Facing the complexity of obesity and its societal stigmas, Dr. Jessica Smith, Director of Bariatric Surgery at the University of Iowa, joins Tammie and Maria to unfold the layers of weight management and bariatric surgery's role in community health. Their heartfelt discussion traverses both my own personal struggles with weight and Dr. Smith's evolution in the field, revealing the intricate tapestry of patient care and the lifetime connections forged. We challenge the prejudices surrounding obesity with a blend of education and empathy, aiming to reshape the narrative and provide a beacon of support for those on their weight management journey.
Weight isn't just a number on the scale; it's a story of metabolic mysteries, societal pressures, and the power of transformation. In this episode, we explore the underappreciated value of strength training and how bariatric surgery can reboot a patient's metabolic system, providing a sustainable path to health that diets alone often fail to offer. Our conversation spins a new thread on body image, highlighting the encouraging shift in younger generations' attitudes and the critical need for honest family dialogues about weight.
But the true marvel lies in the health milestones achieved through bariatric surgery: the dramatic remission rates of chronic conditions, the sustained weight loss, and the metabolic rebirth that defy traditional weight loss methods. We question the status quo of treatment referrals and champion early intervention, sharing insights and personal testimonies that illuminate the path to wellness. As we close, our profound gratitude for mentorship in medicine and the quality of care that touches lives echoes, marking an ode to those who guide and heal within our communities. Join us for an episode that's not just about shedding pounds, but gaining a deeper understanding and appreciation for the journey.
Facing the complexity of obesity and its societal stigmas, Dr. Jessica Smith, Director of Bariatric Surgery at the University of Iowa, joins Tammie and Maria to unfold the layers of weight management and bariatric surgery's role in community health. Their heartfelt discussion traverses both my own personal struggles with weight and Dr. Smith's evolution in the field, revealing the intricate tapestry of patient care and the lifetime connections forged. We challenge the prejudices surrounding obesity with a blend of education and empathy, aiming to reshape the narrative and provide a beacon of support for those on their weight management journey.
Weight isn't just a number on the scale; it's a story of metabolic mysteries, societal pressures, and the power of transformation. In this episode, we explore the underappreciated value of strength training and how bariatric surgery can reboot a patient's metabolic system, providing a sustainable path to health that diets alone often fail to offer. Our conversation spins a new thread on body image, highlighting the encouraging shift in younger generations' attitudes and the critical need for honest family dialogues about weight.
But the true marvel lies in the health milestones achieved through bariatric surgery: the dramatic remission rates of chronic conditions, the sustained weight loss, and the metabolic rebirth that defy traditional weight loss methods. We question the status quo of treatment referrals and champion early intervention, sharing insights and personal testimonies that illuminate the path to wellness. As we close, our profound gratitude for mentorship in medicine and the quality of care that touches lives echoes, marking an ode to those who guide and heal within our communities. Join us for an episode that's not just about shedding pounds, but gaining a deeper understanding and appreciation for the journey.
Welcome to Core Bariatrics Podcast hosted by Bariatric Surgeon Dr Maria Iliakova and TMA LaCoste, bariatric Coordinator and a patient herself. Our goal is building and elevating our community. Core Bariatric Podcast does not offer medical advice, diagnosis or treatment. On this podcast, we aim to share stories, support and insight into the world beyond the clinic.
Speaker 2:
Let's get into it. Today's guest is an expert of bariatric surgery. In fact, she's not just an expert on bariatric surgery. She literally wrote the chapters on hernia repair and operative mutations in general and vascular surgery, which I personally used as a resident when I was going through general surgery residency. She's also had certifications with the American Board of Surgery. A medical degree from UC Berkeley completed her surgery residency at the University of New Mexico and a fellowship in bariatric surgery from UC San Francisco. She is now the Director of Bariatric Surgery at the University of Iowa. Today we welcome Dr Jessica Smith.
Speaker 3:
Thank you so much for coming and being our first professional guest. I'm so excited, so bear with us. Yeah, the learning curve, but thank you so much. Yeah, we're overjoyed for you?
Speaker 4:
Yeah, thanks. Thanks for having me. I listened to the we were talking earlier. I listened to the first two episodes. I think this is going to be really a great resource for patients to just have frank conversations.
Speaker 3:
So I'm excited for you guys. That fills my heart. That's what I'm. Yeah, because obviously I still have a full-time job. This is just. It just fills my cup, yeah, so I appreciate you saying that.
Speaker 2:
Yeah.
Speaker 3:
That's great.
Speaker 2:
Absolutely. Let's get started with that actually. So can you tell us a little bit about your own practice and what made you even go into bariatric surgery from the get-go?
Speaker 4:
Sure, I think I finished my fellowship, gosh, it's now going to be 15 years this year. I think at the time when I was finishing there weren't a lot of people who finished residency saying I want to be a bariatric surgeon and have that identity. I wasn't really exposed to bariatric surgery until I was a fellow in minimally invasive surgery and that was about half of what we did. It's really common now to have residents come for fellowship interviews and they just they're like they know they want to be bariatric surgeons. So when I first started it was maybe 30 or 40% of what I did and that increased a little bit every year and now it's about 60% of what I do because I work at two different hospitals. So I think those of us that do bariatric surgery also do a lot of other things, become experts in other things. We're usually for get surgeons who fix diaphragmatic hernias, we do some minimally invasive hernia repair and other upper GI surgery, and now for me, I'm really excited about doing all of this robotically. So there was always an attraction to the technical aspect and the beauty of seeing. Visualizing the inside of the human body was something that was like for me since medical school, something that I wanted to do, but I think that identifying yourself as a bariatric surgeon is really important because it means that you're a part of something that addresses the whole health of the patient for their lifetime, after an operation, once you meet them, and that's really a special and unique thing in surgery. So I do identify myself as a bariatric surgeon and that goes way back, probably to the fact that my parents were hippies.
Speaker 2:
I'm curious about that, because I'm curious about that. I'm going to be the bariatric connect Because I haven't gotten that one before.
Speaker 4:
Yeah, yeah, seriously, we actually lived on a commune when I was a baby, oh wow. And my parents were children of the 60s. But I'm actually the black sheep of my family. My dad is an artist and my mother was an actress and director and then subsequently a professor of theater. But the fact that they were part of the movement in the 60s of community meant that we were all brought up with a sense of that community and a responsibility to humanity. That, I think, was something I was truly blessed with growing up, and that included fighting all forms of prejudice and thinking about how fellow human beings are part of your global family and really standing up for people who are disenfranchised and victims of discrimination. So it doesn't take very long when you start to practice bariatric surgery to have enough people come into your clinic who break down in front of you and have such a level a weight of blame and shame about their disease. It makes you want to fight for them. It makes you want to fight the things in society that have had such a negative impact on their well-being. And so one of the biggest commitments for me oh, I'm sure you've seen that and, like me, probably have experienced it yourself and so one of the biggest commitments for me why I continue to do it and stay involved and why I think it's wonderful what you're doing is that you develop a relationship with someone that you need to lift up and that you need to educate about the reality of this being a disease. So one of the things that I've had to do, and I still do now, is to, when I have that person in front of me that's broken down and think that this is a last resort and it in the whole if only I were stronger I hadn't done this or hadn't done that to to really say that they need to leave that behind. That it's an absolute myth and it's one that's perpetuated not only by society, of course, but also by medicine, by people in medicine, and so the main roles I, one of the main roles that I have in life, I think is trying to dispel those myths and change the perspective, at least of our patients, that this is not character flaw, it's not their fault and they're to help them fight a disease for their whole life.
Speaker 3:
And actually one of the episodes that we did was I told maria that the five minutes sitting in the waiting room is the worst five minutes of my life, because, exactly what you just said you just feel like I wasn't strong enough, I did something wrong, like all of that.
Speaker 2:
So yeah, how does that feel? How does that? Feel in your office doctor smith, when you're talking with people, do you have people respond to you because you believe in that kind of justice and that kind of dignity? It sounds like that's not necessarily the common place in all of health care. How do you have people respond to you?
Speaker 4:
yeah, I think there's sometimes a few more tears, but I think it's a relief, because I do think that they know, and I think it's the reason they're there is that they there is enough fight and self-worth to make that they want something different for them and I think um, I think, I like to believe that's helpful and it's a message that gets through and stays with them, because I've been there and I. What we impart as people in medicine and as a society, especially western society, we about your weight, defining who you are and your worth, it's a crime. It's a crime to me, and and so I want at least them to know that I don't see you the way that that you think that the world sees you or that you've been led to believe. I don't see you that way.
Speaker 3:
I see you as who you are and that's how, and if you want to make a change I'm here to help you do that that's how maria made me feel and that's why I think we're to the world.
Speaker 4:
She's the world, she's very special, yeah, very kind wow, thank you.
Speaker 2:
I paid you a lot of money to do this. Nice, thank you. I didn't actually if I had. But, dr smith, it sounds like you have gone through this experience yourself. You were saying, and that's something that that you have kind of personally experienced with is that something that you'd be willing to talk more about?
Speaker 4:
seeing it from your perspective, I think I I can save my story for another time, but I am somebody that struggle with weight my entire life. Since I was six years old, I've been on every diet known to me, most medications and including and my mother will cringe that I'm telling this but when I was 12 years old, being offered the price of hamburger per pound that I would lose, I would receive that amount of money per pound, which this sounds barbaric, but I it's just, and I don't blame her or have animosity about that, because it just shows. Here's a loving mother who didn't want that for her child because of how much, how hard society is, especially on women who are overweight and about 12 years old to see me on that path. I think it was hard for her and she had her own struggles and she had a mother. That that was the same and and you're right so, through my own struggles, I found some um, so go ahead. No, go ahead. Sorry, go ahead. I was just gonna say I have found the things that are beneficial for me and the things that aren't, and I try to share those with my patients and try to make them part of our education and our recommendations. And strength training is one of the biggest ones for me and I couldn't survive being a surgeon without exercise being a huge part of my life and that has to be part of the conversation. Like you guys were talking about, that. You still have to do all the things that are good for you because you still have to eat, right you? still have to exercise, I still have to do all of those things, but I believe that the metabolic changes that come with bariatric surgery, I believe in the set point theory. I think there is a reset of your physiology that makes it easier to do all of those things and have them work. So I think I heard someone say something, and I don't know who to credit it to, but it impacted me because you always want to feel like you know what you do matters and you aren't talking out of two sides of your mouth and doing what practicing what you preach, and the saying is, I would rather listen to the person in the foxhole with me than someone shouting down at me from on top of a mountain and so. I think it's a good reason to never feel bad about struggling yourself, and because we don't know everything. Here I have all of the information at my disposal, I have resources, I have experience, all those things and then I still struggle and I still have to do a daily reminder of what I need to do to stay healthy.
Speaker 3:
So anyway, that's a perspective.
Speaker 2:
Like you said, all women. I'm really honored actually that you shared that story, because that is not easy to share something like that.
Speaker 1:
I can tell you also.
Speaker 2:
My mom and I come from a culture, a Russian culture, where a weight is in the US. You have issues with weight. In Russian culture and pretty much all cultures, women's weight especially, is extremely judged and regulated in ways meant to actually and. I think we're now starting to see the impacts of that a lot more and recognize that. So I'm really grateful that you shared that story because it resonates with my childhood and the way that we used to talk about weight in my family too. We didn't have good conversations about weight and body and how we were supposed to manage that at all in my family, so I'm really grateful that you shared that.
Speaker 4:
Yeah, I think I'm happy to say that what I've seen in younger, like college age women is that I don't think that's as common as it was when I was growing up. I think there's a healthier outlook on different body types and what you can do with your body. I think sports and achievement in athletics is actually becoming more important than how thin you are. So I do often have to talk to women. You know more extensively about the myths that were told over our childhood and our young adulthood, growing up as women in the society, because one of the things we're not really told is how detrimental the cycle of dieting from a young age is to our ability to maintain our weight later on that really being on a diet your whole young life and back and forth. And, like you were talking about in the previous time, that when people it's the keeping it off, people regain weight, which ultimately, with diets they almost always do. It's not only more weight than they've lost, but it also the preponderance is fat weight instead of lean muscle and that creates this vicious cycle of insulin resistance. Regardless of whether or not you have diabetes, you know extra weight is insulin resistance and so that we actually need to prevent young women from being on these yo-yo goals, then later on in life.
Speaker 3:
Absolutely. My husband actually. I asked him to listen to those first two episodes and he said I learned so much. And I said what are you talking about? I feel like I've educated you so much and he's I didn't know that diet and exercise really didn't work as well as how it's portrayed to work and I'm like I failed now.
Speaker 2:
But even it was an eye-opener for him that diet and exercise is just not the, not the end of the all, exactly for most people, or pretty much everyone do you feel like you have to break people's misconceptions and myths before you can even start to have a conversation about what the plan is ahead and what we're going to do next and things like that? Or do you feel, yeah, tell me a little bit about that process.
Speaker 4:
I think everybody is a little bit different with how down they feel about being there. People are gung-ho, happy, best decision they've ever made, and they find out early, they realize early, hey, there's something that isn't as difficult or and has some guarantee attached to it. Why am I struggling like this? And so there's that group of people and it's that's just such a blessing to be able to provide that. And then there are people and they and yeah, they tend to be older, because I think it's it is an older outlook who just can't believe they're there. They just can't believe they let themselves get to this place and that is heartbreaking, and so I will do everything I can to have them leave without that, without that burden, and I think most of them get it. When you really all the facts and I like to point out the billions of dollars that the fitness industry makes from making us feel terrible about ourselves- because it's part of that's part of the game, right that's right. So if you succeeded, you get a before and after posted and everyone is all around you, and if you didn't succeed, it's you, it's on you. You didn't work hard enough, and that's the message. And, of course, the majority of people are in the second category. Right, and it keeps them coming back, so it keeps producing money. You're gonna spend money on the next thing and and that is a racket- Because, the truth is told all the
Speaker 3:
things of buying all the things. Yeah, that'll hopefully work absolutely and how do?
Speaker 2:
you feel, how do you feel like people can escape that? How do you feel that the service that you're provided, the knowledge that you're providing, how does that let people let go of that cycle?
Speaker 4:
For me it's education, and you guys touched on this about bariatrics is not bariatric surgery, so the I didn't know that when I came in. Yeah, yeah, it's just extra weight, right, the science of extra weight. Now I lost my thought about what was your.
Speaker 2:
Talking about this spiral or the ongoing sort of use of fitness and diet to keep us on the treadmill but never really getting the results we want. So how do you help people escape that you were talking about education?
Speaker 4:
Yeah, so I think education about not only the differences in the metabolism between people are able to maintain a healthy weight and people who aren't, that we don't know everything about that, but here's what we do know it's not really under your control and then and then also To say, educate with the science behind things, but also to offer the information of we're not in the business of making you a certain size, we are focused on your health. This is the only thing that we can say with certainty. You are likely to lose and keep off at least if half of the extra weight that you care, and not only that. You have a seventy five percent chance of having Serious medical problems go into remission. It's not greatly improve hypertension, diabetes, sleep and that those things tend to persist. The improvement in those things tend to persist regardless of whether or not you regain weight. Sometimes people are reluctant to have surgery because of the potential of regaining weight, and you have to tell them what all the odds are and have them have things be focused on their health.
Speaker 3:
Okay, wait, let me circle back. I have a question for the surgeons. You said Did I understand that right that it's a patient after bariatric surgery? Has they no longer have diabetes, or it's in remission, or what, not even if they gain weight back? There's lots of a chance to know that that's correct.
Speaker 4:
Thank you especially with gastric bypass.
Speaker 3:
Thank you for bringing that up.
Speaker 4:
Yeah, so we yeah.
Speaker 2:
Sorry, go ahead.
Speaker 4:
Yeah, oh, just to say you were probably going to say the same thing that we don't really understand all of the metabolic consequences of weight loss surgery that produce that. But we have plenty of studies that show that it's true. I think that the insulin resistance part of things is improved even if there is weight loss. That is awesome.
Speaker 1:
See, I'm learning as much as.
Speaker 3:
I've done so much research I was telling I think I said in the first two episodes that literally from Brooklyn to Iowa City it's an hour drive. One way did it for a year. Every there and back was listening to something related to bariatric surgery.
Speaker 2:
We're seeing a really beautiful puppy right now. Come on screen.
Speaker 4:
My dog is thanking me for her bone that she just had. Oh yeah, we both got dogs. That's Hadley Hadley's gorgeous.
Speaker 3:
Okay for everyone listening this dog is like a supermodel. It's a beautiful dog.
Speaker 2:
Wow, making us all look bad, but anyway yes, so beautiful but no. So Tammy was saying she had done all of this research and I will say I think you can probably relate to this, Dr Smith but I feel like bariatrics is such an under-understood. We don't understand exactly all the mechanisms and why things happen, and so I feel like I'm learning every day in this field, and even as much reading as we do or as much investigation as we do, there's so much more to be done. Would you agree with that?
Speaker 4:
Oh, absolutely. I will say that we know enough to really fight the myths and tell people that it's actually the healthiest way and most guaranteed way to lose a large amount of weight. We know that for a fact and I think, yes, there are so many and so much research going on with the microbiome and the liver and all the things that we get closer and closer to understanding the exact mechanisms. But if anyone believes that this isn't a part of an abnormal physiology or metabolism, just look at those things that are corrected by bariatric surgery, that aren't corrected by diet and exercise. So I don't know.
Speaker 3:
sometimes you have to convince people that you're actually creating a more normal physiologic state by counteracting the things that are not functioning normally, to mean a healthy weight Again, even in that one episode and you were at the dinner that we were at with Dr Lamaster's that I, even that day, I did not know that surgery was not just restrictive, like I did think that, okay, you're getting smaller and you're absorbing less, but there's way more to it and I'm just like the whole world needs to know this. Look, I know I can get less in and all of that, but there's so much more going on than just eating less, and it makes sense so much more, because when you're on a diet, you are eating less, and so what's? There is a shock. There's a shock to the body of what?
Speaker 2:
Yeah, yeah, I think what you were saying, dr Smith, earlier.
Speaker 4:
Yeah, yeah, I think. And to Tammy's point, why and we can talk about the biggest loser study, because it's probably the best example of this but why bariatric surgery is actually is less weight regain and less impact on your resting metabolic rate than there is when you lose the same amount of weight with diet and exercise is, to me in my mind, because it restores a physiologic state that isn't there, whereas the amount of stress, of physiologic stress that is placed on the body in order to lose a large amount of weight and equivalent amount of weight to bariatric surgery is very detrimental in the long run and it is the reason why when weight is regained, it's more weight and it's more likely to lose, likely to be fat tissue weight. When it comes from when the weight regain is from diet and exercise. Loss versus bariatric surgery is because it's a. It's a. It's a much more stressful way to lose weight, to pound pound it out with huge caloric deficits and, yeah, and a very stressful way to frequent exercise. That's all right. So I want to know about the video.
Speaker 3:
I guess the talk about it no biggest thing is what is the percentage of people gaining it back because they are very successful and don't know how healthy it is?
Speaker 2:
Yeah it's extreme and they're successful at losing.
Speaker 4:
Yeah, but yeah, tell us about this study. Yeah. So this is a study and because he's a hero I think his name is Kevin Hall he's at. This was studied by the NIH, actually, and they took two equivalent groups of patients. One of the groups consisted of the biggest loser contestants and they had a comparable group of patients who had lost the same amount of weight with bariatric surgery and they looked at them down the road. I don't know exactly the time, just to say 10 years down the road. So 90%, 90 plus percent of the biggest loser contestants gained their weight back. I don't know if that's common knowledge or not, but they sort of disappeared off the face of the earth.
Speaker 3:
Wow, yep, that's something to say, so what?
Speaker 4:
they looked at yeah, and you notice, you don't see them. You don't see them. No, that's the whole thing, even with bariatric surgery.
Speaker 3:
Yes, there's a lot of good things to it. You see the good part of the biggest loser, but you don't see the bad part. There's some things with bariatric surgery Not like. It is easier to lose the weight. It comes with its own challenges. So that's the insight that I'm bringing. That, yeah, but yeah, the biggest loser. You don't see that Surprising, you don't?
Speaker 4:
see that they don't advertise that. They looked at it you see my hand. Sometimes I just wonder what lipstick is there. They looked at the resting metabolic rate of both groups. So they had lost the same amount of weight, and so the resting metabolic rate is how many calories you burn when you just, when you're just sitting around like I'm doing right now. Well, I'm talking everything, but let's say why you're sleeping. And so the problem with the biggest loser is that what happened to these people's metabolism is that their resting metabolic rate went down to an extreme. So for the and let's just I'm making up numbers but for the biggest loser group, their resting metabolic rate, having lost the same amount of weight as the patients in the bariatric surgery group, was hundreds of calories a day less. So they needed, at rest, way less calories just to maintain their weight, because they had stressed their body so much with that degree of dieting and exercising, whatever they did, six hours a day or something like that, for that period of time, that the weight that they regained was mostly fat, and so their lean muscle, when they regained weight, was didn't, they didn't maintain the muscle gain that they had from working out, et cetera. And then, in addition to that they gained. The majority of the weight they regained was fat, and so they're, in a way, worse place than they were even before they started the competition right. They need less calories now, and they weigh the same as before they started, if not more. So that's just one example that I'll use of why bariatric surgery is actually safer and less stressful on your body than diet and exercise if you have a massive amount of weight to lose 100 pounds or so.
Speaker 2:
I think that's a really big misconception for people that at certain weights you can still lose the weight with diet and exercise. And it's this whole idea that we see people come in the office sometimes who are at weights of 250, 300, 350 more, but they're not even eating 2000 calories a day and people say that's impossible.
Speaker 3:
I'm raising my hand. That was me.
Speaker 2:
It's obvious. It's not in and out. It's obvious, like you were mentioning with the studies, that a calorie is not a calorie for everybody.
Speaker 4:
Yeah, and that whatever many majority, especially of women that we meet, who are in their, let's say, 50s, 60s, have been down regulating their metabolism for almost their whole life, so their resting metabolic rate isn't as high as it would be, have they not done that? So it's always unfair when you have a couple who's had surgery and the men always lose weight faster and they always lose more. Not that it's a competition but if you ask them how many diets they've, invariably the men will say one or less, and then the women will say a thousand, right, my whole life. So they not only have more lean mass, but they but a calorie deficit. Resetting of their physiology is a novel thing to their body and they respond more dramatically. They respond better. So, to Maria said in either this podcast or previous one, we actually need to be doing this much earlier. In people's health trajectory there's an inflection point on the graph where you can only get so much benefit once you reach a certain point, and that has to do with medical comorbidities. It has to do with BMI you know what weight you are when you start. It has to do with how many diets you've been on, how old you are. The highest chance you have of getting a BMI below 30 with bariatric surgery is if you have it when your BMI is below 40. I think one of the biggest things, one of the things that I think we all need to fight against, is the waiting Waiting until a person has diabetes, waiting until everything is exhausted. People need to be referred sooner, and so that's also a shift in the mentality of primary care providers. Do something before, you can't benefit maximally from the intervention.
Speaker 2:
Absolutely, and using the best tools at our disposal to do that. I am so grateful that you took time to be with us today. Thank you for giving us a lot of food for thought.
Speaker 3:
You taught me a lot, just in this 30-some minute here and again. I've done so much research, but there's so much to be learned, even from you guys, that you know are the professionals. But science continues to move forward. Dr Smith tell us so. You are in Iowa City, you're at the University of Iowa, but if someone is by chance in your area and would love to talk with you, talk with someone on your team, how do they get a hold of you specifically or your team specifically?
Speaker 4:
I think going to the website is the best way. Obviously, there's a lot of information on there and it'll just be the University of Iowa website and backslash bariatric surgery, and then there's a lot of information there, but also a questionnaire for people who are interested and want to pursue. We have just a questionnaire online that they can do and then make sure that they have insurance to cover it, because that's unfortunately a limiting factor for some people.
Speaker 3:
That's right, that's right. So what would you say to someone that's contemplating it, still just has not pulled the trigger?
Speaker 4:
I would say gather information, do seek out podcasts like this. Look at as many websites as you can. Information sessions are out there. But at the same time, you do have to be ready. I think that can't be understated, that it has to be the right time for a person, and I think when you are ready, that trigger will be pulled.
Speaker 3:
Yeah, this is a disease, just, and I guess this could be controversial, but alcoholism?
Speaker 1:
drug addict.
Speaker 3:
It's going to be the right time to treat those. Thank you so much for teaching me so much making me cry a little bit I am so glad that the University and people in Iowa, the rural areas, have someone like you. That because I am just really getting to know you here right now that you are giving your patients the same feeling that Maria gave me. So I thank you for that from a patient perspective, and Jess thanks for having me.
Speaker 2:
I want to say a huge thank you to you, too, because you've been a mentor to me and a huge inspiration in providing very compassionate and thoughtful quality care to people. So I can't thank you enough for what you've done for me personally in my life, for what you continue to do for our whole community and for joining us today. I'm extremely grateful. So thank you Thank you, thank you.
Speaker 4:
Thank you so much. That's very kind. You're welcome. I hope to see you both soon.