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 three of season four of the Healthy Matters podcast. I am David Hilden , and today I am joined by a colleague of mine at Hennepin Healthcare. Dr. Lynn? No , he is a rheumatologist and yes, I'll try to get him to explain what that is in a little bit. But today our main topic is gout, and so you maybe have had gout or you know, somebody who has gout, but we're gonna dive deep into what it is and what can be done about it. Dr . No thanks for being here. Thanks

Speaker 3: 0:46

For having me.

Speaker 2: 0:47

Great to have you on the show, Landon. First of all, just lay down the basics. What is gout?

Speaker 3: 0:52

Yeah, gout is a , uh, very old standing disease. It was originally known as the , uh, disease of kings. And one of the things that we know now is that everyone seems to be a king. The prevalence of gout has done nothing but gone up over the last five decades. Current estimates, we have just about 12 million people in the United States with gout. And gout is a disease that can be terrifying for a lot of people who suffer with it because unexpected sudden attacks of gout are extremely painful. For some they say it's the worst pain in their life, and then for some they say it's their second biggest pain in their life after childbirth. And so trying to emphasize a little bit more awareness about it and how to take care of it is kind of on our to-do list.

Speaker 2: 1:35

I have heard that a couple things that I've heard that it is the disease of kings Zika's , like in Tudor, England, Henry the eighth , or somebody had it, or something like that.

Speaker 3: 1:43

Yeah, and it , um, we can get to that in a little bit too, but it has to do a little bit with the , uh, idea behind , uh, diet and , uh, gout. Because in the time of when the kings of England who suffered from gout, they had very rich foods, rich in alcohol and meat, things that were not accessible to the common folk. And so we wouldn't see that so much in the common folks versus the , uh, royalty or the aristocrats. And nowadays we are kind of seeing that pretty much across the board with everyone. We all eat

Speaker 2: 2:13

Like Elizabethan king's. Okay, so what is it? What, what is happening in the body?

Speaker 3: 2:18

So gout is simply put a problem with uric acid. Uric acid is something that we're all born with. We all are supposed to have it. Um, the problem is that too much of a good thing is a bad thing, essentially, is what it comes down to. Um , when we have too much uric acid for a long period of time, we start running into these gout attacks. Now, gout is not just gout attacks , uh, that's the worst of it, but long term though, gout is also what we think of joint destruction as well, gouty arthropathy. And so we want to think of stopping gout, not just so much to stop the attacks, but also to prevent long-term damage to joints. So when people have elevated uric acid levels for a while, five plus years, they start forming these crystals. And these crystals seem benign enough, they're microscopic. You can't see 'em with your naked eye into your soft tissues. That means underneath your skin and your joints, muscles, et cetera . And your immune system eventually finds one of these things and says, Hey, you don't really belong here. And incites a very strong, powerful reaction akin to you, you know, twisting your toe, dubbing your toe, dropping something heavy on it, and there it is. Uh , it gets very red, hot, swollen, painful, it comes on very suddenly. Most people describe it coming outta the middle of the night. I use the example of the toe because that's the area that a lot of people first get into gout attack, but it's not the only one. People can get it really any joint. But lower extremities, the dependent areas seem to be more affected .

Speaker 2: 3:46

I have heard this about the toe and I've seen it over the last 20 some years. That's where people get it a lot, but it doesn't have to be just your big toe. But do we know why it is so commonly this painful inflammation of your big toe? I mean, why not the fourth toe? Why <laugh>? Why is it the big toe?

Speaker 3: 4:02

Good, good question. I think it actually has to do with a little bit more mechanics. So first gravity, gravity pulls things down, and so your foot is gonna have a higher concentration of uric acid throughout the day. And so if it were to collect and crystallize and form these crystals, it's gonna probably go from low and then work its way up. The other thing too is that your big toe is also the area that we put a lot of stress through. So when you're taking a step or stepping upstairs or anything like that, that area seems to bear a lot more burden, a little bit more stress than say for example, your fourth toe. And so that might be another area that seems to attract more immune presence because of that.

Speaker 2: 4:39

In all my years of treating patients, I've never really thought, why is it the big toe? So thanks for at least exploring that one with me. But it can be other joints as well. These crystals can go in , this inflammation can happen in any joint.

Speaker 3: 4:50

Absolutely. For example, the very first attack for the very unfortunate can sometimes be in the ankle. And the bigger the joint for an attack, the more of the pain is. So one of the worst places to get an attack would be like, for example, the knee or perhaps the elbow. That's when we see people in the hospital. They'll come into the hospital because the pain is so severe and nothing , um, wrong with doing that because , uh, the pain is quite bad. And so one of the things that people are afraid of is that maybe they have an infection in that joint because the pain is unreal.

Speaker 2: 5:22

Why is the pain so bad? I have heard people say, especially when it's like in your lower extremities, in your ankle or your big toe, that the weight of the bed linens hurts. It's just that painful. Yes. Why does it hurt so dang much?

Speaker 3: 5:36

That is a really good question. And that has to do with the level of inflammation that's involved with it. So of the things that cause that level of inflammation, infection of the joint is the other one that's up there. And when people get gout flares and at the peak of their attack, what'll happen is that there's so much immune presence in that area to clear these crystals out, that your immune system essentially can't tell the difference. If it's really fighting gout crystals versus an infection or a bacteria present inside of your joint, it acts the exact same way and that's why the pain is so high. So

Speaker 2: 6:10

How would , how would a patient know they've got this swollen, big toe or ankle or knee or elbow, it's really swollen, it's painful, it might be red. How do they know that that's gout versus something else? What should they know and what should they do? I

Speaker 3: 6:24

Guess I think first is the , the level of pain. Um, the pain is gonna be unreal. And then when they look at it too, it's gonna look very, very, very, very different compared to what it looked like, for example, 12 hours prior. So when you look at your affected joint and you see that, hey, I can't even get a sock on anymore, it won't fit, or it's too tight or it's too uncomfortable, I can't even get my shoe on. Same thing that usually stands to reason that perhaps that this is more of a inflammatory process and that makes gout a little bit more likely. And again, this is for a lot of folks, the worst pain that they've ever felt. So

Speaker 2: 6:57

I have heard on other people say what you said earlier , uh, just a few minutes ago, that , uh, for people who have delivered a child, that might be some of the most severe pain or the most severe pain they've ever experienced. I think gout is a close second. Yep . So if you have not had the honor and the privilege of delivering a child, you don't want to get gout. Let's just put it that way. Um , is it the same as arthritis?

Speaker 3: 7:18

Um, no. So gout and gout attacks are inflammation in a nutshell. It's a very quick response of your immune system to clear what it thinks is an infection. Essentially, arthritis is a long standing progressive. You can kind of think of it as an aging process of your joints akin to getting gray hair. You get it eventually. You can't do much about it. It's slow to go, but it doesn't really bother you that fast that quickly. You just kind of notice it a little bit more day by day.

Speaker 2: 7:48

Gout, you know, it, you were fine yesterday. You're not today. Before I get into treatments, which we're gonna do after the break, I would like to do a little bit about prevalence and what causes it and what are some of the risk factors for getting gout. And I mentioned earlier that you're a rheumatologist very briefly. What

Speaker 3: 8:04

Is that? So a rheumatologist at the basics, the , uh, named rheumatologist essentially means that we take care of people with joints. However, I would say that definition of the profession has really evolved over the last 50 years. And because the understanding of autoimmune disease has changed in the last 50 years now, we recognize that people who used to suffer with things like psoriasis and then swollen knees or swollen joints out of the blue, they have an underlying autoimmune disease. And that's what rheumatologists really focus on. Now we focus on treating underlying systemic autoimmune diseases like psoriatic arthritis, rheumatoid arthritis, and lupus. Those are probably the most well-known ones. Yeah.

Speaker 2: 8:47

People don't often know what a rheumatologist says . It's not just your arthritis. I think it's one of the most complex specialties in our department of medicine. Rheumatology is part of the Department of Internal Medicine and Hennepin Healthcare, and they deal with some of the most complex , uh, systemic conditions. So , um, thank you for that. Okay. The prevalence of gout, you said 12 million people said on the rise, and why is it so many? Yeah,

Speaker 3: 9:09

So , uh, I would say about just about a decade ago, the uh, number was probably sitting around 8 million , uh, US Americans. Uh oh . And now it's right around probably about 12.1. And that data's a little bit behind because the best data that we can get is about four years old. So yes, the rate of gout in the United States is increasing. And the reason why it has to do with a little bit of our, our health, our overall health gout is a little bit more complex than just what we eat. It also has to do with our overall health. It ties in with our body size, our body shape weight, it ties in with our other medical conditions, diabetes, heart disease, medications that we take as well. And then finally, of course, it does tie in with our food, our diet and what's available , uh, now is different than what it was 10, 15 years ago. So you

Speaker 2: 9:59

Talk about uric acid, I don't think most people know what foods have uric acid. I bet it's in a lot of things. Yeah. Should we go there? Should we talk a little bit about diet and it's, its role in gout?

Speaker 3: 10:10

So people really do talk a lot about food and gout. The first thing that you'd find when you Google gout nowadays is, you know, recommendations from everybody about what sort of foods you should and should not eat. And the answers out there are really diverse. But if you look at experts in the field who have done research in it, it really comes down to a simplified list. It's all the good stuff. Yes, it is against , uh, again , um, the disease of kings <laugh> . So , uh, for example, red meat. Uh, red meat is a , uh, big instigator. It increases the level of uric acid in your body if you consume it a lot considerably. Seafood, for example, things with a shell on it. So it's gonna be the lobster, the crayfish, the crab , the shrimp, all the rich seafood. In other words, that's gonna be an instigator. Alcohol of any variety definitely increases uric acid. And something that we don't emphasize enough is the products in the United States that have a little bit more sugar in them, they typically carry a little bit more of high fructose corn syrup. High fructose corn syrup has also been linked with higher levels of , uh, uric acid elevation as well. And so whenever you pick up a regular soda juice or something like that, and that usually is gonna be the thing. So

Speaker 2: 11:22

You just think of that giant banquet table in a castle in 16th century England, everything on there, <laugh>

Speaker 3: 11:29

Pretty much. Yeah.

Speaker 2: 11:30

Uh , but what you said is so important is the , about the , the stuff that we have now, I'm still trying to find the redeeming quality of high fructose corn syrup. It is , uh, um, with all apologies to the businesses and the industries that rely on it, and the lovely taste of that. It's not good for you.

Speaker 3: 11:47

No, not really.

Speaker 2: 11:48

It just isn't. Yep .

Speaker 3: 11:50

So

Speaker 2: 11:50

Do men get it as much as women, women more than men? Is it it not, not, not differentiating.

Speaker 3: 11:55

Uh, that answer's a little bit more complex. So up to a certain age, men do get gout a lot more than women. So for most people, I would say between the ages of 20, all the way to just about 60, it seems to be men much more than women. And then after 60, it seems to even out. And the reason has to do with the differences in our physiology. Women have more estrogen secretion and presence in their body up until the age of about 45, and then in which menopause occurs, and then the estrogen levels drop off. Now, estrogen is something that protects people from having very high uric acid. Estrogen tells our kidneys to essentially take out all the extra uric acid in our bodies. And so for most women, it's really hard for them to get gout as long as they have estrogen premenopausal for men. However, androgens testosterone, as soon as puberty hits the uric acid responds in kind. So as testosterone increases, uric acid increases as well. And we don't really have another hormone in our body that kind of offsets that. And so men are a little bit more susceptible because of that. At

Speaker 2: 13:03

Least as until you hit menopause women. That's right . And then you kind of catch up. That's fascinating. I don't think I knew that, that that that complex , um, role of the mm-hmm . <affirmative> of these hormones that which is what estrogen and testosterone and like are. Um, thank you for that. What about family history? Is it genetic?

Speaker 3: 13:18

Yes, absolutely. So , um, one way you can kind of see that now is the change in the demographic of the United States. Prior to about 2018 , uh, the demographic group who had the most gout in the United States were definitely African American men. Um, after 2018, data now supports Asian American men. Um, and that has to do a lot with genetics. It means that yes, there's family history, so if your mom, dad, brother, sister has gout, risk goes up a little bit more. But it also goes to the question of how do you get gout? It's not just through food. Food is part of the equation for sure, but the other part is just who you are, your DNA , if you will. And so for some people, we have a predilection to hold onto uric acid more, and that's definitely more true of Asian Americans. And then we also have certain people that just simply make more uric acid in their body. They take whatever you give them in terms of food and they crank out uric acid. So that's how you can get little bit more higher levels of uric acid. That

Speaker 2: 14:19

Leads to my next question is how do you diagnose it? Are we checking uric acid levels or are we looking for the pretty crystals? And listeners? I have seen gout crystals under a microscope. They're

Speaker 3: 14:28

Beautiful. Yes. They're , they're

Speaker 2: 14:29

These yellow kind of pretty things.

Speaker 3: 14:31

Yeah. If you have bad enough gout, it looks like Christmas. When you look at a , uh, uh, somebody saw takes me

Speaker 2: 14:38

Back tissue , me skull takes me back to when they made the colorblind me look at things in the microscope. And everything looked about same color, but gout didn't. Yep . It was these beautiful crystals. Yep . They're not so beautiful when they're in your big toe.

Speaker 3: 14:49

No . Uh, patients are not impressed with , uh, the appearance of the crystals when they're suffering from the attack. So

Speaker 2: 14:54

How do you diagnose gout then?

Speaker 3: 14:55

So , uh, diagnosing gout, this is actually really helpful for patients to know. Uh, so that's part of how they recognize if they have gout. So we define gout as something called monoarticular, meaning that it's usually just one place that starts off with an attack. So if you have one swollen joint out of the blue, sudden onset, meaning that it happened to say, for example, overnight, no trauma or anything like that beforehand, you can't explain why it's happening. And it's very, very rapid. So within about 12 hours of feeling a little twinge in that joint, it goes to being very swollen, very red, very painful, very warm, all within 12 hours. So it's a very rapid thing. So if you're kind of seeing that, that is very helpful. And then finally, knowing a little bit more about your personal history, if you're somebody that struggles from high blood pressure and you take high blood pressure medicines, those medicines oftentimes are linked to having higher levels of uric acid. You shouldn't stop taking them, but you should be more aware that, hey, I am a little bit higher risk of it. You look at your body weight, if you notice that, hey, my BMI is something that I do wanna work on a little bit because it's on the higher end, that does put you at higher risk. And of course family history, if you know that your father struggled with gout or your brother struggled with gout, that makes it a little bit more likely too . Rheumatologists used the exact same clues to help diagnose gout. Back in the old days, we said that the only thing that you could do to diagnose gout was to take fluid outta someone's joint. Look at it in the microscope. That is not true anymore. Nowadays, the story of what we're talking about right now, the elements of history and the person's , uh, medical history is just as helpful. So if we know these elements and they check yes, true, we can diagnose people with gout just by using the story alone. If we wanted to get fluid from the joint, we can definitely do that. We have many ways to do that now. It's still not the most fun process in the world. Yep . <laugh>. Yeah. And then we also have ways now to , uh, look at the joint underneath the skin as well, without having to take fluid. We can use , uh, something called ultrasound. Ultrasound has very distinct features when people have gout and a gout flare. And then we also have something called dual energy ct. Dual energy CT is newer to us, and we do have it here and it allows us to visualize and reconstruct, for example , uh, foot and kind of map out and draw the diagram of the skeleton of the foot, all the bones, and it will actually draw out the crystals themselves on the surface of the bones. So you can get an idea of how many crystals there are there too. And how big a problem it really is.

Speaker 2: 17:32

We've come a long way from King Henry vii . Absolutely. So we're learning about gout with Dr No rheumatologist at Hennepin Healthcare in downtown Minneapolis, and never fear folks. Help is on the way. We're gonna talk about treatments and what you maybe can do to reduce your risk of getting out and what you should do if you do have it. So stick around, we'll take a quick break and then we'll be right back.

Speaker 4: 17:56

When Hennepin Healthcare says we are here for life, they mean here for you, your life, and all that it brings. Hennepin Healthcare has a hospital HCMC and a network of clinics both downtown and across the West Metro. They provide all the primary care and specialty care you would expect to find, but did you know they also have services like acupuncture and chiropractic care available at many of their primary care clinics and at their integrative health clinic in downtown Minneapolis? Learn more@hennepinhealthcare.org. Hennepin Healthcare is here for you and here for life.

Speaker 2: 18:34

And we're back talking about gout with Dr. Lynn. No . Okay. So Lynn , we've, we've talked about the prevalence and what it is and how painful it can be. Now let's talk about what can be done about it. So is there a cure for it? Is there a treatment for it? What do you do?

Speaker 3: 18:48

Uh, that answer is there's definitely treatment for it, and it almost is a cure. So let me emphasize that a second. It's almost a cure. The way you take care of gout is simple. You know, it's caused by high uric acid. The treatment is to lower the uric acid. You could do it via a combination of waste . Medications are probably the most effective. We have a couple of different ones in the United States, and then also the things that we can do in our day-to-day life, that can also decrease the amount of uric acid in our body as well. Those two things right there essentially will treat and prevent gout attacks for the remainder of most people's lives if they're, they're focused on it. So let's

Speaker 2: 19:24

Talk about the first one, reducing uric acid. These are medicines that you take every day?

Speaker 3: 19:28

Yes. So we have a few different medications that you do need to take every day and you wanna be consistent with it. And the key things I would impart is that it's not a one size fit all type medications. These are medications that are tailored to the individual. So what you do is very simple. You start somebody at the lowest dose humanly possible of a medicine. You check their uric acid in a few weeks. If it's higher than where you want it, you increase the dose and you keep ongoing until you get to your goal, the goal for that patient. And once they get to that numerical goal, that uric acid their G attack , stop and that's it. Yeah . Yeah.

Speaker 2: 20:01

That's, it's actually, they're really effective these medications to lower uric acid. So that's the first thing. What about avoiding the amount of uric acid you put in your body? We talked about some foods earlier that, that we've already gone over, but what do you tell patients about about their diet? Because you can't just say, don't eat any of that.

Speaker 3: 20:19

Right? We do like to, at least here, we like to emphasize quality of life. We wanna try to encourage adherence because if I tell somebody, I know you love steak, but you can never, ever, ever have it again for the rest of your 60 years on this earth, they're just gonna leave. They're not

Speaker 2: 20:35

Gonna leave state . They're gonna leave their rheumatologist. Yeah,

Speaker 3: 20:37

They're gonna leave me. Yeah. And so I tell them, Hey, be reasonable. Do it in moderation with these medications. You can have this stuff, but you won't be able to have it as much as perhaps you'd like. And that's usually enough where the patient says, okay, I see value in this medication. And then I also see that you're trying to help me keep my quality of life too. I enjoy this, this is part of me. And so we don't emphasize, Hey, you need to cut out anything. We really try to say everything in moderation. So

Speaker 2: 21:07

That is sort of how to reduce future attacks of acute gout with what you eat and maybe take a , a uric acid lowering medication. What about during an acute attack during that agonizingly painful few days?

Speaker 3: 21:20

Yeah. What ,

Speaker 2: 21:20

What do we do about that?

Speaker 3: 21:22

If you know you have gout and you're experiencing the beginning of a new attack, the best thing that you could do for yourself is take an anti-inflammatory. A lot of doctors will prescribe patients a variety of different things from a medication called prednisone to colchicine or very popular endeth is the other one as well. But really any anti-inflammatory will work, whether it's ibuprofen or naproxen. You just gotta make sure you take enough of it and take it early enough. You wanna take it in that first 12 hours of feeling the , uh, onset and attack. And if you can do that, you can save yourself several days of agony. Sounds

Speaker 2: 22:00

Good. That's treatment. I do wanna talk about some of the longer term effects of gout on the human body. Other than just the acute attacks. Are there effects of high uric acid levels? In other words, if you don't lower your uric acid levels, you get these acute attacks, but is , are there other effects on your body long term ?

Speaker 3: 22:20

Absolutely. So we have seen that uric acid being too high in the body for a long time has been linked with increased kidney disease and increased risk of kidney disease. So for people who already have it, and we now see their uric acid elevated, we're more motivated than ever to help them lower that uric acid because we don't really want people to progress towards

Speaker 2: 22:43

Dialysis. Right. Kidney disease, something to be avoided. So people should take it seriously, not only because it's an agonizing week of your life when you have an acute attack, but also because there aren't long term effects of having high uric acid levels forevermore in your bloodstream. Is there anything non medicinal? I I, I'm thinking of this question that I'm asking you, and I treat gout all the time, or at least I treat the initial stuff. I usually send them to a guy like you who knows what they're doing more. But I'm trying to think of , are there non medicinal things you can do other than what you eat? Yeah,

Speaker 3: 23:13

Absolutely. Being healthy. I mean, gout and uric acid is really tied to how healthy we are. Usually that's the case. And so if we lose weight, our uric acid comes down. If our blood sugars are better, our uric acid comes down. If our blood pressure is better, our uric acid comes down. And so when you take care of yourself overall in making your body healthier, your uric acid tends to respond. So

Speaker 2: 23:39

It's, it's sort of like a , a theme that happens on this podcast is I bring a specialist in to talk about a specific condition and it , it is actually a theme. Healthy life choices are really important. Absolutely. They just really are important. I, I love that actually about this is that regardless of what topic I'm talking about, I get a , an expert in a topic and they say, you know, you need to eat right and, and exercise and be healthy and not smoke and all those things.

Speaker 3: 24:04

Absolutely. I mean, we emphasize that in our clinic. We tell our patients, if you're trying to find a diet rather than trying to find things to avoid, why don't you look for things that you should eat more of? Uh , Mediterranean diet is excellent. The dash diet is excellent too, but Mediterranean diet has been associated with lower levels of uric acid across the board. And so if you just wanted to make a simple change when you look up Mediterranean diet and recipes and whatnot, that's a really good place to start.

Speaker 2: 24:32

That's why I wanna move to Myorca . Okay. Now , um, before I let you go, is there any future research or is there, are there any future treatments for gout that, or , or diagnostics that excite you? Um,

Speaker 3: 24:43

Very rarely. We have situations where gout is very, very challenging to control. And the medications that we currently have simply don't fit the bill. And when that happens, we are currently left with a scenario where we have to give bad news to patients. And I really don't love doing that. And so I'm excited about some new , uh, therapies on the horizon that allow us to give medicines , uh, called uricase that just destroy uric acid. In a nutshell, it's an enzyme that we , uh, as humans have a gene to encode, but it's a vestigial gene, meaning that it's a gene that no longer is active through time. Humans have lost the ability to use it. Most other mammals in the world still use that gene so they don't get gout. So when you make uric case this enzyme to any uric acid in your body, it's immediately destroyed. And so this is now something that we're currently looking at using to give people to get rid of all the uric acid present in the body.

Speaker 2: 25:46

That just gets to the root of the problem. Then it , it isn't trying to excrete it out of your body, just destroy it in your body. So that's why my dog doesn't get gout, you know, <laugh> , certain

Speaker 3: 25:56

Dogs, certain

Speaker 2: 25:57

Dogs do some get it? Yes.

Speaker 3: 25:58

Oh, dalmatians,

Speaker 2: 26:00

Dalmatians. Get gout. Okay. If you've listened to this far in the podcast, we have just given you a bar trivia answer for the ages. The one breed of dogs that gets gout is dalmatians. Yep . My black labs safe maybe. Yep . We're talking with Dr. Lin . Know about gout. He's a rheumatologist at Hennepin Healthcare. And Lynn , if I could ask you to leave our listeners with the main points that they should know, what would you like listeners to remember about gout?

Speaker 3: 26:26

I always tell my patients, if you could take three things away from this visit today. Um , number one, I want you to know that uric acid, you have too much of it. You were born with it, it's okay, not your fault, you just have too much of it and it's giving you a problem. Number two , there are ways to get rid of your uric acid. And number three , the

Speaker 2: 26:42

Uric acid can be removed by either medication or lifestyle modification. I recommend both Great tips, listeners, if you are struggling with gout or you think you might be, or you know someone it is and you're wondering where to get help, I hope you have learned something from this show, as have I, and I hope you'll seek medical attention. If the case may be, if you happen to be in downtown Minneapolis, we have outstanding rheumatologists at Hennepin Healthcare. Dr . No thanks for being here today. It's a pleasure. Thank you. It's been great having you on the show today. Listeners, I hope you'll tune in for our next episode in two weeks time, and in the meantime, be healthy and be well.

Speaker 1: 27:18

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. 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, and 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.