Although many adolescents today are overweight, there are some teens whose extreme obesity causes serious medical complications, including Type 2 diabetes, high blood pressure and metabolic syndrome, just to name a few. These teens often are unable to lose weight through diet and exercise. However, not losing weight — and continuing to gain — is a dangerous path for them.
Shaina Eckhouse, MD discusses The Adolescent Bariatric Surgery Program at Children's and how studies show that obese adolescents remain so into adulthood, with the consequence of worsening medical conditions that limit their activities and shorten their lives.
Adolescent Bariatric Surgery Program at Children's
Featured Speaker:
Learn more about Dr. Eckhouse
Shaina Eckhouse, MD
Shaina R. Eckhouse, MD, is a Washington University bariatric surgeon at Barnes-Jewish Hospital and Barnes-Jewish West County Hospital specializing in advanced laparoscopic techniques.Learn more about Dr. Eckhouse
Transcription:
Adolescent Bariatric Surgery Program at Children's
Melanie Cole, MS (Host): Childhood obesity has increased from a relatively uncommon problem to one of the most important public health problems facing our children today. My guest today is Dr. Shaina Eckhouse. She's a bariatric surgeon at the Washington University School of Medicine who works in collaboration with the Healthy Start clinic at St. Louis Children's Hospital. Dr. Eckhouse, I'd like to start first to discuss the health issues associated with obese kids. How are these issues detected, managed, treated typically? What is the prevalence of obesity in this country today for our children?
Shaina Eckhouse, MD (Guest): So, thank you very much for having me on the show. I really appreciate the opportunity to talk about the disease of obesity and the opportunities for bariatric surgery. The disease of obesity is a growing epidemic in the United States, both in adults and in children. Among adults in 2018, the disease of obesity effected almost 38 to 40% of all adults in the United States. In children, it effects over about 18% of all children with over 20.6% of adolescents being effected in the United States. So, it's a growing problem that requires, I think, some time and focus.
The initial evaluation of your children is really with the growth charts done by pediatricians in their office. Monitoring them during their growth spurts and adolescents and noticing that they're increasing at a faster rate than expected based on their height along with a family history of the disease of obesity or comorbid conditions that can occur in concert with the disease of obesity—like diabetes or hypertension or sleep apnea—these are patients that need to be further treated for the possibility of the disease.
When I talk about the growth chart, these patients have either they're over the 99th percentile for their height would qualify them for the disease of obesity. They're considered overweight if they're over 95th percentile. Initially the treatment really is discussing lifestyle changes and how to alter, potentially, habits at home both with the patient being the child and their family as a unit.
Host: So, is there a genetic component when you are working with obese patients? Do you look at the family, Dr. Eckhouse, and see that sometimes the family is obese as well? If you're going to get into the discussion of bariatric surgery and measures that are beyond just exercise programs and diet and nutrition, are you then looking to the family as well for this whole picture that we're going to paint today?
Dr. Eckhouse: Yes. So, it really needs to be a team or family decision because it effects everybody in the household. Genetic causes of obesity are very uncommon. Like leptin deficiency or POMC. They're uncommon. They are harder to diagnose, but have a different kind of presentation and trajectory, and typically effect children at a very early age, as young as two years old to five years old. Prader-Willi would be another one. These are very uncommon.
Most people effected by the disease of obesity are effected by the more common cause, which is a multifactorial disease that's effected by our genetic environment—behavioral, social, cultural aspect of it. That all plays into the disease of obesity.With genetic diseases, there's different types of treatments, and that's where our Healthy Start clinic can be very helpful. But, again, this is very uncommon.
When patients have the disease of obesity where it effects not only either just the child or everybody in the household, it is really important to approach this as a team approach or a whole family unit approach. Without support, it can be a very challenging disease to treat.
Host: Multifactorial is spot on. There are so many reasons. Whether it's school, gym, and recess, and, as you say, environment and lifestyle. It's a very complicated, comprehensive issue that we're facing today. Dr. Eckhouse, speak about when a pediatrician would refer an adolescent patient for bariatric surgery. What would you like pediatricians to know as they're doing BMI and well visits with their patients? What is that big red flag that would say, "You know what? This is time to see a specialist?"
Dr. Eckhouse: Yeah. I think that's a great question. Bariatric surgery is still something that... While been around for a long time for adolescents, it's not something that pediatricians are as comfortable with. Understandably because it's maybe a more—I hate to say extreme approach—but it's a different approach than they're comfortable with and that's where I can definitely help out. I think these patients should be considered for bariatric surgery after they've failed multiple attempts at lifestyle changes, both through the family unit and more intensive approaches where you try maybe weekly behavioral lifestyle modifications.
We also have very specific criteria that we follow based on surgical guidelines based on WHO definitions and ASMBS guidelines, which ASMBS is the American Society for Metabolic and Bariatric Surgery, which is the governing body for bariatric surgery. Adolescent patients qualify if their BMI is over 35 with a serious comorbid condition, like: diabetes, sleep apnea with an apnea hypopnea index of greater than 15, pseudotumor cerebri, or severe fatty liver disease. They'd also qualify, if you didn't know their BMI, if they're 99 to 120% above for weight based on their height. Or a BMI of over 40 with other less serious comorbid conditions like insulin resistance and glucose intolerance and dyslipidemia and impaired quality of life or impaired activities of daily living.
Currently bariatric surgery's practiced around the country for children as young as 13. This has been done in larger centers that have been studying this for quite some time like Cincinnati Children's and Denver's Children's Hospital. We are starting with an age of 15. This is a decision we've made in collaboration with our Healthy Start clinic including Dr. Jennifer Sprague and Dr. Janis Stoll. Then our department of psychiatry including Dr. Ginger Nicol.
Host: Tell us a little bit about the evaluation process. Bariatric surgery's a big deal, and it's a life changing deal. For adults, as we've heard about it, but as you say, children are coming up with all these comorbid conditions that we never saw before. You know diabetes and high blood pressure. All of these things Dr. Eckhouse. Tell us what the evaluation process is like and what happens once a patient is accepted into this program.
Dr. Eckhouse: Yeah. So first, if the pediatrician and the family are both on board, it's getting in contact with either the Healthy Start clinic or my program, the Washington University Weight loss Surgery Program. We cross refer. So, if you start with Healthy Start, they'll refer you to us. If you start with us at the weight loss surgery program, we'll refer the patient to the Healthy Start clinic. So, they're working with both clinics in parallel, a true collaboration. With the bariatric surgery side, the first step is going to a seminar and getting more information. So, our hope is to educate the family and the potential patient or the teenager on what the disease of obesity is, the comorbid conditions that can effect it, the different ways to treat it, but then why consider bariatric surgery at this point. Then tell them both the positives and the negatives of bariatric surgery so that they get the well-rounded whole picture. If they don't know what I know, I've done them a disservice.
Then from there, on the surgery side, we get them set up with our nurse practitioner, Jayme Sparkman who's kind of our gatekeeper into our program. She does our initial evaluation. Then based on that evaluation, we'll refer them on for other studies to make sure that they'll qualify for surgery. Including labs that include vitamin levels, EKG, an appointment with a dietician, a psychologist, a physical therapist. All of these being through the Healthy Start clinic. Then, in parallel, they're being evaluated by the Healthy Start clinic. And actually, the dietician, psychologist, and physical therapist that we use are all part of the Healthy Start clinic as well.
So, they'll do six months medical weight loss with either Dr. Sprague or Dr. Stoll or their nurse practitioner and the dietician that's part of the Healthy Start clinic. Then after six months of medical weight loss, making sure we've optimized all of our options for treatment with lifestyle changes, along with the other workup, they'll come to us. Depending on their comorbid conditions and their history, there may be other studies we do to make sure that we keep the patient safe. We're very comprehensive, again, so that we make sure that the patient's safety is maintained.
Host: What type of surgeries are you doing for adolescent bariatric surgery?
Dr. Eckhouse: So, at this point—Historically is was the sleeve gastrectomy, the gastric bypass, and the laparoscopic adjustable gastric band. At this point with the fact that we're taking out more bands than we're putting in, we are as a team—Dr. Chris Eagon, my partner, and I who both perform bariatric surgery in adolescents—have agreed that it'd be best to limit surgeries to the sleeve gastrectomy and the gastric bypass, which parallels the guidelines that have come out in 2018 by the ASMBS.
These surgeries are each a little bit different. The sleeve gastrectomy's now the most common surgery we do in the United States in adults. It's over 60% of the procedures. And it's the more common procedure done in children as well. The sleeve is done by removing approximately 70 to 80% of the stomach and reshaping the stomach into a tube or a sleeve. By removing this much of the stomach, they get a restriction meaning they're unable to eat a certain amount of time—about the size of a half banana—at a time. Along with the fact that we remove the part of the stomach that regulates hunger and fullness or helps stimulate hunger and fullness changes. So, where they feel full faster and they're not hungry. The gastric bypass is probably what'd I'd say, it's been around the longest.
We've been doing the gastric bypass in adult patients since 1971. We're a lot better than we were in 1971. We've been doing it laparoscopically since the early '90s. It's the second most common operation done in adolescents. The gastric bypass is both a restrictive and malabsorptive operation, meaning we limit how much the patient can eat to the size of about a golf ball. Then we reroute the intestine so that the rest of the stomach and the first portion of the small intestine—known as the duodenum—is bypassed. So, patients get a little bit more weight loss and they also have restrictions. With the sleeve gastrectomy, a patient can lose about 50 to 70% of their excess weight. Excess weight being the amount of weight they have on top of their ideal weight. With a gastric bypass, they can lose about 60 to 80% of their excess weight.
Host: Wow. What an incredible program. As we wrap up, Dr. Eckhouse, tell us about the outcomes that you've seen, how patients maintain their new weight, and how you're helping them at the Healthy Start clinic at St. Louis Children's Hospital. And when you would like pediatricians and other providers to refer and to know about this program.
Dr. Eckhouse: So, the biggest thing with this program is it is very comprehensive and you're right. This is a big change for patients. For some patients and families and for some pediatricians, it may seem drastic. But the outcomes demonstrate the benefit of it. Meaning the proof's in the pudding. We're the only game in town for treating diabetes. Medical management is very good for controlling blood sugars and maintaining a hemoglobin AC1 that's within the range that's beneficial to a patient. With a bariatric surgery, I can help patients achieve remission. Meaning, get off those medications they were on before. We can also reverse fatty liver disease changes and inflammation in a smaller percentage of patients. And we can get patients off of sleep apnea machines and get them off blood pressure medications with the weight loss surgery itself.
The lifestyle is very different because of the fact that we're limiting the size of the stomach to the size of a half of a banana with the sleeve or the size of about of a golf ball with the gastric bypass. So, the patients see us at seven to ten days after surgery, six weeks after surgery, three months, six months, and yearly hopefully forever. Along with the fact that they're seeing the Healthy Start clinic staff as well at one month, three months, six months, and yearly so that we are able to maintain healthy habits long term.
Weight loss maintenance is performed by following a high protein, low carb, low fat diet. This helps optimize and maximize the weight loss. Actually, we recommend patients eat not three square meals a day, but five to six small meals and snacks a day. Snacks are not a bad thing if it's healthy food. In fact, we're not meant to eat three square meals a day. Our culture has dictated this, and, with time, it has negatively effected us. So, our goal is to get patients to eat small meals more consistently. Other changes that we're going to request because of the size of the pouch is to avoid soda and straws because it will overfill the stomach because of the inherent nature of the size of the stomach.
Long term we're also going to encourage exercise. The hope is that with meaningful weight loss, exercise will become easier for patients to do whether it's walking or playing sports in the future or being able to participate at a gym with their friends. We want to make sure that exercise is a component of it because it can help augment weight loss and improve and preserve cardiovascular and cardiopulmonary health.
For the pediatricians, the big thing is knowing that we're here and it's a safe and viable option. The risks are very low. In fact, adolescents have demonstrated even lower risks of complications than adults. That's where we are happy to work in concert with them to figure out who the best patient is to refer. But it's knowing it's a tool in the armamentarium. If the patient's had a tough time with lifestyle changes and has had a tough time with intervention, and the family and the teenager are still motivated and trying to find the best treatment option—along with the fact that they meet our criteria—we're here and available and always happy to talk.
I would like to add that we're going to have an opportunity for more education. I will be giving early bird grand rounds on June 7th at 8:00 a.m. to discuss bariatric surgery for teenagers in more detail. Along with the fact we'll be giving talks at the Children Specialty Care Speakers series in the future.
Host: Thank you so much Dr. Eckhouse for coming on today and discussing something that not many people and/or providers know about as a situation of bariatric surgery for adolescents. Thank you, again, for sharing that information. To consult with a specialist or to learn more about services offered at St. Louis Children's Hospital, please call the children's direct physician access line at 1-800-678-HELP.
That's 1-800-678-4357. You're listening to Radio Rounds with St. Louis Children's Hospital. For more information on resources available at St. Louis Children's Hospital, you can go to stlouischildrens.org. That's stlouischildrens.org. This is Melanie Cole. Thanks for tuning in.
Adolescent Bariatric Surgery Program at Children's
Melanie Cole, MS (Host): Childhood obesity has increased from a relatively uncommon problem to one of the most important public health problems facing our children today. My guest today is Dr. Shaina Eckhouse. She's a bariatric surgeon at the Washington University School of Medicine who works in collaboration with the Healthy Start clinic at St. Louis Children's Hospital. Dr. Eckhouse, I'd like to start first to discuss the health issues associated with obese kids. How are these issues detected, managed, treated typically? What is the prevalence of obesity in this country today for our children?
Shaina Eckhouse, MD (Guest): So, thank you very much for having me on the show. I really appreciate the opportunity to talk about the disease of obesity and the opportunities for bariatric surgery. The disease of obesity is a growing epidemic in the United States, both in adults and in children. Among adults in 2018, the disease of obesity effected almost 38 to 40% of all adults in the United States. In children, it effects over about 18% of all children with over 20.6% of adolescents being effected in the United States. So, it's a growing problem that requires, I think, some time and focus.
The initial evaluation of your children is really with the growth charts done by pediatricians in their office. Monitoring them during their growth spurts and adolescents and noticing that they're increasing at a faster rate than expected based on their height along with a family history of the disease of obesity or comorbid conditions that can occur in concert with the disease of obesity—like diabetes or hypertension or sleep apnea—these are patients that need to be further treated for the possibility of the disease.
When I talk about the growth chart, these patients have either they're over the 99th percentile for their height would qualify them for the disease of obesity. They're considered overweight if they're over 95th percentile. Initially the treatment really is discussing lifestyle changes and how to alter, potentially, habits at home both with the patient being the child and their family as a unit.
Host: So, is there a genetic component when you are working with obese patients? Do you look at the family, Dr. Eckhouse, and see that sometimes the family is obese as well? If you're going to get into the discussion of bariatric surgery and measures that are beyond just exercise programs and diet and nutrition, are you then looking to the family as well for this whole picture that we're going to paint today?
Dr. Eckhouse: Yes. So, it really needs to be a team or family decision because it effects everybody in the household. Genetic causes of obesity are very uncommon. Like leptin deficiency or POMC. They're uncommon. They are harder to diagnose, but have a different kind of presentation and trajectory, and typically effect children at a very early age, as young as two years old to five years old. Prader-Willi would be another one. These are very uncommon.
Most people effected by the disease of obesity are effected by the more common cause, which is a multifactorial disease that's effected by our genetic environment—behavioral, social, cultural aspect of it. That all plays into the disease of obesity.With genetic diseases, there's different types of treatments, and that's where our Healthy Start clinic can be very helpful. But, again, this is very uncommon.
When patients have the disease of obesity where it effects not only either just the child or everybody in the household, it is really important to approach this as a team approach or a whole family unit approach. Without support, it can be a very challenging disease to treat.
Host: Multifactorial is spot on. There are so many reasons. Whether it's school, gym, and recess, and, as you say, environment and lifestyle. It's a very complicated, comprehensive issue that we're facing today. Dr. Eckhouse, speak about when a pediatrician would refer an adolescent patient for bariatric surgery. What would you like pediatricians to know as they're doing BMI and well visits with their patients? What is that big red flag that would say, "You know what? This is time to see a specialist?"
Dr. Eckhouse: Yeah. I think that's a great question. Bariatric surgery is still something that... While been around for a long time for adolescents, it's not something that pediatricians are as comfortable with. Understandably because it's maybe a more—I hate to say extreme approach—but it's a different approach than they're comfortable with and that's where I can definitely help out. I think these patients should be considered for bariatric surgery after they've failed multiple attempts at lifestyle changes, both through the family unit and more intensive approaches where you try maybe weekly behavioral lifestyle modifications.
We also have very specific criteria that we follow based on surgical guidelines based on WHO definitions and ASMBS guidelines, which ASMBS is the American Society for Metabolic and Bariatric Surgery, which is the governing body for bariatric surgery. Adolescent patients qualify if their BMI is over 35 with a serious comorbid condition, like: diabetes, sleep apnea with an apnea hypopnea index of greater than 15, pseudotumor cerebri, or severe fatty liver disease. They'd also qualify, if you didn't know their BMI, if they're 99 to 120% above for weight based on their height. Or a BMI of over 40 with other less serious comorbid conditions like insulin resistance and glucose intolerance and dyslipidemia and impaired quality of life or impaired activities of daily living.
Currently bariatric surgery's practiced around the country for children as young as 13. This has been done in larger centers that have been studying this for quite some time like Cincinnati Children's and Denver's Children's Hospital. We are starting with an age of 15. This is a decision we've made in collaboration with our Healthy Start clinic including Dr. Jennifer Sprague and Dr. Janis Stoll. Then our department of psychiatry including Dr. Ginger Nicol.
Host: Tell us a little bit about the evaluation process. Bariatric surgery's a big deal, and it's a life changing deal. For adults, as we've heard about it, but as you say, children are coming up with all these comorbid conditions that we never saw before. You know diabetes and high blood pressure. All of these things Dr. Eckhouse. Tell us what the evaluation process is like and what happens once a patient is accepted into this program.
Dr. Eckhouse: Yeah. So first, if the pediatrician and the family are both on board, it's getting in contact with either the Healthy Start clinic or my program, the Washington University Weight loss Surgery Program. We cross refer. So, if you start with Healthy Start, they'll refer you to us. If you start with us at the weight loss surgery program, we'll refer the patient to the Healthy Start clinic. So, they're working with both clinics in parallel, a true collaboration. With the bariatric surgery side, the first step is going to a seminar and getting more information. So, our hope is to educate the family and the potential patient or the teenager on what the disease of obesity is, the comorbid conditions that can effect it, the different ways to treat it, but then why consider bariatric surgery at this point. Then tell them both the positives and the negatives of bariatric surgery so that they get the well-rounded whole picture. If they don't know what I know, I've done them a disservice.
Then from there, on the surgery side, we get them set up with our nurse practitioner, Jayme Sparkman who's kind of our gatekeeper into our program. She does our initial evaluation. Then based on that evaluation, we'll refer them on for other studies to make sure that they'll qualify for surgery. Including labs that include vitamin levels, EKG, an appointment with a dietician, a psychologist, a physical therapist. All of these being through the Healthy Start clinic. Then, in parallel, they're being evaluated by the Healthy Start clinic. And actually, the dietician, psychologist, and physical therapist that we use are all part of the Healthy Start clinic as well.
So, they'll do six months medical weight loss with either Dr. Sprague or Dr. Stoll or their nurse practitioner and the dietician that's part of the Healthy Start clinic. Then after six months of medical weight loss, making sure we've optimized all of our options for treatment with lifestyle changes, along with the other workup, they'll come to us. Depending on their comorbid conditions and their history, there may be other studies we do to make sure that we keep the patient safe. We're very comprehensive, again, so that we make sure that the patient's safety is maintained.
Host: What type of surgeries are you doing for adolescent bariatric surgery?
Dr. Eckhouse: So, at this point—Historically is was the sleeve gastrectomy, the gastric bypass, and the laparoscopic adjustable gastric band. At this point with the fact that we're taking out more bands than we're putting in, we are as a team—Dr. Chris Eagon, my partner, and I who both perform bariatric surgery in adolescents—have agreed that it'd be best to limit surgeries to the sleeve gastrectomy and the gastric bypass, which parallels the guidelines that have come out in 2018 by the ASMBS.
These surgeries are each a little bit different. The sleeve gastrectomy's now the most common surgery we do in the United States in adults. It's over 60% of the procedures. And it's the more common procedure done in children as well. The sleeve is done by removing approximately 70 to 80% of the stomach and reshaping the stomach into a tube or a sleeve. By removing this much of the stomach, they get a restriction meaning they're unable to eat a certain amount of time—about the size of a half banana—at a time. Along with the fact that we remove the part of the stomach that regulates hunger and fullness or helps stimulate hunger and fullness changes. So, where they feel full faster and they're not hungry. The gastric bypass is probably what'd I'd say, it's been around the longest.
We've been doing the gastric bypass in adult patients since 1971. We're a lot better than we were in 1971. We've been doing it laparoscopically since the early '90s. It's the second most common operation done in adolescents. The gastric bypass is both a restrictive and malabsorptive operation, meaning we limit how much the patient can eat to the size of about a golf ball. Then we reroute the intestine so that the rest of the stomach and the first portion of the small intestine—known as the duodenum—is bypassed. So, patients get a little bit more weight loss and they also have restrictions. With the sleeve gastrectomy, a patient can lose about 50 to 70% of their excess weight. Excess weight being the amount of weight they have on top of their ideal weight. With a gastric bypass, they can lose about 60 to 80% of their excess weight.
Host: Wow. What an incredible program. As we wrap up, Dr. Eckhouse, tell us about the outcomes that you've seen, how patients maintain their new weight, and how you're helping them at the Healthy Start clinic at St. Louis Children's Hospital. And when you would like pediatricians and other providers to refer and to know about this program.
Dr. Eckhouse: So, the biggest thing with this program is it is very comprehensive and you're right. This is a big change for patients. For some patients and families and for some pediatricians, it may seem drastic. But the outcomes demonstrate the benefit of it. Meaning the proof's in the pudding. We're the only game in town for treating diabetes. Medical management is very good for controlling blood sugars and maintaining a hemoglobin AC1 that's within the range that's beneficial to a patient. With a bariatric surgery, I can help patients achieve remission. Meaning, get off those medications they were on before. We can also reverse fatty liver disease changes and inflammation in a smaller percentage of patients. And we can get patients off of sleep apnea machines and get them off blood pressure medications with the weight loss surgery itself.
The lifestyle is very different because of the fact that we're limiting the size of the stomach to the size of a half of a banana with the sleeve or the size of about of a golf ball with the gastric bypass. So, the patients see us at seven to ten days after surgery, six weeks after surgery, three months, six months, and yearly hopefully forever. Along with the fact that they're seeing the Healthy Start clinic staff as well at one month, three months, six months, and yearly so that we are able to maintain healthy habits long term.
Weight loss maintenance is performed by following a high protein, low carb, low fat diet. This helps optimize and maximize the weight loss. Actually, we recommend patients eat not three square meals a day, but five to six small meals and snacks a day. Snacks are not a bad thing if it's healthy food. In fact, we're not meant to eat three square meals a day. Our culture has dictated this, and, with time, it has negatively effected us. So, our goal is to get patients to eat small meals more consistently. Other changes that we're going to request because of the size of the pouch is to avoid soda and straws because it will overfill the stomach because of the inherent nature of the size of the stomach.
Long term we're also going to encourage exercise. The hope is that with meaningful weight loss, exercise will become easier for patients to do whether it's walking or playing sports in the future or being able to participate at a gym with their friends. We want to make sure that exercise is a component of it because it can help augment weight loss and improve and preserve cardiovascular and cardiopulmonary health.
For the pediatricians, the big thing is knowing that we're here and it's a safe and viable option. The risks are very low. In fact, adolescents have demonstrated even lower risks of complications than adults. That's where we are happy to work in concert with them to figure out who the best patient is to refer. But it's knowing it's a tool in the armamentarium. If the patient's had a tough time with lifestyle changes and has had a tough time with intervention, and the family and the teenager are still motivated and trying to find the best treatment option—along with the fact that they meet our criteria—we're here and available and always happy to talk.
I would like to add that we're going to have an opportunity for more education. I will be giving early bird grand rounds on June 7th at 8:00 a.m. to discuss bariatric surgery for teenagers in more detail. Along with the fact we'll be giving talks at the Children Specialty Care Speakers series in the future.
Host: Thank you so much Dr. Eckhouse for coming on today and discussing something that not many people and/or providers know about as a situation of bariatric surgery for adolescents. Thank you, again, for sharing that information. To consult with a specialist or to learn more about services offered at St. Louis Children's Hospital, please call the children's direct physician access line at 1-800-678-HELP.
That's 1-800-678-4357. You're listening to Radio Rounds with St. Louis Children's Hospital. For more information on resources available at St. Louis Children's Hospital, you can go to stlouischildrens.org. That's stlouischildrens.org. This is Melanie Cole. Thanks for tuning in.