Rock-Solid Advice to Prevent Kidney Stones with Dr. Jorge Gutierrez-Aceves

Podcast Transcript

John Horton:

Hey there, and welcome to another Health Essentials Podcast. I'm John Horton, your host.

If you've ever had a kidney stone, it's safe to say that one of your life goals moving forward is to prevent it from ever happening again. Trust me on this one. I speak from agonizing experience.

The good news: There are simple things you can do to limit your risk of kidney stones. We're going to lay out a defense plan today with the help of Dr. Jorge Gutierrez-Aceves, director of the Center for Endourology and Stone Disease at Cleveland Clinic. Dr. Gutierrez-Aceves is one of the many experts at Cleveland Clinic who pop into our weekly podcast to help us live a little healthier.

So before it's too late, let's find out how you can avoid becoming a member of the Kidney Stone Club. Welcome to the podcast, Dr. Gutierrez-Aceves. Thanks for taking some time for a little rock talk.

Dr. Jorge Gutierrez-Aceves:

Thank you for having me here. It's a big honor, big pleasure.

John Horton:

Well, I have to tell you, I'm really glad to see you here today, but I could have used this chat on preventing kidney stones about 10 years ago. It would've saved me some serious suffering. Those stones hurt.

Dr. Jorge Gutierrez-Aceves:

Yeah, that's what everybody says. I mean, I've been practicing 36 years, 35 years so far, and I treat more than 10,000, 12,000 cases. I never had one.

John Horton:

What, a stone? You're a lucky guy. But then you know all the ways to prevent kidney stones. So that kind of makes sense that you'd be able to avoid them.

Dr. Jorge Gutierrez-Aceves:

Yeah, I think it's important to explain to people that stone is not the disease itself. The disease comes from the kidney, and the stone is just like a symptom of the cyst that the kidney has that forms stones. So I think what we need to work in is what is the reason of the stone formation? And I think this is the main goal of the treatment — and I always tell the patients, I mean, by removing the stone, is only part of the treatment that will resolve the acute symptom of the stone, if you will. But the end goal of the treatment is going to be to understand why the kidney formed stones and how can we prevent stones.

John Horton:

Well, that was exactly going to be my question here. So you're right on. We're on the same page. So let's get into that. How exactly do your kidneys kind of turn into this rock pit? And I mean, why do these stones form in your body?

Dr. Jorge Gutierrez-Aceves:

Yeah. So I think that the simple answer will be the following: The kidney secretes minerals and salts. If these minerals and cells are not washed out from a certain part of the kidney, they're going to get concentrated and they will form a crystal. That crystal is going to be the nidus [core] of a stone.

What happens is, more cells are going to adhere to this crystal until the crystal becomes a real stone and move from the internal part of the kidney, from the tissue of the kidney, to the drainage part of the kidney, which is where it can move then to the urinary tract. And that is when they block the outlet of urine. And this is when the pain comes.

John Horton:

So you're saying this kind of ... it almost sounds like it's kind of a sediment that builds up, these minerals or whatever that kind of accumulate down there, and you said it's kind of like crystals. And I know, every time my kids had one of those little science experiments or you had to make crystals, those are not usually smooth formations that came out. They were usually pretty jagged. Is that part of what causes the pain, that these are really kind of sharp?

Dr. Jorge Gutierrez-Aceves:

No, no. When the crystal ... I need to explain that the crystal is formed in the tissue of the kidney, inside the tissue of the kidney. Anything that is happening inside the tissue of the kidney in terms of initiation of stone is not going to produce pain.

John Horton:

OK.

Dr. Jorge Gutierrez-Aceves:

The crystal embedded in the tissue of the kidney is going to grow, grow, grow, with the adherence of more salts until it literally jumps from the tissue of the kidney to the internal part of the kidney, which is a drainage system. And this drainage system is where urine is draining from the kidney, and the same urine produced by the kidney is going to push the stone to the urinary tract, which is a long tube called the ureter that connects the kidney with the bladder.

And most of the stone, in some segment of this ureter, will get stuck. And being stuck, the urine being produced by this kidney is not going to drain well. The kidney will get the standard, and this is the mechanism of pain.

John Horton:

So it sounds like they're not necessarily jagged. They could be smooth, they can be whatever, but it hurts because it's kind of stuck in that little tube.

Dr. Jorge Gutierrez-Aceves:

Yeah, because at the end, the lumen of the ureter, which is, again, this is all tube draining from the kidney to the bladder, is around 3 millimeters. And any stone, most of the stones that produce symptoms, are bigger than that. So I think, I mean, we, by definition, think that stones less than 5 millimeters have more chances to pass, and stones bigger than 5 millimeters are going to have less chances to pass.

And this is just pure physics. So if the stone is bigger, it's going to have more chances to get stuck in this tube. The ureter is a tube, literally a tube that contracts. They have peristalsis that we call … and this is the way urine drains from the kidney to the bladder. So again, the stone is just following urine in that segment.

John Horton:

Now, most of the time, I take it, we always have this debris, the sediment that's in there, but most of the time, it just doesn't form into a big enough stone to cause problems.

Dr. Jorge Gutierrez-Aceves:

Correct. So if you do some exercise and you don't drink enough liquids, you're not hydrated, well, yes, urine is going to be more concentrated, but it doesn't mean that it's forming stone. But in somebody who has a risk of formed stones, then this concentrated urine may have more salts, the salts and minerals that the kidneys usually excrete.

And the main base of most of the stones is calcium. So this calcium that the kidneys is creating, if you don't drink enough liquids, you're going to have more chances to form stone. And I mean, this is the main basic treatment that we recommend to the patient, drink liquids, get hydrated. And in order to get hydrated, what we suggest is to drink 3, 3 and a half liters a day, which is equivalent to 96 to 110 ounces of liquids a day.

John Horton:

Yeah.

Dr. Jorge Gutierrez-Aceves:

Especially for those patients who have a history or risk for stones here.

John Horton:

Well, and now, you're kind of getting into a little bit of what we want to talk about, which was ways to prevent kidney stones. And it does sound like the number one thing you can do then, is just to hydrate. That's the big thing.

Dr. Jorge Gutierrez-Aceves:

That's it. That's true. I think there will be five things that I can discuss with you during the conversation, how to prevent stones. And this is what we do, discuss with every single patient from stone.

So number one thing is get hydrated, and it's also important to understand how they get hydrated. And I think it's important, because there's some misconception of what they can drink and they cannot drink. I will say that basically, everything can be allowed to drink, with exception of sweet drinks. So several old studies confirm that sweet drinks, especially pops, sodas, especially the black sodas, they increase the risk of stones. Anything else can be allowed. For example, coffee, there is no contraindication to drink coffee.

John Horton:

That's good news. I drink a lot of coffee.

Dr. Jorge Gutierrez-Aceves:

Tea maybe. I mean, tea may, it's allowed, but the green leaf of the tea, if you're drinking green tea, may have something called oxalate that we can discuss in a bit later, and that may increase the risk of stones. But I mean, generally speaking, if you don't drink a lot of tea, you can drink tea. And you can drink beer and wine, which is good news for most of the patients.

And the most important thing, of course, will be to drink liquids. I mean, clear liquids, like water. There are people who don't like to drink water. So we recommend to add some citrus to the water. So lemon, orange, diluted with water. These two things, the citrus increase something that you and me and everybody else have that can prevent stones. We have two natural things inside that can prevent stones. One is called citrate, and the other one is magnesium, and citrate is increased with citrus.

John Horton:

Eat more citrus fruit, and that will help.

Dr. Jorge Gutierrez-Aceves:

Yes.

John Horton:

How does citrus break down or keep stones from forming?

Dr. Jorge Gutierrez-Aceves:

Because citrate is a natural thing that can prevent stones. What happens is citrate blocks how the calcium — which, again, is the base of most of the stones — so if you increase the level of citrate, you will decrease the challenges to have stones. And a natural way to increase citrate will be with citrus.

And also overall, with vegetables and fruits. Vegetables and fruits for everybody who forms stone, this is one of the main recommendations that we do, need to increase in your diet, vegetables and fruits. And need to add to your liquids, citrus fruits — I mean, orange or lemon.

John Horton:

You said so eating ... so, one, hydrating a lot, and it sounds like that works because it pushes that much fluid through. All that sediment in there just gets washed through your system. It doesn't have time to kind of glom together and turn into those stones.

Dr. Jorge Gutierrez-Aceves:

That is the principality of that. Yes.

John Horton:

And then, eat more citrus because it breaks down some of the calcium, or it doesn't form as easily.

Dr. Jorge Gutierrez-Aceves:

Increase the citrate and citrate prevents this [inaudible 00:10:04].

John Horton:

Calcium, great. All right. What about sodium? Because sodium always gets talked about. Is that something that you want to limit also?

Dr. Jorge Gutierrez-Aceves:

The second most important recommendation after liquids is going to be sodium. Sodium is salt. Salt is very bad for stones. And the reason why is, sodium increases excretion of calcium in the kidney. So again, most of the stones are based on calcium with different combinations, but at the end, the base is calcium. So sodium increases in a very confirmed proportion, the amount of excretion of calcium.

So if you decrease the amount of salt, you will decrease the sodium inside, and you will decrease excretion of calcium. And there is a couple of more things that sodium does. And the most important thing is those people who need medication to decrease excretion of calcium, the medication is not going to work if people still eat a lot of salt. So salt, again, is sodium. Sodium increases the excretion of calcium. And this is why the second most important recommendation after the liquids is decrease the amount of sodium or salt in your diet.

John Horton:

Yeah. It's amazing the amount of chemistry that's going on in your body that we're not even aware of all the time.

Dr. Jorge Gutierrez-Aceves:

And talking about salt, it's very important because the most frequent thing that I hear from patients is, “I don't use salt for cooking.” But remember, 75% of the salt comes from outside, comes from prepacked meals or from the food that we buy outside.

John Horton:

Yeah. It's hidden in so many processed foods, especially. It's so high in sodium.

Dr. Jorge Gutierrez-Aceves:

So this is where you need to be more careful in the intake of salt, not really in the amount of salt that you use for cooking, but the salt coming from the products that we buy. And I understand there are people who say, "Well, I cannot go home for lunch. I need to eat whatever is available here." But I mean, let's be sure that the amount of salt and the products that we buy at [inaudible 00:12:13] are not really salty.

John Horton:

Yeah. Now you had mentioned sweetened drinks before, too. I'd imagine you also want to avoid foods that are high in sugars or...

Dr. Jorge Gutierrez-Aceves:

That's a good point. No, I think the concentration of salt in fruits, and fruits, especially fruits, it's acceptable. We know that this will increase the portion of citrate and, again, citrates is a natural thing that can prevent stones. I will say artificial sweetener things, like the pops. I mean, this is a little bit different and this is what we need to avoid.

John Horton:

Yeah. So natural sugars in fruit, you're fine. You want to avoid hitting the candy aisle at the store, or those really sweetened drinks or sweetened products, artificially sweetened products.

Dr. Jorge Gutierrez-Aceves:

Exactly.

John Horton:

We always talk about animal proteins. It seems like beef, poultry, pork, eggs, fish, all that sort of stuff comes up. Is that something that you want to eat in moderation if you have, if you're prone to kidney stones?

Dr. Jorge Gutierrez-Aceves:

Yeah, you're truly driving me through the indications that we discussed with the patients. So again, the first thing is liquid. The second thing is salt. The third one, the most important one, will be animal protein. Yeah, I mean, we can divide animal protein in treat different categories, if you will. Red meat, which is steaks and pork and hamburgers; and-

John Horton:

…all the stuff that ends up on our plates. Yeah.

Dr. Jorge Gutierrez-Aceves:

…white meat or poultry, which is chicken and turkey; and fish and seafood. So the three of them are not good for stones. For years, we have thought that the red meat is worse, but there are some evidence that for some type of stones, fish is not even good.

So I will say decrease the amount of red meat. Depending on the amount of the red meat that you eat, probably, you don't want to eat more than once a week, twice a week. And eat more white meat, which is going to be a little bit less of risk for some, unbalance with some fish and sea food, this is fine. So I think the most important thing is to have a balance. But yeah, we see more incidents of stunts in people who eat a lot of red meat.

And also the amount — it will depend on, really, how frequently you eat meat. If you eat meat more than once, twice a week, probably that should be fine. I always say you don't need to stop eating meat, you don't need to become vegetarian, but just consider that increase in vegetables/fruits will prevent stones because it will increase the trait, and increasing meat is going to increase the risk of stone. So the mechanism of this is that it is going to increase the excretion of calcium also. So meat, and especially red meat, has a lot of calcium.

John Horton:

And I imagine portion size is important there, too, because I know-

Dr. Jorge Gutierrez-Aceves:

…that is an important thing, yeah. It is an important thing, yes.

John Horton:

…yeah. I know we talk all the time on our Nutrition Essentials episodes about that. And people … what we consider a serving is not what is usually a serving, as far as nutritionally. So that's something to watch when you get that half-pound burger, it's a little more than you probably need to put down.

Dr. Jorge Gutierrez-Aceves:

Yeah.

John Horton:

So what other things are … tips do you have, maybe the things we need to avoid or...

Dr. Jorge Gutierrez-Aceves:

So the next recommendation is, it's a little paradoxical, but this is what we understand now, we recommend now. Even when most of the stones, again, are based on calcium, calcium in the diet is good. It's a recommendation.

In the past, we used to say, "Well, you form stones that are made of calcium, don't eat calcium." Now, we do say a totally different thing. Why? Because the most frequent composition on the stone is calcium combined with something called oxalate. And the calcium in the diet will block the oxalate in the bowel and they will be excreted in the bowel and will not be excreted in the kidney.

So the reason of keeping dairy products in your diet and some other sources of calcium is because it will block the second-most frequent component of the salt, which is called oxalate. So there is no contraindication to eat calcium, and there's no contraindication to have dairy products or any other source of calcium in the diet.

In fact, there are some conditions that we do recommend calcium supplements, to decrease the amount of oxalate. And there will be particular conditions … but the bottom line here is the full recommendation, in addition to the liquids, to the salt, to the animal protein, is keep calcium in your diet.

John Horton:

OK, all right. And then, you had mentioned oxalates, and I know I've read things where it says you should avoid foods that are high in oxalates. Oxalates are one of those things where I think we've all kind of heard the term, I don't know if I could actually say what it is. So can you give us just a brief rundown of what oxalates are, and where we might find them?

Dr. Jorge Gutierrez-Aceves:

Yes. And that's very important because, as you say, many people have heard about the oxalate diet — it's called the oxalate diet. This is something that we don't use anymore.

I need to explain very briefly that oxalate comes, as you say … many fruits, vegetables that we are suggesting as a recommendation because they increase the citrate. But with exception of few things, oxalates are something that we are going to eat somehow, I mean one way or the other. And the good news, if you will, is only 10% of the oxalate is excreted in the kidney. Most is going to go in the stool. So really it's not a big issue.

The few things that we do recommend to take care, related to the amount of oxalate that they contain, are basically spinach, very, very high content of oxalate. The second group will be that group formed from nuts, nuts, almonds, probably peanuts. That will be the second group, very high in oxalate.

And then, they come two or three more frequent things, like broccoli, like radish, which is not frequent in diet, and potato. Probably all these five things are what I recommend to people, just take care if you are eating one of these things a lot.

And there, again, you find different diets and different customs, but very frequently people say, "Well, I have salad for lunch every day, and most of my salad come with spinach, and not morning." So I will say, you can eat them, just be sure that you don't have a lot of them.

So this is what I do recommend in terms of oxalate. The so-called “oxalate diet,” again, we rarely use. And there will be very particular condition when people have higher risk to excrete oxalate. Just an example will be after bariatric surgery or some sort of bowel surgery, with the excretion of oxalate is higher. Why? Because it does not go through the stool. So that will be a particular group.

But for general patient population, I will say the oxalate diet is not needed. It's just these four or five things that we mentioned that have a lot of content of oxalate that you need to be sure that you decrease.

John Horton:

Right. Eat those in moderation and you should be OK. It's not like you got to cut them all out. It's just you should be aware of them and kind of be cognizant of how much you're taking in.

Dr. Jorge Gutierrez-Aceves:

Correct. Yeah.

John Horton:

All right. What about … now, you hear medications — are those medications, could they drive the formation of stones?

Dr. Jorge Gutierrez-Aceves:

Yeah, they can increase formation of stone. So the guidelines that we use, we have been using for quite a good time, says that, state that we need to start in basically every patient with diet suggestions. So example, patient who come first time, first one, we don't do any further workup to understand what's going on there. We just give this recommendation that we have been discussing in terms of diet.

But it's a totally different history in patients who have recurrent stone formation. Those patients need to be further evaluated with a study that we call a metabolic test. That is simple, it's just collecting urine for 24 hours. And that study will let us know what is the kidneys excreting more? What is the level of calcium? What is the level of citrate? Where's the level of oxalate, etc., sodium? And then, based on this study, the metabolic test for stones, we can manage the patients, in addition to the diet, with some type of medication.

And we use basically three or four medications. Probably the most frequent one is something called potassium citrate, which is a medicine that increases the level of citrate and also helps decrease in the level of uric acid that's going out.

And the second-most frequent medication will be a water pill — most frequently used is something called hydrochlorothiazide — that will help the decrease in the excretion of calcium. This is the most frequent medicine that we use for high levels of calcium.

And then, some other medications, like allopurinol, which is going to be for people who have high, high level of uric acid in urine.

So there are medications, yes. There are medications that we can use, and we usually use them in combination with the diet, and we usually use them just for people who have recurrent stone events.

John Horton:

Now, those are all medications that you said if you have stones that you can take.

Dr. Jorge Gutierrez-Aceves:

No, no. I mean, let's say that we have removed surgically the stones, but the excretion of the kidney confirms, with this study that I was telling you, that there is a high level of calcium or high level of ... so that is when we use these medications to prevent more stones.

John Horton:

To prevent stones.

Dr. Jorge Gutierrez-Aceves:

Basically, all these medications are to prevent more stones.

John Horton:

OK, all right. Yeah, all right. That sounds great.

And I was going to ask, too, once you get a kidney stone, is there a medication that can just kind of get rid of it? Is there an easy and painless way to make this thing go away, or do you just have to wait for it to pass?

Dr. Jorge Gutierrez-Aceves:

The only type of stones that can be dissolved, and this happens only if it's a small stone, is those stones made of 100% uric acid. And this corresponds to 8%, around 8% of the incidence of stones. Again, the rest may be related to calcium, or some few, like 7%, related to infection. Only 8% of the stones, those made of uric acid, can be dissolved with medicine, called potassium citrate. So this is the medicine that we use most frequently for stones overall, but particularly for those patients who have uric acid stones is the medicine that we use to dissolve the stone. And it helps. It helps. But this is the only type of stone that can be dissolved. There is no other type of stone. There is no calcium-based stone that can be dissolved with medication.

John Horton:

[inaudible 00:23:34.]

Dr. Jorge Gutierrez-Aceves:

Unfortunately, if you have a stone, either you pass it or at some point, if you've it got stuck somewhere in the urinary tract, we need to remove it. I will say that, I mean, this is probably a part of the discussion that many people that we see in these big centers with high concentration of stone patients, we see a lot of people who have recurrent stones, recurrent stones. And some of these stones are in the side of the kidney that, at this time, is not producing anything, the [inaudible 00:24:03] structures. So we can manage these patients with observation, but you're totally right. Observation means that at some point, the stone may move, and may start producing pain and symptoms.

John Horton:

Yeah, yeah — and they do hurt. I do know that.

So you had mentioned surgery and things like that. Is that that common, that they get that big and you've got to go in and get it out?

Dr. Jorge Gutierrez-Aceves:

Yeah. So let me just remind you that the incidence of stones right now in North America is almost 1 in every 11 patients. So it's already 10 patients. So it's high. It's a little bit more than 10%. And there are different factors that contribute to this. So yes, it is, the main reason of care in urgent rooms and emergency rooms, when the stone decides to move and blow the urine tract. And unfortunately, it's not only the pain — the main risk of complication is infection, because once the stone is blocking the drainage of urine, that urine that is not draining well out, that urine has higher risk of complications.

John Horton:

Well, that definitely ... and that would be why you'd have to do the surgery then. You want to make sure you unblock that tube and get it going.

Dr. Jorge Gutierrez-Aceves:

Correct. Correct. So, the main reason of care in emergency rooms is when the stone decides to get past the ureter. And then, the main treatment that we do in every single department of urology in the country is put a drainage to the kidneys, something that we call a stent. And this is just to drain the kidney, prevent the risk of infection, or cure the infection in case that there is already infection, and then, we need to plan the treatment for the stone.

John Horton:

Yeah. And did I read right that you have done 10,000 surgeries to remove stones?

Dr. Jorge Gutierrez-Aceves:

Something like that.

John Horton:

You could start your own quarry. That's a lot of rocks.

Dr. Jorge Gutierrez-Aceves:

[inaudible 00:26:12] And I'm very lucky. I've never had one.

John Horton:

All right. So obviously, we want to prevent kidney stones. It seems like that should be everyone's number one goal, and what's the tips that you had mentioned … I also read where we're maintaining a healthy weight and exercising regularly can maybe help you keep those stones from forming. How exactly do those two things factor in?

Dr. Jorge Gutierrez-Aceves:

So this is one of the diseases that we can consider multifactorial. And one of these factors, I think that the main one, and unfortunately, something that we see more frequently, especially in young population, is obesity.

John Horton:

Yeah.

Dr. Jorge Gutierrez-Aceves:

I mean, we all need to recommend that, decrease the weight, but this is because obesity, for those, increases the risk of some in different weights. So yes, that's a recommendation that we do, which is a general health recommendation, but especially for people who form stones.

And there's some other factors that can be some sort of hereditary factors. So it's very, very frequent that somebody who forms stones has some member in the family who has a history of stones. And there are some other factors, like genetic factors, that we probably are not even well-informed what exactly they are. But yeah, one of the things that we can really recommend is try to decrease weight and try to keep a healthy diet and healthy lifestyle.

John Horton:

Yeah. And I'd imagine a lot of that with the weight goes hand in hand with many of the diet things you were talking about, because if you're eating more fruits and vegetables, eating less of the fattier meats, cutting back on those processed sweetened foods, it seems to go hand in hand that weight management kind of comes with that.

Dr. Jorge Gutierrez-Aceves:

Correct, correct.

John Horton:

What about exercising? Does exercising regularly … how does that contribute to maybe stones not forming as much?

Dr. Jorge Gutierrez-Aceves:

Yeah. I mean, I think exercise … I will consider that more like in the root of general health, to decrease the risk of hypertension, decrease the risk of heart conditions. But really, it's not something that we recommend itself to prevent stones.

John Horton:

OK, all right.

Dr. Jorge Gutierrez-Aceves:

Decrease obesity, yes. But I mean, exercise is just a general health recommendation, but not really direct.

John Horton:

Well, and I have to say, too, you got to watch, if you are exercising a lot, you got to make sure you hydrate because that is how I got into trouble, because I was training for a half-marathon, sweating too much, not drinking enough, and it cost me.

Dr. Jorge Gutierrez-Aceves:

Yeah, that is a very important point because you're totally right. I mean, people need to do exercise for different healthy issues, as we say, but yes, if you exercise, you need to be sure that you get hydrated after doing exercise. This is very, very, very important thing.

John Horton:

Well, Dr. Gutierrez, these have been some really helpful tips. And I'm thinking folks may be able to avoid seeing you in your office, and adding to your 10,000 surgeries list, if they follow this advice. But before we say our goodbyes and you get back to your business of mining, do you have any final words of wisdom to share with people regarding how they can prevent kidney stones?

Dr. Jorge Gutierrez-Aceves:

I think we have discussed basically all the steps that we do. I think what’s important is to recommend for people who have some sort of family history of stones, or some earlier history of stones, that any doubt, any pain that comes, especially comes from the back part of the body, radiating into the front part of the body, maybe another stone. And the reason why I say this is because somebody who has formed stone has between 50 and 70% chances to form another stone, compared to somebody who has not formed a stone. So, it is a recurring disease. And be sure that if you have history of that, if you have another symptom, maybe another stone coming in the way, and you need to look for assistance as soon as possible.

John Horton:

All right. Well, I have to tell you, I have hydrated like crazy ever since I got mine because I never want to have another one again.

Dr. Jorge Gutierrez-Aceves:

You have another stone, just let us know.

John Horton:

Anyway, Dr. Gutierrez-Aceves, thank you very much for your time. Like I said, this has been a wonderful conversation, and I think it can really help a lot of people, and hopefully, prevent them from experiencing that same pain that I did.

Dr. Jorge Gutierrez-Aceves:

Nice talking to you.

John Horton:

Roughly 1 in 10 people will get a kidney stone sometime during their life. But if you follow the advice given today by Dr. Gutierrez-Aceves, particularly when it comes to hydrating, you may be able to dodge that pain. I can tell you, it's worth the effort.

If you liked what you heard today, please hit the Subscribe button and leave a comment to share your thoughts. Until next time, be well.

Speaker 3:

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