Speaker 1: 0:01

Welcome to the Healthy Matters podcast with Dr. David Hilden , primary care physician and acute care hospitalist at Hennepin Healthcare in downtown Minneapolis, where we cover the latest in health, healthcare and what matters to you. And now here's our host, Dr. David Hilden .

Speaker 2: 0:19

Hey everybody, and welcome to episode seven of season three of the Healthy Matters podcast. I am David Hilden, your host, and today we are gonna be talking with one of my colleagues at Hennepin Healthcare, Dr. Anne Kearns . She is an endocrinologist, but today we're gonna talk about one area of her expertise, and that is bone health osteoporosis, bone mineral density, what do your bones do? All of those kinds of questions. It's gonna be a great show. So let's get right into it. First of all, thanks for being on the show, Anne .

Speaker 3: 0:46

You are welcome, David.

Speaker 2: 0:47

Great to have you here. So let's start out with some basics about bone health. Why is bone health important? And, and the way I'm asking it that way is that, you know, everybody thinks about their heart or as an organ or their liver or their kidneys, but they often don't think of their bones as something that they need to stay healthy. Could you comment on that, please?

Speaker 3: 1:04

Well, I think of the bones as like the foundation in your house. It's not sexy, it's not interesting, and you probably just take it for granted until things aren't going well. So bone health , um, is important because we still need to walk and move around. It is something that is dynamic. People forget that it's a dynamic tissue, so it's not like you grow bones and they stay the way they are. They're constantly like your skin being , uh, broken down and renewed,

Speaker 2: 1:32

But they, they feel like just big rocks. That isn't the case. Yeah,

Speaker 3: 1:36

Like many things, we don't know there's a problem until something is measured or something goes wrong. So think about blood pressure or cholesterol. You can't feel it until you have a heart attack or your doctor says, Hey, we should measure it. So bone health is kind of like that. If you break a bone or someone measures your bone density, then you're aware of it. But day to day osteoporosis or osteopenia is not a disorder that you would have symptoms

Speaker 2: 2:02

Of. So let's talk about what factors contribute to healthy bones before we get into what can go wrong. Right.

Speaker 3: 2:08

So the bones are a structural element of our body. So they respond not only to the nutrients that we put into our body, but also to the exercise and the weightbearing. So we know astronauts in space, for example, lose a lot of bone because they don't have gravity. Um, patients who have injuries or who are at bedrest lose bone. So the, the bones respond to weight bearing. So exercise is often a part that people don't realize is important for accruing bone as we grow, but also for maintaining our bones , uh, during adulthood.

Speaker 2: 2:43

That's fascinating about the astronauts, I don't think I've thought of . If you're up in the space station for six months, do they come back with the weakest bones going? I mean, do they, is that what it is?

Speaker 3: 2:52

Well, we know , uh, that they do lose bone. One of my colleagues works for NASA and she said astronauts are very secretive and they actually don't like to be in a lot of studies because if you find something that doesn't go well, it could limit their future or something. And so they're kind of like a little cagey. So doing research on that is a little bit , uh, I thought that was the whole

Speaker 2: 3:15

Point, is that we do research on you, so we gotta

Speaker 3: 3:17

Yeah, but they wanna go back again. And if you find that they've had, you know, whatever

Speaker 2: 3:22

Your bones are weak, you're not going back into space. Yeah . And when you say they lose bone or anybody does, somebody who is bedridden or an astronaut or anybody who's losing bone, it's not like their femur went away. What do you mean by losing bone?

Speaker 3: 3:34

Right. So it's not like the, the shape of the bone changes, it just thins. And we have animal models where a surgical procedure is done to limit weight bearing or to remove weight bearing on a limb of a rat say. And so we can compare what happens when they can't bear weight to bearing weight. So we know a lot about it from animal models , uh, but it's just a , a loss of , uh, the mass of the bones. So if you think about , uh, a structure, 'cause bones are a structure. Think of the Eiffel Tower, right? There's the big ribs of steel and then there's all these cross connections. So when you lose bone, the big ribs gets thinner, but also you lose the cross connections. And you can imagine a ladder where you take out a rung or two, all of a sudden it's not so stable.

Speaker 2: 4:21

I like that cross connection thing . I like the Eiffel Tower thing, which I will never look at again without thinking of somebody's humorous or something. Now that's, that's helpful. What about diet and bone health?

Speaker 3: 4:31

You , so diet is important because , uh, if you, again, bone is a structural , uh, l uh , feature of our body. So if you think about it, like steel reinforced concrete, there's protein, which is like the steel in the concrete, and then there's the mineral. And the main components of the mineral are calcium and phosphorus. So the body regulates all of that mineral deposition to buffer things in the body , uh, acids, things like that. Um, so we have to give the body enough of those nutrients. We have to have a body that can absorb the nutrients and doesn't waste them . So giving your body enough protein, calcium, phosphorus, and in the typical American diet, those nutrients are plentiful. Patients often wonder about other nutrients like magnesium, vitamin K, and those are important. But again, in a typical American diet, they're not , uh, an area of deficiency. Sometimes as we get older, though, we eat less protein, and so often older people don't get enough protein and that affects not only their bones, but their muscles and, and their overall health.

Speaker 2: 5:39

Why should we care if we're losing bone mass? Why is it important?

Speaker 3: 5:44

Right. So , uh, the bones, again, are silently providing a lot of function and mobility. And when they start to break is when you have problems. And certain bones are more susceptible to this than others. The spine bones don't break into like a pencil or a piece of chalk. The way that they break is they kind of collapse. If you think about a cardboard box that is pretty good when it's dry, but you get it wet and it weakens, it kind of collapses and that kind of collapsed , uh, or compression of a vertebral body is a permanent change. And that leads to changes in the shape of your chest so that breathing , uh, can be difficult. Digestion can be affected because your stomach is , uh, squished. So when we get shorter as we age, our legs do not get shorter. Our torso does. And that's related to changes in the bone. But a an unrelated to the bones is the spongy part between the bones, the discs. So that's how we get shorter as we

Speaker 2: 6:46

Age. So if grandma's getting shorter, it's not 'cause her legs got shorter, it's her spine, right?

Speaker 3: 6:50

And they , it typically people will notice things like their waistband is now way up under their breasts instead of at their waist. Their waist is expanding, they get round shouldered . And that can lead to chronic neck pain as you have to hold your head up in a way . So

Speaker 2: 7:06

It really does matter. Um, let's move to the big topic that many have heard of osteoporosis. Could you start us off by simply defining it? What is it?

Speaker 3: 7:16

Yeah, so osteoporosis is a condition where the skeleton is more fragile and more susceptible to breaking. We typically think of it as an age related process. Um, and some of us age more rapidly. Some of us have medical problems that age us more rapidly. Um, but it's really a thinning of the bones to the point where less trauma or less force less energy is needed to break a bone.

Speaker 2: 7:42

Is it different from osteopenia, which I heard you say earlier?

Speaker 3: 7:46

Yeah. So osteopenia is something below normal but not quite as severe as osteoporosis. So it's kind of , uh, an intermediary , uh, between those. Some people with osteopenia because of other factors, have a high enough risk of broken bones that we treat them as if they have osteoporosis. Usually people think of osteoporosis as being defined by measuring their bone density, but you can get that diagnosis by having the right kind of broken bones and the from the right type of injury at the right age.

Speaker 2: 8:18

We don't , you mean like if you break some big bone with relatively little trauma, that's

Speaker 3: 8:23

The biggest signifier that thing's would have gone to that point. In an ideal world, we would be preventing that. So it's like we don't wait until you have your first heart attack to think about your cholesterol.

Speaker 2: 8:35

Yeah, that's a really great way to think of it. So how common is osteoporosis and is it equally distributed in men and women? Well,

Speaker 3: 8:42

It is more common in women and uh , it's about one out of three women and about one out of five men over age 50. I would say women are more commonly affected. I'll just tell you the next, the answer to your next question, David. Yep . Which is why are women,

Speaker 2: 8:58

Why,

Speaker 3: 8:58

Why are women more affected? Well, part of it is because men have higher peak bone mass. So just like height, men on average are taller than women. Bone mass is greater in men than in women. The second factor is women go through menopause, which is a time when the ovaries stop working and the hormone estrogen falls. Uh, estrogen is important for bone health in both men and women, but that fall in estrogen after the menopause in women is associated with more rapid bone loss. So less peak bone mass, more rapid bone loss equals problems for women more than men.

Speaker 2: 9:35

What about demographics? Is it uh, the same in all parts of the world or all uh , racial groups, ethnic groups, that kind of thing?

Speaker 3: 9:42

No, that's interesting. Um, and it's not totally elucidated why , but for example, black women in, in the US and black men, black people in the US have higher peak bone mass. So they are less susceptible, but that doesn't mean they don't get it. Fractures of different types around the world , uh, vary not only because of bone mass, but of lifestyle factors and things , uh, that are actually changing. Um, as people become more westernized in certain Asian cultures where squatting is important , um, or was important, the risk of a hip fracture was lower. But as people move more to sitting in chairs, there's more higher incidence of hip fractures.

Speaker 2: 10:26

Is sedentary lifestyle in general problematic?

Speaker 3: 10:30

Right. So the other big factor is exercise. I know , uh, exercise, if we could say there's any silver bullet in life, probably activity and exercise is it, and that's true for the bones. I mentioned that the bones are a , a weight bearing tissue in our body. So exercising them by bearing weight is important. And studies , uh, bear that out. People who are more active have fewer fractures in older age than people who are less active.

Speaker 2: 10:57

So we've talked about age, we've talked about gender, we've talked about exercise and a little bit about diet. What about genetics? Uh , is is there a family history component?

Speaker 3: 11:08

Well, we alluded a little bit to that when we talked about racial or ethnic differences. So yes , depending on which bone or site in the body you measure between 60 and 80% of your bone density is heritable, meaning it's what you get. So just like short people have shorter kids, thin bone , people probably have thin boned kids. You can't really , uh, pick your parents.

Speaker 2: 11:31

Something that I'm very glad I don't have to do 'cause I love my parents. Um, uh, so let's go on to diagnosis. How does, see you said you don't know you have this, you know, it's not like you , you can feel that your bones got weaker over the last few years. How is it diagnosed?

Speaker 3: 11:45

So it can be diagnosed by the right kind of fracture in the right level of trauma.

Speaker 2: 11:50

What do you mean? Well,

Speaker 3: 11:51

If I bend over to pick up a heavy box and that force compresses a vertebrae, that's a

Speaker 2: 11:57

Problem. So these little minor things of life ended up in breaking bones. So you're saying if you fell off the Eiffel Tower, you'd break a bone, but if you fall down from just standing there and break a bone, that's a little bit different. That's

Speaker 3: 12:08

A little bit different. Or sometimes , uh, I worked closely with orthopedic surgery team because my passion is preventing the next broken bone in people who've already had one. And if they had a suspicion that the amount of injury was too great for the energy, so for example, a minor car accident in an 80-year-old woman may have different consequences on terms of fractures than in a 20-year-old. It's not just the force, it's how much injury you had for that force. But the most common way it's found is by a test called the bone density test. Um, which is a type of X-ray that the computer then analyzes the bone and says how much bone is in that region of your body?

Speaker 2: 12:52

Who should get one of these tests?

Speaker 3: 12:53

Right? So every woman , uh, when she gets to age 65, should have a bone density test. There's less agreement on men. But most people would say all men by 70 should be considered before that age. Uh, it would be dependent on whether you have other risk factors. Your mother broke a hip at age 65, you are on certain medications that could weaken the bones, or you've already had a broken bone and someone says, Hmm , this doesn't seem right. Let's see where they are. Certain other medical conditions we know can predispose you to bone loss. So there are other factors that might lead to screening before then. Typically, we don't do a baseline test in everyone at age 25 or 30. That's not recommended.

Speaker 2: 13:43

So someone's going to get their DEXA scan or their bone mineral density scan and what can they expect,

Speaker 3: 13:49

Right? So it's a relatively simple test, meaning you'll, you'll be positioned by a technician on a table. We measure it routinely in the lower spine called the lumbar spine and in the proximal femur or what we call the hip, we can measure your bone density in your finger, in your heel, in other parts of your body. But the standard areas are the lumbar spine and the proximal femur or hip area.

Speaker 2: 14:13

So let's talk about the results. How do we interpret those results

Speaker 3: 14:16

All ? So there's usually several measurements that come out from it. The T score is a standard deviation from the young adult average bone density. So when these tests were developed , um, many people of all ages were measured and the distribution, just like in a blood test, the distribution of normal is based on measuring a bunch of healthy people and saying, okay, this is what the range is for healthy people. So the T score is the standard deviations below that peak bone density, even though we're , we don't routinely measure people, another score they may say is a Z score . A Z-score is a standard deviations based on your age. So how are you compared to other 50-year-old women, other 80-year-old women? The way we don't talk about it. And I hear patients coming to me saying, well, my doctor said I have the average bones of an 80-year-old and I'm only 50. We don't talk about that no more than we talk about your height being the average height of a 12-year-old

Speaker 2: 15:21

Before we leave osteoporosis. And the basic definitions. What are the advantages to knowing this? Um, uh, in general terms, why would you wanna know that you have osteoporosis? Is there something you can do about

Speaker 3: 15:34

It? There are effective treatments. Uh, you may be advised to modify certain activities that are more risky for having broken bones. I think of it as , uh, all of us want to age gracefully and maintain our independence and our mobility and broken bones , uh, at least temporarily and sometimes more permanently alter that.

Speaker 2: 15:54

We are talking with endocrinologist at Hennepin Healthcare, Dr. Anne Kerns . We're talking about osteoporosis and bone health in general. When we come back from the short break, we will talk about ways to prevent fracture to keep your bones healthy and treatment options for osteoporosis. Stay with us. We'll be right back

Speaker 4: 16:14

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Speaker 2: 16:51

And we're back with Dr. Anne Kerns talking about your bone health. So Anne , what are the treatments that are available for osteoporosis? Maybe starting well with the things people can do just from home or things they can buy at the store ranging all the way up to what they need to see the doctor for.

Speaker 3: 17:07

Right. So when I talk to a patient about treatment, I tell them I'm gonna break it down into three categories. One is nutrition, the second is exercise, and the third is medications. Um, I find that often patients are interested in nutrition and exercise and may have fears about medication. So I don't like to shortchange what they can do outside of taking a prescription medication. Um, we talked about the importance of exercise and weight bearing to bone health. I wish I could tell you this is the best exercise regimen for preventing or treating osteoporosis, but that doesn't really exist. Partly because humans are humans and to study them would mean that someone would actually exercise and do it consistently. And we just don't, we talk about weight bearing exercise and resistance training, and that can be as simple as if you're already sedentary, maybe you start a walking program, you know, you don't need to go to the gym and pump a bunch of iron, but you can begin to be more active with whatever other issues you have that may impact that. The next category is nutrition. People forget that weight loss equals bone loss. So we know this both from illness that results in weight loss, but also in weight loss procedures, weight loss medications. So you want to maintain a healthy weight. And sometimes as we get older, our appetites change and we start losing weight and become frailer. Part of that is not just weight, but the nutritional components. So everyone's pretty much aware of calcium, phosphorus , um, but the hidden one as we get older is protein. So , um, milk is a very good source of all of those. It has good protein, calcium and phosphorus, but many people don't tolerate it or don't prefer it. And that's where maybe the nut beverages. I grew up in a dairy farm, so we don't call those milk.

Speaker 2: 19:08

Oh, you mean like the liquid that comes from almonds all Yeah . Yes .

Speaker 3: 19:13

We don't, in my family we don't call it milk because we're dairy people. It's like calling margarine butter. We don't,

Speaker 2: 19:19

Okay, so in all disclosure, I drink about a gallon of milk a day, but there I I I seriously do and I didn't grow up in a dairy farm , but I , sorry , but I am from Minnesota. We're from kind of dairy country. We eat cheese and milk like constantly. But these nut products,

Speaker 3: 19:33

Yeah, the soy,

Speaker 2: 19:34

The nut pepper , soy , almond rice , do they have , do they have the right thing ? Theyre all

Speaker 3: 19:37

Fortified with calcium to be equivalent to uh , milk. There are some, believe it or not, milks that have added calcium too . I forget the brand of that. Lactate milk has just as much calcium, whole milk, skim milk, all has the same amount of calcium. All you lose there is the fat

Speaker 2: 19:53

And there are a lot of people who are intolerant to lactose. Yeah.

Speaker 3: 19:57

Uh, yeah. So then the lactate milk is just, has as much, but a lot of people, even though they tolerate it, they just don't prefer it. Yogurt has a good amount of milk. Some breakfast cereals are fortified with calcium. Some orange juices are fortified with calcium. Oranges themselves don't have so much, but it, the juice is fort

Speaker 2: 20:16

Sometimes juices do.

Speaker 3: 20:16

Yeah. People often point to spinach and broccoli as good sources of calcium and they are relative to other vegetables. Okay. But a cup of broccoli maybe has 50 milligrams of calcium. And if you have to get 1200 milligrams of calcium a day, that's a lot of

Speaker 2: 20:36

Broccoli. It is a lot of broccoli. How much calcium's in the nachos and salsa I had the other day?

Speaker 3: 20:42

Uh , yeah,

Speaker 2: 20:44

A lot of what we all joking aside doesn't have a ton of it. Does it?

Speaker 3: 20:48

<laugh> ? Not, not really. But if you eat a variety of foods, I think you'll find that you get close to the calcium. And when we think about calcium supplements, okay, we in the bone field have studied calcium supplements a lot and there is still controversy over how well calcium supplements themselves prevent broken bones. So if I were recommending people, I would say you should try to make changes to your diet. And if you absolutely have a very low diet, taking a calcium supplement might be reasonable. I don't think that there's any way to say that only calcium supplements will prevent broken bones because the , the data just isn't there and it probably isn't where the biggest bang for your buck is unless you have a very restricted diet.

Speaker 2: 21:35

What about the thing you always hear with calcium? What about vitamin D?

Speaker 3: 21:38

Right? Vitamin D doesn't exist in milk. We add it. Mm-Hmm <affirmative> . Okay. And we do that to prevent rickets, which is a softening of the bones that happens in kids. Vitamin D is a steroid hormone actually, and it's made in the skin from cholesterol in response to UV light. So anything that prevents UV light from acting on the skin, living in Minnesota this time of year, right? Darker skin pigment, avoiding sunlight using sunscreen, all of those things limit vitamin D production in the skin. Aging of skin , uh, limits vitamin D production. So limited sunlight exposure is the biggest factor that's easy to fix with a supplement. You don't need mega doses. There was a big trial that just came out that said mega doses aren't better in anything. So

Speaker 2: 22:28

You take a thousand a day or something. Is that good

Speaker 3: 22:30

Enough? Yeah, a thousand a day is a good amount. We don't generally recommend more than 2000. The toxicity isn't really great until you get into high levels, but there's no benefit. So,

Speaker 2: 22:41

So you've talked about exercise, weight bearing and resistance. You've talked about dietary things people can do. What about the medications that you probably prescribe?

Speaker 3: 22:49

Right. So the medications , um, have really been a revolution in our ability to lower the risk of broken bones. The first description, although you didn't ask me this, why is osteoporosis an endocrinology? David Anne ? Well it is . So

Speaker 2: 23:06

Anne , why is osteoporosis the , the realm of an endocrinologist <laugh> ?

Speaker 3: 23:10

It's because the first description of osteoporosis was by an endocrinologist at Mass General Hospital, fuller Albright, who made the astute observation that it was related to estrogen deficiency after the menopause. And he did the first trials of estrogen replacement as a treatment for osteoporosis and found that it worked fast forward to the women's health initiative, which was a huge trial in the US about hormone replacement in post-menopausal women. And that confirmed his findings that it does lower the risk estro

Speaker 2: 23:46

Estrogen

Speaker 3: 23:46

Helps, right? It has some other side effects and issues depending on , uh, your age and things. So for some women who are close experiencing menopausal symptoms, estrogen is a good way to , uh, treat symptoms and , uh, help the bones when you stop estrogen. The bones experience that just like when , uh, menopausal happens naturally. So thankfully we have other treatments. Um, one of the mainstays is bisphosphonates. Those have been around for a number of years. They're pills that you take once a week, once a day , uh, once a month. They don't grow new bone. What they do is they stabilize the existing bone and prevent deterioration of that structure. They're not used indefinitely. They're used usually for a few years and then a time off. I talk to patients about it . It's like you paint your house, you don't paint it all day, every day over and over. You paint it, it wears off, you paint it , it wears off. Um, so they're more like that and that's the usual starting place for, for most patients is that type of medication. And

Speaker 2: 24:49

Those have now been around a great long time and we know how effective they are at stabilizing bone mineral density. But we also know a couple of side effects. And as a primary care doctor, I hear this from especially women a lot. So how big a deal are the side effects either to the gastrointestinal system or what mo Everybody's afraid of the health of their jawbone,

Speaker 3: 25:11

Right? So I like to talk about side effects and then complications. Okay. Side effects are things that are temporary while you taking the medication. You might experience digestive upset. It can be anything from heartburn, belly pain, constipation, diarrhea, those things, they go away. When you stop the medication. Complications are usually a little more serious and that can be what we call medication related osteonecrosis of the jaw, which is a big mouthful, pun intended. Yeah.

Speaker 2: 25:38

In your mouth.

Speaker 3: 25:39

Right? And it's not only from bisphosphonate, but that's a , a common , uh, medication. Uh, that can cause that. Thankfully it's very rare. And if you maintain good oral hygiene and keep your teeth in good shape , uh, that lessens that. Um, the other rare, rare complication is some unusual breaks of the thigh bone . Thankfully, studies have shown us that when we take a time off those medication, those risks go down quite rapidly. The good news about taking a time off medication is that the benefits of the medication linger for a while . So you, you, you kind of have a , a win-win there.

Speaker 2: 26:17

Is there anything else that you haven't covered in treatments? Right ,

Speaker 3: 26:20

So for more advanced cases, we actually have bone building medications and those are things that I as a specialist , uh, help patients walk through and manage. And that's an another level of care, either because you've broken bones on the standard medications or the numbers are too bad. Uh , something like that that would wind you up in, in my office.

Speaker 2: 26:39

Before I let you go, let's talk about , uh, how to keep your bones healthy. Are there things that put people at higher risk for bone problems that they could perhaps avoid?

Speaker 3: 26:48

There are some things that are under our control and some things that aren't. Uh, the things that are under our control. We've already talked about nutrition, exercise, avoiding unhealthy habits. Um, and that's where you're smoking, drinking too much. Alcohol and recreational substances are probably the biggest factors that we have control over. How, how well we age and what other medical problems we develop is not so much under our control. Sometimes those problems themselves or their treatments can have detrimental effects on the bones. Usually your doctor who's giving you medications should be aware of that , um, and be guiding you. And they may say, because steroid medication taken for months can cause thinning of the bones, they may recommend a bone density test and a more close follow up for that potential problem. But that those are the main risk factors. Some cancer treatments that lower estrogen in women or testosterone in men also have a negative impact on the bones.

Speaker 2: 27:49

Tons of information about your bone health with endocrinologist. Dr. Anne Kearns . Ann , what tips would you leave us with about bone health?

Speaker 3: 27:57

I think if you're a woman at 65, you should be getting a bone density. It's a simple test. It's covered by Medicare and it will just tell you what the situation is now and then depending on the severity, what is recommended, maintaining a healthy lifestyle sounds generic. Uh, and it really is. But that's the best thing that we, we can do. Good nutrition, regular exercise , uh, and don't forget to enjoy life. Sometimes I see patients with osteoporosis and they start restricting their life and I'm a believer in we have to move forward and enjoy.

Speaker 2: 28:31

I love that. Last tip. Thank you for that last tip. We've been talking with endocrinologist Dr. Anne Kerns . She works with me here at Hennepin Healthcare in downtown Minneapolis. Thanks for being with us today.

Speaker 3: 28:42

Thank you very much,

Speaker 2: 28:43

David. It's been a great show. And before you came to join us at Hennepin, you worked down at the Mayo Clinic where I believe you wrote a book. Could you tell us about that?

Speaker 3: 28:50

Yes. I wrote a book specifically on the topic of bone health and osteoporosis, and it's aimed at the general public and it's called Mayo Clinic on Osteoporosis.

Speaker 2: 29:00

So listeners, if you wanna learn more about the subject, be sure to check out Dr. Kern's book and we will put a link to it in the show notes. That's all the time we have for today. But I hope you'll join us in two weeks when we will be talking about traumatic brain injury and concussions. It's gonna be a great show and I hope you'll join us. In the meantime, be healthy and be well.

Speaker 1: 29:19

Thanks for listening to the Healthy Matters podcast with Dr. David Hilden . The Healthy Matters Podcast is made possible by Hennepin Healthcare in Minneapolis, Minnesota. Please remember, we can only give general medical advice during this program, and every case is unique. We urge you to consult with your physician if you have a more serious or pressing health concern. Until next time, be healthy and be well.