Bone loss with weight loss? with Dr. Kristen Beavers

In this episode, Dr. Mia and Dr. Kristin Beavers discuss the relationship between weight loss and bone health, emphasizing the importance of exercise, nutrition, and monitoring bone density through DEXA scans. They explore the impact of new diabetes medications GLP-1 inhibitors (such as ozempic, wegovy) on bone health and provide practical tips for maintaining bone density, particularly in older adults.

Kristen M. Beavers, PhD, MPH, RD, is a Professor of Internal Medicine, Section on Gerontology and Geriatric Medicine and an Associate Director of the Sticht Center for Healthy Aging and Alzheimer’s Prevention at Wake Forest University School of Medicine. She received her BS from Cornell University in Human Biology, Health, and Society; MPH and RD from The University of North Carolina at Chapel Hill in
Nutrition; and PhD from Baylor University in Exercise, Nutrition, and Preventive Health. Dr. Beavers’ academic and professional interests lie in the study of nutrition and exercise as interdisciplinary sciences, specifically as they relate to prevention and etiology of chronic disease and disability. She has been continuously funded by the NIH for the past decade and has developed a strong research program focused on mitigating loss of bone mass and strength in persons undergoing intentional weight loss, with three NIH-funded clinical trials underway.

Takeaways

• Weight loss can lead to bone loss, especially with caloric restriction.
• DEXA scans are crucial for assessing bone density and osteoporosis risk.
• Calcium and vitamin D are essential for bone health, especially during weight loss.
• Protein intake should be increased to help preserve bone and muscle during weight loss.
• Weight-bearing exercises are important for maintaining bone density.
• New diabetes medications GLP-1 inhibitors may be associated with bone loss, but more research is needed.
• Balance training is important to prevent falls and fractures in older adults.
• Older adults should be screened for osteoporosis, especially if they have risk factors.
• Maintaining adequate nutrient intake is challenging during weight loss.
• Prior fractures are a significant indicator of osteoporosis risk.

Chapters

00:00
Introduction to Bone Health and Weight Loss

02:56
Understanding Bone Loss During Weight Loss

05:56
DEXA Scans: Measuring Bone Density

08:59
Osteoporosis: Risk Factors and Screening

11:59
Emerging Diabetes Medications and Bone Health

14:57
Exercise: Loading Bones to Prevent Loss

17:57
Nutrition: Key Nutrients for Bone Health

20:59
Practical Tips for Maintaining Bone Density

23:57
Conclusion: Summary of Key Takeaways

Transcript

0:02

Welcome to Ask Dr. Mia podcast. Today I have Dr. Kristin Beavers with me. Kristin is a colleague of mine within geriatrics department of internal medicine at Wake Forest School of Medicine. She is a professor and has gotten her PhD and a nutrition degree at Baylor University in Texas. And she actually has been here for a long time and have been doing a lot of work in the study of nutrition, exercise, mitigating loss of bone and strength training in people who undergo intentional weight loss. So knowing Kristen's background, I think you get an idea of what we're going to talk about today, which is really... weight loss and bone loss and how to strengthen our bones, even if we're either intentionally or unintentionally losing weight. So welcome to the podcast, Kristen. Thanks. And I'm starting out this season by asking people kind of what kind of caregiving experience that they have in their real life. I know you have two kids of your own. Yes, right. So I have two lovely children. Maddie is 13 years old, so she's in middle school, and then my son Owen is nine, so he is in elementary school right now. So that's my primary caregiving responsibility. I would say as related to this talk topic, my mom was visiting us a few years ago when she unfortunately had broken her ankle and foot actually attending a sporting event for one of my children. was sort of just like cap and bee walking and hit an area where the pavement was uneven and the ground. And anyway, the importance of what I study came in laser like focus, know, like when you have trouble ambulating and every step matters, you pay attention to things like how far is it to the toilet? How far is it? You know, how many stairs are in my house? Things of that nature. So, you know, I certainly can't relate to all the aspects of caregiving for Asian parents just yet, but I've had. and some exposure to it. Yeah, absolutely. And speaking of mothers, my mother and her mother, my maternal grandmother have all had osteoporosis. In fact, my grandmother's osteoporosis was quite severe where she would, any little injury like falling from a seated position that was very low on the floor, she would break a bone. And it was devastating toward the end because it really limited her function and she was kind of confined to her bed, which is kind of an extreme scenario. And that osteoporosis treatment in China is still perhaps not as widespread as here. And they were noncompliant in their own way about taking medication. So very excited to talk with you today about bone and weight. So I guess to start out with, what do we know about weight loss and bone loss in general, do we automatically lose bone every time we lose weight? Mm-hmm. Yeah, I mean, that's great place to start. would say, know, people generally, the answer, the quick answer is likely yes, especially in most cases of caloric restriction, so dietary type weight loss. So, you know, people say they want to lose weight, they want to lose fat, but some of what you lose does come from the musculoskeletal system. There have been a... many studies over the years that would suggest that if people lose, you know... 10 % of their weight, which would be a reasonable target for like a lifestyle intervention. think most dietitians would say that would be a successful intervention. You're looking to lose about one to 4 % of your bone depending on the site. So weight bearing, you know, the hip is the area that, you know, when you think about fracture, that's a, that's a, you know, an area that we, we watch a lot because those types of fractures can really be life changing, maybe even life ending. And so at that specific site, you're looking at maybe like 2 % loss. accompanying about a 10 % weight loss intervention. That seems like a lot of bone to me because yeah. Well, I mean, it varies. I mean, I will say just to put that into context for you, bariatric surgery, which is another area that I study, these folks lose a lot of weight and they also lose a lot of bone. And those types of interventions where success might be like losing 30 % of their weight in that same time frame as a lifestyle. intervention you're looking at maybe 10 % bone loss. does vary based on the surgery type, but I'm just saying the general rule of thumb is the more weight you lose, the more of that would be bone. I don't think I fully realized the implication between weight and bone, but that makes sense because when we lose weight, the amount of pressure and stress on our bones also decreases. And so our bone doesn't need to work as hard to lift the same amount of body. Right. And I mean, I think in that, right, that's exactly right. That's something like Wolf's Law. So your bones do respond to the stresses they're placed under. And so you might think, and I mean, that, you know, if you're losing weight, that you will lose bone and that would be adaptive. But we know from a large body of observational data that when older adults lose weight, they also tend to fracture more. And that's the reason we think it's worth intervening upon to try to mitigate the bone loss if we can. Gotcha. And so in order to check for bone loss, know I routinely recommend my patients to get a DEXA scan. I know it's not done as often as one should. Can you just tell us what is a DEXA? What are they measuring? So DEXA stands for Dual Energy X-Ray Absorbed Geometry. So it is a bioimaging tool. It is a scanner that basically emits two X-rays. So that's the dual energy X-ray part. one of these X-rays has a... I'm trying to think of ways, but it's stopped by bone. One of the X-rays is actually stopped by fat. And so what you get after having one of these scans done, and you could do it of your whole body, you can do it at regions. So again, the hip is a particularly important region from a kind of a bone assessment standpoint, as is the spine. It gives you actually kind of a very pretty picture, like a sophisticated x-ray of what your body components look like. And so from this tool, you can get things like your bone density, you can get your fat mass, kind of honestly dirty secret to DEXA is that the leftover ends up being quantified as lean mass. And so it is used pretty routinely to measure lean mass, just know that there, I mean, when people say that they're thinking it's muscle and it does map onto muscle. Some of it is also water weight. It's also connective tissue. It's more than that. I think what DEXA is really good at is measuring fat and bone. And so for the purpose of this talk and for osteoporosis, it is kind of clinically how bone health is. monitored, so with a DEXA scan. the bone images that are typically obtained, again, at the hip and spine usually, sometimes the forearm if you can't get one of those sites, is compared to what a young adult reference standard would be. And kind of based on that comparison of where you fall in relation to the young adult standard, they folks can quantify, or doctors can kind of put you in different bins of either normal bone density, low bone density, or osteoporosis. And do we know if there are any race or gender differences in terms of what a healthy bone amount is like? yeah, it certainly does vary by but the young adult standard tends to be a young white woman. I mean, that tends to be the comparison, but there are no there are definitely different reference groups that can be used. Gotcha. Okay. All right. So after, say, people get a DEXA scan, or now I know there's actually two x-rays, not just one, one to look at bone and one to look at fat, you get a report. And I see those reports, they kind of are started at zero, but then go down to minus two. And if people are having minus two, then that usually puts them into an osteoporosis category. Mm-hmm. anywhere in between minus one and minus two is usually what's called osteopenia, meaning there is some loss of density in the bone, but not to the point of osteoporosis. Mm-hmm. Yes, and it's negative 2.5, but yes, that is absolutely right. Yeah, yeah, you got it. Nope. Uh-huh. That's right. Mm-hmm. great. So in terms of bone density, I know sometimes a lot of my patients also have had back surgery and so their lumbar spine is not a good measure, but you're saying people could use their forearm, their hip to compare. Yeah, and usually, I mean, osteoporosis is a systemic disorder. So if you have it at one site, the assumption is it's elsewhere. And so if you can't measure the spine, for the reasons you cite, actually a lot, personally, in the work that I do, the spine ends up being kind of problematic. I it is hard to interpret because, well, I'm interested in weight loss and sometimes when you have major, if you have someone, let's say that's losing weight and they have major shifts in tissue in their abdomen, I mean, that's where people tend to maybe lose some weight, that can affect the reading of DEXA. Also, know, typically we think, and it's not wrong, but that the more dense your bones are, you know, less likely you are to fracture. But, you know, if you have compression fractures, it's... at the spine, let's say, or if you have osteophytes. So if you have kind of arthritis at the spine, that can artificially make your bones look more dense. And the spine, think, is particularly susceptible to that, maybe more so than the hip. anyway, this is all to say, if you can't do the spine for whatever reason, the other site that people will typically do is your distal radius. even if you couldn't do the spine, you can just do the hip. mean, clinicians could use that information. Yeah, and distal radius for us, for the non-medical audience is risked. Yes, that's right. No, no, you're totally fine. You're living in the bone world, so this just comes easily to you. And in general, according to the US Preventative Task Force for women older than 65, that's usually when we start recommending screening for osteoporosis. And sometimes we do screen. for people who are younger but at a higher risk for osteoporosis fractures. Like for example, if they have been taking steroids for a long time or that they maybe have undergone a major weight loss surgery like what you had mentioned before for gastric bypass or have had eating disorders, things that have maybe prevented the absorption of calcium and vitamin D that puts them at a higher risk for osteoporosis, they could potentially be screened sooner. Great. Well, transitioning a little bit, because I know we have heard a lot of news about some of these new diabetes medications, GLP-1 inhibitors. What do we know about these new drugs besides the fact that they reduce blood sugar? Mm-hmm. Yeah, man. This field is just exploded for sure And it's exciting. I mean it really is. Yeah these medications these increment meds in particular the GLP one receptor agonist, you know, the go bees the mandaras things like that You know as you mentioned were originally kind of approved for diabetes and for hyperglycemia, so managing blood sugar and things like that. And people recognized that people were also losing weight on them. And so the field started moving then to thinking about using these medications more for a chronic weight management standpoint. And they are very effective at inducing weight loss. mean, think the typical weight loss for, and I mean, honestly, every day I feel like there's a new drug in the pipeline, there's a whatever, but you'd be looking at annually maybe. 15 % weight loss on some of the earlier generations, maybe up to weight loss is rivaling bariatric surgery with some of the multi agonists. mean, like this is, it is definitely a brave new world in terms of, know, obesity management with these medications. So, you know, in terms of what we know about bone loss, the field is emerging. for sure. studying bone takes time. I'll just say, just bone remodeling takes time. So you're looking at least, I would say, to feel pretty confident year-long interventions, to see changes in bone that might exceed just what an error on the machine would be, something like that, to really feel confident in it. So anyway, this is just simply to say the evidence base is emerging in this area. There are data from what are called preclinical studies. So these might be like cells or animals or things of that nature that actually suggest these medications are good for bone. So they increase bone formation, decrease bone resorption. Like there is a body of data that kind of would suggest mechanistically that they have that effect. The data I've seen in people, again, limited as it is, does suggest that like with other weight loss, modalities if these medications induce significant weight loss, which again, depending on the dose and how long you're on, they really can, likely you're going to experience bone loss. And so I think that that's just something to be aware of and just monitoring. Maybe something, there was a big study that actually got an FDA approval for major cardiovascular risk reduction with one of the weight loss medications and resulted in the insert for the medications, of just noting that among older adults and women who were taking the medication, there was a trend for increased risk of fracture. And so these are emerging. I mean, think it just, to me, it's based on reasoning by analogy. What we know about other weight loss modalities that typically cause bone loss, I think it's reasonable to... to think that these would. I mean, it could be different, but likely if they're causing significant weight loss, some of which are losing his bone. And then thinking about what the risk benefit there is, is probably something at least to be mindful of. Right. Yeah. So it sounds like it's still a little too early to tell exactly whether they make you loose bone or potentially neutral or potentially help you gain a little bit of bone. So, okay. Well, that's good to know. And I know that for these drugs, they basically, you know, simulate a natural protein that we have in the body and that they basically prolong the time that food stays in the stomach so that it takes us longer to digest them and that makes us feel full sooner so that we don't eat as much. And there are so many different ones. I can barely keep track of the brand name versus the generic name and which one, I mean, I think we hear about Ozempic a lot. That's one. Wigovie is another one that we hear these just are names on the commercials. Mm-hmm. But which one did you say was the one that seemed to have benefit for heart as well? So, Govi, the semaglutide 2.4 was the one, there's a big study called Select that got the, that people who were taking this medication also saw a reduction in MACE, major adverse cardiovascular events. And so there was then the FDA approved it for that indication, which I think is really important for older adults because they, you could be taking it for that reason beyond the weight loss, you know. Yeah, yeah, I'm still dealing with a lot of insurance authorization for these medications for people who don't have a diagnosis of diabetes and maybe they do really want to lose weight by going on these drugs. It's pretty difficult, at least my experience thus far, in terms of getting them approved. There may be other folks who are better at it than I am, but certainly that's been my experience so far. yeah, yeah. yeah. I was just going to say, and I think that that just brings up another thing to be thinking about with these medications. mean, they appear to be, mean, highly effective as long as you can access them and are on them. And so, and with many other weight loss approaches, it does seem like when these medications stop, that weight regain is likely to happen. And so, I think if there are barriers to access issues, that is something important to think about. Right, right. And when it comes to say someone has already lost a lot of weight and that you assume they probably have weak bone either from that weight loss alone or because of their other risk factors, what can someone do to improve their bone health? Mm-hmm. So we, yeah, we've been studying this for a while. Like, you know, what could you maybe add to weight loss to try to mitigate the bone loss? You maximize the fat, improve the cardio metabolic stuff, but spare this musculoskeletal system. And certainly exercise is something that, you know, that has been shown, especially weight bearing exercise or a loading based exercise. So if you can kind of, if you can load your bones and again, progressive resistance training. So going to the gym and using, you know, weight machines or certainly free weights or even therabands can do it. Although I will say sometimes the stimulus, it's hard to, you your bone, you have to stimulate it. And so it does depend on the intensity of what you're doing. I mean, I'll just say that. So sometimes home-based exercises are a little bit harder to kind of reach the intensity that you need to actually build bone. But exercise can be effective. And again, I think especially if it has some type of loading component to it. What do you mean by loading? So when you think about like exercise prescriptions, there are kind of, I mean there's several tracks, but like you think about like an aerobic track, so like kind of walking, maybe swimming, biking, but these things aren't really pulling on the bone in the way, you might like grab it like loading like jumping. or what would be another example, like wearing a weighted vest maybe while you're walking could like load yourself while you're walking or certainly, you if you're pulling on, if you're lifting weights, I mean, that sort of your muscles are kind of, they're attached to your skeleton, right? So there's pulling on your skeleton as you're doing that. like anything that would kind of compress the bone, gravitate, either loading, taking advantage of gravitational loading or, know, muscle. contractions will stimulate the bone versus something again, more like swimming, which doesn't, know, like you're in the water. It's very buoyant. You're not really, you know, um, it's great. I mean, there, there are benefits to, you know, swimming or cycling cardiovascularly, but it's not really, um, uh, affecting this, you know, loading the skeleton and where you might expect it to respond. Cause again, going back to some of the talk about four, your skeleton will respond to the loads placed on it. And so if you, you know, that's, if you want to offset weight loss associated with bone loss, one way to do it would be to load it some other way. And exercises, depending on the type, is one other way. Interesting. Yeah, so I wonder, there are, you know, sometimes people think about what type of exercises are good for people with arthritis. I think those are probably the type of exercises that load on the bone because, you know, we generally encourage people with arthritis to do water aerobics or swim because there's lower pressure on the bone. But I guess it's, harder for the bone to see. It's good for your heart, but maybe not the same way as running. this is a tried and true kind of tenant of exercise physio. Like there's a specificity to the training. It does depend on what you're doing in terms of the outcome you're getting. And probably why in large part, like when you think about the national guidelines for exercise, it recommends an aerobic and a strengthening component. So you can kind of see those entire benefits on the entire body system. yeah, I have to say I am much worse at the strength training part compared to the aerobic part. Yeah, yeah. I definitely need I will run. mean, I just I don't know. I just I do as much for my mind. Honestly, it's my body. But I will do that every day. Like, that's not even a thing. I don't like I just like to get outside. But like, I need someone to be. I need it. Yeah. Like, I mean, telling me to do this to lift weights. Yeah, no, no. Lifting weights is hard and it may be a little bit less familiar than other exercises. Yeah, yeah. Yeah, so for people who do say put on a, hold on to handheld weights while they're walking or putting on a weighted vest. the... Potential benefit is that you could be strengthening your bones while doing an exercise. Okay. Yeah. And we found, mean, so yeah, we actually just kind of wrapped up. I mean, it's still not prime time yet, but had done a large study funded by the National Institute on Aging thinking if you could use a weighted vest sort of as a stimulus to offset bone loss happens when people lose weight. And and kind of the premise behind that, again, as we said, is that one of the reasons that you are losing bone when you lose weight is you're unloading yourself. Well, we'll load you back. And so we'll do it by using a weighted vest. another reason that we chose the the weighted vest is the kind of tool here is because we know for older adults, and this study was conducted in older adults, getting them to walk is, I'm not saying it's easy, but that's a different lift than getting them to go to the gym. And quite honestly, that study was launched during COVID. And I had, I mean, you I just really did not appreciate like the, can wear the vest anywhere. know, getting people back into gyms during that time was really hard. And I mean, I think it just does speak to the whole, there are access issues. know, have to, adults would have to, you know, go to a gym and, you know, depending on where they live, that may be hard. You know, ideally for that group, you would have, you know, some type of safety supervision, you know, just to, and I mean, whereas the vest sort of circumvents some of that because you can really kind of do it. around your neighborhood, around your house, something. Gotcha. Well, I know your results are coming out soon and we will eagerly await to see whether the weighted vest helps with reducing bone loss while exercising. But transitioning a little bit to talk about foods or what type of diet that can help us build bone. Mm-hmm. Yes. So, and I'm a registered dietitian by training, so this is sort of, this is a low-hanging fruit, I guess, for me to think about. So when you think about nutrients that are really beneficial to the musculoskeletal system, I mean, the top three that come to my mind are protein, calcium, and vitamin D, because we just know that they're important. I they're for lots of aspects of health, but certainly skeletal health. So from a weight loss standpoint, I would say across the board, The problem with weight loss is that you are less likely to take in the adequate amounts of these nutrients. So it might not be that you need to have excess. It just might mean that you shouldn't be deficient. Do you know what I mean? And that can be hard to do when you're reducing your calories. mean, so sometimes supplements can be really helpful in that way to meet the recommended dietary allotment for these nutrients. But I would say, we've done some work and I have some colleagues, a lovely mentor who's done some work looking at calcium and vitamin D. Again, it does seem like with those nutrients that you just want to make sure that you are sufficient. Maybe mega super dosing, I don't know if that's worth, but it's worth noting that your calcium absorption goes down when you're losing weight. It just does. And so you might need to take more just to absorb more. But generally speaking, meaning the... recommended daily allowance for those ones is okay. Protein, it does seem like if you can go a bit above what is recommended. So right now what people recommend typically is about 0.8 grams of protein per kilogram of body weight, which I know is kind of frustrating, but you could kind of do the math and figure out where you would stand based on your weight. And if you can get that closer to one, even 1.2, that probably is going to help offset... not only bone, but also muscle loss that happens with weight loss to preserve those tissues. So for an average person who, don't know, 150, 160 pounds, that is what, 75 kilos? And so, you said 0.8? That's what the RDA is. But if you think if like one is what you'd want, if you're 75, you'd want about 75 grams of protein per day. spread out kind of throughout the day is sort of the, that's the other kind of trick with that. So your body can only absorb so much at one time. And people tend to be pretty good at getting like their adequate levels of protein during the evening meals. that tends to be breakfast is one that sort of gets, know, that, so I think if you can, you know, from a practical standpoint, you would just be intentional about thinking about including protein during breakfast or throughout the day as snacks. But again, this is why this is hard to do. I mean, it's hard to do maybe period if you're not really paying attention to it and then putting yourself in a state where you're reducing your calories. then it's, know, then I think you'd be even more intentional about where those calories are coming from. Right. And how do you know how much calcium is, say, too much versus not enough? What are some equivalents in terms of, I don't know, a yogurt? How much calcium is in that versus... Because in general, I don't typically recommend for people to take calcium supplements because I find that they can certainly have some constipation associated with them. and that I'd rather for them to eat yogurt, cheese, milk, that kind of thing. But there are other ways of getting calcium, right? Mm-hmm. For sure. mean, even like, think that, you know, we sneak it in orange juice, you know, like orange juice is fortified with this because, and so that's way to do it. Certainly. mean, it is calcium is in, leafy green vegetables. It's just our ability to absorb it is a little bit impaired, but not impossible. And so, you know, I think especially just, I'm recalling some of my early kind of nutrition knowledge. think even if you, if you can cook greens and some type of. acid environment, which maybe sounds crazy, but like that's what a stir fry is, or that's like, you know what, that can liberate some of that, the calcium that's in the greens and so you can absorb it better. So yeah, there are certainly ways to do it. But again, I and I hear what you're saying, but you know, multivitamins are also a way to, you know, kind of hedge your bets and maybe not doing a, well, anyway, yeah, there are other ways, dietary or non dietary, to meet your calcium needs. Right, and I know for vitamin D especially, we have to make the vitamin D in our skin by exposure to sun. So if you're not outside, hardly at all, it's very likely that people are deficient in vitamin D and that we, know in other studies for the general public who are older adults, supplementing them with vitamin D really hasn't shown the benefit that we were hoping to in terms of, you preventing fractures and whatnot. But I think certainly if your vitamin D is low, then repleting that is helpful for your bones. Honestly, that that generally feels like the story of like nutrients. It's that well, it's just you want to be you don't be low. It you don't necessarily be super physiologic, but you just don't want to be low. And so and to put to your point, depending, I mean, you do make vitamin D in your skin. It doesn't even take that much time. But I mean, I think it's like 15 minutes on your hands. It's not that much. But like, certainly, I mean, depending on if you're able to go outside or where you live, you know how, you know, how cloudy it is, know, time of year, that can certainly influence your body's ability to synthesize by MND. All right, so to summarize the lessons that I think you taught us today for bone health, we know that weight loss oftentimes comes with bone loss and that to prevent too much bone loss, we should be conscious of the type of exercise we do, do kinds that load our bone. So, know, a weighted vest or... I wonder if rowing is something that can, I guess we move the muscle so that that loads the bone. That's my preferred manner of exercise. And then, so exercise, not just getting your heart moving, but also loading your bones and that pay attention to how much calcium, vitamin D and protein you take during the day. And that some of these new drugs are just too early to tell in terms of whether they help or don't help. in terms of bone. Anything else you want to add? I think that maybe the only thing I was just thinking about, know, when people, I mean, we are concerned about bone and the clinical endpoint of interest is fracture, you know, but I mean, so people tend to fracture when they fall. And so thinking about balance training, I think is really important. And then the other thing maybe I would just circle back to when we were talking about. osteoporosis and like the DEXA scans are great and that is clinically how we measure it. You know, sure, there is a movement in that field that to recognize prior fractures is really important. You know, it's not, know, if you've had a prior fragility fracture, like that probably would mean that you have osteoporosis even, you know, like just because you have that you've already had the endpoint and certainly having had a fracture increases likely if you have another one. So just, just something for people to be aware of, you know, even if they haven't had a DEXA scan that, you know. Right, yeah, my mom's first diagnosis of osteoporosis was actually because she was texting on her phone while walking down the stairs and then slipped and I think it landed on her outstretched hand and then fractured her wrist or the forearm bone, I should say. It wasn't exactly the wrist, but it was the forearm. And so, yeah, yeah, from there, you know, then it was, she had a dexascan and showed that. she had weak bones, which was not surprising given her mother's history. yeah. Well, thank you for joining us today, Kristen. Thank you. stop