The Fat Doctor Podcast

The Lose Weight or Die Narrative

• Dr Asher Larmie • Season 5 • Episode 14

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 Medical moralism has transformed heart health from a medical issue into a moral judgment. When we label cholesterol as "good" or "bad" and patients as "compliant" or "non-compliant," we're not practicing medicine - we're passing judgment. 

In this episode, I expose how the "lose weight or die" narrative serves financial interests while ignoring the real social determinants of health. I ask whether our obsession with metabolic markers has become a moral measuring stick rather than genuine care, and challenge listeners to question whether health status should ever define human worth. 

This episode's journal article is  "Evidence for the Association Between Adverse Childhood Family Environment, Child Abuse, and Caregiver Warmth and Cardiovascular Health Across the Lifespan: The Coronary Artery Risk Development in Young Adults (CARDIA) Study.” 

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Episode 14: "The Lose Weight or Die Narrative"


Hi and welcome to episode 14 season 5 of the Fat Doctor Podcast. It is Wednesday, the 9th of April, and I'm your host, Dr. Asher Larmie, a weight-inclusive GP who is very excited today to talk about what I have dubbed the "lose weight or die" narrative.

Does that make sense to some of you? Some of you are going to understand this without me having to explain it. You go to the doctor, and they give you the impression that if you don't lose weight you're going to die. And it's quite a nebulous thing. What will I die of? A heart attack, a stroke? Cancer?

And as I've said before, and I'll continue to say, you know what folks, chances are you are going to die of a heart attack, a stroke or cancer, possibly dementia. These are the most common causes of death in the global North, for want of a better word or Western society, whatever you want to call it. I still haven't found a decent enough word that I can use here that I don't find offensive. But you know what I'm saying, in parts of the world where I live, those are the main causes of death for people. And so, yes, you will. But the idea is that if you don't lose weight, you will, and more importantly, that it's coming soon. It's difficult to say when, because the doctor doesn't specify. They don't say you're going to die of a heart attack on the 20th of November 2045. It's very nebulous, but there's a real sense of urgency. Do something now, pay for it later.

So I want to look at the "lose weight or die" narrative today. I quite like saying it. And specifically, I'm going to look at heart health just because it's one of the most common ones. It's one we talk about a lot. When we think about physical health, we're often thinking about heart, right? We're often thinking about risk factors for heart disease, the main ones being high blood pressure, high cholesterol and diabetes. Those are the main risk factors for heart disease. I mean, you could also include nowadays non-alcoholic fatty liver disease or MAFLD as we like to call it, metabolic syndrome is coming up. We like to use all sorts of fancy words, but really it's the big three: blood pressure, cholesterol, HbA1c—that's what we really care about. And so I'm going to focus on that instead of avoiding it, saying folks, there's more to health than your blood pressure. I'm going to take an alternative route today and talk a little bit about blood pressure and cholesterol.

I want to examine how heart health has become a bit of a moral issue rather than a medical one. Once upon a time it was a medical issue. It's very reasonable for doctors, medical professionals to be concerned about your risk of heart disease. As I said, it's the number one killer in the UK certainly, and so preventing heart disease is a very sensible thing to do. That's a good pursuit for all healthcare professionals. The problem is that we start moralizing it, and that, I think, is very problematic.

Medical advice nowadays is often wrapped up in this moral judgment rather than evidence which would be much more useful. I don't know if you've heard of this term "medical moralism." It's one I was introduced to relatively recently, but it's basically something I've been talking about for a long time and just didn't know that this was the term that people use. It's this idea, this framework that basically frames health as a moral obligation and illness as a moral failure.

As opposed to it just being like this is health, and this is illness. We've now started saying, well, health is an obligation. It's a debt that you owe. It's a responsibility, and if you do happen to fall ill, well, that's a moral failing. You've done something wrong.

And in the same way that when it comes to nutrition and food there's a lot of moralizing going on, you know, like good food, bad food, junk food, etc. Processed food, whatever—those have become quite moral judgments when it comes to food. We do the same thing in medicine.

You ever heard of good cholesterol versus bad cholesterol? I mean, I get it. I know why we do it. We're trying to explain things in a way that people understand. You know, when we talk about low-density lipoproteins and high-density lipoproteins, not everybody understands what that means.

But we've started using good and bad, haven't we? In fact, we use good and bad to talk about patients. Do you know that? Well, you probably guessed that. But we do. We talk about our good patients. "Oh, that's a good patient. Oh, I'm not such a good patient, that's a bad patient," or we use terms like "compliant" and "non-compliant."

This is a disgusting term. In other words, if you listen to me, you are compliant and therefore good. But if you don't listen to me, you are non-compliant and therefore bad.

It sort of places the healthcare professional in the role of judge and jury, doesn't it? Like I have decided that this is the thing that you should do, and if you don't do it, well, you're non-compliant and you're a bad person. You're a bad patient, and whatever happens to you, that's your fault.

That's the kind of moralism that we experience, especially when it comes to heart disease. If you've had a heart attack or a stroke, or any cardiac event we now call this secondary prevention. It happened, and now our job is to prevent it from happening again. So that's called secondary prevention. In other words, it happened, and we want to prevent a second one.

Primary prevention is, it hasn't happened yet. You haven't had a heart attack yet. You might never have a heart attack, but we want to prevent it from happening. Primary prevention makes up a large bulk of the work that we do, certainly in primary care, and even if you're a cardiologist, a lot of the work that you're doing is primary prevention.

That has become a very moral place to work in, where we are saying to our patients, you know, if you don't do something now, or if you do something now, if you're good now, if you're bad now, if you behave, you don't behave, you're compliant, you're not compliant—then that puts you at risk.

It's risk, isn't it? It's a risk that we can't really quantify, even though we try very hard to quantify it, even though we have calculators—literally got a calculator to calculate your risk. It's still very flawed and not particularly accurate. It's very basic.

And it creates, in my opinion, a real barrier to effective care. When we start moralizing, that's it. We've lost people, and we're causing harm, as I'm sure you know.

And we use these metabolic markers—blood pressure, cholesterol, HbA1c being the three most important ones—as a kind of moral measuring stick. These numbers begin to define you. People can quote them at me, you know, like you can quote your phone number or your social security number—you can quote, "My blood pressure is, I know what it is."

Once upon a time, that wasn't the case. It was measured in a clinic, and a doctor said something to you, and you might pay attention, and you might remember it. But you're not measuring at home every five minutes, and you're not being told how important it is. So it's kind of one of those things that you learn about yourself rather like your blood type, and then you don't really think about it unless you're bleeding, or you're giving blood. And that's what blood pressure used to be like. But now it's like part of our core identity.

And it's because it's now part of our identity, it's a moral issue. We've begun to oversimplify things in order to maintain those moral judgments as well. Like I said, bad cholesterol and good cholesterol. We've really oversimplified something very complex in order to educate patients, but it's become a thing like, you want to be good when you're having your blood sugar measured. You want it to be good sugar, good sugar level, good HbA1c, and if it goes up, bad—I'm a bad person. I've done something bad, whereas actually blood sugar, especially over time, really isn't related to what you do or what you eat. It's much more complex than that.

It's not going to really change. Your HbA1c isn't going to massively change because you had a slice of cake one day. It really isn't. I know that's the impression we gave you. Touch sugar, gosh, that's it. Sugar's going up, and it may well increase in the moment of eating it, of course, but that's not going to have a long-term effect, because for the vast majority of us, unless you're a type 1 diabetic, our body is able to handle that sugar. Some are better than others. That's not your fault. That's just the situation.

But this idea that, "Oh, your blood sugar is terrible, terrible, very low, very high, very this, very that." And so it really becomes a marker of success, and beyond that, just a marker of whether or not we're decent human beings.

And we become really ashamed. If you get told your cholesterol is high or your blood pressure is high, or your A1c is high, that creates shame, immediate, instantaneous shame. Oh, I'm a bad person. I'm a non-compliant person. I don't take care of myself. I obviously don't care about my body. If I just did this, if I just did that, if I just, you know—because we've been told that it's very binary, very oversimplified, very complex issue distilled down into a few things. If you eat this, if you exercise this amount, if you get enough sleep, then your blood pressure will come down, your blood sugar will be normal, your cholesterol will come down. No, it's not that simple, it really isn't. I wish it were that simple. It's way more complex than that.

But in order to fit people into little categories of good and bad, compliant and non-compliant, that's what we've turned it into. And it's bullshit.

And when we focus on these numbers, when we obsess over these numbers, we have a tendency to either overtreat or miss something. That's the problem. It's either one or the other. So we're over-treating a lot of people. For example, there's lots of evidence nowadays that we are over-treating type 2 diabetes, and we are so desperate to bring the blood sugar down to what is considered normal, and that is actually causing more harm than good.

We're over-treating certain things, because, of course, every time you start a treatment, there's side effects, there's long-term risks, etc. And it's a real balance. Because, as I said, we're talking about primary prevention here, we're talking about something that hasn't happened yet. That may never happen. We're trying to prevent it from happening.

And hey, I don't have a problem with primary prevention. I am going to be the first to tell you, skin cancer is a real bitch. Melanoma is something that you really want to avoid, in which case I suggest you use SPF when you go out into the sun, especially if you're unmelanated.

I am the first to tell you to get your cervical pap screening done, even though I am yet to book mine in, and I must remember to do that. But I keep forgetting until I remember again. But I'm all for cancer screening of any kind. Immunizations. All of this stuff is preventative, right? It's risk prevention.

I'm getting the MMR to prevent myself from getting measles. I may never come into contact with measles, and never have it, but it's worth it for me, right? And so I don't have a problem with preventative medicine per se. I have a problem with the moralizing of it.

And we saw it a little bit with vaccinating, right? It became a very toxic issue. But I saw it a lot with breastfeeding as well. As somebody who breastfed all three children, and I'm very pro-breastfeeding, don't get me wrong, I used to hate the way that people treated parents who were formula feeding as less than adequate. They don't care about their children—that kind of thing, because that's not true.

We either overtreat or we miss things. There's nothing wrong with sensible preventative medicine. Nothing wrong with that, absolutely good stuff.

Stopping smoking has been shown to improve health across a number of different illnesses, and it reduces the risk of a number of different conditions, including cancers and heart disease, etc. So I don't have a problem with stop smoking advice. I'm not going to say that that's bad per se, but we have become a little bit obsessed with it.

Now, if you're a smoker, you don't care about your health. You don't care whether you live or die. You're a non-compliant patient. You don't care about your risks. You're not looking after you. All these moral judgments, not helpful, not helpful at all. And the same goes for A1c, blood pressure, etc.

So in some cases I think we're over-treating, and in some cases I think we're missing things because we are oversimplifying. We are missing things because people do not fit nicely in boxes.

For example, thin equals healthy, right? But there are plenty of thin people who are at risk of developing a heart attack or cancer or whatever. And we're missing it because it doesn't fit nicely into one of those boxes.

And we've just created this moral panic. It's becoming an obsession. People are so obsessed about their risk of dying, their risk of having a heart attack, their risk of things. And again, it makes a lot of sense—nobody wants to get sick, and also everybody is going to get sick one day. We shouldn't be so terrified.

I was so terrified of developing diabetes. Terrified. It sent me into paralysis for years. I was just not going to see a doctor because I was so afraid they were going to ask me to do an HbA1c, and then they were going to find out I was diabetic, and I just couldn't handle the idea. Terrified, not because I couldn't handle the idea of having a condition that, let's face it, is fairly easy to treat. Plenty of drugs out there. It's a relatively easily managed condition. There are some conditions that aren't. Unfortunately, we have very little medication or treatment available. Diabetes is not one of those conditions.

So actually, it wasn't the condition itself. It was the judgment. It was the moral judgment, because it had become a moral panic. We are obsessed with blood sugar in society today. And that was the issue.

I want to point out also that there is absolutely a financial motive behind prescribing weight loss, but also prescribing all sorts of preventative measures. Think about who's making all the money. Pharmaceutical companies are making all the money, right? Who is profiting from preventative medicine? Pharmaceutical companies for the most part.

Especially the ones that are prescribing weight loss drugs because they're seen as a cure-all for everything, but also the ones that are creating blood pressure medications and statins. They're the ones that are benefiting, right? So it's in their best interest, the pharmaceutical industry. It is in their best interest to create this moral panic because it's going to make doctors overtreat, and it's going to make patients much more keen to be overtreated, or much more receptive to being treated.

And then we've got the weight loss industry, the weight loss industrial complex is profiting from preventative medicine. It's where they make their money. Nowadays people are less inclined to buy weight loss for cosmetic reasons, for vanity. Not that I've got a problem with vanity. Much less interested in "I want to be thinner" and much more interested in "I want to lose weight for my health." That has become the driving force of the weight loss industry. That's how they sell weight loss to us. So again, preventative medicine is huge. They are massively profiting.

And then there's the healthcare system. We have made an awful lot of work for ourselves. We, the medical establishment, have created entire jobs. I remember the first time I heard of a lipidologist, and I was like, a lipidologist is a made-up word that doesn't exist. Of course they do. This is somebody who is basically a weight loss doctor. But when I was growing up, when I was in medical school, you didn't have the option of specializing in lipidology.

When you look at non-alcoholic fatty liver disease, we require an awful lot more hepatologists or gastroenterologists that specialize in the liver nowadays, because there's this "new condition" that everyone's getting. And now you have to have a test, and you have to have this. And you have to see a specialist. And we're creating an awful lot of work for ourselves. And the thing about that work is, it pays. There's money to be made in that.

So who's profiting? Not you, not really. This is a theoretical risk. Is there actually any evidence that all of this preventative medicine works? Well, I mean, that's a tricky question to answer in a podcast. Yes and no, sure to a degree. But not that much.

It's also this idea that we're going to live forever, right? We can't live forever. You're going to get older, and as you get older your body is going to struggle. Our bodies do not survive forever, and people are always like, "Oh, don't you want to live?" I don't want to live long. I want to live well.

I have no desire to live into my nineties. If I can get into my nineties, and I'm healthy, and I'm happy, great! But it's not my driving force. My driving force is living well, but that has stopped being a thing. It's quite weird now to talk about, "I'd rather die younger, but have a happy life than live into my nineties and develop dementia, but not have a happy life." Anyway, tangent.

I think that we have to be very aware of the financial implications when it comes to preventative medicine, and it goes beyond just the prescriptions themselves. It's into research funding, medical education, clinical guidelines. The pharmaceutical industry, the weight loss industry, and certain individuals who are profiting from preventative medicine—all of these people are very much involved in research and medical education and clinical guidelines. In fact, they are the ones that do most of this stuff.

And so there's a bit of a conflict of interest there. If you're a doctor who's on a guidelines committee, and does all this research, and maybe is involved in medical education yourself, and are getting paid by pharmaceutical companies in the weight loss industry, bit of a conflict of interest, if you ask me. If I were one of those people, I'd be more inclined to tell people about preventative medicine, too, right? And if the research is there because it's being funded by the weight loss industry, that's even more problematic.

And there's something to be said there about over-medicalizing and fear-mongering and medical moralism. I think it's something that I'm going to explore more over time, because it's churning away in me, but for now I will say that there are so many more things.

You've all heard of social determinants of health, right? I imagine you have: access to healthcare, economic stability, racism, ableism, any form of marginalization or oppression, discrimination, food deserts, food apartheids, safe neighborhoods, access to education and prison systems. All of these things impact cardiovascular health, as has been demonstrated over and over and over again.

We could go back to the 1960s. There was something called the Whitehall Studies in the UK. Whitehall is where civil servants work, and they studied civil servants. I don't know much about these studies, because they're quite old now, and not necessarily applicable to modern life. But what they found was that income was key. They basically looked at all the civil servants—the ones who had high-paid jobs, middle-paid jobs and lower-paid jobs, and they found that when it came to cardiovascular health, the more money you made the better your cardiovascular health.

This was back in the sixties. We've known about this before then. In fact, we've always known about how income impacted our health. We knew that nutrition and malnutrition impacted our health. We knew that if you were poorer you were less likely to live longer. That's kind of obvious and common sense.

So we've known about this for a really long time. And the research suggests that the impact of social determinants of health far outweigh things like diet and exercise and stuff—significantly outweigh.

And yet medical moralism, in order for it to take hold, and for people to profit from it, you have to ignore the social determinants of health. Right? Because if it's a moral judgment, if it's an individual responsibility, then we can't really talk about social determinants of health.

And that is the problem. That is the situation we found ourselves in. We are so focused on preventative medicine, on weight, on cholesterol, on blood pressure, on A1c, that we are forgetting all of the really important stuff. Like I said, the social issues, the social barriers that are actually the parts that are most important. And if we were to address them would do the most amount of good.

There's no profit to be made from improving neighborhoods, you know, improving access to healthcare. In fact, it's the opposite. You lose money when you do these things. Nobody wants to lose money.

I want to continue on now with "Everything You've Been Told About Weight Loss Is a Lie," the segment in the podcast where I talk about a study. I've chosen one that I think goes well with this theme. It was published at the beginning of last year. It's a new study. It's called "Evidence for the association between adverse childhood family environment, child abuse and caregiver warmth and cardiovascular health across the lifespan: The coronary artery risk development in young adults study (CARDIA)."

I don't like the title, as I often say. People really need to work on their titles. But it's a good study, a really interesting study. And they followed this group of people for over 20 years in this cohort, the CARDIA cohort, and they were examining the impact of childhood family environments on cardiovascular health. So you may well have heard of childhood adverse events, or ACE scores—adverse childhood events.

And they were looking at child abuse. They were looking also at caregiver warmth, which was really interesting. And they basically used various questionnaires. They tracked their cardiovascular health over 20 years. They also looked at things like smoking and cholesterol and blood pressure, and all this other stuff. So it was a pretty decent study. It's been around for a long time.

So I just want to tell you the highlights of the study, because I think it's fascinating, and there are plenty of things to be said. But here are the highlights. You will not be surprised to learn that higher childhood adversity was linked to poorer cardiovascular health in adulthood.

This is not going to come as a shocker for any of you, is it? Higher childhood adversity was linked to poorer cardiovascular health, and each unit increase in adversity reduced the odds of ideal cardiovascular health by 4%.

And so there was a real linear relationship. The more adversity experienced in childhood, the worse your cardiovascular health is. And when we see that kind of linear relationship, we tend to think that often gives us support for the idea that one causes the other. We can't say for sure that adverse childhood events cause poorer cardiovascular health. And also we have to figure out why they cause poorer cardiovascular health. But when we see this linear relationship, that's quite a strong association.

Childhood abuse was associated with 13% lower likelihood of achieving ideal cardiovascular health and caregiver warmth increased the likelihood of achieving cardiovascular health by 12%.

And the association between childhood adversity and poor cardiovascular health persisted in those with higher adult income, but was not significant in lower income groups. So what that shows is that actually, there's a difference. If you were born into a higher income family, then your experience in childhood, for example, child neglect, child abuse, and also how warm your caregiver was, whether you experienced a safe and happy childhood—that has quite an impact on your cardiovascular health.

However, if you're in a low-income group, it has much less of an impact, because having a low income is enough to cause damage to your cardiovascular health with or without the childhood adversity. Isn't that interesting?

So it's both income and childhood adversity. I grew up in a middle class home. It was middle class, not fairly. Child of immigrant parents, but middle class, and I grew up with quite a bit of childhood adversity. I have a relatively high ACE score, and so my risk of poor cardiovascular health is higher because of that, because I didn't have that warm caregiver that some people have.

That's a real privilege to grow up in a family, not only with a higher income, but with a warm caregiver, to not experience neglect or abuse, physical abuse, mental abuse, etc.

So I want you to remember this next time you're stressing about your blood pressure and your cardiovascular health. I want you to remember that actually a lot of what is going on has already happened.

You had no control over who you were born to, or where you were born. That just happened, right? And all of this stuff happened in childhood, and unless you're a child listening to this podcast, which I assume you're not, it's done.

And the reason I'm telling you this is not so you can feel really terrible about your life, because, like I said, it's a theoretical risk, folks, it's just a potential thing out there. And also these numbers are not that high: 12%, 13%. It's not like 100%, is it? So there's no guarantees in life.

But you also have to remember that this is far more powerful than diet. You're not going to find 12% or 13% when it comes to diet or exercise. It just doesn't exist, certainly not with weight loss.

So remember that. Remember that your childhood is one of the many reasons—not one, it's just one of the many reasons why your risk is what your risk is, and therefore it is not a moral judgment. It's just one of those things. It's just disease, right? And it's not something you need to feel bad or ashamed about.

Last, but not least, I received a couple of questions very similar, so I have meshed them together for the "Ask Me Anything" portion of this podcast. Basically two people who are in recovery from binge eating disorder and neither of them are restricting. And basically they're in a good place. They are sort of intuitively eating. They're allowing themselves to eat what they want, etc. So, for the most part, however, the eating disorder professionals have instilled in them that binge eating disorder is really bad for your health.

And there is this real worry now: "But how is it bad for my health? What is bad for my health? Should I be worried?" Especially because people who have a history of binge eating disorder and are in recovery may well binge from time to time. And so there was a kind of fear, I guess, of what does that mean?

And so I did a little bit of research into this, because we know that eating disorders are bad for you. We know that binge eating disorder is bad. But when you actually look into any of the studies, there is an automatic assumption. If you have binge eating disorder, you eat a lot of food. A lot of food equals fat, fat equals unhealthy, and they don't—there is no—that's just an assumption that is made.

There's no effort been made to sort of challenge that, or to ask, well, actually, what are the risks? And I couldn't find any evidence. Just because you binge, just because you eat certain food does not necessarily mean that that's bad for your health, right? I think, from what I can understand, it's probably more the emotional and mental health implications rather than the physical health implications when it comes to binge eating disorder. But there really isn't enough evidence, because once again we are so obsessed with weight, and we are so sure that weight causes disease that we never think to question it.

From what I can tell folks, the most important thing is that mentally and emotionally, you're well, energetically, you're well, socially, you're well. The second most important thing is that you're not restricting because restriction leads to weight cycling. Weight cycling is harmful. Weight loss isn't an option. Obviously, with a history of an eating disorder, weight loss isn't an option.

And so we find ourselves in a situation where, if you are binging from time to time, and that's where you're at, what are we going to do about it? How are we going to get you to stop?

Now, there may be room for understanding what's causing you to binge. Why is it happening? Are you speaking to a health professional about that? Maybe you're going to therapy, or you have a coach, or it's a community that you're speaking to. Sure, I'm sure there's things that can be done here. But ultimately, it is what it is.

What are you going to do about it? Is the question I'm going to ask. What will you do? If I told you to stop binge eating today—stop binging today, would you? Would you stop?

And I think the fact that you've stopped restricting is fantastic. I think the fact that you're in a much better place now than you were before is fantastic. I think the fact that you've got support is fantastic. I think the fact that you're unlearning beauty standards and body ideals, and all of that stuff is fantastic. And I think you're doing the very best that you can, and sometimes the very best that you can is enough—in fact, not sometimes, always. The very best that you can is enough.

We don't need to be perfect, and I think it all comes back to the fact that we have such a moral obligation now, such a moral judgment when it comes to our health that we're really panicking. And it causes us to really question so many things like, is this okay? Is this not okay? What do I need to do? How do I do it? When do I do it? What do I...? And really, I feel like just saying to people, "Whoa, it's okay. Slow down, relax, enjoy life a bit more, worry less about your blood pressure."

I'm not saying totally ignore it either. But actually, we know that the more you stress about it, and the more stigma you experience, the less likely you are to actually address these health issues. Like I said, I didn't go and see a doctor for years because of the fear of getting diabetes, and then I got diabetes, and then I realized, oh, it is what it is, and there are days when I hate myself for it, but more and more now I'm just like, it's a health condition. Just a condition. There's nothing I can do about it. There are no good and bad patients. There are no compliant and non-compliant patients.

It's not about—I don't have a responsibility to look after my body and to reduce my HbA1c, and to prevent my risk of this and that and the other. I don't. And in fact, that's what we're going to be talking about a little bit more next week. In next week's podcast, episode 15, we'll be talking about how health status does not define your worth.

Hope you enjoyed this episode. Don't forget Weight Inclusive Wednesdays is coming up next Wednesday, the 16th. For those of you who are members of No Way or the Masterclass membership, you automatically get access to Weight Inclusive Wednesdays. For those who want to join, it is just a really safe space to have conversations, to form community, to discuss problems, highs, lows, anxieties, worries. It's just a safe space that I'm creating, and it's a small fee to join. And if you're low income, or if you have multiple marginalized identities, you get 50% off.

If you want to find out more, click the button in the show notes. If you're not signed up for my newsletter, then you could sign up for my newsletter, and then you would get access to all of this information. I have, as I said last week, dropped it down to one newsletter a week. There's one newsletter a week from me, and one newsletter a week from No Way. If you're signed up to No Way, you don't have to be signed up to both.

And this month's masterclass will be on high cholesterol for those who are in the masterclass membership, or who just want to watch the high cholesterol one. That comes out next Tuesday, the 15th.

Thank you very much for listening, and I will catch you next time.