Healthy New Year’s Resolutions: Think “Glow,” Not “Glitz”

By Maria Jauhar, M.D.

The sparkle of the holiday season is often reflected in our eyes when we turn our attention to New Year’s resolutions. Our enthusiasm is something to value a great deal, because it gets us going. On the other hand, the tradition of New Year’s resolutions can lead to quick-fix attempts and short-term ambitions.

The fact is, the resolutions that work are almost always steady, incremental efforts. No matter whether it’s exercise, diet, or any kind of positive habit formation, it turns out to be more important to do a reasonable amount with relentless regularity, rather than to take on a lot all at once.

Let’s take a look at some of the “usual suspects” that arise when New Year’s resolution time comes around, and see how a steady approach can turn them from daydreams into parts of our lives.

Think Beyond the Top 10

The 10 most common resolutions people make at the turn of the year show an admirable ambition for change. Getting more education, a better job, a new romantic relationship, and so forth. When we look carefully at these ambitions, though, do we focus too much on the outside world, when the answer may well be within ourselves?

The climactic scene in The Wizard of Oz is uncommonly wise. Each of the seekers discovered that they had been carrying the answer around within them through the whole adventurous journey.

Beyond the Top 10 are the changes we make within ourselves. Our beliefs, our habits, and our expectations are the keys. With them, we open the door of actions that lead to achieving what we desire.

The Goal is Balance, Not Perfection

The single greatest defeater of New Year’s resolutions is unreasonable expectations. We tend to want it all, and fast.

Taking steps toward our goal in the outside world is a vital part of turning resolutions into reality. Don’t think how far off a degree might be; enroll in a class. Don’t defeat your career ambitions by inventorying your faults, call friends and tell them you’re considering a new career path, and then ask them what they think. Wherever we look for improving our lives, the great journey begins with a humble step.

Quality of Life Begins with Life Itself

Quitting cigarettes, eating right, and exercising regularly are the three most vital resolutions of all, because without life, we have nothing to improve. And because these new habits take time and encouragement to form, it’s a good idea to surround yourself with support, from family, from friends – and from a professional.

Lining Up a Professional Ally

Ask any college or professional athlete about the first day of training “camp,” and they’ll tell you it starts with a physical exam. Nutritional resolutions are vulnerable to fads when you start without the perspective of a qualified person, one who knows your unique physiology. And research shows that more people succeed at quitting cigarettes when they have support, like medical supervision. So when you’re serious about your new year’s resolutions don’t forget to talk them over with your family physician.

To schedule an appointment with us at Island Family Medical Center, call 912.897.6832 or use our online appointment request form.

 

Holiday Stress Reduction: Reclaiming the Rest from the Festive

By Maria Jauhar, M.D.

The last thing we think of, when we see the bustle of preparations, is the idea that a holiday might be meant for rest and restoration. Yet wisdom traditions around the world and through the ages have seen these short days and long nights as a time for paying attention to what’s inside.

Contemplating the true meanings to be found here calls for at least some moments of tranquility. Yes, rest is an important part of the meaning of “holiday,” and it is still achievable, even amidst the other traditions we have layered on it over the course of many years.

It Starts with the Expectations

Recreating a long-ago memory of childhood or family celebrations is frequently a formula for frustration. Many of us strive in vain to bring back our image of perfection based on times that have changed and circumstances that might be vastly different today.

It’s the spirit of those memorable holidays that we want to experience, not the exact arrangements or circumstances, so give yourself some slack. Creating celebrations that work today is the goal.

Just About Everybody Feels It

Anxiety and stress are so commonplace during the holidays that even the Mayo Clinic published some tips for dealing with it. Just knowing you’re not alone and feeling free to mention your feelings to friends can help. The very groups around which holiday observances are based – religious gatherings, community organizations, and social circles – are places to find a reassuring voice of understanding and encouragement.

Judgment is a good feeling to avoid. Judging ourselves or others harshly for not “living up” to the image we hold of the holidays is a burden we can do without. Often there are relatives and friends we see rarely during the year, or even only at the holidays. Accepting that others are feeling holiday strains based on their own life experiences will help us get along with those friends and relatives we don’t see very often.

Take a Break Now and Then

Even a few minutes away from shopping, cooking, cleaning, and errands can make a difference in how good our holidays feel. Yet time away may be the most often overlooked solution. Whatever quiets your mind and slows your breathing can bring you back refreshed, with your happy outlook restored. For some it’s a massage, a meditation, or an exercise class. For others, just gift-wrapping can be a relaxer, with its manual concentration, repetition, and sense of completion.

A Taste of Routine Can Be Refreshing

Abandoning our normal eating, sleeping, and exercise patterns is a big contributor to holiday stress. Doing our best to stay close to the healthy habits that got us to the holidays is one of the best things we can do to see us through them happily.

Staying in touch with your family physician is one of those practices to hold onto. To schedule an appointment with us at Island Family Medical Center, call 912.897.6832 or use our online appointment request form.

Seasonal Tips for Staying Healthy: Make Wellness a Family Tradition

By Maria Jauhar, M.D.

When we are thankful, we like to show it. So, as families and loved ones gather this holiday season – from Thanksgiving through New Year’s Day – why not show how much we’re grateful by focusing some of that holiday glow on our health?

When you think of it, the pause that comes with the holidays, the break from routine could be an annual reminder to take care of what’s precious. It’s strange but true that the everyday often crowds out higher priorities. Like teen or young-adult children’s checkups. Or even your own.

Shift Family Health from Defense to Offense

Getting though the holidays without the added pounds, learning to recognize and mange the stress that can come from holiday expectations, staying safe as we travel – all these are important, and we’ll deal with them in greater depth in later blogs.

For now, we’d like to introduce something more unusual. Let’s have the holidays remind us of the proactive practices that can protect our families and loved ones for many years to come.

Put Time and Togetherness to Good Use

Taking small children for regular checkups is part of many household routines. And we put checkups back up on the priority list later in life, when age reminds us we’re not immortal. But a big span in the middle of our lives – our most active, demanding years – may be characterized by letting the checkups slip.

If that’s true of your teens or young-adult children, or even of yourself, why not let Thanksgiving signal that it’s time to get your checkups on the calendar?

To give thanks is one thing. To show thanks is even better.

Not All the Blocking and Tackling is on TV

Let’s not forget the basics as we make our holidays a reminder of how grateful we are for health. Eating well, exercising properly, managing stress and above all quitting cigarettes – these are the blocking and tackling of avoiding preventable illness.

Proper eating and stress management are so important that we’ll talk about them more specifically in upcoming blogs, as the holidays progress. For now, let’s just say it’s not the holiday foods that threaten our weight control. It’s the recipes. For example, turkey and sweet potatoes would make almost anyone’s healthy eating list, but stuffing and brown sugar are just as likely to be things we want to limit. Portion size is another opportunity to touch all the holiday bases without tipping the scales.

What We Do – the Most Important Factor in Good Health

And here’s an important point about preventable illness. Even the greatest threats to our families’ health can be minimized by what we do. Even our risk of heart disease and cancer, where heredity does play a role, can be reduced significantly by healthy habits and regular monitoring from a family physician.

To schedule an appointment with us at Island Family Medical Center, call 912.897.6832 or use our online appointment request form.

The Great American Smokeout: No Step to Health is Greater

By Maria Jauhar, M.D.

For ourselves, a loved one, an organization, a workplace, or even a circle of friends, the greatest step forward, the greatest gift, the greatest service we can do is to stop smoking cigarettes.

Smoking is the most ferocious, merciless threat we face. No type of warfare, no terrorist threat takes so many lives. Hands down, smoking is still the number one cause of premature death in the United States. It is the largest single cause of preventable disease. It damages nearly every organ of the body. And it is an addiction, which means that stopping is not easy.

It Begins with a Single Day

Like the process of smoking cessation itself, the Great American Smokeout began with a single day. In 1970, the residents of Randolph, Massachusetts, were challenged to put down their cigarettes for one day and donate the money saved to a local high school. In 1974, a Don’t Smoke Day was promoted in Monticello, Minnesota. And in 1976, the California division of the American Cancer Society promoted the first Smokeout, prompting nearly one million smokers there to quit for a day.

Now observed each year on the third Thursday of November, the Great American Smokeout is credited with hastening the spread of smoke-free public spaces. The attention and information that resulted from the Smokeout encouraged public officials to adopt regulations that recognize smoking for what it truly is, a serious threat to public health and well-being.

The Hidden Danger of Progress

Complacency may be the next great hurdle in further reducing the danger to our society of smoking. People who can remember “before” are becoming senior citizens. The days when somebody was smoking everywhere you went are not even a memory to the young people most in danger of beginning. As a result, the Center for Disease Control and Prevention estimates that 3,200 Americans under the age of 18 begin smoking every day. Another 2,100 young adults who have smoked occasionally become daily smokers – every day.

As a result, one in 13 Americans aged 17 or younger will die prematurely from a smoking-related illness if the current rate of smoking continues.

People with Help Do Better

Because smoking is an addiction, quitting is a kind of recovery. So although there are “cold turkey” examples among the acquaintances of many of us, just stopping is not the norm. Smoking cessation for the vast majority of persons takes effort, resources and a bit of outside help.

Research confirms it. According to the American Cancer Society, studies show that people most likely to succeed in quitting cigarettes use two or more of these assists to get the upper hand:

  • Telephone smoking-cessation hotlines
  • Stop-smoking groups
  • Online quit groups
  • Counseling
  • Nicotine replacement products
  • Prescription medicine to lessen cravings
  • Guide books
  • Encouragement and support from friends and family members

Many people succeed after more than one attempt to quit, so it is important to keep trying. Judging ourselves harshly, or accepting “failure,” can lead us down the road of disease and death.

We’d be happy to help. To make a support plan for your own new smoke-free life, schedule an appointment by calling 912.897.6832 or use our online appointment request form.

National Diabetes Education Week: It’s that Important

By Maria Jauhar, M.D.

Since all November is National Diabetes Month, aren’t we overdoing it a bit to designate this week National Diabetes Education Week? Experts on the disease have thought about that and concluded no, this is not overdoing it at all.

The threats from diabetes go from head to foot and from painful to fatal. They range from death by stroke or cardiovascular disease to blindness or chronic pain in the legs and feet.

We’ve written here about the scale of the problem, but maybe some of that bears repeating, too. One in every 11 Americans has diabetes. That rate has tripled since 1980, an epidemic by any reasonable definition.

Education as Medicine

Yet the relentless climb of diabetes rates began to plateau after 2010. The causes of that good news are hard to isolate, but undoubtedly awareness is one of the factors for which we give thanks. So, diabetes education may prove to be among the most efficient and effective treatments for Type 2 diabetes that we have in hand. The American Association of Diabetes Educators has a locator that will help you find out more.

Power to the Patient

Though, yes, heredity plays a role in diabetes, more factors than that are well within our grasp. Sensible exercise, good eating, and monitoring blood sugar levels in our annual or semi-annual checkups put us in a position to avoid Type 2 diabetes in many cases, and to control it if it should arise.

Monitoring – It’s Not Just for Patients Anymore

Staying aware of our blood sugar level and adjusting our eating and activity accordingly is part of a healthy life, even for those of us who have not been diagnosed with diabetes. The onset of the disease is subtle. Healthy people today include glucose levels in their “lab work” for the annual or semi-annual checkup they schedule with their family physician. Paying attention to those readings and discussing them with the doctor just makes sense for all of us in the face of the epidemic diabetes around us.

Learning For Life

Perhaps anyone who is concerned or even interested in getting a life-saving knowledge of diabetes – for one’s self or loved ones – should consider attending one of the personal education classes to which doctors send patients who are at risk, showing signs of pre-diabetes, or who have notched a high glucose reading or two.

The American Diabetes Association’s local program coordinators can direct you to free or low-cost classes that equip diabetics, their families and even people who are becoming concerned about diabetes with what they need to know.

To schedule an appointment with us at Island Family Medical Center for an assessment of your own risk, call 912.897.6832 or use our online appointment request form.

Family Health & Fitness Day: Passing Along Our Greatest Legacy

By Maria Jauhar, M.D.

There’s background music playing in the heart of most every parent. We want to provide our children with prosperous, healthy lives. If we can pass it on a little better than we knew it ourselves, so much the better. Our health habits are often overlooked when we consider what to give our children. Yet these may be the most important legacy of all.

Nowadays, it’s rare for a family to keep the same home from generation to generation. People are advised to expect more than one career in a lifetime. Wealth is notoriously vulnerable to outside influences. The things people handed down to their children throughout history are now mostly that – history.

But health and fitness is a distinct exception.

A Day of Celebration

September 24 marks the 20th year of Family Health & Fitness Day. “Our goals for Family Health & Fitness Day are to emphasize the importance and fun of regular physical activity and to encourage families of all ages to take advantage of the many health and fitness programs offered in their communities,” said Pat Henze, FHFD director. Organized by the Health Information Resource Center, it is observed annually on the last Saturday of September.

Life Lessons

Most of today’s threats to longevity have a behavioral component. What we do regularly has a lot to do with how long we live. How much we enjoy living stems too from what we focus on, and the building blocks of what we call quality of life are found in what we do every day.

With that in mind, what are we showing our children?

The chance to do better is huge. The Surgeon General’s Report on Physical Activity and Health said children 12 to 21 are not exercising nearly enough.

Incriminating Evidence

Rates of childhood obesity and the threats that come with it, including diabetes and high blood pressure, are alarming. By 2012, fully one-third of children and teens were overweight or obese. Over the course of 30 years, obesity doubled in children and quadrupled in adolescents. And it strikes at ever-earlier ages. Obesity in children 6 to 11 has gone from 7% to 18% since 1980.

There are many causes, including sedentary interests and fast food, and therefore many solutions including placing parental limits on “screen time,” packing lunches and demonstrating a healthy diet at home. Heredity plays a part, but DNA is not destiny. Most of the causes of childhood obesity can be changed.

The Prescription is Fun

Exercise is one solution with wider benefits than simply working down the checklist of problems. In fact, FUN is the best approach to childhood exercise. Demonstrating and encouraging the delights of games, community parks, walking trails – just getting up and getting outside – is a good place to begin, and begin together. Starting young is a tremendous advantage too, because it’s much more difficult when the age of “cool” sets in.

Your Ally: “Doctor’s Orders”

You can gain focus on your family health and fitness initiatives by beginning with a trip to your family physician. The findings of a physical exam could be just the thing for getting the idea across to children. For adolescents a doctor’s say-so could outweigh the cool factor and get your dialogue going. And if you don’t have a family physician, then we’d like to help. To schedule an appointment with us, call 912.897.6832 or use our online appointment request form.

 

Healthy Aging Month: How We View Change – Has Changed

By Maria Jauhar, M.D.

Until recent years we all thought we knew what getting older looked like. After all, we’d seen our older relatives move through stages that most of them had in common. Our overall perception was once encapsulated in the expression, “Getting old is not for sissies.”

Healthy Aging Month was founded to bring another point of view to the attention of a rapidly growing population. It’s not surprising that the influential “Baby Boom” generation now swells the ranks of America’s seniors, but with 82 million “Generation X-ers” joining them at age 50 and above, a huge proportion of society can live better by taking a different view of aging.

Let’s Get Physical – and Social and Financial and Mental

Healthy aging calls for attention to all the key aspects of well-being, from the body to the bank account. So Healthy Aging Month reminds people to pay attention to them all. September was chosen as the month to celebrate because, more than the calendar year, the school year sticks with us as the time to begin learning new skills and insights.

And “new” is a lot of what healthy aging is about. New knowledge, new goals, and new habits can be the foundation for a life we didn’t foresee when our mission was establishing a career, making a home, or rearing a family. One of the delights of this new view of aging is that in many cases the focus can shift in a good way to the self.

Seemingly “Soft Stuff” Counts

Catnaps can reduce the danger of heart disease. People with goals and a sense of drive to achieve them are less likely to develop Alzheimer’s. These findings are research-backed, and they’re just two of the lifestyle tips you can find on the Healthy Aging Magazine website.

Among the magazine’s 10 Tips to Celebrate Healthy Aging Month are some that sound strangely simple, yet contribute a lot to a person’s fresh approach to living.

One of the most unexpected of these tips might be this one. Remember your favorite age or chapter in your life. Picture yourself as that age and feel it. Some of the other tips might remind us of things our parents seemed to harp on. Stand up straight. Smile. Walk like a vibrant, healthy person.

They might have sounded tiresome when we were teenagers, but later in life they can shape for us an approach to living that helps make living worthwhile. Do we stand and walk this way, or carry this facial expression, because we have to? Or is it just a habit we developed as life progressed? With consciousness and desire, we can just as well develop a new and different habit that serves us much better.

Put Professional Coaching On Your Side, Too

Of course, regular medical attention plays a big role in preventing drastic medical attention at any stage of life. This is especially true as we grow older. A firm foundation for this preventative care is to develop a relationship with a family physician who can get to know you overall – at your best and not just when something goes wrong.

And the best time to develop that relationship is before you need it.

 

Lace Up Your Sneakers and Begin Walking

By Maria Jauhar, MD

We are in the middle of the 12th Annual Medical Fitness Week, which is sponsored by the Medical Fitness Association. The purpose of Medical Fitness Week is to challenge everyone to walk 10,000 steps every day of the week – or 70,000 steps in all.

An average person has a stride length of approximately 2.1 to 2.5 feet. That means that it takes about 2,000 steps to walk one mile – 10,000 steps would be about 5 miles. Studies have shown that most people walk only 1,000 to 3,000 steps a day. If you are someone who just doesn’t seem to move as much as you could, then adding these additional steps has many health benefits. Even if you are physically not able to walk 10,000 steps a day, this week could be the start of a journey that could transform your life.

To track your steps each day, wear a pedometer or fitness tracker. Put it on when you get up in the morning and wear it until bed time. Record your daily steps in a log or notebook. By the end of the week you will know your average daily steps. You might be surprised how many, or how few, steps you get in each day.

A reasonable goal is to increase average daily steps each week by 500 per day until you can easily average 10,000 per day. For example, if you currently average 3,000 steps each day, your goal for week one is 3,500 each day. Your goal week two is 4,000 each day. Continue to increase each week and you should be averaging 10,000 steps by the end of 14 weeks.

There are many ways to increase daily steps. Here are few suggestions. Use your imagination and come up with your own list:

  • Take a walk with your spouse, child, or friend
  • Walk the dog
  • Use the stairs instead of the elevator
  • Park farther from the store
  • Better yet, walk to the store
  • Get up to change the channel
  • Window shop
  • Plan a walking meeting
  • Walk over to visit a neighbor
  • Get outside to walk around the garden or do a little weeding

Continue to track your daily steps and/or mileage and keep notes on how you feel, how your body is improving, or other changes you are making to improve your health.

If you are in very poor physical condition or at any point you feel that you are progressing too rapidly, then slow down a bit and try smaller increases. If you have any health concerns, then schedule an appointment with us first by submitting an online appointment request or calling us at 912-897-6832.

Are You Prepared?

By Maria Jauhar, MD

This month, on April 16, we celebrated National Healthcare Decisions Day (NHDD), which was created to inspire, educate, and empower the public and providers about the importance of advance care planning. NHDD is an initiative to encourage patients to express their wishes regarding healthcare and for providers and facilities to respect those wishes, whatever they may be. The theme for 2016 is “It Always Seems Too Early, Until It’s Too Late.”

Some Important Facts

1. Medicare Requirements

The Federal Patient Self-Determination Act requires that all Medicare-participating healthcare facilities to inquire about and provide information to patients on Advance Directives. It also requires these facilities to provide community education on Advance Directives. All healthcare facilities are required to provide information about health care decision-making rights, ask all patients if they have an advance directive, educate their staff and community about advance directives, and not discriminate against patients based on an advance directive status.

2. A Country Unprepared

The U.S. Agency for Healthcare Research and Quality, in a 2003 article, “Advance Care Planning: Preferences for Care at the End of Life,” found that less than 50% of the severely or terminally ill patients studied had an advance directive in their medical record, only 12% of patients with an advance directive had received input from their physician in its development, and between 65% and 76% of physicians whose patients had an advance directive were not aware that it existed.

The Purpose of National Healthcare Decisions Day

A key goal of NHDD is to demystify healthcare decision-making and make the topic of advance care planning inescapable. Today, no one in the U.S. should be able to open a paper, watch TV, surf the Internet, see a physician or lawyer, or go to a healthcare facility without being confronted with the topic of advance care planning. Among other things, National Healthcare Decisions Day helps people understand that advance healthcare decision-making includes much more than living wills; it is a process that should focus first on conversation and choosing an agent.

Resources

1. AARP

AARP features an End-of-Life Planning resource center with perspectives on starting advance care planning discussions, facilitating discussions with adult children about end of life planning, frequently asked questions and considerations for siblings planning care for parents.

2. A|D Vault/MyDirectives.com & MyDirectives MOBILE

MyDirectives.com, a service of ADVault, Inc., is a free online platform that allows consumers to digitize your voices and treatment priorities in a comprehensive legal advance care plan that is secure in the cloud and available 24/7 anywhere in the world to you, your loved ones and your medical providers. MyDirectives also features a Discussion Guide and Conversation Starters to help people have discussions with doctors, family and healthcare agents. The new MyDirectives MOBILE App makes users’ emergency advance care plans accessible even when their iPhones are locked.

3. Aging With Dignity (Five Wishes)

The Five Wishes document helps individuals express care options and preferences. The advance directive meets the legal requirements in most states and is available in 20 languages for a nominal fee. Order online or call 850.681.2010.

4. American Hospital Association

The American Hospital Association has advance care planning resources from some states hospital associations and a Put It In Writing brochure for patients and families to document their wishes.

5. American Bar Association Advance Care Planning Toolkit

5 Springtime Health Tips

By Maria Jauhar, MD

April is here and so is spring. By now, for most of us, our New Year’s resolutions are a distant memory and we have settled back into our old routines. But it doesn’t have to be that way. Here our five things that can revitalize your health as spring marches on toward summer.

1. Start Fresh

While many New Year’s resolutions fail simply because we lack willpower or we don’t have an effective strategy for breaking old habits, there’s another reason many of us haven’t seen any real change since the first of the year. Simply, when we make our New Year’s resolutions, we are in the heart of winter, with shorter days, weather that isn’t all that great – even for Savannah – and just a more lackluster attitude. With spring comes the opportunity to revisit your resolutions and start over. The weather is mild, the clocks have been moved ahead one hour, and the amount of daylight we get is increasing daily. Use this time to jumpstart your resolutions.

2. Stretch Your Body

Sure, you’ve been cooped up these past few months waiting for the weather to truly turn. Now that it has, take advantage of it. Ramp up your exercise routine, whether that is simply walking more, taking a bike ride, signing up for a yoga class, or joining an adult sports team. It doesn’t take much to get your heart moving, and with the spring weather upon us, this is the time to take it to the next level.

3. Stretch Your Day

When we moved the clocks ahead one hour for Daylight Savings Time, we gave a jolt to our internal rhythms. If your body was set to wake up at 6 a.m., well, 6 a.m. is now 7 a.m. While it may seem difficult to adjust to the one-hour time change, by forcing yourself out of bed at 6 a.m. every day will reset your internal clock in about one week. Plus, it will give you one more hour in your day. By getting up at 6 a.m., you can also enjoy the sunrise, which is enough to get anyone moving with a little more energy.

4. Enjoy the Early Spring Harvest

Winter was the time for root vegetables. With spring comes lighter meals anchored by the vegetables that begin popping out of the ground this time of year – such as asparagus, beans, and onions. Instead of sautéing your veggies in a pan of butter, try drizzling on just a little bit of olive oil, seasoning them with salt and pepper, and roasting them in the oven or cooking them on the grill. The flavors will be enriched while you’ll eliminate must of the fat that comes with sautéing.

5. Take Care of Your Liver

Traditional Eastern philosophy focuses on the Principle of the Five Elements (known as the Wu Hsing in Chinese), which describes the flow of Qi and the balance of yin and yang.

According to the principle, all change – in the universe and in your body – occurs in five distinct stages. Each of these stages is associated with a particular time of year, a specific element in nature, and a pair of organs in the body. Spring is represented by the wood element and includes the liver and its complementary organ, the gallbladder. These two organs are usually the primary targets for springtime cleansing and health regimens. To cleanse your liver, add some sour foods like vinegar and lemon into your dishes.
Also think about pungent flavors. Sprucing up your meals with mint, spring onions, ginger, horseradish, mustard, and pepper will leave you feeling clear and invigorated.
Finally, fending off the cool spring winds with gently warming herbs like fennel, oregano, rosemary, caraway, dill, and bay leaves will keep you thriving until the summer heat hits full-force.

We Can Help

If you want to turbocharge your efforts to improve your health, then schedule an appointment with us by submitting an online appointment request or calling us at 912-897-6832. We’ll spend time with you to develop a plan that will improve your overall health. This might include a medical weight loss program, anti-aging program, and healthy lifestyle management initiative.