9 | Kidney Stone Prevention: What Every Clinician Should Know

Kidney Stone Prevention

Melanie: "The worst piece of advice is to limit calcium. This is how we used to treat stones, but this was massively debunked about three decades ago. And this is harmful advice because when you tell someone to limit calcium, it's increasing their urine calcium and increasing the risk of stones. And this is something that I still hear literally daily."

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Colleen: Welcome back to the Exam Room Nutrition podcast. I'm your host, Colleen Sloan. I'm a registered dietician and pediatric pa. Now, I've heard that kidney stones can be as painful as childbirth, and I've never had a kidney stone, but I have had natural childbirth, and I can tell you it's excruciating. So today we are going to help you navigate the world of kidney stones and find out how nutrition plays a role in prevention so that you can help your patients steer clear of the dreaded stones. Joining me today is the Kidney stone expert, Melanie Betts. She's the founder of the Kidney Dietician an online platform, and she uses personalized science-based approaches to help individuals prevent kidney stones through dietary interventions. You can connect with her at thekidneydietician.org and also you can follow her on Instagram @the.kidney.dietitian.

Melanie, welcome to the show.

Melanie: Thank you so much for having me, Colleen. I'm so excited to be here. I'm always excited to talk about kidney stones.

Colleen: Awesome. Awesome. So I'm really excited to learn from you because I am not the expert in this field, so this is gonna be excellent for me to get a nice refresher on kidney stones. So I wanna start by understanding exactly who is at risk for kidney stones and maybe what those risk factors would be.

Melanie: Yeah, so the most common risk factor, most kidney stones are caused by something called idiopathic hypercalciuria. So basically high urine calcium for reasons that we don't know, right? 

 So, people who form stones tend to be male, although females, are forming stones so kidney stone prevalence is increasing, but it's increasing faster in women. So we're catching up. So I can almost not even say that it's more common in men. People who don't drink enough water, and people who eat way too much sodium. Those tend to be from like a lifestyle standpoint, the people that form stones, there are a whole handful of medical conditions that make kidney stones a whole lot more common. One of the most common ones is hyperparathyroidism. So that messes right with your calcium balance and that can cause very high urine calcium. Some rare genetic conditions called primary hyperoxaluria. People who have inflammatory bowel disease are actually at a higher risk of kidney stones. People who have bariatric surgery and also actually people who have eating disorders who purge excessively, So laxative abuse or excessive vomiting, you, you also see a higher risk of stones in those populations. 

Colleen: Okay, before we even discuss treatment, let's talk prevention. What is the best way to determine an effective treatment plan?

Melanie: so this is something I'm actually incredibly passionate about. So truly, if you are working with someone who has had kidney stones and they want to work on preventing more of them, the only way to. Even begin to know what we can do to help prevent stones is something called a 24 hour urine test. There's a company called Litholink that does the vast majority of these tests because most hospitals and clinics, labs aren't set up to measure all the things that we need for this sort of like this full stone panel on that 24 hour urine test. And this urine test is so, so important because it's gonna tell you why that patient is forming a kidney stone, even for the same type of kidney stone say, Calcium oxalate, which is the most common. There are many different sort of things that could be going on in someone's urine that could be causing that stone. So as their practitioner, we really need to know why they're forming stones so we can know how we can target that why to really, effectively prevent them.

Colleen: Excellent. Yeah, that makes perfect sense. So let's get into the nutrition aspect of things. Is there like a basic recommendation of a quote unquote kidney stone prevention diet? Are there certain guidelines we should be following?

Melanie: Yeah, so not really because everything really should be tied to that 24 hour urine test. And that's actually in the official American Urological Association guidelines is that, all of the nutrition related recommendations that are in, that document are all sort of, based on something in a 24 hour urine test. So, for example, it says that only people who have confirmed calcium oxalate stones and who have high urine oxalate should be limiting how much oxalate they eat. So there really isn't one kidney stone prevention diet, so as I mentioned, those calcium oxalate stones are definitely the most common.

About 80% or so of stones are made of calcium oxalate and the most common cause of stones in general is high urine calcium. So of course you would know that about your patient with that 24 hour urine test. So I wanted to talk to the things that we can do as a dietitian to help lower that urine calcium, since that really does tend to be the biggest driver of kidney stones in general.

So the things that we can do, to help lower urine oxalate is make sure that someone is eating the right amount of sodium or salt. That is definitely the biggest tool that we have as a dietician in our toolbox to help get that urine calcium down. Also making sure that they're eating the right amount of protein.

So most people in the United States are actually eating a whole lot more protein than they need, and most of our protein comes from animal sources and in, the guidelines they call out, “non-dairy animal protein”, which really can contribute to kidney stone. So, making sure that they're not eating too much protein, essentially, especially from those non-dairy animal sources, can help get urine calcium down.

And then the other big piece that tends to come up is making sure that people are actually eating enough calcium because when we eat enough calcium, that actually, significantly reduces how much oxalate we absorb in our intestine, therefore, reduces the amount of oxalate in our urine and prevent stones.

And so, there really is a big push to, and we'll talk a little bit about this later, but less of a push to strictly control how much oxalate someone eats and really it's much more effective, and much more pleasant for them actually to make sure that they're eating enough calcium to block that intestinal oxalate absorption to therefore, reduce urine Oxalate and prevent stones. So the other big thing is, of course, fluid, right? Like making sure that someone is, is drinking enough water. So the, the big things that tend to come up most often when I'm reviewing those 24 hour urine tests is really low sodium, eating the right amount of protein, eating enough calcium, and drinking enough.

Colleen: What an excellent overview that was. And we're gonna jump into each specific nutrient that you mentioned because, you know, we can say low. We as clinicians, we do wanna know what that means. So I love that. Thank you for that overview. That was fantastic. I wanna touch on, a strict low oxalate diet, because you had mentioned that not everybody needs to be following that, but specifically for those of us who aren't dieticians, what foods are considered in that group or what foods would be considered, in a low oxalate diet? 

Melanie: So there actually is no definition of what a low oxalate diet is. Some doctors or, and some people will say that that's 50 milligrams of oxalate per day. Some people might say a hundred, but honestly, there's, there's not really a definition. And even if there was, honestly, trying to figure out how much oxalate that's in specific foods is virtually impossible. Which is one of the reasons why I really, really dislike , when doctors say like, oh, like, just.

follow a low oxalate diet or only eat 50 milligrams of oxalate per day. Not only is that gonna limit a lot of very nutritious foods, it's also incredibly stressful for patients to figure out how much oxalate they're eating. 'cause like I said, there's just, there's hugely conflicting lists out there.

And a lot of the information that is out there is wildly inaccurate. So it's really, really difficult to quantify what foods are high in oxalate. But I will say that however they go about it, a low oxalate diet will inevitably limit, completely remove or significantly reduce all whole grains. If we think beyond kidney stones, right, whole grains are good for us for other reasons. And whole grains are always gonna be higher in oxalate than their sort of refined white counterpart. Like say whole grain bread is gonna be higher in oxalate than white bread. And so people are gonna be, replacing those healthy whole grains if they are replacing them with, refined grains. It's also gonna limit many vegetables. Some of the, the notoriously high ones is spinach, Swiss chard. And, and lots of other vegetables. And also it's gonna limit some fruit, some raspberries are a big one. And the other huge thing with oxalate is it's gonna limit a lot of very nutritious nuts, seeds and beans and legumes and those types of things. So, you, you might be thinking like, man, these are all the foods that I want, basically all of my other patients to eat.

And, and that's true, right? And that's, why we really only want to restrict oxalate when it's absolutely necessary, because it will cause truly unhelpful changes in someone's diet if we don't go about it correctly. The other thing about a low oxalate diet is there's actually no data that even associates a lower oxalate intake with lower risk of stones.

There's no data out there. We do know that reducing how much oxalate you eat lowers how much oxalate is in your urine. That, that is definitely a well established fact. Up to about 50% of the oxalate that's in your urine can be attributed to, how much oxalate that you're eating. But because this low oxalate diet removes a lot of these other healthy foods, it's also removing a lot of other things that are ironically, pretty good for kidney stones. So things like alkali magnesium and phytate and other things that we just know are sort of potent stone inhibitors for people. So if you are working with someone who does have that high urine oxalate, the first step is to make sure that that person is eating enough calcium as I mentioned before, that calcium is going to significantly reduce the amount of oxalate that's absorbed in their intestine, and prevent stones. And I will say eight out of 10 times when I'm working with someone, if they have high urine oxalate, we add in that milk and yogurt, we see that urine oxalate come tumbling down and we don't need to be worried about it. But if you do have someone with stubbornly high urine oxalate, we wanna go about this in sort of a reasonable way, right?

Like, we don't wanna say, eat X amount of oxalate per day because as I said, that's gonna be very stressful and very difficult for them to even figure out. So instead, as we know as dietitians kind of really working with that person, what are they eating? Are they having a spinach smoothie every day? All right, well that's one thing. Like let's get rid of that spinach and that alone you're gonna see a lower urine oxalate. Are they having, Three servings of nuts every day and, and it's almonds. Okay, well let's maybe reduce that to one serving or maybe swap in some lower oxalate nuts and just kind of like looking at what they are actually eating and identifying those super high sources of oxalate and just focusing those instead of just saying like, Ugh, let's just get rid of all this oxalate. If that makes sense. 

 Colleen: It sounds like to me, you're saying that not everyone should ever be following a low oxalate diet. And correct me if I'm wrong, but I don't think oxalate is labeled on the food label. Right. So if we're recommending that to our patients, how are they supposed to even be tracking that? Because it's not a milligram or something that they can be monitoring. So for those of you who are listening who work with patients with kidney stones, I hope you heard her loud and clear. A low oxalate diet is really not recommended for, it sounds like anybody, but you should be looking at the specifics of their diet. So Melanie, you touched on calcium. I wanted to dive into that a little bit deeper for my clinicians. I hear you that it's really, really important and it makes complete sense the way that you explained how high calcium foods are important. But I want you to educate us on what are those types of foods and how many servings per day should our patients be eating? Give us just the general rundown on calcium and their diet.

Melanie: Yeah, so, calcium is gonna be really important for. Honestly, anyone that has any sort of calcium stone, from a bone health standpoint, first and foremost, people who have kidney stones, especially due to this high urine calcium, are at a much higher risk of osteopenia and bone disease in general.

So the guidelines are actually, completely in line with the general, guidelines for Americans. So they say somewhere between 1000 to 1200 milligrams of calcium, depending if you're a woman and post menopause and all that sort of good stuff.

And so generally that comes down to about three servings of dairy per day. I will say that whenever possible, as long as people tolerate it and are okay with consuming it, I do recommend dairy. just because I know that there's a lot of calcium in there. We see in studies that dairy is associated with a lower risk of stones and typically it's gonna be around three servings of, of dairy per day, as, as I mentioned, which is perfect because we tend to eat three meals a day. So if we have one serving of dairy with each meal, that's gonna definitely get you to your thousand to 1200 milligrams of calcium per day. And it is important for most people to be pairing that dairy with their meals, because we really want to eat that calcium when we are eating these other nutritious foods that have oxalate in it, right?

So if we're having yogurt as a snack, that's great. It's gonna help our bones. It's not gonna increase stone risk, but if we're having that yogurt with our meals, it's really gonna do as much as it can to reduce that intestinal oxalate absorption. If, that makes sense. I typically recommend low fat or fat-free milk. Yogurt, even lower sodium cheeses or even cheese in general can be a good source of calcium. Of course, the question always comes up, what if someone doesn't drink milk? They don't tolerate milk. Cetera, et cetera. In that case, I do say that using milk substitutes like a coconut milk or oat milk, can be okay.

But we, know that calcium supplements, like taking a calcium pill actually is associated with a higher risk of stone. So it's, it's very nuanced here. And that's likely because calcium supplements increase urine calcium a lot more than natural occurring calcium, like in a glass of milk. But clinically I will say that that calcium is just so, so, so important. And I don't want people taking calcium supplements who have high urine calcium. and those milk substitutes do a wonderful job of getting urine oxalate down and, and I don't tend to see the same urine increase in calcium as I do with calcium supplements. So, when necessary, those plant-based, milk substitutes can also be an option for people.

Colleen: So for my nutrition newbies, when you say a serving of dairy, Tell us, how do we educate our patients on, okay, well what is a serving.

Melanie: So about one cup or eight fluid ounces of milk. The same thing is gonna be true for any of those milk substitutes. One ounce of cheese, which is typically one slice like in the packages of cheese or four dice, I like to compare it to as well. Four dice of cheese, or three quarters of a cup of yogurt.

Colleen: Perfect. Super helpful. Thank you. let's move on to protein next because you had mentioned protein a little bit and I love that you mentioned that most Americans overeat protein because there's a lot of misconceptions, especially in the fitness world about how much protein you need to be having. So I'm really excited to dive into protein. So talk to us all about protein. I'll let you take the floor in the discussion on protein.

Melanie: Yeah, so the reason I care about protein from a stone standpoint is that when we eat too much of that non-dairy animal protein, it can raise that urine calcium, as I mentioned before. It can also actually raise urine oxalate, ironically. So, oxalate is only found in plant food. So meat, fish, chicken is, has zero oxalate, but our liver can make oxalate from some things.

One of those things being, certain amino acids. And so, that meat, even though it's oxalate free, can actually raise urine oxalate. And it will reduce your urine pH, which can make certain types of stones more likely. So if you do find that someone is eating excess protein, generally we are talking about that non-dairy, animal protein, so that's beef, chicken, fish, seafood, poultry, Game meats, any animal flesh, which is kind of crude, but it's a good way to think about it. That's really the protein that's gonna do all this stuff in your urine that I was just talking about. The amount of protein that we recommend does include all sources of protein, but just know that really it's that non-dairy animal protein that's going to be causing these harmful changes in someone's urine.

So the overall protein recommendation is somewhere between. 0.8 to 1.2 grams of protein per kilogram body weight, which is really a pretty big range. And I think that's where it's so important to have a dietician kind of weigh in to know how much protein is appropriate for this person.

Colleen:  That's really helpful. Okay, so now let's get a little bit more detail on the serving size with protein. So let's just give a scenario of somebody, maybe it's 180 pound man. 

And how many grams total that would be in a day. And give us some ideas of protein sources, maybe some animal and non-animal based protein sources, and what does a serving look like for that?

Melanie: So 180 pound man is about 82 kilograms. I just did the math. So if we gave him one gram of protein per kilogram body weight, which is kind of right in the middle of that range that I mentioned, So they need say, let's about 80 grams of protein per day. And like I said, that does include protein from all sources, and there's a little bit of protein in basically everything we eat except fruit. Like even vegetables, like serving a broccoli is gonna have  two grams of protein., but obviously that's, not much. Most of our protein, of course, comes from meat and other animal sources and plant proteins. So for reference, one three ounce serving of say, chicken, and this, is true of, all animal flesh. So fish, chicken, beef, all have about the same amount of protein. So three ounces, which is like a deck of cards is 25 grams of protein, which is a lot right?

So if you're eating a six ounce portion, which many of us would easily be doing, that's 50 grams. That's very well on your way to meeting that 80, gram goal for this hypothetical 180 pound man, right? So the animal flesh is definitely the most protein rich food. If you compare that to say a half cup of black beans or any beans, you're gonna get maybe eight grams of protein. So even if you had a whole cup of beans, which is really quite a bit, that's gonna be like 16 ish grams of protein, which is much, much less than, the very small portion of chicken say. So swapping people over to more plant proteins. And I certainly do not think that everyone with stones needs to or should be vegetarian or vegan at all, but I do think that incorporating some of these plant proteins in place of some of those animal proteins can be beneficial. The other wonderful source of protein for many kidney stone farmers is, is dairy, right? So a cup of milk is gonna have eight grams of protein, which is fairly significant. So people really can get a fair amount of protein from milk.

You can also get a fair amount of protein from whole grains. So one slice of whole grain bread probably has like four grams of protein or so. And all of these little bits add up, especially when we are thinking about only meeting 80 grams for the whole day.

Colleen:  Okay, so we've touched on calcium, we've touched on protein. Let's move on to sodium. And thinking about, hey, what about following a low sodium diet? Does that help prevent kidney stones? And then let's, talk a little bit about like, what is a low sodium diet? What does that mean, how much that is?

Melanie: Yeah, so the recommendation for kidney stones is anyone who has high urine calcium should be following a “low sodium diet”. I put it in quotations because it's actually not a low sodium diet, it's just actually the amount of sodium that all of us should be eating anyway. So the recommendation is 2300 milligrams of sodium per day, which is exactly what the dietary guidelines for Americans say all of us should be doing anyway.

So. It isn't really that low, but it is low of course, compared to what the typical sodium intake is in the United States. So most of us are eating somewhere around 32 to 35 ish hundred milligrams of sodium per day, which is maybe a thousand ish milligrams more than what we should be eating.

So, for most of us it ends up being a low sodium diet. And the reason for stones that this is so important is it lowers that urine calcium, as I alluded to earlier. For the vast majority of people, it's not the salt shaker that's really where all that salt is coming from. It's the sodium that's already in our foods, right? It's in, say dressings and sauces and restaurant foods is a big thing. Canned foods, Like frozen or prepared foods that you get at the grocery store, that is where most of our salt is coming from. And so for many people, a low sodium diet is gonna look like perhaps trying to cook at home a little bit more often, or being very choosy with the foods that you order at restaurants. Looking at nutrition facts labels is so, so important because if you don't do that, even as a dietician, you have no idea how much salt is in there. So it typically ends up being a lot more fresh fruits and vegetables and unprocessed proteins is, kind of what it typically ends up looking like.

Colleen:  Which we should all be following. Might I add. I looked at a package of the cup noodles and I was blown away by how many milligrams of salt are in just one package. So that piece of education is really important to let our patients know that, hey, maybe less processed, less packaged foods, and just trying to cook more at home. So I love that piece. All right, so let's shift gears a little bit and close out the conversation by discussing fluids. How much should we be telling our patients to be drinking, and then which beverages would be the best options for them?

Melanie: So I will say that fluid is not only the only piece of nutrition advice that spans all types of stones, like basically everyone with kidney stones, unless they have a reason for fluid restriction like heart failure or something, everyone should be drinking fluid, period. And the recommendation is to consume enough to produce at least two and a half liters of urine per day.

So if you need to make two and a half liters of output, assuming that you are losing some fluid through breathing and feces, et cetera, et cetera, around three liters of fluid per day is what I typically recommend people aim for. Of course there's some wiggle room. People who are much larger or smaller might have, more or less needs, but generally three liters of total fluid per day is what I aim for.

Colleen:  And then, can they have juice? Can we have soda? Are there any specific beverages that they absolutely should be avoiding, like coffee or tea? Talk to us about the different types of fluid that would be appropriate.

Melanie: Yeah. So the three fluids that I love to recommend is like, pretty much drink as much as you want, pretty much,  Is water. Obviously not exciting, but so true. Most of the fluid that they drink should be water, but if you've ever tried to reach three liters of fluid per day, it's a lot. And so I'm a huge fan of mixing it up, just to make this more feasible for people and make it more exciting because water does get boring. Like, let's be real. So, water of course. Milk is another great one. And my third sort of, general recommendation is I love all of the unsweetened sparkling waters that are around. Such as LaCroix or bubbly, or my personal favorite, it's the most delicious, I think is Spin Drift. Like all of them are wonderful as long as they don't have that sugar, or artificial sweetener potentially in them. Because it's just such a good way to mix it up. I also recommend (this is perhaps controversial), but, coffee and tea, as long as they're not packed with sugar. So one or two cups per day I say are totally fine for kidney stone formers. Black tea is the highly controversial piece of that because black tea has a fair amount of oxalate in it. However, if you look at studies, people who drink tea tend to have less stones. So to me it makes no sense unless someone has that stubbornly high urine oxalate to take away tea. It's a fluid, that fluid is the most important thing out of all of this for someone with kidney stones to be focusing on that is by far the thing that's gonna most reduce their risk of stones. So if they love tea, great. The other drinks that I recommend sometimes to mix it up is actually crystal light lemonade. Crystal Light Lemonade actually has a fair amount of citrate in it, which can be helpful for some people depending on that urine test. And also diet lemon, lime soda, so like a Diet seven up or diet squirt or something like that. Some people get a little, anxious about those because of the artificial sweeteners. I say in the amounts that you're realistically gonna consume them, it's not gonna do you any harm. But, again, just as a way to mix it up for people and make it more exciting, I think those drinks can be incorporated as well.

Colleen:  So I wanted to get into the nuances here with that diet sodas versus the regular soda. Is it the sugar content that you're worrying about or is it something else?

Melanie: Yes, So drinks that that are associated with a higher risk of stones, the only ones are sugary drinks. and Diet Cola. So obviously any sort of regular soda's gonna have a ton of sugar so that we want to avoid. Juice, I do not recommend in amounts. If someone loves juice, fine having a small portion, that's cool, but that's definitely not something that I want to have them drinking a liter of a day, right? Just because of that sugar load, even a hundred percent juice. Things like sweet tea, lemonade punch. energy drinks, Gatorade, anything that has a lot of sugar in it, or sugar at all, I would say honestly is something we don't wanna be focusing on.

Colleen:  Excellent. Thank you so much. That was so helpful. All right, so I like to close by having you give us the worst piece of advice that a clinician could possibly say to a patient either struggling with kidney stones or who have had them in the past, just to give us some what not to do advice.

Melanie: Okay. So I would say the worst piece of advice is to limit calcium. This is how we used to treat stones, but this was massively debunked about three decades ago. And this is harmful advice. 'cause when you tell someone to limit calcium, it's increasing their urine calcium and increasing the risk of stones. And this is something that I still hear literally daily, people that connect with me online, hear this advice from their doctor. So please, please, please, please, please, please never tell someone with calcium stones to limit how much calcium they're eating unless they are consuming like 5,000 milligrams per day.

And then we can go there. But usually that's not the case. Right? And the second thing would be to just tell them to like, oh, just follow low oxalate diet and just Google it. For all of the reasons that I just talked about, they're going to get so confused and so much misinformation and it's going to take out a lot of very healthy foods in general..

Colleen:  Melanie, thank you so much. I so appreciate the fact that you brought so much science into the discussion and I learned so much from you. If there is anything else that you would like to add or anything you would like to close with, I'd love to hear that.

Melanie: Yeah, so I just wanted to let everyone know that if you have patients who want to really dive into this, kidney stone nutrition, there are certainly dieticians available who specialize in this, but they can be hard to find a kidney stone specific dieticians. And so that is why I started a course Kidney Stone Nutrition School, which is for patients that walks them through all of this to learn exactly what they should be doing to prevent stones. And if you are really interested in stones, if anything that I said was just fascinating to you and you love stones as much as I do, I also have a training for registered dietitians, but really it would be useful for any practitioner about kidney stones. And that is my Dishing Out Prevention, complete kidney stone training for dieticians, and you can find both of those resources on my website.

Colleen:  That's awesome. What a valuable resource for patients and clinicians. And clinicians. I wanna remind you that you don't have to know it all and do it all. Melanie clearly is the expert in stone, so she's here to help you. So don't feel like you have to give your patients all of this information in the clinic visit, but hopefully Melanie was able to debunk some myths or maybe any guidelines that are outdated that you might've been following, and now that you can provide appropriate education to your patients to at least get them going to prevent those kidney stones. I'm gonna go ahead and link all of the resources Melanie had explained down below in the show notes, so you can easily find those. Melanie, thank you so much for the gift of your time. I'm so grateful that you're with us. I'd love to have you back on again.

Melanie: That would be great. I would love to be back. Thank you for having me.

Colleen:  All right, guys. Now it's time for my nutrition notes. In this section, I like to provide you with a nutrition tip, an interesting quote or an interesting case that I think might add value to your day.

So today I'm gonna leave you with a nutrition tip and I actually got this from Melanie's Instagram page. So like I said, if you want to dive deep into the world of kidney stones, please follow her @the.kidney.dietitian.

The topic of alcohol comes up a lot with regards to kidney stones, and I know we didn't discuss this with my conversation with Melanie, so I just wanted to give you some suggestions. If your patient does ask you about drinking alcohol, if they do have kidney stones or at risk for kidney stones. And so I have good news with fellow wine lovers like myself. Wine has actually been associated with a lower risk of kidney stones. And as I'm sure you know, it also has some benefit for heart health. Beer has been shown to be sometimes associated with lower risk of kidney stones and liquor has been shown to have no effect on kidney stone risk.

So if your patients drink alcohol, that's fine, but this is not a recommendation for them to start to drink alcohol. As alcohol has other negative health consequences as well, especially if drank in excess.

As a reminder, alcohol should be limited to one serving a day for women and two servings a day for men.

Thank you so much for joining me today. I hope you found value in this content and conversation with Melanie on kidney stones, so you'll be ready for the next time your patient asks you, I have kidney stones. What foods can I eat to prevent them from happening?

If you'd like to submit a question for our experts to answer, you can send me a message at Instagram @examroomnutrition, and I'd be happy to have that question featured. 

Well, that's all for today. So thank you so much for joining me, and as always, let's continue to make our patients healthier. One exam room at a time. I'll see you next time.