#205 Nutrition Studies, Coffee and the CRAVE Trial: Beyond Journal Club with the NEJM Group

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So if you've been trying to figure out how to actually fit learning into your life, this has been one of the easiest ways I've found. Use the code COR25 for 25% off at the checkout. Go to oakstone.com forward slash mixap. That's oakstone.com forward slash mksap and use the code COR25. I think almost everyone picking up the newspaper looking online, especially online, is likely to be very confused about how diet affects health or anything else because you'll find for almost every food that if you look on the internet, it's either going to kill you or make you almost immortal, but everything in between. Yes, the headlines, the social media reels feel like they're all over the place and the topic of nutrition research feels quite pressing. And so we've got a great episode lined up featuring the Crave Trial on Coffee and Rhythmias published in the New England Journal of Medicine in March 2023. And with that, we'd like to welcome you to another episode of Beyond Journal Club, a collaboration between Core IM and NEJM Group. The goal of Beyond Journal Club is to take landmark clinical trials and to put them into context, telling the story of how we got to where we are and what it means for how we take care of our patients. I'm Dr. Shriya Trivedi, an internist at BIDMC. I'm Dr. Clem Lee, a Med-Peace Hospice within the Mass General Program System and a deputy editor for NEJM Clinician. I'm Dr. Greg Katz, cardiologist at NYU. And I'm Dr. Katerina Lynn, NEJM Editorial Fellow. So I'm so excited that we get to delve into nutritional research today because this is what patients ask us about all the time. I mean, I cannot tell you how many people come to see me who are confused about what to eat or drink. Is red wine good or bad? What about meat? What about eggs? What about coffee? And we're so fortunate to have Dr. Walter Willett here with us to delve more deeply into nutritional research. I was told when I was a doctoral student that probably diet's important, but it's just too complicated. I sort of like complicated things. Dr. Walter Willett is professor of epidemiology and nutrition at the Harvard T.H. Chan School of Public Health. And he's been doing nutrition research for decades and he's one of the most cited people in literally just all of science, not just nutrition. Yeah, a pretty big deal. So today we're going to start by getting into why it's so hard to ask the big questions of nutrition. And then we'll discuss what we can glean and what we have to look out for in both large RCTs versus observational trials. And finally, we'll get into the crave trial to help answer the question that our patients really care about. Can I have a cup of coffee in the morning or is it going to give me a regular heartbeats? All right, yeah, I don't know about you guys, but like I was saying earlier with all these health influencers, right, they say things with such certainty sometimes that even with my own education and the degrees that I have, I can sometimes even get persuaded. And this is all saying that I also know at the same time nutrition research cannot be simplified into these 60-second clips. And so let's get to nutritional research and why it's so hard to study and oftentimes way too complicated to draw quick zinger conclusions from. Well, in the perfect ideal world, we would just do randomized trials. For practicality, they're very often in fact usually going to be not possible to do. For example, for red meat consumption, it probably you really need to be on a bad diet for three or four decades before you actually have a myocardial infarction. And we know that because you don't have those diseases before age 30 or 40 usually. So again, if you're doing a randomized trial, that's not going to be feasible to randomize many thousands of people at birth and follow them. So the effects of diet on outcomes that we care about, whether it be cardiovascular disease, cancer, mortality takes decades to show up, right? And most people, we can barely make a change in our diet consistently for a week, let alone 30 years. And even a randomized control trial that has perfect adherence to nutrition has its own set of problems because it's really hard to just test one thing. If you tell somebody to eat more of one thing, that means they're eating less of something else or they're eating more calories overall. And so ideally we would love to change one variable at a time and see the effect, but that's impossible in nutrition. And so you can't do the typical placebo versus drug that you would do in other types of studies. And then when these trials are run, we need to consider whether people are actually following their assigned interventions. Take for example, the Mr. Fit trial from the 1980s. It was a RCT that included replacing saturated fat with polyunsaturated fat. And in the end, there was no effect. The people who joined mostly had already changed their diet because they'd read the news and made the changes already. And then as the trial went on, there the intervention group did reduce their saturated fat intake, but the control group did it right in parallel. So in the end, there was really never any meaningful difference between the intervention and the control group. This is hard business. So the best alternative will usually be long-term epidemiologic studies like we're doing, plus combining that information with results from shorter-term studies with intermediate endpoints. Yeah, it's good to hear from Dr. Willow why we often must resort to observational studies. And we will review the Bradford Hill criteria on a previous episode on microplastics. These are criteria to help identify strong associations and observational studies that can point towards causation, though we can never really say that the Bradford Hill criteria prove causation. Yeah, and with all that in mind, let's get into when we look at a nutritional study, how we can look at it with a critical eye and really build up that chain of causality with some level of confidence. For the average person or physician, looking at that, I think there's several things to consider. First of all, usually the first study is the most unreliable study. It's the replicated finding that is going to be what you, I think, trust more in terms of making any decisions that it's been reproduced by two or three other groups or sometimes the same investigators using additional approaches. So reproducibility is really important, not just the most recent finding. And then also, how does it fit with other evidence? Maybe we have some studies that show, for example, in controlled feeding studies that an intermediate endpoint points in the same direction. Sometimes animal models, consistent animal models can help, but usually that's so far from human biology that those are not going to be so reliable. So mostly, I think, consider first the study itself. Is it that prospective? Is it large? A long term? And if you can have the methods for assessment been validated, although that may not be in the story, but then how does it fit with other information, including has it been reproduced by other investigators? Nice. So I appreciate hearing that thought process, right? Like when you see a new headline in the world of nutrition or a new research study, you know, he's mentioned a bunch of times he's like short term intermediate endpoint studies. And I just wanted to clarify what exactly he meant by these. I can use an example, trans fatty acid intake and heart disease. So we're doing some short term studies looking at changes in blood lipids as the outcome. These are studies, controlled feeding studies of about 50 people and putting them on diets for about three weeks and then looking at the short term changes. And those short term studies did show that trans fat elevated LDL cholesterol, reduced HDL cholesterol and elevated blood triglycerides. And we know that that pattern of lipid changes is associated with increased risk of heart disease. Putting those two kinds of studies together and each of those were replicated over time, that gave us a really strong foundation to conclude that trans fats were an important risk factor for heart disease. So we're using short term intermediate end points in addition to the larger epidemiological studies. And for many of these studies, we're recording diet with methods like the 24 hour dietary recall or food frequency questionnaires. Yeah. So a lot of these food frequency questionnaires, there's a lot of bias that comes with them. So let's listen to how Dr. Willett tries to minimize the bias for these recall methods and then perhaps we can apply a more rigorous lens to nutritional studies. In our studies, what's really important is that we are minimizing bias because their prospective studies were collecting the information before people are diagnosed with disease. Once they've got a disease, then we're very likely to get biased information. They are thinking about their diet differently. So the important point is that we're getting the information in a way that's unbiased with respect to disease. Yeah. So prospectively before someone has a disease in question can help, but there are also other steps that Dr. Willett takes specifically when it comes to these self reported questionnaires and recalls. And then we've done from the very beginning a series of what we call validation or calibration studies where we take actually now our most recent one about 1300 people who were all already in our study. And then we've gone back to them and collected very detailed data using way diet records, recording everything that they eat over two one week periods over a year. We have lots of biomarkers from blood measurements, urine measurements, doubly labeled water measurements, which gets it energy intake. And so we can compare our simple questionnaire provided by several hundred thousand people with this very detailed measurement. And then we can actually do statistical corrections to adjust for measurement error. But what's really very important is that we have repeated these measurements every four years, very few. In fact, I don't think any other studies have actually done that before. And that does turn out to be really important because people's preferences change over time, manufacturing changes over time. Oh man. So the next time I look at an individual study, I know after hearing the steps that he takes, I'll also try to see, did these investigators, you know, take other measures to actually verify the soft reported data collection? OK, it's time for me to be the naysayer in the room again. I hate doing this, but I just have to bring up, even though we now have some extra tools from Dr. Willett to help us make the data more trustworthy, I think there are still a lot of caveats with the traditional data when you discuss. So for most of these observational studies, the data is collected from a food frequency questionnaire. And we need to keep in mind that even really well validated data collected over a short period of time, and then it's extrapolated to all of these years. And we just need to be honest that even if you're measuring people for two weeks and you're tracking every morsel that goes into their mouth, you don't know what's happening for all of the other years in their lives. I mean, most people's diets change from day to day or week to week or month to month. And we're not following people around for decades, figuring out what they're putting in their mouths. Right, Greg. And another thing to keep in mind is that people signing up for these nutritional studies might be more likely to do other healthy behaviors, meaning the healthy user effect. Yeah. And we also need to think about some very common confounders and to make sure that they were controlled for. These confounders might include health care use and socioeconomic status. And all of that rigor is really helpful, but we're still left building a chain of evidence from imperfect data sources. And even if we're talking about the same food, we might be talking about different things. And so if you tell me you eat ground beef once a week, 80, 20 ground beef is a very different product than 93, 7 ground beef. And so the level of complexity with all of this stuff is just profound. And sometimes it makes it hard to know if we're even assessing the same thing. And something else to bring up is that we have evidence linking entire diets to lipids, blood pressure and cardiovascular events. But that still leaves a lot of uncertainty when patients ask about specific foods, not diets. So like we can study the Mediterranean diet, but then people have specific questions about eggs. But even if you're talking about eggs, sometimes that raises more questions than it answers. And so with eggs, what's the bioactive compound? Is it the entirety of the food matrix? Is it a specific preparation? Is it the dose? Is it the timing? And coffee is another great example. It's so commonly consumed, but coffee has a million things in it. And it's really hard to study. Yeah, exactly. Coffee isn't just caffeine, right? It's the antioxidants, the polyphenols, the other bioactive compound. So yeah, it is a complex question. When we ask is coffee good or bad, that is a total oversimplification. All right. So after all the discussion about nutrition research and the complexities of it, let's make it a bit more concrete and do some application. Let's talk about coffee and that oversimplified question. Is it good or bad? If I had a dollar for every time a patient asked me if coffee was good or bad, I think that swim lessons for my kids would feel so much more affordable. Like I literally have patients asking me every single day of my life, whether coffee is bad or good for them. If they're allowed to have a cup every single day. And the concern really makes intuitive sense. I mean, caffeine is a stimulant. It affects autonomic tone, calcium handling, catecholamines. And so for decades, so many of my patients, their whole lives, they've been told that coffee might provoke irregular heartbeats. Okay. But I also have to admit, whenever I drink coffee, Greg, I also get palpitations. So I really do sympathize with your patients. And a lot of people will still drink coffee, even if it gets all the symptoms. Yeah, like me. Well, let's look at the evidence. So it's been really popular. A long study topic. Many observational studies haven't shown increased risk between coffee and A-fib, including large cohorts and meta-analyses. And surprisingly, some even suggest lower A-fib risk among certain coffee drinkers. Yeah. And speaking of the overall benefit of coffee, I just want to put out there like this one big observational study that was actually published in the New Literature of Medicine back in 2012. And it showed that those who drink more coffee actually tended to have a lower risk of death. You know, you can read a lot about coffee and all of coffee's effects on health. And, you know, sometimes I feel like you can take any of the individual components and find a mechanism. And then you pick catecholamines, you say increases sympathetic stress. You pick antioxidants, you say it helps with inflammation. Right. As Treyha mentioned before, there are so many ingredients, polyphenols, antioxidants, phytochemicals. And so some of these might have anti-inflammatory or cardio protective effects. So even mechanistically, I don't think it's obvious which ingredient explains any purportive benefit of coffee. And so if you want to be an influencer, basically pick a random molecule and coffee, find a plausible biologic mechanism and then the epidemiology you like and then post about it on social media. And then boom, goes viral. You have 5,000 comments on Instagram, including people fighting with each other in the comment thread. Painful, painful, all of it. Yeah. So I think we'd all agree that observational studies, especially the diverse group of chemicals that actually make up coffee, those observational studies aren't perfect. But the Cravedrial, the one that Katerina picked out, was, you know, really asking a more targeted question. And this question was, does short-term coffee consumption lead to arrhythmias? This is a much easier question to answer because we have more control over short-term coffee consumption, right? Even if we can't control all the specific ingredients in said coffee. Right. And so investigators of this RCT had a more focused goal in mind. What actually happens to heart rhythms on days when people drink coffee versus when they don't? Now, some of you like me might be wondering what the acronym Crave stands for. And so I'm here to tell you that it stands for coffee and real-time atrial and ventricular ectopy, which I think described the trials succinctly. So I give this 10 out of 10. Premature atrial contractions were the primary outcome, but ventricular ectopy was also measured as a secondary outcome. Clem, the investigators, thank you for your compliments on their acronym. And so after this trial was done, the media headline basically simplified this to caffeinated coffee is safe. There's no increase in premature atrial contractions. But that headline, it's true, but it hides a lot of nuance. Yeah. So let's get into it. Who were the participants in this trial, Katerina? So there were a hundred healthy people and they were on average 39 years old. Most were non-Hispanic white and the medium BMI was 24 and very few had chronic health conditions like diabetes or hypertension. And that baseline about half drink one to three cups of coffee daily. Okay. So far, nothing crazy there. I also found this to be really interesting that the participants didn't know their assignments until the night before. So the night before they would get a text message telling them that they were to drink coffee or not drink coffee for the next day. There was also a second text message at 8am the next morning. And so for the 14 day trial, each day was randomized and researchers made sure that no person got the same assignment of coffee or no coffee three days in a row. Can you just imagine getting a text message or being like, you can drink coffee tomorrow? That's a good point. How do the investigators make sure that the participants who got the text message to drink coffee will actually were drinking coffee and the ones that were randomized to have standing from coffee did not drink their coffee? If I'd been this trial, I would have certainly been excluded because I would have withdrawn consent and so it's super clever how they track these folks. And so participants were given Fitbit watches, Xio patches, continuous glucose monitors and a smartphone app called Eureka that tracked their geolocation. Yeah, so the researchers basically tracked their participants using this app to see if they went into a coffee shop or stayed away from a coffee shop. And this is specifically for people who reported in the beginning of the study that they went to coffee shops to get coffee. This didn't really apply to people who made their own coffees at home. They also gave participants surveys to fill out and then had them press a button on their Xio patch when they drink the coffee. And both of these we know as a weaker form of validation since people can forget to press a button or lie on a survey. Interestingly, they were offered reimbursement for coffee, even if they didn't follow their assigned coffee days as long as they provided receipts. It's a smart way to try to make coffee reporting more accurate since people were reimbursed regardless of whether they followed their randomization. Yeah, that is smart. I definitely would fess up that I accidentally during coffee, even if I wasn't supposed to knowing that, hey, I got some reimbursement out of it. All right, now let's get into the end points, though. Start with our primary outcome, PACs, premature H-Rail contractions. I got to say, why? Like, I don't know. And maybe this is embarrassing to say, but I don't know. I kind of like ignore PACs when I see them on EKGs. So I basically ignore PACs also unless they're really symptomatic. So I don't think that you're wrong there. But the thing that really everybody is worried about with caffeine is the risk of AFib. And, you know, if you look at the burden of PACs across a population or for an individual, the burden of PACs is a pretty decent predictor of future AFib. So from a clinical perspective, PACs are a pretty reasonable target if you want to think about the risk of AFib down the road. It's not perfect. And, you know, ideally you'd power the trial and follow people for long enough to actually see AFib, but looking at PACs isn't so bad. Okay. Thank you for explaining that a bit more. And I guess, Katarina, I'll turn it over to you. Would you do the honors of telling us what do they find regard to coffee drinking and PACs on those xyopatches? So for the daily number of PACs, they found no difference. So for coffee versus no coffee days, there were 58 versus 53 PACs over 24 hours. That's like two PACs an hour. So basically a minimal burden. Interesting. And there were multiple secondary outcomes. So they looked at PVCs, so premature ventricular contractions, step counts, sleep and glucose levels. And these were all using the gadgets they have put on the participants. Yeah. So there was no difference in their glucose levels, but the other secondary outcomes are really interesting. There were more PVCs on days drinking coffee, 154 versus 102 on average. The people in the study also took more steps during their coffee days, about a thousand more steps each day on average, but they had 36 fewer minutes of sleep per night. Both of those measured via their Fitbit. Hmm. And when they analyze the data per coffee drink, for each cup of coffee, someone drank, they had 587 more steps, but 14 minutes less sleep daily per cup of coffee. Interesting. I can't help but wonder like, were people just walking more to coffee shops? And that's why they had more steps. Yeah. I think that is certainly one theory that has been brought up. The other is that maybe coffee gives you more energy and helps you exercise more. And to put that into perspective, the average American walks about 5,000 steps a day. So if coffee makes you walk a thousand steps more, that's like a 20% increase in exercise. That is awesome. Right. Like I feel like Duncan Starbucks, like they got a new motto, like, did your trainers increase your step count by 20% like that? Yeah. Before we get carried away, it's worth mentioning again that this was a small time limited study. There were only a hundred people and the trial was only two weeks. Yeah. But I think we got to give the researchers credit where it's due. We talked a lot about how nutritional studies are really hard to perform. And to that end, there's multiple reasons from a research perspective why this study is rigorous. The first is it's a very clear intervention. Second, the adherence was really well tracked. Third, these outcomes, PACs, PBCs, step counts, they're objective. And so it's not based on symptoms. There's no placebo effect. It's not palpitations. And four, everybody served as their own control. Coffee on some days, no coffee on others. And so we don't really need to worry about balancing the groups. This is nice. It's a type of nutrition question that is truly testable. This is not, does coffee cause cancer? But does coffee over a short term period cause this concrete thing that we can truly measure? So I'm personally really happy that we have this trial. And that is a big deal coming from Greg Katz, if anyone knows. All right. So where does this leave us with coffee and then the messaging to our patients? It's a complicated question. Crave was done on healthy people, so we can't extrapolate it to people with cardiovascular disease. And so it's really more complicated than blanket statements like coffee is positive, no increase in PACs, people were more active. Or on the flip side, coffee is negative. And so it's really complicated. And so it's really complicated. People were more active. Or on the flip side, coffee is negative, more ventricular ectopy, less sleep. Yeah. Catarina and both of those interpretations could technically be correct. If I'm counseling like a young, healthy person who values energy and activity, I think this data feels reassuring. But if I'm talking to someone with symptomatic PBCs or a lot of sleep issues, I think this data leads to a very different conversation. Yeah. Like, Crave, like you have symptomatic PBCs or we're presuming every time you drink coffee to rounds, but what does that mean for your long-term cardiovascular health? Again, like I'm still stuck on those end points, right? I don't know the relevance of those PACs and PBCs per se. My honest assessment is that we can't really tell anything about long-term cardiovascular risk. And more than that, there's a difference between saying that PACs are associated with AFib versus something is associated with more PACs. So it's also associated with AFib. Those aren't really the same thing. And, you know, going back to the study, 50 PACs over a 24-hour period, that is a normal number of PACs for a healthy, like totally well-patient tap. Yeah. What about those PBCs, right? There was a difference. So do we think about PBCs differently? Yeah, it's really interesting because PBCs are often thought of as harbinger of bad cardiovascular outcomes. But even 100 PBCs in 24 hours is it's kind of a nothing burger for a sick patient who has heart failure, let alone a young, healthy patient who doesn't. There's 100,000 heartbeats in a 24-hour period. So I'm not going to even spend five seconds thinking about whether 100 PBCs or 150 PBCs is really anything much at all in the grand scheme of things. So I guess what we're saying is Clem is not going to go into heart failure, you know, with the 150 PBCs he's having every day drinking coffee. Yay. But also if you told me that I could get my patients to walk a thousand more steps a day by just giving them coffee, then there's a decent chance I would sneak into their houses and just force them to drink coffee every morning. OK, that's creepy. And I'm going to be locking my doors from now on. You're not my patient, Clem. Yet. A rhythmic clinic. Exactly. I do want to bring up one more study. It's coffee in patients who already had a fib. This is cleverly called decaf by the authors, which stands for does eliminating coffee avoid fibrillation. It was published in JAMA in November 2025. So the decaf study took 200 coffee drinking patients who had a fib and were going for cardioversion. They had a half-drink caffeinated coffee for six months and another group not drink coffee for six months. Fortunately, they saw that the coffee group actually had a lower rate of recurrence of a fib or atrial flutter. One thing was that the a fib and a flutter were only clinically defined. There wasn't a more structured or continuous way of measuring heart rhythms. So we wouldn't have known if like a patient had, you know, a short bout of a fib while they were sleeping or if it happened subclinically. Exactly. And since most patients reported few a fib symptoms, even if a fib recurred, they may not have noticed it. Yeah. And also maybe it's just me, but I feel like if you want to study if coffee triggers a fib, then you should probably include more people who said that coffee triggered their a fib. And sadly, in the decaf trial, only 40% of the patients reported that coffee triggered their a fib in the first place. But even with all of those caveats, these two studies are probably some of the best data that we're going to have on the question of coffee and arrhythmias. And so my take is that even if you take the most pessimistic read of the data for this group of patients who are pretty young and pretty healthy, that coffee is probably fine for you with respect to irregular heartbeats, but it might cause you to have a few more PVCs and mess up your sleep a little bit. So what are you going to tell your patients the next time they ask, which for you, Greg, maybe tomorrow, if drinking coffee is good or bad for arrhythmias? I bet you it will be tomorrow. And so what when my patients, even those who have a fib, ask me if they can drink coffee. I tell them that if you like coffee, you can drink coffee, but you shouldn't start coffee because it's a therapy for a fib because it's not. And if it causes palpitations for you, like it does for Clem, then you don't have to drink it. But if you like coffee, I don't think that there's any compelling evidence, even including these trials to say that it's harmful for you, even if you have irregular heartbeats. Here at Coriam, we're talking about the real things that can help anyone in health care. And today we're talking about how the scrubs you wear, that can make a real difference. I remember the first time I saw one of my colleagues walk into a sign in a room looking way more put together after a night shift. 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I think it's step one to be able to look at the data and see what they actually say and to interpret that correctly. And hopefully we've given you enough tools up until now to interpret data with all of its caveats. But then the next step, which arguably is harder, is actually talking to patients about nutrition. So there's a lot of what might be called implementation research that needs to be done where we do know a good direction, but how to make it easy for people to move in that direction. Certainly good advice is important as a starting point, but almost in all cases, just advising people alone is not sufficient. It has to be. There are barriers in terms of cost availability for many people and we want to try to remove those barriers as much as possible. The role of physicians here, of course, is a key issue. And one of the things I've realized for quite a while is we actually haven't given physicians the tools that they need to incorporate nutrition counseling into their practice, or even though I've had some really good physicians during my life, none of them has asked me about what I ate. That's a starting point, only a starting point for moving onwards. How can you go start the discussion without knowing what a person's eating? Yeah, I think we've all been guilty of this and not asking our patients what they're eating or drinking for that matter. And I think on top of it, the other common scenarios when our patients are bringing up a very specific nutrition question like, and I won't be able to help us with this, right? Like how do we communicate in a way that really resonates with a patient about what the nutrition research is lacking and what it might be telling us? And how do we say it in some level of confidence knowing that there's all these gaps? So I think a good rule of thumb is that when the data are mixed or even when there are confusing messages or contradictory messages about a topic, that probably means that the effect size is weak. And so the stakes of any decision that you're making about that individual item is probably pretty low. And so that's why when in general, I know this is not going to sound satisfying, but when I'm talking with patients about nutrition and we're focused on details that I don't think are all that important, I try to redirect them to things that are probably a better use of our time. Yeah. And how do you like respond when a patient's like, oh, my wife is putting garlic all over my food. Dr. Katz, is that good for me? I've seen that too. And what I tell them is if you like garlic, then you should eat garlic. But garlic is in a superfood because there's no such thing. And so when people are asking me questions about very specific foods or phytochemicals or nutrients, you know, I try to redirect them to the bigger picture nutritional advice that's consistent across a whole bunch of data sources. But if you don't like something, you shouldn't be choking it down because again, there's no such thing as a magical food. And so sometimes I'll have patients do a food log for a week or a 24 hour diet recall. And I usually find that a fair number of my patients have very, very straightforward things that could be improved in their diet, whether they're drinking too many calories, they're eating baked goods, cookies, pastries, candies. And so if you look at the sort of consensus across all of the different diet tribes, there's a whole bunch of things that seem to be pretty consistent, you know, not too many calories. Drinking your calories is bad for you. Soda is junk food, legumes, vegetables, fruits, whole grains. Nobody disagrees that those are good. And so think about the things that none of the diet gurus recommend and try to avoid those things. And so when I'm talking with my patients, I really try to focus on the low hanging fruit of their diet improvements. I think that one message is like, it's really easy to confuse yourself. And a lot of questions about healthy eating are come from people who know what junk food is and who are trying to find loopholes in that concept. Yeah. This is so hard. And I am so glad we're talking about this because I think this is tricky on many fronts. The science is hard and on top of that, the conversations can be hard. I'm always amazed, by the way, like what we tell our patients and then like what our patients actually like hold on to. So I'm really curious from our listeners, even like what other approaches do you have in terms of handling these conversations, knowing the limits of the research and how hard some of these outcomes can be to really study? Yeah. And this is my personal opinion, but I believe that we as clinicians don't think critically enough about nutrition. So I really hope that we've given you all some food for thought, pun intended. And the next time you pick up your morning cup of coffee or when you hear about the latest diet in the news or on social media, we hope that you now have more tools to help you think more critically about your food and diet. And that is a wrap for today. Please feel free to share today's episode with your friends and colleagues. And special thanks to Dr. Walter Willett for kindly dedicating his time and sharing his wisdom with us. Yeah. Thank you to our peer years, Dr. Jay Leopold and Dr. Jim and Wong for the accompanying graphic. If you have any feedback or suggestions, please email us at hello at Corayimpodcast.com. Opinions expressed our own and do not represent affiliated institutions. Ah, I think we've all been able to give this, not asking our patients what they're eating or for their drink. Yeah. I think we'll start over. Yeah. I think you've all been, you know, some days I put my hoodie on to like be like the focus mode, but it's not helping. It looks like you're about to like start rapping. Which I was listening to TI before this. Do you guys know TI? Yeah, of course. Chalamet or TI. Yeah, you're an M&M. Yeah. All right. Nails this line. All right. Some days call for some oomph to amplify your everyday look, like when you want the look of false lashes without the extra effort, reach for Thrive Cosmetics liquid lash volumizer mascara. Or when you want all eyes on your smile, keep in power gloss ultra glossy lip serum in your bag. It's a burst of 24 hour hydration that smooths like a serum, shines like a gloss and can be worn sheer or layered. You'll also look and feel your best with Thrive Cosmetics. 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