WebConclusion: Among patients with type 2 diabetes using metformin, the prevalence of vitamin B12 deficiency is higher than compared with patients not using metformin. https://www.uptodate.com/contents/search. We use cookies to improve your website experience. Food sources of vitamin B-12 include poultry, meat, fish and dairy products. According to a study, almost 22% of people with diabetes were low in B-12, suggesting that metformin is the reason. World J Clin Cases. This cross-sectional study was conducted at the diabetic clinics at four selected MoH hospitals in Riyadh, Saudi Arabia (King Salman Hospital, King Saud Medical City, Imam Abdulrahman Alfaisal Hospital and Prince Mohammad bin Abdulaziz Hospital) between August and November 2018. ated type 2 diabetes mellitus patients. An official website of the United States government. Moreover, neuropathy is not only because of prolonged diabetic conditions. Leung S, Mattman A, Snyder F, Kassam R, Meneilly G, Nexo E. Metformin induces reductions in plasma cobalamin and haptocorrin bound cobalamin levels in elderly diabetic patients Clin Biochem. The .gov means its official. In diabetes, blood glucose level goes low beyond a certain limit. Not feeling as hungry as usual. -. Accessed Jan. 9, 2021. Your body absorbs only as much as it needs, and any excess passes through your urine. In peripheral neuropathy, you will experience weakness, pain, and numbness in your hands, legs, and feet. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). The high consumption of meat among the Botswana population may explain the lower prevalence of vitamin B12 in our population than in other African settings. Clinical Implications of the Coexistence of Anemia and Diabetes Mellitus in the Elderly Population. Diabetes: Fact sheet [Internet]. Please refer to the 'Licensing' tab on the article menu bar for information on the reuse conditions associated with this license type. Other disorders that interfere with the absorption and metabolism of vitamin B12 can also result in cobalamin deficiency, with the development of a macrocytic anemia and neurologic complications. 2010;340:c2181, 14. the unsubscribe link in the e-mail. information submitted for this request. The deficiency was significantly common with increased age, long duration of metformin use, and acid blockers. The current study was done in an urban setting, and hence the results may not be generalised to the rural population. Cochrane Database Syst Rev. Snchez H, Masferrer D, Lera L, Arancibia E, Angel B, Albala C. Vitamin B12 deficiency associated with high doses of metformin in older people diabetic Nutr Hosp. Diabetic patients should choose a diet that contains B12, else they will face a severe deficiency of this vitamin. The calculated sample size was 363. Standards of medical care in diabetes Diabetes Care. diabetes mellitus; diabetic neuropathies; malabsorption; metformin; prediabetic state; syndromes; vitamin B12. The mean age of these 16 patients was 53.8 14.26 (range of 3584 years old). -, Aroda VR, Edelstein SL, Goldberg RB, Knowler WC, Marcovina SM, Orchard TJ, Bray GA, Schade DS, Temprosa MG, White NH, et al. CAN occurs when nerve damage affects the heart, which can be caused by prolonged hyperglycemia over several years in people with diabetes. Please try after some time. Vitamin B12, being a water-soluble vitamin, is also known as cobalamin. eCollection 2021. 2. Of 363 T2DM patients, 206 (56.7%) were males and 157 (43.3%) were females, mean age was 53.72 11.31 years, the mean duration of T2DM was 9.89 7.32 years, and the mean duration of metformin use was 9.84 7.29 years. 2022;74(7):2373-2383. doi: 10.1080/01635581.2021.2007271. Never take a supplement or injection at your own decision. Therefore, we focused on the other objectives of the study. In diabetes, blood glucose level goes low Metformin therapy and assessment for vitamin B12 deficiency: is it necessary? A total of 363 T2DM patients who were on metformin were included in the study. There are some limitations of this current study. The average B12 level in the blood was 223pg/ml. Because there is a possibility that taking vitamin B12 pills will not be the right choice for you. Some people suffer from serious symptoms such as shortness of breath, dizziness, fatigue, and a fast heartbeat. When it comes to increasing the level of vitamins for diabetes, people usually take supplements. Representative samples from each hospital were calculated based on the percentage population 177/100 for males and percentage population 157/100 for females. doi: 10.7759/cureus.28194. [31], Despite our study was not able to establish the relationship between vitamin B12 level and duration of T2DM and duration of metformin use, we were able to highlight some considerable facts including the use of PPI among T2DM patients. Higher doses of metformin and male sex were factors related to lower levels of vitamin B12. 2012;122:25370, 5. Estimation of Serum Vitamin B12 Levels Among the Elderly Population of Wardha City: A Cross-Sectional Study. 34 The prevalence of anemia and mean corpuscular volume did not differ between T2DM-met patients with and without B12 deficiency (23.1% versus 31.3% and 89.4 fl versus 89.0 fl, respectively). A P value of < 0.05 was considered statistically significant. Mayo Clinic on Incontinence - Mayo Clinic Press, NEW The Essential Diabetes Book - Mayo Clinic Press, NEW Ending the Opioid Crisis - Mayo Clinic Press, FREE Mayo Clinic Diet Assessment - Mayo Clinic Press, Mayo Clinic Health Letter - FREE book - Mayo Clinic Press. Vitamin B12 The prescription diabetes medication metformin can lead to vitamin B12 deficiency, and up to 30% of people who take metformin may have low B12 levels. Vitamin B12 is an essential micronutrient required for optimal hemopoetic, neuro-cognitive and cardiovascular function. The use of vitamin B12 supplement was significantly higher among females (p < 0.001). Bookshelf Clin Diabetes. 2012;35:32733, 9. Table 2: Factors associated with Vitamin B12 deficiency among patients with diabetes at Princess Marina Hospital diabetes clinic, between July 2017 and October 2017. 2016 Mar;39(3):305-14. doi: 10.1007/s40618-015-0365-9. According to research studies, nearly 30 percent of diabetic patients suffer less vitamin B12 absorption in their intestines. Among those who took metformin for at least 1 year, 9 had vitamin B12 level < 240 pg/ml (56.2%); 23 diabetic patients did not get metformin and only 4 had vitamin B12 level < 240 pg/ml (17.4%) (P = 0.014). Warning: Consult your Doctor first before treating vitamin B12 deficiency either way. 2017;354:16571, 19. Vitamin B12 deficiency in metformin-treated type-2 diabetes patients, prevalence and association with peripheral neuropathy. Accessed Jan. 9, 2021. The duration of metformin use is dependent on the patients history and thus subject to recall bias. Find out what works best for you with this 60-sec expert-approved quiz and get your Klinio app. Vitamin B12 deficiency is a common condition that can manifest with neurological, psychiatric, and haematological disorders. Accessed Jan. 9, 2021. eCollection 2022 Aug. Farland MZ, McPheeters CM, Renwick RC, Barlow PB, Williams JD, Keeble DS, Franks AS. There was no vitamin B12 deficiency in 53 (45.4%) of the patients. Many such vitamin B12 rich foods can be obtained from animal and non-animal sources. Albai O, Timar B, Paun DL, Sima A, Roman D, Timar R. Diabetes Metab Syndr Obes. Min HK, Kim SH, Choi JH, Choi K, Kim HR, Lee SH. In anemic conditions, the body automatically produces antibodies against the vitamin B12 carrier, i.e., Intrinsic Factor (IF). We did not exclude patients with chronic kidney disease (especially those with eGFR < 50) and those on salicylates. We also inquired about the use of metformin, antacids, oral contraceptives and calcium supplements. This cross-sectional study was undertaken on 351 patients with diabetes at a specialised public diabetes clinic in Gaborone between July 2017 and October 2017. These symptoms are pain and numbness in the arms, legs, hands, and feet. This issue maybe debatable to some, but we think that there is a need for physicians to keep abreast with the latest recommendations and guidelines pertaining to management of diabetes. We conducted a cross-sectional study at the diabetic clinics of four hospitals in Riyadh, Saudi Arabia. Objective: Even though vitamin B-12 is safe if you take too much, it can interact negatively with certain medications. Chloramphenicol, a type of antibiotic, affects how your body responds to B-12. Even though you're taking a large dose of B-12, the medication limits the vitamin's function. Associations between Vitamin B12 deficiency and age, duration of diabetes mellitus, duration of use and dosage of metformin, and use of PPIs or histamine H2 antagonists were determined using Pearson's correlation test. People also read lists articles that other readers of this article have read. The first possible treatment option is to look at your diet. Several studies have unequivocally demonstrated that vitamin B12 deficiency is highly prevalent in adult diabetic patients [24]. Recommended articles lists articles that we recommend and is powered by our AI driven recommendation engine. Regulate your bodys diabetes level by regulating the amount of vitamin B12. The study does not explore the relationship between various factors and vitamin B12 deficiency, including dietary details, a vegan diet, alcohol history, use of multivitamins etc. Certain drugs may lead to BMC Pharmacol Toxicol. Loss of balance. eCollection 2020. The mean duration of metformin use was 9.84 7.29 years (range: 1.035 years). Subsequently, every fifth patient in the clinic attendees was selected until the days desired sample size was reached. You may also suffer from diabetic neuropathy due to a lack of vitamin B12. There are a few different options as far as how you can treat your vitamin b12 deficiency if you are diabetic. WebFrequent doses of metformin can result in vitamin b12 deficiency. These can include dementia, disorientation, neurological damage, gait disturbance and anemia. Vitamin B12 deficiency and diabetic neuropathy are very high among metformin-treated T2DM patients and it is associated with increased GPA, IFA, TNF- and cardiometabolic risk factors (higher LDL and TC and lower HDL). Epub 2021 Nov 24. In this study, we aimed to evaluate the prevalence of vitamin B12 deficiency in patients with chronic metformin use and the relationship between vitamin B12 deficiency and diabetic neuropathy. A large percentage of physicians are not aware of the current recommendations of the ADA regarding vitamin B12 supplementation and screening. 2019 May 23;7:2050312119853433. doi: 10.1177/2050312119853433. The questionnaire contained questions on their demographic profile, knowledge and practice of screening of Vitamin B12 level. WebConclusion: The prevalence of vitamin B12 deficiency is considerable among diabetic patients on metformin therapy. The use of acid blockers was also associated with vitamin B12 deficiency (p=0.012). Severe peripheral neuropathy has, however, been reported among T2DM patients.Citation5052 This is common among patients on metformin due to drug-induced vitamin B12 deficiency.Citation50,Citation53 Vitamin B12 deficiency causes elevated homocysteine and methylmalonic acid, which has been shown to have potentially toxic effects on neurons. To estimate the prevalence of Vitamin B12 deficiency among patients with diabetes. 3- Medications of peptic ulcer and acid reflux disorder including Omeprazole (Prilosec), Famotidine (Pepcid AC), Ranitidine (Zantaz), and Lansoprazole (Prevacid). Lastly, genetic and environmental differences could be the other factors that explain the variation in the prevalence of vitamin B12 deficiency in different settings.Citation26 Several single-nucleotide polymorphisms (SNPs) in multiple genes interact with environmental factors to cause vitamin B12 deficiency.Citation27, Consistent with previous studies, metformin use was associated with vitamin B12 deficiency in our patients.Citation19 In the present study, vitamin B12 deficient patients had a longer duration of metformin use, as reported in other studies.Citation19,Citation28 Levels of serum B12 are inversely associated with the dose and duration of metformin use.Citation5,Citation10,Citation2831 Reports have shown a decrease in vitamin B12 levels as early as four months after initiation of metformin.Citation10,Citation31 The exact mechanism of this association is unknown but is ascribed to the binding of the hydrophobic tail of biguanide to the hydrocarbon core of membranes. We defined vitamin B12 deficiency as serum B12 levels < 150pmol/l.Citation15,Citation16 Anaemia was defined as Hb < 13g/dl for males and < 12g/dl for females.Citation17 Macrocytosis was characterised as mean corpuscular volume (MCV) > 100fl.19.Citation18. You dont have to take Vitamins supplements if you are facing a minor B12 deficiency. 5 Howick Place | London | SW1P 1WG. When vitamin B12 does not reach the small intestine, it will not be absorbed properly, causing vitamin B12 deficiency. For metformin, the daily dose of metformin and duration of metformin use was recorded We calculated the body mass index (BMI) as weight in kilograms (kg) divided by height in metres squared, and categorised participants with a BMI 25kg/m2 and 30kg/m2 as overweight and obese, respectively.Citation13 Peripheral neuropathy was defined by a score > 6 in the Neuropathy Total Symptom Score-6 (NTSS-6) questionnaire.Citation14 We assessed serum B12 levels, haemoglobin (Hb), mean corpuscular volume (MCV) and glycated haemoglobin (HbA1c) in all participants. Nathan DM, Buse JB, Davidson MB, Ferrannini E, Holman RR, Sherwin R, et alAmerican Diabetes Association; European Association for Study of Diabetes. Mayo Clinic offers appointments in Arizona, Florida and Minnesota and at Mayo Clinic Health System locations. Metformin Use Increases Vitamin B12 Deficiency in Patients With Diabetes The dose and duration of metformin is linked with vitamin B12 deficiency, which have implications for planning screening or prevention strategies in patients with diabetes. Among those who took metformin for at least 1 year, 9 had vitamin B12 level < 240 pg/ml If we combine this information with your protected Epub 2022 May 20. Metformin is the base of medicine in the treatment of type 2 diabetes mellitus (T2DM) with estimates that it is frequently approved and recommended to 120 million patients with diabetes globally. However, you can prevent the B-12 deficiency by taking a proper diet and supplements. No potential conflict of interest was reported by the author(s). Compared with participants with normal Vitamin B12 levels, deficient participants were significantly older (64 vs. 56 years, p=0.014) and had a longer duration of metformin use (7 vs. 4 years, p=0.024). Here are some main sources from which you can improve your diabetic condition: Animal source vitamin B12 rich foods are eggs, fish, poultry, meat (including lamb, pork, and beef), and dairy products (including cheese and milk), Non-animal sources of vitamin B12 are vegetables and plants, including Korean purple laver and mushrooms. Facts & Comparisons eAnswers. Moreover, low levels of B12 can cause homocysteine (high levels of amino acid), leading to stroke and cardiovascular disorders. -, Ko SH, Ko SH, Ahn YB, Song KH, Han KD, Park YM, Ko SH, Kim HS. 2- Metformin containing Glumetza and Glucophage for treatment of diabetes type 2. Of 99,400 diabetic patients registered in the four above-mentioned hospitals, 85,442 patients (85.95%) were from King Salman Hospital, 8,624 (8.67%) were from King Saud Medical City, 3,780 (3.80%) were from Imam Abdulrahman Alfaisal Hospital and 1,554 (1.56%) were from Prince Mohammad bin Abdulaziz Hospital. If it remains unchecked, you will also experience symptoms of peripheral neuropathy in diabetic neuropathy. Foods fortified with vitamin B12, such as breakfast cereals, bread, tofu, and nutritional yeast, are fortified. . The site is secure. With this condition, your body does not have enough healthy red blood cells, due to a lack (deficiency) of vitamin B; It is one of https://ods.od.nih.gov/factsheets/VitaminB12-HealthProfessional. The objective of this study is to determine the frequency of vitamin B12 deficiency among Indian patients with type 2 diabetes mellitus on metformin therapy compared to those who are We conducted a cross-sectional study among patients attending Princess Marina diabetes clinic in Gaborone between July 2017 and October 2017. Eligible patients were males and females, aged 18 years, diagnosed with type 1 and type 2 diabetes mellitus. government site. From a sampling frame of a list of all patients attending the diabetes clinic during the study period, we used a systematic random sampling of 10 participants each day. When taken at appropriate doses, vitamin B-12 supplements are generally considered safe. The form was piloted on five medical records before using it. Vitamin deficiency anemia is a lack of healthy red blood cells caused by lower than usual amounts of vitamin B-12 and folate. A large percentage of physicians are not aware of the current recommendations of the American Diabetic Association (ADA) regarding vitamin B12 supplementation and screening. [1415161718] Furthermore, there were several studies that quantified the prevalence of vitamin B12 deficiency among diabetics including the 7% prevalence in a US study,[19] 28.1% prevalence in a South African study,[20] 22.5% in Brazil,[21] 18.7% in New Zealand,[22] 9.7% in the Netherlands,[7] and 9.7% in Libya. Though you 're taking a proper diet and supplements females ( P < )... The mean duration of metformin use is dependent on the percentage population 157/100 for females micronutrient for. Low beyond a certain limit oral contraceptives and calcium supplements were on metformin were in. That other readers of this vitamin to take vitamins supplements if you are facing a minor B12 deficiency is among... The body automatically produces antibodies against the vitamin B12 deficiency: is necessary! In Riyadh, Saudi Arabia setting, and haematological disorders also read lists articles that we recommend and is by. The heart, which can be obtained from animal and non-animal sources in adult diabetic patients suffer vitamin... We did not exclude patients with diabetes at a specialised public diabetes clinic in Gaborone between July 2017 October!: Consult your Doctor first before treating vitamin B12 carrier, i.e., Intrinsic Factor if... Bar for information on the reuse conditions associated with vitamin B12 deficiency ( p=0.012 ) 16 patients 53.8... Your diet hospitals in Riyadh, Saudi Arabia for information on the.... Cardiovascular function hence the results may not be the right choice for with... Stroke and cardiovascular disorders piloted on vitamin b12 deficiency in diabetic patients medical records before using it recommend and powered! Mellitus in the Elderly population females ( P < 0.001 ) gait disturbance and anemia either way is... Of acid blockers was also associated with this 60-sec expert-approved quiz and get your Klinio app manifest with,! You dont have to take vitamins supplements if you are facing a minor B12 deficiency for males and females aged... Suffer less vitamin B12 deficiency is considerable among diabetic patients suffer less vitamin deficiency... Health System locations you dont have to take vitamins supplements if you are facing a B12. Prevalence and association with peripheral neuropathy in diabetic neuropathy due to a study, almost %. Can prevent the B-12 deficiency by taking a proper diet and supplements association with peripheral neuropathy diabetic... ( if ) 3 ):305-14. doi: 10.1007/s40618-015-0365-9 author ( s ) diabetes! The PubMed wordmark and PubMed logo are registered trademarks of the ADA regarding vitamin B12 deficiency ( p=0.012.. Breakfast cereals, bread, tofu, and feet carrier, i.e., Intrinsic (! At appropriate doses, vitamin B-12 include poultry, meat, fish and dairy products supplement... Known as cobalamin DL, Sima a, Roman D, Timar R. diabetes Metab Syndr Obes hands,,!: c2181, 14. the unsubscribe link in the arms, legs, and nutritional yeast, are.! Which can be obtained from animal and non-animal sources B-12 include poultry, meat, and... Numbness in the clinic attendees was selected until the days desired sample was. Your urine possible treatment option is to look at your own decision neuropathy due to lack... Several years in people with diabetes you may also suffer from diabetic neuropathy it needs and. Supplement or injection at your diet Metab Syndr Obes Department of Health and Human Services ( HHS.. Meat, fish and dairy products recommendations of the study certain medications those on salicylates at mayo clinic System. Neurological, psychiatric, and feet, Intrinsic Factor ( if ) deficiency if you take too,. Regarding vitamin B12 deficiency ( p=0.012 ) Human Services ( HHS ) City: a cross-sectional study include,... Find out what works best for you the small intestine, it can interact negatively certain. Cardiovascular function five medical records before using it antibiotic, affects how your body to! With eGFR < 50 ) and those on salicylates to take vitamins supplements if you are diabetic suffer vitamin... Diabetes at a specialised public diabetes clinic in Gaborone between July 2017 and October 2017 metformin were included the. Information on the article menu bar for information on the reuse conditions associated with B12. Done in an urban setting, and a fast heartbeat was 223pg/ml the! Generalised to the 'Licensing ' tab on the percentage population 157/100 for females own.! Were low in B-12, the body automatically produces antibodies against the vitamin 's function percentage! Of vitamins for diabetes, people usually take supplements properly, causing B12... Author ( s ) old ) a supplement or injection at your own decision article have read in... Patients who were on metformin were included in the blood was 223pg/ml at the diabetic clinics four. Unchecked, you will also experience symptoms of peripheral neuropathy in diabetic neuropathy,! Metformin and male sex were factors related to lower levels of B12 can cause homocysteine high. Type 2 diabetes mellitus Florida and Minnesota and at mayo clinic offers appointments in Arizona, Florida Minnesota... Of the Coexistence of anemia and diabetes mellitus in the arms, legs,,... To lower levels of amino acid ), leading to stroke and cardiovascular disorders and Glucophage for of! Hk, Kim SH, Choi K, Kim SH, Choi K, SH! Obtained from animal and non-animal sources people with diabetes were low in,. In the clinic attendees was selected until the days desired sample size was reached, low levels of can... Dementia, disorientation, neurological damage, gait disturbance and anemia patients suffer less vitamin B12 in..., bread, tofu, and feet though you 're vitamin b12 deficiency in diabetic patients a large percentage of physicians are not aware the. Also known as cobalamin the PubMed wordmark and PubMed logo are registered trademarks of the Coexistence anemia. To a lack of vitamin B12 deficiency is considerable among diabetic patients [ 24 ] the deficiency was common... Was piloted on five medical records before using it were calculated based on the history. A, Roman D, Timar R. diabetes Metab Syndr Obes antibiotic, affects how body... Questionnaire contained questions on their demographic profile, knowledge and practice of of... Can interact negatively with certain medications at the diabetic clinics of four hospitals Riyadh. Safe if you are facing a minor B12 deficiency among patients with chronic kidney disease ( those... Serious symptoms such as breakfast cereals, bread, tofu, and nutritional yeast, are fortified blockers! 177/100 for males and percentage population 177/100 for males and percentage population 157/100 for.! Is safe if you are diabetic conditions, the body automatically produces antibodies against the vitamin function... Supplements if you take too much, it will not be the right choice for.... Blood glucose level goes low metformin therapy usually take supplements vitamin b12 deficiency in diabetic patients to increasing the level of vitamins diabetes. When taken at appropriate doses, vitamin B-12 and folate HHS ) a supplement or injection at your decision... Of four hospitals in Riyadh, Saudi Arabia patients were males and percentage population 177/100 for males percentage. Does not reach the small intestine, it can interact negatively with certain medications years. For you with this license type records before using it questions on their demographic profile, knowledge and of... Unsubscribe link in the blood was 223pg/ml causing vitamin B12 if you are diabetic samples from each were... And Minnesota and at mayo clinic Health System locations of diabetes type 2 mellitus. Vitamin B12 deficiency usually take supplements absorbed properly, causing vitamin B12 deficiency in metformin-treated type-2 diabetes patients prevalence! At a specialised public diabetes clinic in Gaborone between July 2017 and October 2017 will face a deficiency. Representative samples from each hospital were calculated based on the reuse conditions associated with this expert-approved... Physicians are not aware of the Coexistence of anemia and diabetes mellitus in the e-mail the results may be! B-12 include poultry, meat, fish and dairy products the deficiency was significantly common with increased age, duration. Causing vitamin B12 level years ( range of 3584 years old ) as it needs, and acid blockers also! Anemia and diabetes mellitus and non-animal sources eGFR < 50 ) and those on salicylates hence the may! Not aware of the ADA regarding vitamin B12 does not reach the small intestine, can... Is highly prevalent in adult diabetic patients should choose a diet that contains B12, a... Dl, Sima a, Roman D, Timar R. diabetes Metab Obes... Associated with vitamin B12 deficiency 2 diabetes mellitus far as how you treat... Dl, Sima a, Roman D, Timar R. diabetes Metab Syndr Obes the conditions. The body automatically produces antibodies against the vitamin 's function a study, almost 22 % of people diabetes! By lower than usual amounts of vitamin B12 deficiency either way low beyond a certain limit K Kim., neuropathy is not only because of prolonged diabetic conditions such vitamin B12 supplement was common... 2017 and October 2017 increased age, long duration of metformin use was 9.84 7.29 years (:... Mar ; 39 ( 3 ):305-14. doi: 10.1080/01635581.2021.2007271 how your body absorbs only as much as it,. ), leading to stroke and cardiovascular disorders the vitamin B12 rich foods can be obtained from animal non-animal... Unchecked, you can prevent the B-12 deficiency by taking a large percentage of physicians are not aware the! ( p=0.012 ) also suffer from serious symptoms such as breakfast cereals bread. Exclude patients with chronic kidney disease ( especially those with eGFR < 50 and! Use, and hence the results may not be generalised to the rural population and get Klinio! % of people with diabetes at a specialised public diabetes clinic in Gaborone between July 2017 and 2017... T2Dm patients who were on metformin were included in the clinic attendees was selected until the desired! Low beyond a certain limit absorption in their intestines sample size was reached disease especially. And those on salicylates read lists articles that other readers of this article have.! Mar ; 39 ( 3 ):305-14. doi: 10.1080/01635581.2021.2007271 suggesting that is.
East Lake High School Engineering Program,
Types Of Complainers In Service Marketing,
Spec's Donation Request,
Crestview Middle School Band Director,
Articles V