NZ Herald - Plus Feature May 2023

A New Zealand Herald Commercial Publication | Friday 26 May, 2023

FUTURE PROOF YOUR HEALTH Covid update | Health insurance Early signs of dementia | Ageing with confidence

Artists impression

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inside Future proof your health

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Probiotic breakthrough

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Ageing with confidence

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Covid-19 update

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Spotting early signs of dementia

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Health insurance

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Writer Diana Clement | Designer Courtney Wenzlick | Commercial Revenue Manager Kelly Spice Head of Commercial Publishing & Innovation Margaret Hawker Advertising Enquiries E: Kelly.Spice@nzme.co.nz M: 021 605 297

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Six steps to take now to future proof your health It’s never too late to start future proofing your health.

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eople who stay healthy often live longer and more fulfilling lives. With good health and fitness you can be better equipped to handle health challenges that come your way.

Action is always better than inaction in life. Here are six tips to prioritise your health: 1. Prioritise your mental health Mental health is just as important as physical health. Looking after your mental health is essential for overall well-being. Taking time to relax and recharge for your mental health should be a regular part of your routine. This can include activities such as reading, taking a bath, spending time in nature, practising yoga, meditation and mindfulness. Your mental health can benefit from connecting with others, exercising regularly and making sure you prioritise sleep. It’s important to maintain a healthy work-life balance.

Seek support when needed from trusted

friends or whānau, or from a mental health professional or support group.

Get started today: set a time for each day to do 15 minutes of meditation, yoga or other stress reducing activity. The Mental Health Foundation’s wellbeing portal has more advice: Mentalhealth.org.nz/five-ways-towellbeing 2. Eat better Our bodies should be shrines. What goes in matters. A healthy diet can help prevent chronic illnesses, such as diabetes and heart disease, and can also help maintain a healthy weight. Aim to eat a variety of whole foods, including fruits, vegetables, whole grains, lean proteins, and healthy fats, to get the nutrients your body needs.

• Eat fresh: It’s easy to eat fresh in New Zealand thanks to the wide variety of food grown here. Look for fresh, in season produce. Check out local farmers markets,

which are a good way to find fresh food at economical prices.

• Avoid highly processed foods: If you need to read the ingredients to know what’s in the food you’re eating, then it’s processed.

Processed foods, such as packaged snacks and fast food, tend to be high in salt, sugar, and unhealthy fats. Try to limit your intake of these types of foods and instead choose fresh, whole, food, cooked from scratch.

• Watch your portion sizes: eating too much can lead to weight gain that causes other health problems as people age. The aim is to eat until you’re satisfied, rather than stuffed.

• Cook at home: Cooking at home allows you to control the ingredients and portion sizes of your meals. A home-made curry, for example, will have less fat, and sugar than a takeaway. If you don’t know where to start, visit the lovefoodhatewaste.co.nz website, which is a great resource for people who don’t know how to cook.

• Be mindful of your snacking: Snacking can be bad for your health if it adds to your consumption of calories, salt, sugar, and processed food. If you can’t train yourself out of eating between meals, then look for snacks that are low in sugar and unhealthy

fats, such as fresh fruit, raw vegetables, or nuts and seeds. A raw carrot or apple can fill a hole without being unhealthy.

• Stay hydrated: Drinking enough water is important for overall health and wellbeing. Try to carry a bottle of water with you and sip from it regularly. Always drink a glass of water with meals.

Get started today: sit down and plan next week’s meals.

3. Exercise regularly You don’t have to run the Rotorua Marathon to stay fit. Plan to do regular moderate exercise such as walking, biking, or swimming. Try out different exercises until you find one or two that you enjoy. It can help once you find an activity you enjoy to team up with a partner or friends. It’s social and motivating to work out with others.

The Ministry of Health Manatū Hauora recommends that older adults do 30 minutes of moderate physical activity on five or more days a week. The Ministry suggests adding three sessions of flexibility and balance activities, and two sessions of musclestrengthening activities in your weekly workout schedule.

If you don’t like exercise, try to find ways

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Gardening is exercise. So too is dancing.

Other ways to add incidental exercise to your day include riding a bicycle to work, taking the stairs, walking while listening to audiobooks or podcasts, and standing up during meetings or while on the phone.

The Ministry recommends setting goals, tracking your progress, being active with others, trying a range of activities, making exercise part of your normal routine, and ‘snacking’ on activities by having short periods of activity. Make swaps such as coffee breaks for walking breaks.

lifestyle and risk factors, the better your chances of remaining healthy. As well as adding healthy lifestyle habits, look at reducing risk factors such as excessive drinking, or high stress activities in your life.

This can help avert developing many chronic diseases. Stay alert to new health risks, and keep abreast of research.

Get started today: write a personal wellness plan

Get started today: book an appointment with your doctor or other medical professional for a well woman or a well man checkup.

6. Embrace technology Technology can be a powerful tool for maintaining good health. A wide variety of free and paid for technology is available to help with diet, exercise, and sleep.

What’s more, hardware such as simple fitness trackers and smartwatches can be affordable. There is quite literally an app for everything. Some of the most popular apps that help people stay healthy include: • Headspace: reduce stress and anxiety, improve sleep, and increase focus with this meditation app.

• Strava: track your walks, runs, and rides, and compete with others. Strava is a great way to build a community around your exercise routine.

• WaterMinder: track your daily water intake and get reminders to stay hydrated throughout the day.

• Fooducate: make healthier food choices with information about the nutritional content of different foods.

• Couch to 5K: get off the couch and build up to running five kilometres.

• Yoga Studio: take part in video yoga classes and create personalised routines.

• MyFitnessPal: track your calorie intake and weight loss goals.

5. Build awareness The more self-aware you are of your own

Get started today: choose and download a new app to try out.

Get started today: if you don’t already exercise, choose an activity to try this coming weekend, and set a time to get started and stick to it.

4. Stay up to date with preventive care Prevention is better medicine than cure.

Preventive care is essential for identifying and treating health issues early on. This can include regular check-ups with your primary care provider, screenings for various health conditions, such as cancer and heart disease, and keeping your vaccinations up to date.

Annual flu and the latest Covid vaccinations are important. It’s also a good idea for people aged 50+ to get vaccinated against shingles. A variety of free health screening programmes are available. New Zealand’s National Screening Unit provides screening for bowel, breast and cervical cancer. Organisations such as Melanoma New Zealand and Diabetes New Zealand offer free screening in many communities.

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Probiotic breakthrough:

Now available in New Zealand

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Revolutionary next-gen targeted probiotics have become available in New Zealand for the very first time.

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ulti beneficial bacteria strain Akkermansia muciniphila accounts for up to 4% of people’s intestinal bacteria, but has not been available commercially until now.

Previously, the probiotic strain which helps support the mucus lining of the gut was only available by faecal transfer, says Kevin Glucina of Matakana Health, which distributes Akkermansia exclusively in New Zealand and Australia, via the Pendulumlife.co.nz website.

“Since 2004 when it was first discovered there have been thousands of studies on the benefits of having Akkermansia and the risk of not having it,“ says Kevin Glucina, of Matakana Health. Those benefits can include supporting a healthy gut lining, and GLP-1, a hormone produced by the gut, which helps create a healthy balance between insulin and glucose levels.

Commercial production wasn’t possible in the early days following the discovery, because the bacteria lived inside the lower gut wall, where there is no oxygen. It was nearly impossible to grow in a lab setting as a result, says Glucina. That all changed with groundbreaking research by US company Pendulum that led to the commercialisation of three products, Metabolic Daily, Akkermansia and Butyricum.

“With the backing of the Mayo Clinic, Pendulum developed technology to produce Akkermansia in an anaerobic lab,” says

Glucina. That was a big deal. It’s the first new probiotic genus to come on the market in 50 years. “Most of the other probiotics are just slightly different strains of what has already been there for years,” he says.

Similar to how Smartphones have changed how we communicate, Akkermansia has changed how we approach gut health. “This is a game changer,” says Glucina. “The pent up demand is incredible. You can’t get these products anywhere else in the world apart from America and New Zealand.

“Customers have been wanting Akkermansia for years, and no one has been able to give them live strains. We’re sending shipments every day all over the world, and to doctors and healthcare practitioners across New Zealand and Australia.”

Matakana Health, which was one of the very first superfoods companies in the world, sells all three Pendulum products. Metabolic Daily contains exclusive probiotic strains: Akkermansia muciniphila, Anaerobutyricum hallii, and Clostridium beijerinckii, as well as other strains. Customers who need more concentrated doses, can order Akkermansia or Butyricum probiotics on their own in capsule format.

Matakana Health, also offers a range of its own brands as well as supplement brand Tru Niagen, Keto Naturals, Love Organics other leading brands, via its website Matakanasuperfoods.com

Pendulum’s next-generation probiotics have been developed through years of rigorous research at some of the top scientific institutes around the globe.

They contain unique health-supporting strains not available anywhere else on the market.

METABOLIC DAILY SUPPORTS

BUTYRICUM SUPPORTS

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GLP1 levels (hormone which signals normal feelings of fullness) Healthy mucin levels Gut barrier integrity

Available exclusively online at www.pendulumlife.co.nz | info@pendulumlife.co.nz Always read the label and use as directed. If symptoms persist, see your healthcare professional. Dietary Supplements are not a replacement for a balanced diet. Matakana Health, Auckland. TAPS MR9209

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Ageing with confidence Photo/GettyImages

Don’t let little wee worries put you off your game

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rowing old is great. It comes with plenty of benefits, such as more time, fewer responsibilities, and just feeling more comfortable in your own skin. But there are also some niggly little health issues that can bug people as they age. Things like a little hearing loss, cataracts and joint pain.

Bladder leakage in particular is a very common problem, affecting one in three women in New Zealand and one in five men. Yet the taboos around talking about and seeking help for bladder leakage often stop active people living life to the full.

Men and women who are prone to bladder leakage sometimes avoid social outings, because simply sneezing or laughing can be a trigger. Avoiding holidays isn’t uncommon either. People with bladder leaks may stay

home, simply because they don’t want to dispose of single-use pads in their host’s rubbish bin.

The good news is that Kiwi company Confitex has come up with a solution that’s both environmentally friendly and practical.

The company’s products, Confitex for Men male trunks and Just’nCase by Confitex female briefs, are high-performance leakproof underwear that use patented textile technology to solve an age-old problem.

They come in a variety of sizes, styles, absorbencies and colours, all with a panel of absorbent and leakproof textile technology right where it’s needed. What’s more, they’re stylish, comfortable and discreet, says Confitex founder and design director Frantisek RihaScott.

“Our underwear feels and looks just like everyday trunks and briefs, and can be machine washed and tumble dried just like the rest of your laundry ,” says Riha-Scott.

“It’s ordinary underwear with extraordinary protection.”

Confitex’s products are quite simply a revolution for thousands of New Zealanders

affected by bladder leakage. Making the change to wear, wash and reuse pee-proof products has many benefits in social and practical terms. Confitex underwear helps save money in the long run, and is lighter on the planet and ethically manufactured as well.

The Confitex story is a real New Zealand number 8 wire success. It started back in 2013 on the pure alpine ski slopes of the Southern Alps, when Riha-Scott and a fellow young endurance ski racer came up with the ingenious idea of creating high-performance absorbent sports underwear to give them a competitive edge. It meant they didn’t have to stop for toilet breaks during downhill races.

But soon Riha-Scott saw a much larger market for leakproof underwear. His research found that people with light bladder leakage had little choice but to use ugly, uncomfortable single-use pads, liners and shields.

“The incontinence undies that were on the market had such horrendous designs and didn’t provide reliable leakproof protection,” says Riha-Scott. “I thought I could help.”

Drawing on his textile design training and extensive research into microscopic textile

technology, Riha-Scott created an innovative multi-layered textile technology system that wicks moisture away from the skin quickly, absorbing liquid and retaining it without leaking, even under bodyweight pressure. It has since been granted multiple international patents.

He incorporated this multi-layer textile into comfortable fabric underwear for men and women.

In 2015 Confitex launched its underwear at New Zealand Fashion Week, tackling the taboos around bladder leakage head-on and making international headlines as the world’s first fashionable range of washable incontinence underwear.

Since then, the rise of period pants has normalised the idea of reusable absorbent underwear, but Confitex briefs and trunks remain at the forefront of innovation.

Confitex for Men and Just’nCase underwear are available only from confitex.co.nz, with discreet delivery to your door.

FOR LIFE ON THE GO If you or someone you love leaks a little, you can feel confident in Confitex.

Confitex for Men trunks and Just’nCase women’s briefs look, feel, wash and dry just like ordinary fabric underwear, but with built-in leakproof protection right where you need it for peace of mind.

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The luxury retirement village with a heart of gold If you’ve heard that Tamahere Country Club is widely regarded as NZ’s finest retirement village you’ll be forgiven for thinking it may be quite an ‘exclusive’ place to live.

Ask any resident, however, and they’ll most likely tell you what they love most about life here is the community, and they’re far more likely to use the word ‘inclusive’ than ‘exclusive’.

Yes, there’s facilities and beautiful architecture to delight the senses, but the true beauty of life here runs deeper than bricks and mortar.

It’s the youthful energy of the community and the connections that create a life-enriching value that can’t be measured in dollars and cents.

If you’re aspiring to a retirement address that feeds the soul we invite you to be our guest for a guided tour of Tamahere Country Club.

We have a range of homes available for immediate occupation.

Call Sandy on 021 628 385 to secure your home.

Visit our Showhome at 46 Tamahere Drive, Tamahere, Hamilton Monday – Friday, 10am – 2pm (excluding public holidays) tamaherecountryclub.co.nz

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Should we still be worried about Covid-19?

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ovid-19 is a thing of the past in most New Zealanders’ minds. Despite the mental shift, the reality is that Covid-19 still killing people and blighting lives and livelihoods. Around 1,000 deaths are expected this year, despite the World Health Organisation officially declaring Covid-19 over as a global health emergency.

In the week to May 14, 12,277 new cases of Covid-19 were reported, although wastewater analysis suggests many cases are not being reported. In the seven days to May 14 the rolling average of people hospitalised with Covid-19 was 249, with 12 in ICU. The number of deaths attributed to Covid was 30. In the words of Otago University epidemiologist Michael Baker, the country is experiencing its fourth wave of Covid-19.

Baker said in late April that the wave was being driven by the XBB 1.5 subvariant of Covid-19, and might also reflect other factors such as waning immunity.

“Extrapolating from hospitalisations and deaths in the last 12 weeks [prior to April 23]

would imply 12,000 Covid-19 hospitalisations this year and around 1,000 deaths,” Baker said. The data for the analysis was sourced from the Ministry of Health and Institute for Environmental Science and Research.

The public often assumes that only older New Zealanders are dying, with the subtext that older people’s lives are not as valuable as those of younger people. Of the last 50 deaths before the May 14 cut-off, one person was aged less than 10 years old, two were in their 20s, one in the 30s, one was in the 50 s, three in their 60s, 13 in their 70s, 18 in their 80s and 11 were aged over 90.

In total 2792 people in New Zealand have died with Covid as an underlying cause of death, or Covid as contributory. That doesn’t include people who had Covid and died, but Covid wasn’t the cause of death, according to Ministry of Health data.

The government is currently rolling a free Pfizer bivalent vaccine to all New Zealanders aged 30 and over and anyone at higher risk of severe illness, providing it has been at least

six months since their last booster or positive Covid test. The aim is to help people stay well over the winter.

A bivalent vaccine is one that helps prevent two strains of a virus. The current Pfizer vaccine targets the Omicron BA.4 and BA.5 strains. The original Covid vaccines were monovalent.

It’s not just people’s health that suffers from Covid-19. Some businesses have really suffered as a result of Covid. That’s not just from a lack of custom. Some struggle to find staff or afford rising wages and salaries.

Radio New Zealand reported that food courts, for example, were really struggling to recover after the pandemic. At the time of writing, only one stall was still open at the once thriving Rialto Mall food court in Auckland’s trendy New Market. Nerperit Singh owns Aroma Indian Cuisine, said much of the downturn was thanks to local office workers, who were most of the clients, working from home.

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Dementia – spotting early signs As we age it’s common to worry about dementia. The odd bit of forgetfulness doesn’t indicate you have dementia, or mate wareware as it’s called in Te Reo Māori.

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t’s normal to forget meetings, names or telephone numbers occasionally, just to remember them later, says Alzheimers New Zealand principal clinical advisor, Lyneta Russell. Making a wrong turn while driving is also normal.

On the other hand, failing to remember recent events or having regular difficulty driving a familiar route, could be a sign of concern.

Dementia is a term used to describe a group of symptoms that affect cognitive function and memory, which gradually get worse. Over time it’s likely that all the functions of the brain are affected.

There are several types of dementia,

including Alzheimer’s disease, vascular dementia, Lewy body dementia, and frontotemporal dementia. The early signs of dementia can vary depending on the type and the individual.

However, some common early signs include: • Memory loss: forgetting recent events or conversations, misplacing items, or relying heavily on memory aids such as notes or reminders.

• Difficulty with daily tasks: struggling to complete tasks that were previously easy, such as cooking, cleaning, or dressing oneself.

• Language problems: difficulty finding the

right words, following a conversation, or writing a coherent sentence.

• Confusion and disorientation: feeling lost in familiar places or struggling to navigate simple directions.

• Changes in mood or behaviour: becoming easily frustrated, anxious, depressed, or withdrawn, or displaying uncharacteristic behaviours such as wandering or aggression.

More warning signs can be found at: Alzheimers.org.nz/about-dementia/10warning-signs If you experience any of the warning signs you should see your doctor or health care provider for a medical assessment, says Russell. The assessment will indicate whether you have a treatable disease, or it might indicate that you do, in fact, have a form of dementia.

“At this stage you might be referred for further tests or assessments,” she says.“It’s really important to get a diagnosis if it is dementia as the benefits include knowing what is going on, the opportunity to find out more about the type of dementia you have,

access to services and support for you and your family and the ability to plan for your future.” Getting an early diagnosis allows you to access treatment, advice and support.

Russell says everyone can take steps to keep their brains healthy and reduce the risk of getting dementia. “As we get older, our risk of developing dementia mate wareware increases. However, evidence shows there are things you can do to help reduce this risk.

These include keeping active, eating healthily and staying mentally alert and social,” says Russell. “Reach out to your local Alzheimers or dementia organisation if yourself or somebody you know needs more support.”

As well as Alzheimers New Zealand a number of organisations can help. That includes the New Zealand Dementia Foundation [NZdementia.org] and Dementia New Zealand [Dementia.nz].

There are also support groups for whānau and carers of people with dementia. A list of local groups can be found by calling 0800 004 001, or visiting Alzheimers.org.nz/getsupport/find-local-help.

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Regular eye checks can prevent vision loss E

ye health can be maintained by a well-balanced diet and regular eye checks can detect age related vision loss earlier.

Eye Institute’s Dr Narme Deva, an expert in cataract surgery and retinal disease, said it is important to get regular eye checks at an optometrist or eye specialist to ensure any eye conditions are caught early on.

Many conditions, especially those that are age-related, don’t have any symptoms until they have progressed.

People often check their eyes when they are five-years-old and then often not again until their 40s unless they have blurry vision, Dr Deva said.

It is important to have an eye check at least once in your 20s and 30s, or more frequently if there is a family history of eye problems.

“Most people develop symptoms of difficulty focusing on nearby objects in their 40s (presbyopia).

“This is part of the normal aging process but from your 40s you should get your eyes checked every five years or so.”

This should become yearly from the time people reach 60 to 65.

The reason for these checks is to help optometrists and eye specialists find conditions before they become symptomatic.

Dr Will Cunningham

There are also things people can do at home to maintain good eye health.

“All the stuff your parents would have told you growing up – a good healthy balanced diet rich in green leafy vegetables, Omega 3 fatty acids.”

Definitely do not smoke as it increases the risk of developing eye problems, Dr Deva said.

UV rays can start affecting people’s eyes from quite a young age so sunglasses, wide brimmed hats and safety eyewear are important.

“Try to protect your eyes.”

One condition that is not always age-related is diabetic eye disease and it can cause significant eye problems.

“The biggest risk factor is the duration of your diabetes which you can’t control as once you’ve got it you’ve got it, but how well you control you sugar levels can help a lot.”

Uncontrolled high blood pressure can also affect eyesight.

COMMON AGE-RELATED EYE CONDITIONS: Cataracts The lens inside your eye is important for focusing but it can become cloudy as you age. It’s like looking through a frosted window.

Surgery is the only treatment. It is a

Prof. Helen Danesh-Meyer

Dr Nick Mantell

Dr Shanu Subbiah

Dr Sophie Hill

successful small procedure to remove the natural lens and replace it with an artificial lens that lasts for your whole life. Cataracts are completely treatable with surgery.

Glaucoma Glaucoma refers to a group of conditions relating to damage to the nerve at the back of the eye. It is often linked to eye pressure problems and can lead to vision loss.

This is irreversible but if it is picked up early enough, the vision loss can be preventable. That’s why regular eye checks are important.

Age-related macular degeneration Macular degeneration affects your central vision. There’s evidence that lutein and zeaxanthin (green leafy vegetables) give protection for the macula which is the area affected by macula degeneration There are two types, wet and dry and they can coexist.

Dry is the most common and a certain combination of vitamins (AREDS) can slow the progress. These are available over the counter.

Wet can be controlled by a series of medications (anti-VEGF drugs) into the back of the eye.

Dr Narme Deva

Dr Adam Watson

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Dr Divya Perumal

Dr Graham Reeves

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Dr Baswati Sahoo

Our talented specialists and advanced technologies make the incredible gift of improved eyesight an everyday reality.

Eye Institute’s Dr Narme Deva is an expert in cataract surgery and retinal disease. Photo/Supplied

Dr Peter Ring

Dr Jay Meyer

Dr Shira Sheen

Dr Peter Hadden

Dr Verona Botha

Prof. Charles McGhee

Dr Kevin Dunne

Eye Institute is conveniently located throughout Auckland (Remuera, Northcote, Manukau and New Lynn), in Hawke’s Bay and Wellington

SPECIALISTS IN: Cataract, Cornea, Dry Eye, Laser Vision Correction, Glaucoma, Neuro-Ophthalmology, Oculoplastics, Oncology, Retina, Uveitis

0800 99 20 20 www.eyeinstitute.co.nz Eye Institute is an Affiliated Provider to Southern Cross Health Insurance and a Health Partner for nib

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Getting the right healthcare when you need it Buying private health insurance is a great way to ensure you get healthcare when you need it.

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ew Zealand’s public health system is very good by world standards.

Never-the-less healthcare is rationed and there are times when being able to skip the public hospital queues can mean the difference between life and death. Private health insurance can help with that.

People without private health insurance sometimes struggle to get the treatment they want. General practitioners [GPs] sometimes won’t refer patients to a specialist. Once referred the public hospital can still reject the referral. If the hospital accepts the referral, patients are then rated on a clinical access priority score. The higher the score, the more quickly a patient is seen.

Private health insurance allows people to avoid running the gauntlet of the public system and enables them to get assessments

and treatment in a timely manner.

Health insurers and their various policies differ. But generally, they cover you for nonurgent medical treatment. That might include doctors’ visits, specialist appointments and operations, depending on the policy chosen.

Acute treatment such as a car accident or heart attack will still be treated in a public hospital. Health insurance policyholders might choose to do their follow up treatment privately rather than wait for the public system.

Health insurance isn’t cheap. But it offers peace of mind. According to the Financial Services Council, which represents health insurance providers, around 32% of New Zealanders have health insurance. That means nearly seven in 10 Kiwis don’t, which leaves most reliant on the public system

unless they have savings and can afford to pay for private medical care.

Everyone has their own story about private health insurance. When it comes to the “do I buy it” question, the three big ticks in the yes column are: 1. get diagnosed quickly.

2. be treated in a timely manner.

3. have access to expensive drugs prescribed by your specialist, but not available free through the public system.

The “no” column is usually cost. Many people can’t afford it, although some choose not to buy private health insurance for ethical reasons.

As well as skipping waiting queues, some private health insurance policies also come with annual health checks and other benefits.

Southern Cross Health NZ, for example, offers free out of hours online GP assessments, and up to three mental health counselling sessions per policy per year. With some of its policies, AIA New Zealand offers a mental health support benefit, a parent grieving benefit, and an obstetric care allowance.

Policies such as NIB’s non-PHARMAC Plus, cover life saving drugs not available for free on the public health service.

Health insurance does cost more as people age. Nick Astwick, chief executive Southern Cross Health Insurance, acknowledges that premium levels increase as people get older.

They’re priced to reflect the higher level of claiming among older health insurance users, he says.

“Last year, the average amount claimed by members over 65 years was more than three times the average for members aged 35 to 49 years.”

If people are struggling to afford their premiums, Astwick recommends they contact their insurer to explore options such as switching to a different plan or adding an excess to lower premium payments.

“We actively talk to our 50+ members to check they’re on the right plan for their circumstances. One in five people we contacted last year changed their plan or increased their excess to lower their premiums.”

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