What to Eat for Kidney Disease: 9 Questions, One Answer

All right. Well, thanks so much for giving me the opportunity. Dr. Barnard told me that kidneys is really complicated. So he said I had five hours to lecture you guys. So I hope you got your coffee and you're ready because we're going to run through five hours of stuff. I'm just kidding. I just have one word for you based on the entire talk and that's it. So my word is eat more beans. Thank you. We're done. Oh, wait a second. Did you want more than that? Okay. So I'll give you a little bit more. So I figured how do I make it simple for you guys to understand kidneys and nutrition? Because it's so complicated and you're going to get all sorts of conflicting advice. Eat more, eat less, cut out the beans. No, that's the message. So here's the thing. The reason we don't talk about kidneys so much is because when you think about kidney disease, most of you don't know if you have it or not. In fact, 14% of the US population has kidney disease. And yet when we talk about all sorts of things, heart disease, everything else, by the way, you have one heart. But when God was making the body, he felt that kidneys are so important that you have two. Just remember that for all the cardiologists in the room, there's two. We're more important. So the reason it matters is because there are no symptoms to kidney disease. Nine out of 10 people who already have it don't know they have it. If you go by those numbers, there are several of you in this room who might have it. But you've never thought about it that way. And that's why you're not worried about it. You're born with about a million kidney cells in each kidney. And from the moment you're born, the only thing they do is they die. How depressing is that? But the beauty of life is not that we're going to die. The beauty of it is how we live. So this is why we're going to ask nine important questions. And at the end of those nine questions, the most important thing is do those nine questions agree on a uniform plan that you can understand right now and you can take back to your personal lives. For those of you guys who are clinicians or health care providers, you can use it for your patients. I was just about to come up and I heard a comment that a lot of people still argue against what the kidney diet really should include. So let's get into this. Let's start with salt. Should we care that you are cutting salt or not? Because the data is very interesting. A lot of people feel that you don't need to worry about salt. But here's where it gets very interesting. If you cut down your salt, you immediately have a benefit that is so powerful that it is equivalent to one blood pressure medication. Take a listen to that for a second. Cutting out your salt, getting less than two grams a day is equivalent to one blood pressure medication. The benefits don't just stop there. If you start to look at the data, the data is fascinating. Back in the day, this is the dark ages before we had the internet. We had phones. We didn't have cars. We used to give two types of medications together. We had the prills and the sartan. If anybody does it, tell them, stop it. Because putting them together lowers the protein in the urine, but it also causes kidneys to fail faster. But here's a very interesting study. The first part of it was everybody was on a prill, lysinopril, lowers the protein in the urine. So then they wanted to see what's the impact of adding a second medication to lower the protein or just cut out the darn salt. This number is fascinating that you can actually lower the protein in the urine by 51%. So the ultimate question is, why do you care if there's less protein? The reason you care is the more protein you spill in the urine, the faster the kidney dies. That's why it matters. So if you get a 51% reduction, it matters a lot. And in kidney patients, by the way, if you have very thick, foamy urine, there's a number of causes that can do it. But one of those causes of foamy, bubbly urine, kind of like soap suds, is actually the first sign of kidney disease. It's not an elevated blood test. What should you do? Don't worry about the salt shaker. Just eat beans. That's it. That's my whole talk. But no, here's where it matters so much is every time you eat out, just eating out can give you 1200 milligrams, 1400 milligrams of sodium, depending on what you're eating. And by the way, when patients come in and they say, Doc, I don't eat any salt. All we do is a urine test. We know. So don't, don't, don't worry. It's like when I do the obesity medicine side and a person says, Doc, I don't eat anything. And then we do a blood test. We know tricks to see exactly how much sugar you eat, what you ate the last week. All I need is a simple blood test. So keep in mind, it's a safe space and honesty is always the best medicine. So salt shaker, not the problem. All your processed food, absolutely the process is what gets us into trouble. So eat at home. You don't have to worry. Now, potassium. Did we get the entire story on potassium wrong? And the answer is don't know. When you start to look at the advice that our registered dietitians give, our doctors give, the advice is actually very simple. They say, look, you got to cut out the potassium in your diet. If you have advanced chronic kidney disease, you need to follow a low potassium diet. But the I want to ask here is, is all potassium the same? Or is there a difference in potassium that you should know? Now, KDGO is something that makes the national guidelines and it's a very important body, has brilliant doctors on there. But KDGO never said you need to cut out all fruits and vegetables. Never said that. What it talks about is you need to cut out the bioavailable potassium. A very big difference. Bioavailable versus potassium in general. So what does that mean when it comes to bioavailable? It's actually a very simple thing. I know we heard a talk today on processed foods and so forth. I have all sorts of data and opinions on that. If you start to think about where bioavailable potassium comes from, it's very simple. It starts to come from the right-hand side of the slide. All your deli meats, all the salt shaker substitutes that you're doing. But where it's not really coming from is the fruits and vegetables. If you saw the breakfast this morning and you had berries, awesome job. And the potassium in berries is not what you need to worry about so much because we're going to show you what matters so much. First, when you think about the potassium content in things like berries, it's actually very low. Now people blame the banana for everything, right? I feel so bad for bananas everywhere. They come to me, they cry, they tell their stories. How somebody said, I actually watched a YouTube video where somebody said, I won't name names, somebody said don't put a banana in your smoothie because it's going to make you not absorb all sorts of things. And I was like, this is discrimination. Leave the darn banana alone. So what matters so much is if you have fiber. If you have fiber with your potassium, it matters because the fiber is going to bind to the potassium. And when you go to the restroom, you're going to be able to excrete more of that potassium. So fiber foods are not bioavailable potassium. That's number one. Number two that comes really, really important when you talk about this is the effect on your body's pH. Now I have a story to tell you. Every time I give a talk and I give lots of talks on this topic, somebody always asks me about alkaline water. And I just want to tell you now alkaline water tastes really good depending on your taste buds, but it doesn't do a darn thing for your body. Nothing. Zero. Zilch. So if somebody told you it's going to change your pH, by the time it gets to your stomach, it's neutralized. But fruits and vegetables are very interesting because fruits and vegetables will actually change the pH in your body. We're going talk about that in a second. Potassium bioavailable versus fiber bound. That's the message. Now let's get into phosphorus. Why doesn't the level of phosphorus warn us? In other words, if you see your phosphorus is normal and let's say you don't have kidney disease or you do, why is it that the phosphorus concerns us so much? The reason is, while your phosphorus is in the normal range, your body is working extra hard to keep it in the normal range. This is a really important point. I'll give you a very simple analogy from obesity medicine. When we see a patient and they're a pre-diabetic, we tell them, hey, you're just pre-diabetes, you know, there's a little bit of metformin, see you later. What's the problem that your body says when you're a pre-diabetic? It's the exact same problem that phosphorus says. What happens with pre-diabetes is your pancreas shoots out more insulin to lower the blood sugar in your body. So when you do an A1c and it's normal, you assume everything is fine. Meanwhile, your pancreas is working overtime. Phosphorus, when you check your phosphorus and it looks normal, you're like, hey, that guy up on stage with the bald head doesn't make a difference. Phosphorus is fine. Why should I worry? Because inside your body, everything is working harder. Did you know that you can lose 50 percent of your kidneys and your blood tests won't change? What a crazy concept. Because the other 50 percent that's left, they work way harder, twice as hard, and yet nobody gives them a darn raise. By the way, that's my plea to give me a raise, anybody. But the thing that matters so much is when you think about a blood test, a blood test is designed to catch disease. It's not designed to catch prevention. And that's what this is all about, is prevention. What are the different types of phosphorus? I got a question outside, was they have an animal that's being given that has CKD and they're being given certain types of foods. So here's what you want to understand. Processed foods, when you eat them, essentially 90 percent of the phosphorus in processed foods gets directly absorbed. There's really nothing to slow it down. When you go to the next one, which is non-processed meats, dairy, eggs, you're talking about less, anywhere between 40 to 60 percent. But think about what happens with beans, nuts, grains, etc. Whole foods. With whole foods, yes, they have phosphorus. And the phosphorus is on the same number as we're talking about the other two agents. But what's different? Plants have phytate. Phytate loves to bind with phosphorus. It's like a marriage. They bind and they're in it for life. And then when you go to the restroom, the phosphorus goes out of your body. So the power of plants is very, very important to understand. And when you think about phosphorus, don't just look at a number. Look at the mechanism. When people talk about why we should stop plants, they forget the power of plants in their diet. And that's where it matters so much. So if there's one lesson, get rid of the processed foods, add beans. Everything in life is about beans. Oh, and don't blame the banana. That's the other part of this. So, protein. Protein is one of those really, really, really controversial topics. And everybody talks about protein. So let me put my obesity hat on for a second and tell you about a protein. So, you know, if you eat too much sugar, it converts to fat. Did you also know that fat converts to fat? I know it's obvious. But what about protein? If you eat more protein than your body can use, it also converts to fat. So don't let the message fool you. On average, depending on what your age is, you can absorb between 20 grams to 40 grams of protein in one sitting. Keep that number in mind. So when people feel like I need that protein shake and they're putting all this protein at once, the excess protein is going to do two things. One, it's going to convert to fat. Two, it's going to make your kidneys work way harder than they should. And remember, there's a term called glomerular hyperfiltration. All these people that, you know, give talks, they throw these fancy words around because it makes them look smart. I'm not that smart. So glomerular hyperfiltration just means there's more pressure on the kidneys. That's it. That's all it means. And what drives that pressure? High blood pressure, salt, sugar, diabetes is a huge proponent of it. And then, of course, excess protein. Why is the protein so confusing? Because depending on which smart person you listen to, they confuse the heck out of you. They tell you it's between 0.55 to 0.6 of ideal body weight. And if you're somebody who's a diabetic, you need more protein because you're going to have lots more protein spilling. KDGO says 0.8. UK Kidney says at least 0.8 to 1.0. So who should you listen to? And this becomes very, very important to consider. What advice should we be telling people? So I want to tell you what's more important than how much protein is what type of protein you're eating. So when it comes to the most acid load, once again, fancy term is called PRAL, P-R-A-L, potential renal acid load. So PRAL matters because the more acid goes to the kidney, the faster the kidney declines. So what gives you the most acid load into the body? It turns out it's meat. What's neutral? It turns out it's poultry, chicken, etc. Fish, eggs, dairy is essentially neutral. And what's actually kidney protective? It's plants. Specifically, it's soy protein. So whenever we have an option on a patient where we need to give more protein, the preference is always soy over anything else. And of course, beans. All right. So when we start to think about protein, there is some data to say if you did a very low protein diet, you would actually see fewer kidney failures. The problem with this number that you're seeing 0.3 to 0.4, nobody on God's earth can get to this number. This was done in very controlled studies. They gave them keto analogs so that they wouldn't get absolutely malnourished. But it's impossible for us to replicate. So what do I focus on instead? The quality of the protein makes such a big difference. And be flexible. In kidney disease, everybody talks about don't do this, don't do that. You know, this whole idea of eliminating everything, and I see this in obesity too, is where you eliminate everything and the person is finally like, screw it. I can't eat anything, right? I just need to go outside and eat grass because it's vegan. So I want you to know we're not talking about elimination. We're talking about substitution. Take the meat, switch it to plants. It's a substitution. It's not an elimination. So what to do? For most people who are heavy on meat, we give them the advice to start small. We truly believe in not using willpower, but using habits. You know, when you do something bad one time, it's fine. Everybody makes a mistake, right? No big deal. When you do something two times, it's the start of a habit. A habit is neither good nor bad. How long does it take to form a habit? Some people say two weeks, some people say three weeks. What's the data? The data shows in one study, the average was 66 days to form a habit. But if you look at the data, some people formed it in two weeks, some people took 255 days before that habit kicked in and became automatic. So what we tell people is one, you're human. Two, if you make a mistake, no big deal. Just don't turn one mistake into two, into three, into a week, into a month, into the rest of your life. So fiber. Fiber is very interesting and the gut is very interesting. I know you got some amazing talks on the gut microbiome and I don't want to go ahead and take anybody's thunder. But here's the thing. Kidney doctors don't really care about the kidney as much as we care about the gut. The gut means everything to kidneys. We are gut doctors more than we're kidney doctors. No offense to GI guys. So what the heck does fiber actually do? Here's a very complicated analysis of what happens if you eat a ton of protein. You eat a ton of protein, you get all sorts of urea forming, the bacteria in your gut turn it into ammonia, ammonia raises the pH of your gut, the tight junctions in your gut start to loosen. When those tight junctions loosen, the problem that you run into is all the bad stuff in your gut starts to go into the body. And the problem you get running over there is what we call uremic toxins. Uremic toxins is what makes the person confused. It's an indication to start dialysis. Back in the day, there was Japanese data that would show that they didn't have enough dialysis machines at that time. Once again, this is in the stone ages, right? No phones, no cars, no nothing. Totally kidding. Don't take it seriously. When they had patients needing dialysis, there weren't enough machines. So the option was you're going to go essentially on hospice. You're going to plan for your death. So what they did was they would reduce the protein and they would use plant protein. And what they would find is people who were stage five, GFRs of 10, 9, 8, they were able to stay there sometimes for years. So when you think about the alternative, the alternative is the more animal-based proteins you're eating, the more you're loosening the tight junctions in your gut. And as you loosen it, those endotoxins, those uremic toxins, it's what's getting in your blood. And because your kidneys can't clear it, they start to build up and eventually reach the brain. And as they do, they start to make you confused. And that's one of the indications to start dialysis. So when you talk about kidney patients and you start to restrict plants, it matters. Now, don't get me wrong. If your potassium is high, we need to make changes. But those changes come in the form of all the other stuff, the bioavailable potassium, looking at your medications and what's causing it. And we change there. Whether we need to give you a potassium binder, whether we need to give you diuretics, whatever it is, we can change it. But once again, what we don't want to do is start to eliminate all the food that has secondary benefits. And the secondary benefits are fiber. Same story, two different analogies. It leads to the same idea. Fiber is going to help you to create short chain fatty acids from the bacteria in your gut. They're going to keep that tight junction tight. You start to do the other thing. Lots of processed foods, lots of uremic toxins are able to get through those tight junctions. And you're looking at earlier dialysis. So you don't have to be fancy about this. All you need is PCRM to do a conference every day and eat the darn food. Right? If you do that, you're already good. So that's a hint for Dr. Barnhart, wherever he is. So feeding fiber, the data is very clear. Instead of uremic toxins in your blood, they do go down. Now, the problem with studies is when a study finds a neutral result or it doesn't look better, you always have to ask, how did they differentiate the patients? When people go into a study, just recruiting for a study, there's already a biased sample. Certain people go into a study, for example, there was a study right now of eating really bad food and they're going to give you $800 and they're going to keep you in the lab. I got so excited. I was like, this is great. $800? Wow. But keep in mind what they're going to do to you. So certain people enroll in studies, you have a certain population already going in. Then how you stratify that population matters. For example, when studies look at obesity, they forget that a person who has a BMI greater than 30 behaves differently than a BMI less than 30. So if you look at a study from a BMI 25 to 80, I have patients who have BMIs over 100. And what I can tell you is they are absolutely addicted to food. And the data is actually very clear. They will go and get McDonald's delivered. And then because it's McDonald's, they will add a Diet Coke. And did you know that Diet Coke's acid once again does what? Loosens the tight junctions. So you start to get into trouble from it. So very simple. Increase fiber. Do it slowly. You've heard enough numbers, enough talks already that you understand what those limits are. Now for sugar. Sugar is very interesting because people argue that is there a direct link to kidney damage? Well, yes and no. Diabetes is ranked the number one cause of kidney failure. And when does diabetes start? 5 to 10 years before your A1c ever goes up. So when you see a pre-diabetic in your practice, that is not, oh yeah, it's just pre-diabetes, no big deal. A pre-diabetic is a huge red flag. It means the pancreas is tired. It can't work overtime. So you have to take it very seriously. Insulin resistance is no joke. All that extra sugar has been going through the kidneys. And what's the problem? You look at a blood test of the creatinine in the blood and it doesn't look like anything happened. So is there a direct link? But is sugar bad for the kidneys? Absolutely yes. So remember diabetes, remember high blood pressure and remember excess weight. Those are the three biggest causes of going on to kidney disease and eventually kidney failure and dialysis. So what we don't know about artificial sweeteners is do they really harm? What we learned from the obesity literature is when, now this is in my study, so obviously we're not mice, so take it with that. But when you give mice diet drink, they actually eat more of their chow. What we see in our own clinic over and over and over again is when you take things like Splenda, Stevia, all of these alternative sweeteners, don't get me wrong, Stevia is natural. But when you're talking about a substance that's 300 to 400 times sweeter than sugar, it's like giving somebody who's a cocaine addict heroin. Now they've tasted heroin injected, they're chasing that high. Nothing tastes as sweet. A strawberry doesn't taste as sweet because your brain is used to a level of sweetness that's so much higher. So keep that in mind as you're thinking about it. If you love coffee like I do, I'm a coffee addict and the data is so amazing on coffee, lowering the risk of kidney disease two to three cups. That's just me because I get paid by Starbucks. I'm kidding. I'm joking, joking, joking. Please don't kick me out. All right, sugar and drinks. I have a saying in our clinic, both kidneys and obesity, eat the fruit, don't drink the juice. When you drink the juice, you get bioavailable potassium. When you eat the fruit, you get unbioavailable potassium. I got to love my English. I don't know if that's a word or not, but you have decreased potassium because it's bound to fiber. So eat the fruit, don't drink the juice. Now, processing. Processing is very interesting because we can go and argue about what is processed, ultra processed food. But I'm going to give you a very simple way to understand processed food. Processed foods is things like salt going in, is things like phosphates getting sprayed on, is things like potassium salts that are being added. It's things like taking the fiber out and giving you juice. My definition of processed foods is different than a lot of the definitions. And the reason is, as you think of processing, it starts to add things in there that you don't want. Now, for all of you who are thinking about this is complicated, I'm going to give you the single most important thing to remember from this talk. All you got to do is look at the label. Don't look at the list of how much sodium potassium it is, but look at the ingredients. And all you want to do is look for four letters. Four letters, that's it. P-H-O-S. If you see it, put the candy bar down. If you see phosphorus, remember, even if you're healthy, your body is trying to eliminate that phosphorus. If it's in there more than you need, your kidneys are going to work overtime. Your parathyroid glands are going to work overtime to release the P-T-H. So, acid load. Acid load is really important because for us, as kidney doctors in advanced kidney disease, we care. Because the more acid you have, the faster the kidneys die. So what do we do to treat it? We're very scientific. We have all of these amazing drugs. They're called baking soda. We give you sodium bicarbonate. What's the problem? We're giving you sodium, right? In a person who shouldn't have sodium to begin with. Some people are like, well, why don't we give them potassium bicarbonate? High potassium can stop your heart. So you're damned if you do, you're damned if you don't. What the heck is the alternative to sodium bicarbonate? So here's something that's very, very interesting. Let's look at the decline in kidney function. Because remember, from the moment you're born, you're dying. This is such a great talk, right? It's so motivating. You should be so inspired that that's the only message is you're just all dying. But what's fascinating is the kidney function is going to decline for every single person in this room. But with fruits and vegetables, it's going to decline less. And that's compared to the most common medication we give, which is sodium bicarbonate. And if you don't give anything and they have excess acid in the body, they're going to decline much faster and put the alkaline water down unless you like the taste and you don't mind spending a whole lot of money for it. Alright, acid load. What is acid forming? We covered this already. The more meats you eat, the more acid you get. The more alkaline foods that you eat, the better the acid. What's alkaline foods? Once again, beans. Everything in life is about beans, right? I'm sponsored by the bean company. I get paid so much money to talk about beans. It's ridiculous. I have a jet plane waiting for me after this talk because I talk about beans. Alright, so keep that in mind is beans are awesome. Fruits and vegetables are awesome. Bioavailable potassium is the devil. Bioavailable potassium is really important to understand. And of course, kidney stones. What's calcium got to do with it? It's very simple. If you eat more calcium, you get a kidney stone. If you eat less calcium, you get a kidney stone. So what is a mere mortal to do if you got a kidney stone? This is so confusing. Let me clarify for you. The reason we say that is if you eat calcium in your food. So what should you eat? My number one sponsor, beets. Right? If you eat beans, what ends up happening is the calcium in food binds to the oxalate in food and then it goes out when you go to the restaurant. But if you take calcium by itself, it doesn't bind to the oxalate in food. The oxalate goes inside your body, makes its way to the kidneys and binds to the calcium in your kidney. And when it does, that is the formation of a kidney stone. So once again, calcium in food lowers the risk of kidney stones. Why does low calcium matter? Because if you eat low calcium foods, McDonald's, hint hint, if you eat low calcium foods, then the phosphorus is going to go inside your body, bind the calcium and form a kidney stone. So don't let the experts fool you about the sentence I started with, that low calcium is bad, high calcium is bad. That's not it. It's the calcium with food lowers the risk of kidney stone. Now, if you're taking calcium products because your doctor said for bones, et cetera, that's fine. But don't forget the calcium in food. That's the best calcium you can get. All right. So stones, what should you do? Calcium with meals. The second thing that really matters is water. How much water? Here's a very simple rule of thumb. All you want to do is make your pee a light lemonade color throughout the day. So if you take a gallon of water at once, you didn't do anything. But if you're drinking water throughout the day, that's what matters. And if you don't like numbers and you don't want to measure how much urine you're making, a light lemonade color is the most important part of stones. A few cautions before I stop. A couple of things. Vitamin C, if you take too much as a supplement greater than a thousand, vitamin C converts to oxalate. Oxalate without food calcium does what? Form kidney stones. So can vitamin C form kidney stones in high doses? Yes. But what about vitamin C in fruits and vegetables? Absolutely not. So do you have to worry about fruits and vegetables? No. Other things are things like star fruit, things like erstolochia. Those are things that are really important. We've been warning people forever about that. But one thing to remember on here is creatine. Creatine gets a really bad rap because they say, oh my god, my creatinine went up because I took creatine. That means I damaged my kidney. Absolutely not. Creatine does not damage the kidney. Creatine goes into your body, converts to creatinine. But let me ask you a very simple question. Is creatinine a kidney test? No. It's not a kidney test. Why? Are you measuring the function of your kidneys? You're not. You're assuming, once again, assuming that if you have more creatinine in the blood, that means kidney's ability to clear must be reduced. But here's why that's not true. What if you go to a blood test and see that you didn't drink a lot of water, you're dehydrated from whatever the night before? Your creatinine is higher. Does that mean your kidneys are bad? No, you're dehydrated. What if you had a big steak the night before? What's going to happen? Your creatinine is going to be higher. The creatine converted to creatinine. There are so many things that can shift your creatinine that you want to know. So one number in a creatinine doesn't mean anything. You want a trend. Month over month, every three months, you want three numbers at a minimum to see what are the changes. If your creatinine jumped up from one number, and I get asked this question, oh, my EGFR dropped from 60 to 50. Am I dying? Well, yes. But you're not dying from kidney disease, right? So there's some hope, not a whole lot, but there's some hope. A couple of things. If you're on dialysis, you do need more protein. But remember, the type of protein matters. Because in dialysis, acid is more of a problem. We watch your potassium like a hawk. We have ways to lower your potassium. So keep that in mind. But higher protein because dialysis is a catabolic event. It is incredibly hard on you. Do you know what the five-year death rate on dialysis is? 50%. 50%. And that number hasn't changed. Because we don't have the ability that your natural kidneys do to clear all the toxins. Going three hours, three times a week is not the same as your kidneys working 24 hours a day, seven days a week. The ultimate question. I gave you nine complicated things in whatever time I had. And the question is, do the nine agree? So let me give you the answer. Plant-based is a terrible term that now gets used for all kinds of processed food. A whole food, plant-based diet, without the whole foods, you're just another person making fun of bananas. Add the whole food, and you're a hero. So keep the plants as the center. And keep in mind that if you start to eat plants, that helps. If you start to eat packaged foods that are highly processed, but they're still vegan, you're not helping yourself. So the difference here, once again, is what's outside. And you know, I get the luxury of talking to you guys right before lunch. So everything. For salt, eat beans. For potassium, eat more beans. For phosphorus, eat more beans. For fiber, eat more beans. For sugar, eat more beans. For processing, eat more beans. For acid load, eat more beans. And for God's sake, for stones, eat more beans. So that's it. Food is medicine. I want to thank you guys so much. Thank you very much for a very informative and entertaining talk. There's a lot of questions, and we're not going to have time to get to maybe just one or two. So if you're around, maybe people get bugs outside. A lot of questions about potassium. Sometimes the doctor will say, you need to cut back on potassium. They come see their health coach or their dietician, and there's kind of a discrepancy. They're not as smart as you are, the doctors. And so how do you deal with that? Yeah. So doctors do the best they can with the education they have. This is why conferences like this matter. We're trying to teach people to let go of the idea that fruits and vegetables are the cause, but to understand that bioavailable potassium is what you should focus on, not everything else. And what are the resources you have, like handouts for both patients or resources they could share with the... Yeah. So we're building that. We have a nonprofit, selfprinciple.org. It's a 501c3. And we're building all of those documents in there so that people have easy access, because the world is confusing. Yeah. Yeah. That's right. A couple of questions, a lot of questions about kidney stones as well. And I think one thing I struggle with with patients and they're naturally urologists is the difference between a low oxalate diet and eliminating high oxalate foods. Those are kind of two different things, right? Well, so a high oxalate food is spinach, right? So put the spinach down. But when it comes to most fruits and vegetables, they have calcium. So pick foods that are rich in calcium and you're not going to get stones. Right. And one last question. There's a lot of questions here about protein as well. Does... Let's see here. Let me get to here. For patients that are malnourished, you know, have sarcopenia and chronic kidney disease, or does that change the way you think about the protein recommendations? It does. Another great question is, you know, if you're a clinician and you have a patient with near stage four, near stage five, they're still waiting to see the dietician or the nephrologist, you know, what do you tell them? So stage four, stage five, once again, the nephrologist is really important because there's a trust factor with your doctor. And stage four, stage five is where protein matters, acid load matters, potassium matters. But if you listen to everything we talked about today, it's the type of protein, it's the type of acid load, it's the type of potassium. Right. All right. I think it's about all the time we have. Thank you again for a great talk. Just one comment before I step off stage, which is, listen, though, the world is a very difficult place. There are all sorts of smart people with all sorts of opinions. The only message I have for you is realize that there's a lot of hope. I know I joke about you're dying. Forget that joke for a second. Practice kindness, practice gratitude. And if you truly want to be selfish and live longer, just be kind to others. If somebody has a different opinion, don't worry about it. It's not going to change who you are. Be kind to everyone. Practice gratitude. This is what this conference is about. I appreciate the opportunity you guys gave me for that. Thank you so much.