliver the most impact based on trends in your employees’ health risks and medical claims costs.

From large businesses to the corner deli, business owners welcome ways to increase productivity, lower rates of absenteeism and cut costs. Likewise, health promotion programs can range from modest to elaborate.

In determining where to focus a corporation’s limited resources, looking at costs, benefits and best practices is a good beginning point. This section profiles six aspects of wellness and explores their benefits to employees and employers.

Why is blood sugar so important for your body? Energy. That’s right. Blood sugar provides the body with energy that your body needs to function properly. Glucose (comes from sugar) helps fuel and replenish the body so that it processes like it should. Besides giving your body energy and stabilizing it, you may ask, “Why is blood sugar really important?” Here’s why: High or low levels of blood sugar can actually be dangerous to your health. Unusual amounts of blood sugar can lead to sweating, dizziness, confusion, shaking, seizures, a fast heart rate, and other complications. A couple of well-known blood sugar disorders are Diabetes and hypoglycemia.

Blood sugar levels can depend on

(1) overeating

(2) unhealthy eating

(3) lack of exercise

(4) stress

(5) medication and

(6) by disease or infection.

Now you’re probably thinking, “What’s the best way to combat all that?” A healthy diet and exercise will help you maintain normal glucose levels. Choosing the right foods to eat and exercising regularly will balance your glucose levels so they don’t skyrocket on you. This does not mean you can’t enjoy all the foods you’ve loved your whole life. There are natural and safe substitutes that will allow you to keep the “sweet” in your diet.

Xylitol, a common sugar alcohol, is a naturally occurring substance that looks and tastes like sugar, but is healthier for you. Sugar alcohols, also known as polyols, are commonly used as sweeteners and bulking agents. Table sugar and other carbohydrates can elevate blood sugar to unhealthy levels or cause reactions to the insulin that is subsequently produced. The great thing about xylitol is that it’s absorbed into the blood stream much slower than table sugar and other carbohydrates and that means it carries 40% less calories.

Sugar alcohol comes in a variety of forms (e.g., xylitol, mannitol, sorbitol, and others). These can be found in an assortment of foods such as soft drinks, candy, chewing gum, cookies, and many other “sugar-free products.” Xylitol is crystalline in form and a normal substance found in everyday metabolism. The FDA has given xylitol its safest rating as a food additive which means it’s perfectly healthy and safe for human consumption. It’s even safe to consume for those with diabetes and hypoglycemia.

Blood sugar and sugar alcohol are closely related to stabilizing, maintaining, and assisting the body process and function properly. If not closely watched, blood sugar levels in the body can cause serious health issues. Sugar alcohols can help reduce calories and keep blood sugar levels in areas that they need to be so that you can live a healthier and more energetic life.

Many people have their predispositions about the word “diet.” Do you remember Richard Simmons’ line? “Don’t die it; live it!” You may have your own, and that’s okay. But, can I tell you, friend, that I’ve an acronym of “diet” that is empowering and useful? Here it is –

Doing what’s right

Identifying the bad food vs. the good food

Energizing your heart, mind, and body

Taking control of your life

This acronym is nothing like a ball-and-chain or a weight to hold you down and depress you! It’s a helpful tool to remind you that a diet plan has many wonderful rewards. Doing what has right has to do with following your doctor’s prescribed diabetic diet plan to maintain your healthy glucose levels. Learn to identify the bad food versus the good food by looking at the labels when grocery shopping. Energizing your heart, mind, and body is a result from these healthier lifestyle options. Make certain to take control of your healthy life. This involves living life to the fullest with the ones who love and care for you. What can be better than that?

Still skeptical about the diabetic diet foods, huh? Well, I’ll answer any questions you have. Let’s get started!

What are the foods that I should eat? Do not worry, I am not going to say bark or dried-out chicken! These foods are healthy and tasty!

o  Broccoli

o  Spinach

o  Green Beans

o  Unsweetened oatmeal

o  Strawberries

o  Sparkling Water

o  Fish and Lean Meats

o  Cinnamon

o  Yogurt

o  Fruit

That is right! You can have tasty and healthy foods!

Do I have to give up all my favorite foods? Healthier options is the answer, my friend. Yes, the best answer is to give up those dangerous foods for good, but reality and real life is present. Moderation and complete exchanges of unhealthy foods for healthy and tasty foods is the best answer. I know this is going to be hard, so I will give you some helpful hints –

o  Exchange high-fat foods for low-fat foods.

o  Disguise the small portions by serving it on a dessert or salad plate.

o  When eating out, ask for a “to-go” box and put half of your meal in the box before you eat.

o  By drinking a glass of water 10 minutes before each meal, you will not eat as much.

o  If you’re still hungry after your meal, wait 20 minutes.

o  Do not eat with the TV on.

Okay, I know how to eat, but how much should I eat? Portion control is a sensitive subject, is not it? Well, it’s much easier controlling the amount of food that it’s taking huge amounts of medication. Here are some helpful portion comparisons –

o  A deck of cards is one serving of meat.

o  A slice of bread is one serving of bread.

o  A scoop of ice cream equals one serving of pasta.

Why should I keep to a healthy diet? The rewards are endless and are very healthy –

o  Healthful glucose levels.

o  Steady and healthy weight management.

o  Your family.

o  Your life.

When it comes to working wellness into your workforce, you want someone who knows the ins and outs of wellness, and who can counsel employees and provide primary care – all within the context of the current regulatory and legal environment.

AAOHN’s survey reported that more than half of staff members (61 percent) want to receive wellness information from a healthcare professional, such as a consultant or an on-site occupational health nurse (OHN), compared to flyers or flyers (18 percent) or human resources staff (15 percent).

OHNs can develop, implement and evaluate components of work site wellness programs like screening programs, exercise/fitness courses, stress management, use of tobacco cessation, nutrition and weight control programs, in addition to chronic disease management programs.

Plus, OHNs can help employees navigate through complicated health care plans and may even serve as a triage point between employees and their personal health care providers.

Workers might refrain from seeing their health care provider when it means time away from work, inconvenient parking, waiting time in the office and co-pays.

In situations where personnel are under treatment for chronic conditions like heart illness, onsite nurses can routinely monitor risk factors like blood pressure (BP) or cholesterol on a regular basis.

It is often easier for an staff member to ask an onsite nurse for information about symptoms or prescription medication than it is to schedule a follow-up visit to a personal health care provider.

Benefits realized by employers include enhanced staff member morale and retention, a recruitment advantage, increased productivity and decreased time away from work.

In corporations with a safety department, the OHN can evaluate and address work-related health issues, including participation in workstation investigations to correct potential ergonomic problems, and proactively addressing muscle strains by developing stretching programs and involving employees in leading stretches.

Diabetes. High blood sugar. Isn’t that an â..old people’ disease? Doesn’t that only cause problems for your grandparents or other elderly relatives and friends? Is that the disease where you have to give yourself shots every day? That’s the disease that you get from eating too much sugar, right? Isn’t it true that only fat people get that illness?

Before we go much further, let’s go over some basics about diabetes. First, about 5.5 million Americans are currently being treated for diabetes. Studies imply that 5 million more Americans have undetected diabetes and another 20 million have an impaired glucose tolerance that may lead to diabetes. That’s a significant amount of people. The National Institutes of Health state that millions of people lose their vision annually due to undetected diabetes. Most important to note is that the third leading cause of death in the United States is the complications of diabetes.

There are two different forms of diabetes and it’s not the Type I and Type II that you always hear about. The first form is called Diabetes Insipidus. This kind of diabetes is very rare and has two causes. There may be a low level of a hormone called vasopressin or the kidneys cannot effectively respond to the vasopressin. The key symptoms of this metabolic malfunction are an extreme thirst and high urine output.

The more common form of diabetes is called Diabetes Mellitus. It is the result of a problem with the pancreas and its production of insulin. The body’s blood sugar level is dependent on the proper amounts of insulin produced to breakdown the glucose (sugar) in our diet. Diabetes mellitus is a chronic illness of carbohydrate metabolism. Genetics definitely plays a part in developing diabetes but a diet of highly processed, low-fiber foods has been seen as a major contributor in most cases. This type of diet leads to obesity resulting in overweight individuals having a higher risk of diabetes.

Diabetes mellitus is the Type I and Type II diabetes that you’ve heard about. Type I, known as insulin-dependent or juvenile diabetes. This form of diabetes involves the destruction of the beta cells in the pancreas that produce insulin. It is most common in children.

Individuals with Type I diabetes show the following symptoms:

o  Irritability

o  Frequent urination

o  Abnormal thirst

o  Nausea/Vomiting

o  weight loss

o  Fatigue

o  Weakness

o  Unusual hunger

o  Frequent bedwetting (in children)

Type I diabetics are also susceptible to episodes of high blood sugar (hyperglycemia) and low blood sugar (hypoglycemia). Either of these conditions can cause serious medical problems.

Hyperglycemia can sneak up gradually over a period of hours or days and it is most common during an illness. A chief warning sign is the inability to keep down fluids. Possible complications include stroke, coma, blindness, kidney failure, and nerve damage. Hypoglycemia, in contrast, comes on rapidly and can be caused by skipping meals or exercising too much. The signs of hypoglycemia include dizziness, hunger, confusion, sweating, and tingling lips. Complications can be double vision, trembling, disorientation, and coma.

Type II diabetes is most likely to happen in individuals with a family history of diabetes. This form of diabetes is slightly different. The pancreas produces insulin but it doesn’t work properly. As a result, the blood sugar level remains high because the glucose cannot get into the body’s cells as quickly as it should.

Folks with Type II diabetes exhibit the following symptoms:

o  Blurred vision

o  Itching

o  Unusual thirst

o  Fatigue

o  Slow wound healing

o  Numbness in hands and feet

o  Skin infections

o  Lingering flu symptoms

o  Loss of hair on legs

o  Increased facial hair

o  Small, yellow bumps on the body

A common first indicator of diabetes in men is a condition known as balanoposthitis. This condition is an inflammation of the penis and foreskin and usually accompanies frequent urination.

There is a wide range of natural health options that are available to diabetics. Maintaining a proper diet and participating in an exercise programare two of the most important ways to control diabetes. Your physician and dietician will be most helpful in developing a food plan that will be best for you. A rule of thumb for a diabetic diet is to eat foods that contain complex carbohydrates, low fat, and high fiber. That means plenty of fruits and vegetables, including juices. The complex carbs enter the system more slowly, the fiber helps slow the blood sugar spikes, and the low fat keeps the fat levels in your bloodstream down. Prevent the simple sugars and the saturated fats.

Exercise is of equal importance since obesity is a major contributing factor in Type II diabetes. Your physician and therapists can help you develop a weight reduction program to fit your needs.

In addition to diet and exercise, there are nutritional supplements that have been found helpful for diabetes. These supplements are:

Chromium picolinate – enhances the effect of insulin resulting in lower blood sugar levels

L-Glutamine – reduces sugar cravings

Biotin – helps in glucose metabolism

Manganese – important for repair of the pancreas

Don’t take any supplements that contain cysteine, an amino acid. It can cause problems with the ability of the cells to absorb insulin properly.

Vitamins B, C, and E are also helpful as antioxidants. They work toward the prevention of secondary complications of diabetes such a vision and vascular problems. However, large doses of Vitamin C or B1 should be avoided because they could inactivate insulin.

Several herbs are also advocated for diabetes. These herbs are cedar berries, huckleberry, ginseng, bilberry, dandelion root, buchu, and uva ursi. Each herb has a specific role in maintaining proper glucose levels.

Because diabetes causes problems with the circulatory system, it’s vital to avoid tobacco in any form. Tobacco constricts the blood vessels and slows the circulation. Tobacco use provides less oxygen to the extremities. This lack of oxygen plays a major role in the development of foot ulcers commonly seen in diabetics.

There are many reasons to try to prevent the onset of diabetes. It threatens your overall health and can lead to a wide range of complications. Here are just a few.

Diabetic Retinopathy – This is damage done to the retina and is the leading cause of blindness in the United States.

Diabetic Nephropathy – This is damage done to the kidneys and is the leading cause of death in diabetics.

Diabetic Neuropathy – This is damage done to the nerves and is characterized by numbness, tingling, and pain. It affects the feet, legs, and hands.

It has been said that diabetes is deceptive, insidious, and inconvenient. If you feel that you are experiencing signs of diabetes, check with your primary care provider.