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: 0:18

Hey everybody, it's Dr. David Hilden , host of the Healthy Matters podcast, and welcome to season three, episode nine. Today is all about cholesterol, what it is, and what you can do about it. To help me out today, I have a colleague of mine from Hennepin Healthcare. His name is W Anu . He is a doctor of cardiology. Yes, he's a heart doctor and he's gonna help us learn all about the effects of cholesterol on your heart. Ed , thanks for being here.

Speaker 3: 0:41

Hey, my pleasure. It's an interesting topic.

Speaker 2: 0:44

It really is . And , and you see the effects of high cholesterol all the time, but I wanna talk first of all about what exactly is cholesterol, what are lipids and the role in human health? So if you could start us out , define what cholesterol is, please.

Speaker 3: 1:00

Sure. So , uh, broadly speaking , uh, when we talk about , uh, lipids, the first thing that comes to mind might just be cholesterol, or we think of them as some sort of , uh, a fatty compound. And indeed, for the most part, the broad term lipids is organic compounds that are in our body that will include things such as cholesterol, and then fats go by the name triglycerides, but it goes beyond that. Um, other things that people might be familiar with will be what we call fat soluble vitamins. Very essential ones like vitamin K, vitamin E, D, A, all these are things we need from day to day . And they fall actually under the group of lipids. And a very large significant aspect of lipids that we may not be thinking about is something we call phospholipids. The whole infrastructure of every cell is made of phospholipids.

Speaker 2: 1:53

So are they necessary for our existence then? They're necessary for the human bodies , is what , what I'm hearing?

Speaker 3: 2:00

No lipids, no people.

Speaker 2: 2:02

Oh,

Speaker 3: 2:02

Oh . So it , it, you know, from many aspects of it, our , uh, persistence through many things we have gone through to be here, for instance, will require that triglycerides or fats were serving us as an energy source. The cave person will not be , uh, surviving if there were not this energy sources that are stored to allow for the aerobic activity. And you and I, when we're out there saying we're doing aerobic exercise, we're counting on the triglycerides to be cashed out. And that's how we're making energy out of it. The phospholipids, as I mentioned to you earlier, they are the walls of every cell. Everything we have is made of phospholipids and the heart functions the way it does. Uh, the brain functions the way it does because phospholipids are there because parts of cholesterol are there . Another, another very common place where people may be familiar with the value of lipids is people have heard of estrogen, people have heard of testosterone, cortisol, all these are cholesterol products. The first step of the production of all these hormones , uh, sex hormones or like cortisol, is , um, a hormone that's gonna be involved in stress response, electrolyte control, things like that. The first step of making them, it requires cholesterol. So in any aspect to look at it, when I say no lipids, no people, yes, if you do not have lipids, we won't be there. And now one question might ask then why? Why are we trying to get rid of this thing serious ? Yeah .

Speaker 2: 3:31

Why are we trying to get rid of 'em ? I was gonna ask you that very question. We have to have lipids. It sounds like we should have as much as we, as we can get our hands on, but we're always talking about trying to get rid of 'em.

Speaker 3: 3:41

Absolutely. And there lies, the issue with lipids is that what happens is in those bloodstreams, if there's too much of them lingering for too long, then this lipids start to become a nuisance, particularly the triglycerides and the cholesterol start to stick to the walls of the blood vessels. And by doing that, they start to block it. And that's where the heart attacks and other problems come . So it's too much of a good thing kind of , uh, issue we're dealing with.

Speaker 2: 4:08

Okay. So blocked blood vessels are clearly a downstream effect, no pun intended, of too much cholesterol or the wrong kinds of cholesterol. So help us out with those topics. Some of them are good, some of are bad, some of them you want to have more of, some of them you want to have less of. Could you talk us through the various profiles of the lipids that people will get when you go to your doctor and get your cholesterol checked, you get LDL, you get HDL, you get triglycerides. What do all those mean?

Speaker 3: 4:35

Yes , broadly speaking, when we are getting a blood test to look at our cholesterol, it includes a couple of those lipids, right? So the total cholesterol will have the triglycerides, which is one part of the lipids. Then they will have some components of cholesterol. And usually what we deal with end up being the good cholesterol called HDL. And many people remember it differently. HDL happy should be high. That's the good cholesterol. And then there's the LDL, you know, L lousy , um, you know, should be low , um, that sort of stuff. So there's the LDL cholesterol, the HDL, cholesterol, triglycerides, those are what you see when you get your blood test.

Speaker 2: 5:17

I love that, first of all, 'cause I always say HD l's good should be high. LD l's low should be, you know, is it should be low. It's bad. I like happy and lousy. Yeah. Okay, so we have LDL, we have HDL, we have triglycerides. What is the effect if they're high, if they're low?

Speaker 3: 5:33

Yeah, so in general, in general, when I, when I talk to people just to simplify, to kind of give them a broad understanding of what numbers would be reasonable, I speak of them in terms of dollars or half dollars. So what I say to them is, usually if your tall cholesterol is , is more than two bucks, you know, more than 200, probably something to pay attention to the bad cholesterol, we usually like it to be about a buck a hundred. And the more it starts to go above that, we start to wonder, is this something we should be thinking about? What other risk factors you may have the HDL, the good cholesterol, half a buck 50 cents, and then the triglycerides, we do not like them to go above a buck and a half. So 150, those

Speaker 2: 6:18

Are really good kind of broad categories to think of. So what is the effect then of someone who has numbers that aren't in those ranges?

Speaker 3: 6:27

Every time you're looking at , uh, someone's cholesterol and looking at the risk attendant to that and what to do with it, you first have to look at the overall heart risk of that individual. And the way I discuss it with people is that if you think of heart disease as something you're trying to protect people from, and then they're gonna be culprits, like they're gonna be difficult to handle, you know , uh, customers coming at you such as tobacco use , uh, such as high blood pressure such as high cholesterol and diabetes. The way to think about them is if you have only one of this difficult customers coming at you, probably you can't deal with it gently and not have to jump into aggressive treatment right away. Whereas if you have got more of them mixing up in that situation, so someone has some higher cholesterol numbers, but also high blood pressure than diabetes, you probably will be forced to have a more aggressive approach to it. So one thing that's worth looking at is your high number and my high number are gonna have different ways of being treated depending on what other risk factors are you carrying with you.

Speaker 2: 7:40

I wanna explore that a little bit more if we could , um, Dr. Anu , so it's not just about the numbers you get at your doctor, you have to put it in context of your own personal risk profile. How would somebody know , um, what their own risk profile is in , in other words, do you recommend that they just see their doctor or do they, should they go to one of those online calculators to do their risk? What do you recommend?

Speaker 3: 8:03

I like the suggestion of , uh, going for the online calculator because the more people are engaged in it, it's available there. Um , the more proactive they are there , uh, nobody can take care of oneself than oneself, right? So if they have some sense of what it is like before they go for consultation, I think that will be helpful. And these are available if people , uh, look them up as , uh, heart risk calculators or, you know, the term we use for heart diseases art, sclerotic, cardiovascular disease, quite a long word. But if you look at it in short, it goes as A-S-C-V-D. So if people look at A-S-C-V-D risk, there you have it, a calculator will show up and then it'll actually have you enter the risk factors that we will be looking at in the clinic setting. And in general, those are the four things I mentioned are the ones we call the modifiable risk factors. Um , just to repeat , uh, tobacco, diabetes, hypertension, and your cholesterol levels. And other than that, you enter your age and gender and then it'll speed up a number for you. So that will tell us the extent of risk.

Speaker 2: 9:13

So listeners, we'll put a link in our show notes to one of the common calculators if you're interested in calculating your personal risk. Before we move on though, <inaudible> , let me give you just a scenario. So I get my cholesterol numbers and the total cholesterol is high, it's in the two hundreds. My l DLS in, you know, in the mid one hundreds. My HDL is 30, so it's pretty low. What should I do with that?

Speaker 3: 9:35

So , um, in your case , um, with that calculator, we'll quickly find out, you know, based on your age, what are the risk factors? You know, you may have , uh, clearly the low HDL is gonna point to us that you are losing a protective , uh, factor as far as heart disease is concerned. So when we plug it in there, the calculator will give us what will be a 10 year risk for you. So your LDL is not that high ,

Speaker 2: 10:01

Uh , in the one 50 is not terrible,

Speaker 3: 10:04

But , so let's say it's in the one 50 . So let's kind of getting into the intermediate range. Um, but your HDL being low is gonna expose you there. If you say to me, my blood pressure is okay , uh, and all the other risk factors we discussed are non-existent, you probably will be a person that I'll say, you know, let's look at this another six to 12 months and see where we go. But let me add another scenario. And I know you are a very healthy individual, but let's

Speaker 2: 10:30

Just , oh, yes. And I'm, I'm a spring chicken too. I'm a yeah ,

Speaker 3: 10:33

You are, but let's make you, let's make you this , um, you know, 40 ish kind of person and then, you know, no other risk factors. Your blood pressure is stellar. You are like one 20 over seven ish. I look at that and I say, no , actually not worrisome yet, because for you that's , there's just that one character that's trying to bother us. It's no big deal. Let me take it to the other extreme and I'm not gonna wish it up on you. So we'll take another individual who, let's say, still working on smoking cessation, has diabetes, blood pressure is not stellar for this individual. Even if the cholesterol level was the LDL cholesterol would have been just 110, 120 , similar HDL iq , maybe even slightly higher, 35, 36, I still will be concerned about that individual again, because the other risk factors will be begging for the cholesterol and triglycerides to be taken care of, or they're gonna collaborate with the other risk factors and create a mess for

Speaker 2: 11:33

You. Yeah . So it's very individualized. I often do that with patients in the room. I will look at the calculator in the room and I will unclick smoking and watch your risk go down, or I will, I will unclick the high blood pressure so it gets your blood pressure under control. So it's, it's much more about your total risk profile. So let me pivot a little bit. Is high cholesterol, just to use kind of the general term, is it hereditary or is it all about what we

Speaker 3: 11:58

Eat? There is definitely , uh, some familiar component to it. What we have noticed is most people can address the familiar aspect of it by what they do. So the nature and nurture part of it can kind of be balanced. So if someone was to have a significantly high amount of cholesterol and they have managed to modify some of the things that they do, that sort of addresses the unfavorable numbers that , uh, people will get. But clearly there is a familiar component. Now, the diet part you mentioned is very interesting because out of the lipids, the triglycerides are definitely influenced by diet. The cholesterol part of it is not really significantly influenced by diet because the main generation of your cholesterol is your liver. We started with the premise that the cholesterol is so essential for your body. So if you say, I'm not gonna eat a lot of cholesterol, the liver will make sure to make more because it says, Hey, this person's starving for cholesterol, I'll make more for this individual. If you're eating a ton of cholesterol, the liver will probably step back a little bit. So , uh, that is why when it comes to management of it, when people say, well, if I, what if I just completely avoid all cholesterol related foods? Will I survive, you know, with getting my , uh, cholesterol lower? And I tell them, well , I mean your liver will make a little more. Exactly. So you can drop it by diet maybe about seven to 10%. Uh, but the cholesterol part of it is not very well managed by diet. The triglycerides are very well managed by diet.

Speaker 2: 13:35

That's a really good distinction. I've, I've often told people, you need pine cones and grays on grass your whole life, your liver's gonna continue to make cholesterol. And some of our livers don't have an off switch. No . And we're gonna talk about the off switch after the break, which is a medication class called statins. We'll take a deeper dive into that class of medications when we come back, stay with us

Speaker 4: 13:57

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Speaker 2: 14:34

And we're back talking with Isha Anu about cholesterol. Are you able to tell us what , what kind of a diet would be a healthier diet for your cholesterol profile

Speaker 3: 14:44

In general? Things that don't taste

Speaker 2: 14:46

Well arm . Yeah , exactly . So you gotta eat pine cones in grass <laugh>.

Speaker 3: 14:50

Yes. Yes. If we're gonna go that direction, so, you know, which, which are the foods that , uh, crank up our triglycerides. So we know them, they usually test good, you know, if we go to the state fair, they are , you know, all over to kind of pull us. And these are items that are , uh, the fried foods, you know, there is the animal protein that is , uh, involved in there . There is saturated fats. The way I look at it is, you know, people sometimes say to me, tell me the one food item I should avoid, or, you know, what will it be? And I said , I do not know of such a food, because again, it's a matter of moderation is what we're dealing with. I do not think anybody who went on to have a very nice ice cream or went on to have a great steak or uh , fried donuts , uh, here and there is gonna be the person I'm gonna be worried about. The problem will be when you hear someone saying to you, Hey , um, every morning my breakfast is fried donuts and then bake . It's like, well, we need to have , uh, a little bit of, you know, modulation of that diet.

Speaker 2: 15:49

Mad respect for that diet there. I have mad respect for that diet. The donuts and bacon diet.

Speaker 3: 15:55

Hey , uh, you know, convenience is what gets us there, right? So some of these things are easier to kind of pick up quickly it and get going. So they are convenient and that's how we kind of get in trouble. So when people say to me, then, what is the bad diet? I'll say, well, the bacon and , uh, donuts repeated every morning. That is bad diet. And those actually are the people who can do something with their diet, adding some hot brand whole grain to it, maybe adding some almond in there, changing some of the , uh, fats they cook with to maybe olive oil that make the biggest difference and , um, how their lipid composition will be. So I, I try not to offend one food part versus another by pointing at it as the worst enemy of the heart. It's the quantity that I would like people to

Speaker 2: 16:45

Think about. That's common sense. You're an equal opportunity cardiologist. Yes . I like to tell people, eat like you , uh, eat like you live in the south of France. But then maybe that's just my own , uh, uh, sure . Bias towards Mediterranean style foods. Okay, doctor Anu , let's talk about statins. They are among the most highly prescribed medications in the country. They're very effective, but all medications have positive sides and downsides. So I wanna delve into that. If we could, could you first start us out and tell us what are statins and how do they work?

Speaker 3: 17:13

So statins are our most common agent in the armamentarium of taking care of lipids at the basic form. They're actually compounds that were extracted from yeast. And over the years we have taken this yeast extract and we have modified it to become more and more potent in lowering cholesterol. How does it work? The statin goes to the liver and it interacts with an enzyme that's supposed to be involved in the processing of cholesterol. And by interrupting, it pretty much forces the liver not to have as much of cholesterol made . What is more than the liver reacts to this by producing excess amount of receptors that come to the surface of the liver and starts to suck out all the cholesterol from the blood vessels essentially, that are coming through. This is stuff we have picked up in our diet, for instance.

Speaker 2: 18:06

So it causes your liver to manufacture less cholesterol and it can help to suck out the cholesterol from your bloodstream. Absolutely. And they're highly effective at doing this. So why isn't everybody on one?

Speaker 3: 18:17

Well , um, there is the side effect aspect of it that , uh, we do not wanna put this in , uh, drinking water , uh, although if you have considered it, considering how prevalent heart disease is and how common cholesterol problems are. So that's why we go meticulously through that risk stratification we talked about to say who really will benefit from this as opposed to the possible side effect that might come from it. I've

Speaker 2: 18:42

Known some cardiologists who just about wanted to put it in the, in the drinking water.

Speaker 3: 18:46

Oh, absolutely. Absolutely. Um , be because of how, you know, heart disease is the number one killer still, you know, worldwide, if these drugs have the ability to reduce cholesterol and thereby reduce those plugs building inside the blood vessels, why not? But we have noticed that particularly when the statins are getting used at the higher levels, they start to irritate the liver a little bit. And they also , uh, have been associated muscle and joint aches and, you know, people, people don't like that. So because of that, we refrain from , uh, uh, just spraying them all up ,

Speaker 2: 19:23

Giving it to everybody. Yeah. Uh , before I get a little bit more into those downsides, because I hear about that as a primary care doctor all the time, people are so worried about these side effects of statins and they're real, they really are. But heart disease is so exceptionally common, remains the leading cause of death in the country by far. And statins are also proven to reduce the risk for many, many people. So I would like to focus for a moment on their benefits. Mm-Hmm . <affirmative> . Um, who would benefit from that? And is this proven or are we just guessing? It

Speaker 3: 19:54

Has been proven , uh, again and again, we have proven this , uh, now for over 40 years that these medications actually work. Um, who should get it takes us back to that method of calculation we're talking about before. To step back from that calculator though upfront , anybody, let's say who has diabetes as a candidate for this medication? So we look at that, people who have the familial type of high cholesterol, particularly if they're bad cholesterol, their LDL cholesterol has climbed above 190. They're right away candidates for this , uh, treatment. For people who unfortunately already have had a stroke or a heart attack, all of them should be protected by this

Speaker 2: 20:39

Medication. Just about every one of them ,

Speaker 3: 20:41

All of them. There has to be a good reason where something has happened due to a side effect or something where you cannot take it otherwise. Aspirin and statin are pretty much things you're gonna be taking for the rest of your life because they have proven to be protecting you from recurrent events. So the old challenging group then that is left is okay, people didn't have diabetes, they don't have the wacky , uh, close to 200 of just a lousy LDL cholesterol. They have not had heart attack or stroke. That is a majority of us. How do we do it? And for those, we always go back to that calculator we talked about. And once we notice that your 10 year risk, which is that what calculator tells us, your 10 year risk of heart disease is starting to creep about 10%, you start to become a candidate for , um, statin. And that 10 year risk is not just based on your lipids, it's gonna be based on all the other , uh, collaborators. We talk about

Speaker 2: 21:37

All those other risk factors. So if you are not one of those people in the highest risk groups, diabetes, extremely high, LDL already had a heart attack, but most of us, the risk calculator is a good next step. And if it's pushing 10%, you might wanna consider a statin. I think that's really important to know. And I would echo that , um, to, to listeners that these medications are about as studies as anything there ever has been studied. So, and I always say that science isn't truth, it's the seeking of truth. And we, we learn new information and doubt is an actual part of science. We continue to study things and statins have been studied a great deal. So I would concur with that, that that the benefit is outweighs the risk for those groups that we've just talked about . Absolutely. Now let's talk about the downsides. What are the actual side effects and what are maybe real and what are maybe myths?

Speaker 3: 22:26

So if you dare go onto the internet and look up how bad statins are, I think you feel like you're reading about arsenic or you know, <laugh> sign some , some, the most dangerous thing you have ever seen. I will be very comfortable to say that of all the drugs you'll be seeing laying in the , uh, pharmacy , uh, including aspirin. By the way, statins if not used at the highest dose, are probably the safest medications you can ever use. And if anybody will question this, I would like to hear why they think so. So,

Speaker 2: 23:05

Oh , I read it on the, in internet, Dr ,

Speaker 3: 23:07

Dr

Speaker 2: 23:07

Io . I

Speaker 3: 23:07

Read it. Oh, there, there are cults. I have noticed <laugh> because, you know , um, some people come to me and say, have you noticed, you know, it can't do this. I'm like, well, you know, it says one in a million is what it has done. You know, that's what that , that's, and

Speaker 2: 23:20

You've got about a one in three chance of having a heart attack.

Speaker 3: 23:22

Yeah . So yeah, yeah, they do something. But I will emphasize, I'll emphasize that the biggest trouble people get in statins, you know, when they're working with their providers is that there is tremendous enthusiasm for someone instead of using a regular hammer to take a sledgehammer. So let's say, let's call one of the generic ones, atorvastatin. You know, if you're using atorvastatin, instead of trying to get away with , uh, 10, 20 milligrams of it, you take 80 milligrams of it and wax someone with it, they're ambitiously trying to reduce their cholesterol. Side effects will come through. So if you are using them at the lower dose, starting dose , 10 milligrams, 20 milligrams of these medications, I will challenge anybody to come back to me and show me how at dose doses, liver gut irritated or they were muscle X or anything like that. So the bad drop for statins is really a dose dependent thing that we have kind of got involved in and we don't know how to get out of it. But as a lipid expert, that's what I do in clinic all the time. Uh, people get sent to me saying, you know, person has refused, person has side effects, so on and so forth. I take them on five milligrams of it. I tell them to take it, take it morning, take it evening whenever you want to. And I'll tell you, success rate of getting people back on statins, still tolerating it, their liver tolerating it, it's about a hundred percent.

Speaker 2: 24:48

Yeah. So if, if you're not, if you think that your statin's causing you side effects or you're just worried about that, perhaps go find a doctor such as Dr . Anu here, who can work with you on your doses, your timing, all of that. Absolutely. Um, that makes perfect sense to me. Okay, so I'm on my statin. Does that mean I can just do whatever I want, then can I have that donut and bake it and diet, or is there anything else I'm supposed to do?

Speaker 3: 25:09

I'm very glad you brought that up because every time statins have been studied and we have guideline recommendations from the American College of Cardiology or American Art Association before the statin prescription already, it says therapeutic lifestyle changes should have been fully deployed.

Speaker 2: 25:26

Therapeutic lifestyle modifications. Yes.

Speaker 3: 25:29

Yes.

Speaker 2: 25:30

Does that mean like, I gotta live healthy,

Speaker 3: 25:32

Something like that. So we're talking about the exercising most days of the week for about 30 minutes. And then from your diet, again, not , uh, doing the donut and bacon, you know, every morning , uh, but rather mixing it up with maybe oatmeal, few, few of those mornings and such. So people should not think of the statins , uh, for that matter, any kind of medication as , uh, a pure alternative to the other when they are studied and when they're recommended. Always the cornerstone of the treatment is going to be the therapeutic lifestyle changes. It is an addition to that, that you like to put the statins. So unfortunately, no, it's not take statin and eat donut . It'll be yes, you take the statin, continue with the lifestyle changes and things will work better that way.

Speaker 2: 26:23

Is there anything on the horizon , um, beyond statins? I know there are some newer medications, they're not for everybody, but what, what does the future look like?

Speaker 3: 26:30

There are some , uh, medications , uh, on the horizon. Most of them are injectable agents that , uh, do lower, they focus on lowering the LDL cholesterol. There are some they're looking at for elevating the HDL cholesterol, but the impact of those has not been good. So right now , uh, on the market , uh, there are a class of drugs called the QMAPs . The couple of them people may have run into that are the injectable ones. And then another drug called , uh, inion that's also an injectable drug that , uh, does the LDL lowering. But mainstay continues to be statin.

Speaker 2: 27:08

Yeah . And those are only for people who is really, really at high risk and the statins aren't completely doing the job. Right.

Speaker 3: 27:13

Absolutely. They are very rarely used . I have , uh, uh, very few of them in my clinic. Yeah. So

Speaker 2: 27:18

Everybody out there, you should be working on your risk factors, your therapeutic lifestyle modifications, and your statins before you go to those

Speaker 3: 27:26

Absolute point.

Speaker 2: 27:26

Okay. As we wrap up here , uh, Dr . Anu , if you could give listeners some tips about their lipids, what would they be? You

Speaker 3: 27:34

Know, over the course of this discussion, I think we hit on some highlights, which I would like to refocus again. And one is the more engaged a person is in their own care and be aware of their lipids and what their risk is, I think they're gonna get the best care. This best care is gonna be obtained by them sharing the decision making process with their provider. And the more they know about it, the more they have maybe probed that calculator. I think that will have , uh, good results when they're talking with their provider. I don't wanna say challenge their provider, but ask their provider, is this dose really appropriate for me? Always settle forth the lowest possible dose if you have to be started on a medication. And final point I'll say is the lifestyle changes are not to be replaced by anything. The whole focus of the treatment and whatever thing you do in cardiovascular , uh, risk reduction has to be therapeutic, lifestyle changes, and then if those have not worked, maybe consider a medication.

Speaker 2: 28:31

That sounds like absolutely outstanding advice. Thank you for being on this show today. We've been talking with w Anu , a cardiologist here with me at Hennepin Healthcare in downtown Minneapolis. Thanks for being with us. W Hey ,

Speaker 3: 28:43

Good for having

Speaker 2: 28:43

You . It's always great to work with you. I've worked with Dr. Anu for years, and so I have learned a great deal from him. And I think perhaps you have two today on the show. Two weeks from now, we'll be talking about a LS otherwise known as Lou Gehrig's Disease, and I hope you'll join us for that episode. In the meantime, be healthy and be well.

Speaker 1: 29:02

Thanks for listening to the Healthy Matters podcast with Dr. David Hilden . To find out more about the Healthy Matters podcast or browse the archive, visit healthy matters.org. You got a question or a comment for the show? Email us at Healthy matters@hcme.org or call 6 1 2 8 7 3 talk. There's also a link in the show notes. The Healthy Matters Podcast is made possible by Hennepin Healthcare in Minneapolis, Minnesota, an engineered and produced by John Lucas at highball Executive producers are Jonathan , CTO and Christine Hill . 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.