Dawn Harris Sherling: What Food Additives Are Doing to Your Microbiome

Harlan Krumholz: Welcome to Health & Veritas. I’m Harlan Krumholz.

Howard Forman: And I’m Howie Forman. We’re physicians and professors at Yale University, and we’re trying to get closer to the truth about health and healthcare. This week we have an exciting interview with Dawn Harris Sherling, a doctor in Florida, Yale Medical School graduate, who talks about the benefit from changing your diet to less processed and less ultra-processed foods, and it’s really an incredible discussion that we got to have with her. But first, Harlan, we like to get started talking about current health news—and there’s always health news. So what’s on your mind today?

Harlan Krumholz: I thought, guys, we have a guest today who’s going to talk a lot about research on additives and emulsifiers and all the stuff that goes into food, and I don’t know, I’m going to lead in with something about that. So there was a really nice piece that was written in Vox by Keren Landman, who’s a senior reporter who covers health there, but she’s a doc, a researcher and epidemiologist, and she reported out that the WHO was about to declare aspartame as a carcinogen. Now, you’ve heard me talk a lot about these artificial sweeteners, and there were a lot of them, and we can remember way back, you know, it was saccharine, there was a big scare about saccharine and whether that should be on the market, and ultimately, people were weighing in about whether it could be a carcinogen. And then we’ve had all these other things.

You go to the marketplace, and there’s all these kind of sweeteners in there. And I think I’ve talked on this show about the research that has suggested that actually these are bad for your metabolism. That in fact, it’s not that you can substitute these and all of a sudden be healthy, but actually, there’s a broad range of evidence that suggests that it’s possible this can cause derangements in metabolism and actually, when you’re drinking all this diet stuff in order to lose weight and be healthier, in fact it may be doing the opposite. But I’ve been talking about the metabolic effects, and as you know, largely at the encouragement of my daughter Hannah, I don’t know, almost a decade ago, I swore off this stuff. And by the way, it’s hard to swear it off completely because even when you look in toothpaste, this stuff is in there. It’s everywhere. It’s not just in gum and diet drinks—

Howard Forman: I’ve never looked at my toothpaste, but have you been that strict to be able to remove it from your toothpaste?

Harlan Krumholz: When I discovered it in the toothpaste, I’ve moved to toothpaste that doesn’t have it. I know that may be even a little nutty because maybe you think it’s not that much in the toothpaste, but it’s not like the label says that “we put in artificial sweeteners.”

Howard Forman: I didn’t even know. I presume you mean like Crest and Colgate have aspartame in them?

Harlan Krumholz: Well, I don’t know. I was home, I think I was using one of those, and I’m looking at it, and it had it in it. And so Hannah got me to stop, and you saw me in those years. I was drinking so much diet soda, thinking I was helping myself, but then people don’t really lose weight. But now, if this comes true, then it’s going to be signaled as a carcinogen. And she raised something really interesting how, I don’t know if you know the history of this, but in the seventies, the G.D. Searle company had this substance, this artificial sweetener, was trying to get it approved. The FDA was actually stonewalling it because the evidence was a little bit unclear. They weren’t sure what was going to go on. Reagan comes into office. Did you know this about aspartame?

Howard Forman: I think remember this. As you’re saying it, I remember this.

Harlan Krumholz: So Reagan comes in office. Do you know who is the CEO of G.D. Searle then?

Howard Forman: Oh, it’s one of the cabinet members subsequently.

Harlan Krumholz: Don Rumsfeld!

Howard Forman: Yes, yes. Yep.

Harlan Krumholz: Don Rumsfeld, who becomes the head of the Department of Defense. Rumsfeld comes into the Reagan administration, next thing you know, the FDA approves the substance. Now, true and unrelated? I don’t know, but it was a big deal because an independent FDA board warned that the drug might induce brain tumors, and then the agency’s newly installed director, according to this article, overruled them, and then the FDA ultimately then approves it. How do we think about this, and what are your thoughts?

Howard Forman: Look, I think it’s important that we get better information out to the public. And unfortunately, when we introduce food substances into the population without having done any type of long-term randomized trials of them, it becomes up to the epidemiologic evidence to be able to find these relatively small, but on a large scale, big effects. And so this is challenging. It’s like you said, it’s very easy to talk about tobacco. It’s even easy to talk about alcohol. We obviously know about other exposures that have led to cancers like radon and other environmental exposures, but aspartame is widely, widely consumed, and it’s hard to know whether it is or is not causing cancers in one population or another. But it sounds like the weight of the evidence now suggests that it does lean toward more cancers.

Harlan Krumholz: Yeah. And so she says that in mid-July the International Agency for Research on Cancer, which is a branch of the WHO, will release the results of their new review. It’s going to do it. So let me just say, we’ll put it the link with the podcast. I really recommend people take a look at this Vox article. I think she did a terrific job, and I think it’ll be a point of conversation going forward as to what we should be doing about this. Okay. Hey, let’s get on to our guest.

Howard Forman: Dr. Dawn Harris Sherling is a board-certified internal medicine physician and author. In addition to practicing medicine in southeast Florida, she’s currently associate professor of medicine and associate program director of the Internal Medicine Residency at Florida Atlantic University. In her book, Eat Everything: How to Ditch Additives and Emulsifiers, Heal Your Body, and Reclaim the Joy of Food, Dr. Sherling melds her professional and personal experience to advocate bringing joy rather than restriction to the forefront of a healthy diet and educates about the effect of additives and emulsifiers on our microbiome.

She’s also a fellow of the American College of Physicians and a diplomat of the American Board of Obesity Medicine. Dr. Sherling completed her undergraduate degree at the University of Florida, received her MD degree from Yale School of Medicine and completed her internal medicine residency at the Brigham and Women’s Hospital in Boston. So first of all, welcome to the Health & Veritas podcast. I will start off by saying Harlan and I have talked an awful lot about pharmaceutical treatments for obesity and approaching that end of metabolic syndromes and obesity, and your book is on the other extreme from that. And I was wondering if you want to just talk a little about what motivated you and maybe explain to our listeners what the microbiome is.

Dawn Harris Sherling: I got motivated to write this book after a trip to Italy pretty much cured my own irritable bowel syndrome symptoms. And it was pretty remarkable that within 24 hours of being in Italy, where I thought I was going to be miserable because I was eating all the things that we tell people with IBS not to eat, gelato and pizza and garlicky things and oniony things and all these dairy items, and I had no problem. And not only did I have no problem, but I was much better than I had been in the U.S. And it was such a dramatic change for me that it got me questioning what’s going on with our food here in the U.S.?

And when I got back to the U.S., I started doing a deep dive into PubMed and I’m a little obsessive, so I just kept going. And I was finding research in mainstream journals, in Gut, in Gastroenterology, in Nature, in Cell. This wasn’t fringe stuff, and I was lucky because at the time, all of this information started to come out on our microbiome. And so you asked me about the microbiome, and basically, it’s been in the news a lot, and it’s mostly bacteria but also fungi, viruses, other organisms within our gut and in other places too, but for the purposes of this, we’re talking about our gut microbiome.

And those bacteria specifically, and the other organisms as well, are very much driven by what we feed them. So I have a garden analogy in my book, Eat Everything, and really, these microorganisms within our gut are a little ecosystem, and what we feed it and what we nourish it with turns out to be really, really important. And that research started to come out in the 20-teens really, and I feel like we’re hearing about it now in the news. Every week, every month there’s another article on the microbiome, how important it is, how it plays into disease states or healthy states, and what we’re doing and how we manipulate it is so very important.

Harlan Krumholz: It’s so great to have you on, and really appreciate you’ve taken the time to study this and to produce your book. It’s chock-full of lots of insights. But talk to us a little bit about the research you’ve done into food additives and emulsifiers, and how might these substances impact our health? How did they end up in our foods? And I don’t know, what have you learned about them?

Dawn Harris Sherling: So there’s been this huge explosion in food additives. And so we’ve always as human beings been trying to preserve our food because that’s how we survive, when our food lasts longer, so we’ve been processing food and preserving food for thousands of years. Really, within the last hundred years we have found these other substances besides just drying the food, salting, those types of traditional techniques. We now have a plethora of substances that can make food last longer on the shelf, where it can last for months and months and months, where a hundred years ago that just was not possible. And so what we’ve come up with are particularly emulsifiers I talk about a lot, those are pretty new and have had this explosion in their growth, other additives as well, but since the 1970s, really we’ve seen—

Harlan Krumholz: Do you want to just explain what emulsifiers are?

Dawn Harris Sherling: Sure. Sure, sure, sure. Great question. So an emulsifier is something that brings hydrophobic and a hydrophilic substance, so an oil-loving substance and a water-loving substance, together because we know that oil and water don’t want to mix. And so it’s really something that we use in detergent. So if it’s in our soap, we call it a detergent, and if it’s in our food, we call it an emulsifier, and it’s really just to bring oil and water together. So let’s take peanut butter for an example. So when you go and buy peanut butter in the supermarket, you’ll notice it doesn’t separate unless you’re getting the natural kind. If you get the natural kind of peanut butter, you’ll notice this layer of oil that floats to the top, because oil will float to the top, and so that then doesn’t likely have emulsifiers in it.

The peanut butter that can sit on the shelf for months and years and not separate has to have something in it to prevent that from happening. Same with salad dressings and lots of other things that we buy that they want to keep the oil molecules, the fat molecules, and the water molecules together. So that’s an emulsifier. Unfortunately, it looks like emulsifiers may be having really detrimental effects to our microbiome, maybe degrading the lining of our gut, which can turn out to have profound effects to our health. So how these things wound up in our food, I think you guys asked me, which it wound up in our food because it makes food last longer, and we’re always on the hunt for that as human beings. How do we get this to last longer? How do we make it more shelf-stable, because that’s ultimately going to make it cheaper? I don’t know if we’re seeing those cost savings as much as the ultra-processed food companies at this point, but it does make food cheaper theoretically if it can last longer. So it wound up in our food—

Harlan Krumholz: And just to tell us, when a company wants to put this in our food, what do they have to go through in order to get it evaluated?

Dawn Harris Sherling: That’s a great question. And so the Food and Drug Administration actually has a category called GRAS, which is “generally regarded as safe.” And so a lot of these items that were approved that are in our food supply were approved decades and decades ago before we had ever heard about the microbiome, or we had heard about it, but we didn’t think it was very important. We didn’t realize all the things that it did. So these items were never tested against, and they’re still not, what does this do to the microbiome? They were tested to see if they were carcinogenic or teratogenic. So do they cause cancer? Do they cause birth defects? And in the absence of those things, a lot of these items were approved, and now what we really need to be asking, and there are some researchers who are asking, “Well, we’re ingesting these things.” We used to think if we ingest something and we don’t digest it and it’s not fuel for us, we just poop it out. It just passes right through us and that’s it, it’s totally benign. That’s what I was taught when I was in medical school, and I don’t think it was that long ago, maybe 20 years, 20-plus years, and that’s what I was taught. But we know that’s not true now, and we know whatever we eat, if we’re not using it as fuel—nature abhors a vacuum—something is going to use it. And the thing that’s using these substances—fibers and additives that we don’t digest—our microbiome is using, and what we put in there definitely changes the composition of the microbiome. That is established fact at this point, but the regulation has not caught up to the science. And so nobody’s saying, “Hey, before we approve these substances, let’s see what it’s doing to the microbiome.” No one’s saying, “Hey, let’s go back. Let’s see what these substances do to the microbiome now that we know how important it is.”

Howard Forman: So I’m holding your book, for our listeners, who obviously can’t see it, but this is an extraordinary book. It’s very unique in a lot of different ways because it’s heavily based on science—you have 295 references—but it’s also extremely approachable. And not only is it approachable where you explain these things, but you also go into great detail about what practical things individuals can do to eat everything, to get away from emulsifiers and other food additives and how to change their diet. And you’re not an absolutist either. You don’t tell people to either stop all at once or they might as well just keep going. Can you give our listeners a few single pieces of advice from the book that they could immediately take home from this podcast and start to help change their diet in a positive way?

Dawn Harris Sherling: So the first thing is, I have to be practical, right? I’m a primary care doctor, and people have busy lives and people are stressed and they don’t have a lot of time. It doesn’t make sense to say, “Completely change the way you live and live this whole other way,” because that’s not how change happens, for the most part. We need to do it in a stepwise fashion, just one thing at a time. So I tell people, “When you go to the grocery store, pick one item.” And I talk about ultra-processed food a lot in my book, and that’s been in the news a lot recently as well. And so the idea is, how do you spot an ultra-processed food? And you look at the back of the package, don’t look at the front. Ignore things like organic and natural and handmade and artisan, whatever that means. Forget those words. Look at the back of the package. Look at the ingredients.

And I do list some particularly worrisome additives for which there is good evidence that we should be avoiding, but if you see something on the back of the package and you can’t picture how that might appear in nature, put it down, pick something else. But you can’t do that with all your groceries at once. You’ll be in the grocery store for way too long, so pick one thing. Say, “I’m going to look at my yogurt, and I’m going to pick a yogurt that doesn’t have all these additives.” And then the next time you go to the grocery store, say, “I’m going to look at the bread I’m buying, and then I’m going to pick a loaf of bread that doesn’t have these additives.” And probably that loaf of bread is going to be in the freezer section, because for bread to stay fresh more than a couple of days on the shelf, it either needs to be from a bakery or it needs to be frozen.

The bread that stays shelf-stable for weeks and weeks and weeks, there’s no way real bread will do that. So if we remember back to what real bread is or if we visited countries where bread is a big deal, you go and you buy the bread and it lasts a couple days at most, unless you freeze it. So go to the freezer section, pick a bread without all those additives in it, and then the next time pick a different item and that’s how we slowly start to create change. And the thing of it is, this isn’t so radical. These are new substances really within the last couple of generations. I know my grandmother wouldn’t recognize a lot of these things. For some people, it might be their great-grandparents at this point. And there are other places in the world where, although fewer and fewer of them, but these are not normal edible substances. So it’s not like this is something radical and different. We can all do it.

Howard Forman: I want to take this back to the patient directly. And you start off the book, I think it’s in Chapter 1 or Chapter 2, you talk about these two patients in I think Palm Beach, or maybe it was West Palm Beach, coming from two extremes of the income scale. You actually see these patients. You see the struggle for it. I’m just wondering, how do you start those conversations with both extremes? How do you begin to talk to that woman who goes to the galas in West Palm Beach or the service worker who is grab-and-go eating all day long?

Dawn Harris Sherling: Back then when I wrote about those two patients, I was in a practice that was right between one of the wealthiest areas in Palm Beach County, and then we have some very poor areas in Palm Beach County as well, and so I saw both of those patients. Now my practice is mostly seeing uninsured patients, so I don’t counsel well-to-do patients that much anymore, and I’m mostly caring for actually the most underserved patients. And while it’s difficult for anyone to make dietary changes, certainly my patients who are the roofers, who are the landscapers, who are the house cleaners, they don’t have a lot of money, they don’t have a lot of time. And at the end of the day, they are bone-tired, and so those patients actually don’t want to be on a bunch of medication.

They don’t want to have to take insulin because they don’t have insurance. They can’t afford the fancy new medications that cause weight loss as well as control diabetes. They are stuck with those older medications that for the most part cause weight gain, not to mention the fact that a lot of them don’t work in clean environments where it’s impossible for our farm workers in the middle of the day to inject insulin. That’s completely impractical. And so they are very motivated actually to be well because just as we talk about disparities in food and food deserts, and I do touch on that a little bit in my book, disparities in getting medical care when you don’t have insurance is incredibly challenging.

And so my patients are amazing insofar as they have overcome obstacles that we can only imagine to come to this country, to stay in this country, and the changes that they’re able to make, not everybody because again, change can be challenging, but some of them make changes that really also inspired me to write this book. Because I would have a patient come in with diabetes, and by the time they come in, folks tend to be pretty ill and having a lot of symptoms from it, they would come in with their blood sugars in the 300s, in the 400s with something that we call hemoglobin A1C at 12, at 13 percent—

Howard Forman: Just give our listeners a little sense of how off that is from normal.

Dawn Harris Sherling: So a normal blood sugar is 100 fasting or less, a normal hemoglobin A1C is less than 5.7, and folks are coming in with three times normal. And at first I was like, “All of these patients are going to need insulin.” When I first started seeing these patients, I was like, “Everyone needs to go on insulin,” because that was what I had been taught. And when they were like, “Nope, can’t do it,” for various reasons, financial or logistical or what have you, they were like, “Can’t do it,” I said, “Okay. Well, let’s try to limit your carbohydrate intake and let’s try to limit this ultra-processed food carbohydrate intake, which turns out actually raises blood sugar faster. So we have a measure called glycemic index, and we know the more food is processed, the faster the blood sugar will rise. Let’s try to get that out.”

And I said, “What were you eating as a kid in your country of origin?” And they would tell me, and I would say, “Okay. Can you do that? Can you go back to that?” And they were like, “Yeah, I can do that.” And when I would see them back, their blood sugars were way better controlled. I did also start a medication called metformin because it’s very cheap and very effective and does not cause weight gain, so we did do that. Sometimes they were already on metformin, sometimes we started an additional oral medication if things were really out of control, but they would come back and I would expect a 1 or 2 percent drop in their hemoglobin A1C, and it would return to almost normal. It would return to, if I would’ve given them insulin and dosed it appropriately. And “Folks,” and I said, “How can this be?” I said, “Oh, this is just an outlier. This is an anomaly, right? This person must have a very strange type of diabetes that we don’t see too often.” But then it happened again and again and again, and I was like, “Okay, there’s a pattern here.” And it amazed me just how big an impact food can have on our metabolic health that we really, really have to start talking about more.

Howard Forman: I want to make sure that before we wrap up, I want to just ask you one more question and just tell our readers a little bit more. This book is truly for those that want to understand the science, it’s fascinating, for those that want to understand what they can do to make their own lives better, it’s fascinating, and it’s very, very practical. And to that, you’ve got 25 recipes in here. Who has a book with 295 references and 25 recipes? It may be the first one ever. Can you tell me, I don’t want to put you on the spot, but have you made all those recipes? They look very good.

Dawn Harris Sherling: Oh, not only did I make them, but I made them again and again and again to check and make sure that the measurements were right.

Howard Forman: That’s great.

Dawn Harris Sherling: And when the book was being proofread, my family was basically eating that stuff constantly, which is good because they like it, and that’s why I included it. Hopefully the healthy food and sometimes not-so-healthy food because I have a brownie recipe in there, I have a cookie recipe in there because we need our treats too. Not every day, occasional treats or maybe a small treat every day.

Howard Forman: I like a small treat every day.

Dawn Harris Sherling: So part of this comes from the fact that I’m a physician, but I’m also a mom, and I do cook. I enjoy cooking. My husband and I both cook actually, and we enjoy that. Some of those are his recipes. I have to give credit where credit is due. The Korean noodles is definitely his. I leave him to make that one.

Howard Forman: And the arepas?

Dawn Harris Sherling: Oh, the arepas are mine. I’m from Miami, those are my arepas.

Howard Forman: That’s great. That’s great. Well, it is such a privilege to have you on the podcast, and it’s so great to see you. I should just mention, it’s your husband’s 20th reunion, I think it’s yours as well, isn’t it? 20th reunion.

Dawn Harris Sherling: We actually went. We were there last summer briefly for the 20th reunion. We stopped in and then looked around at colleges for my son.

Howard Forman: Very nice.

Dawn Harris Sherling: We were there briefly last year.

Howard Forman: Well, it’s great to have you back virtually and in person, so thank you very much.

Harlan Krumholz: And so my last question, I’m just looking at my notes, the one thing I wanted to ask you at the end here is, so, your irritable bowel syndrome, completely gone—

Dawn Harris Sherling: Completely gone.

Harlan Krumholz: ... with this new approach?

Dawn Harris Sherling: Well, completely gone, but I will say that sometimes when I’m traveling around the U.S., if I am going off the rails because I’m not perfect, and even when we make changes, we sometimes go back to our old ways and when I’m traveling, it can be challenging. So if I have too many meals in a row of an ultra-processed-laden kind of diet, then things will start going off the rails a little bit. But I have to say that as soon as I go back to getting this stuff out of our diet, things go right back to normal within a day.

Harlan Krumholz: Great.

Howard Forman: That’s terrific. Thank you again.

Harlan Krumholz: What a pleasure to have you on. Thank you so much.

Dawn Harris Sherling: Thank you. Thank you so much. This was great.

Harlan Krumholz: Well, Howie, that was a terrific interview. I’m so glad. Actually, this was your contact, and you brought her on, and it was really timely for her book. That was really nice.

Howard Forman: I enjoyed it.

Harlan Krumholz: But let’s get to your piece. What’s on your mind this week?

Howard Forman: In May, the CDC first reported that cases of fungal meningitis, which has a very high morbidity and mortality rate, had been identified in individuals who had returned from having plastic surgery in clinics in Matamoros, Mexico. And I am the most geographically challenged person that you probably know, to say the least, but this turns out to be a city that is adjacent to the U.S. city of Brownsville, Texas. It’s literally a six-minute car ride from a hotel over the U.S. border, according to what I looked up on Google Maps. This is one epicenter of medical tourism primarily for plastic surgery and attracting thousands of U.S. citizens in search of a better appearance or the appearance they are seeking at a dramatically lower price. And the CDC has done a really great job—we don’t give it enough credit—for working with Mexican officials to track down 161 listed individuals from the United States who received care at these two clinics in the first five months of the year before they closed them on May 13th.

And they found that 34 of them presumably had developed fungal meningitis and seven of them had already died. So, many of the patients have been also lost to follow-up partly because some of their names were not listed properly or addresses were not trackable, so it’s probably worse than the numbers I’m presenting, and the catastrophe’s probably a little bit worse than I’ve described. And by the way, this is not unique to Mexico. In the United States in 2012, 12,000 individuals were treated with potentially contaminated lots of similar medicines used for epidural spinal injections. At least 25 individuals died due to this contamination, and over a hundred others developed fungal meningitis in the U.S. The contaminated medication was traced back to a compounding pharmacy in Framingham, Massachusetts, and for some follow-up, the Department of Justice indicted 14 people associated with that disaster. So I bring this up for a few quick reasons.

One, it is not clear that individuals really understand the risk involved with cosmetic plastic surgery. I think people think that because it’s optional and it’s cosmetic, that it’s lower risk. Many plastic surgeries are higher-risk than people realize, including risks of sudden death. And in the last few months, I’ve personally seen several bad complications of plastic surgery in our own emergency department at Yale unrelated to fungal meningitis cases that we’re already talking about. Some were medical tourism; at least one was a local in-office example. These were not minor complications, either. So second point, common procedures like epidural anesthesia or other epidural injections that people commonly get, a high risk in the wrong hands or with contaminated medications.

And because they’re so common, we may take for granted the fact that they can go catastrophic if we are not watching out and being more careful. The U.S. may seem overregulated to some, but that regulation does provide safeguards. A third point, cheaper care in Mexico or elsewhere may seem like a great deal, and there are obviously great physicians outside the United States, but if individuals are going to use these services, they should really do a lot of vetting and make sure they know what they’re getting when they do medical tourism, as it’s called. And lastly, the plastic surgery itself. Ninety-four percent of plastic surgeries are conducted on women. They are growing at rates that are at least twice the rate of other healthcare costs. Plastic surgeons are growing in number and productivity.

I can’t tell you exactly what drives it, but if you go on TikTok and watch the innumerable videos that promote the perfect body or the means to get there, you’ll start to understand it. And I don’t begrudge anyone the opportunity to feel good about themselves, but there are real risks and costs associated with this approach. The health consequences of our seeming obsession with social media, and in the case of TikTok and Instagram, in particular, I think are underexplored. And I think that each time we talk about this on the podcast, it reminds me that there’s a lot more to it than just the time we spend on those applications.

Harlan Krumholz: Great job. You’ve been listening to Health & Veritas with Harlan Krumholz and Howie Forman.

Howard Forman: So how did we do? To give us your feedback or to keep the conversation going, you can find this on Twitter.

Harlan Krumholz: I’m @hmkyale, that’s @hmkyale.

Howard Forman: And I’m @thehowie. That’s @ T-H-E-H-O-W-I-E. You can also email us at health.veritas@yale.edu. Aside from Twitter and our podcast, I’m fortunate to be the faculty director of the healthcare track and founder of the MBA for Executives program at the Yale School of Management. Feel free to reach out via email for more information on our innovative programs, or you can check out our website at som.yale.edu/emba.

Harlan Krumholz: Health & Veritas is produced with the Yale School of Management and the Yale School of Public Health. Thanks to our researchers, Ines Gilles and Sophia Stumpf, and to our producer, Miranda Shafer. Week in, week out, they are absolutely amazing.

Howard Forman: They really are. Thank God for them.

Harlan Krumholz: Talk to you soon, Howie.

Howard Forman: Thanks very much, Harlan. And welcome to Megan Ranney, our new Dean of the Yale School of Public Health. Have a great week, Harlan.

Harlan Krumholz: Absolutely.