80. Progress Note #4: Does Sugar Cause Hyperactivity?

Hello everyone, I'm Dr. Darsha, and I'm Dr. Altamash Raja, and welcome to Medicine Redefined. A podcast where we will explore the often overlooked but necessary components of health, what we consider to be the fundamentals. We will investigate topics and practices that can give you and your patients the best chance to optimize a healthy lifestyle. It's time to move the needle forward and put the health back in healthcare. Welcome to an episode of the Progress Note. In Medicine, the Progress Note is a medical record that documents a patient's clinical status or achievements during their care. It typically consists of four components. The subject of data, the objective data, the assessment, and lastly the plan. It essentially is a systematic review in a point of time. Our goals with these episodes are to highlight mainstream practices, take a deeper dive, and approach polarized topics with nuance. While advancement is always happening in medicine, rethinking data as well as our beliefs is a rare occurrence. Join us as we continue to make progress, hold ourselves accountable, and redefine medicine. Alright, Progress Note number four here with Dr. Raja, what's up man, how are you? I'm doing well man, I'm doing well, cut a little bug here, a little rhino, and it's only a second time around after having a child, so I feel like that's a win, you know. That's how bad, I mean, so for the listeners right now you are enjoying the West Coast, you are in SoCal, and over here on the East Coast, man, all we're talking about right now in the clinic in hospitals is this quote unquote triple-demick, right, which I don't even think is a thing, but sure, I mean increase in flu, RSV, and COVID of course, so all my friends with little ones are definitely catching a bug, so consider yourself lucky with only twice. Yeah, yeah, yeah, yeah, I want to say I'm not complaining, but since I've lived the episode off with this, maybe I'm complaining a little bit, but I guess I'll stop there. Sure, sure. Well hey, congrats, you just finished your boards for sports medicine. Oh yeah. So yeah, that's a big relief, so it is, it is, you know, I'm not a fan of just waiting for such a long time. I never understand why, and I never will, and I don't think anybody really really understands why we have to wait such a long time to, to wait between everything, right? It's between the exams, between how long is it match between the rank list? I think the website said December 30th is expectation, so it's like almost two months. That's crazy. Given that, what, how many people probably take a year, like 600, 700? Oh, less than that, because they all for a twice a year. So I think 700 all for the whole year, and so half of them probably took it in the summer offering, so probably less than that. I don't know, I don't know, maybe they're like handgrading it individually on scantron, I don't know, who knows what it's having in mind, you know, being that it's medicine, that's crazy. So maybe we should redefine that process as well. Yeah, that'll be the next project as well, yeah. So what's on the end of today, man, let's get into it, yeah. Yeah, so we, today's progress now, so those are fourth one, we're going to be talking about sugar, and whether it causes hyperactivity, now mainly in children, right, because rarely do we ever tell an adult, oh, you should eat sugar because you're going to become hyper, but we often tell it to kids. So it's something that I've been hearing a lot, you know, just from my friends who are parents, they'll be more aware of giving treats, cakes, you know, candies. And since, you know, it's middle of November, so kids might still have their Halloween candy around, plus we're also going into the holidays. So, you know, we're thinking Thanksgiving, pies, and we're going into Christmas and New Year, so candy canes and just more festivities and more sugar all around. So I thought this would be an appropriate time to at least release an episode to say, hey, does sugar actually cause hyperactivity in children? Yeah, it's a great point, actually, when I was thinking about the topic, I was like, I mean, we've got a past Halloween, but then you're right, Thanksgiving around the corner, and then we got Christmas and then New Year's and then Valentine's Day. So it's just opportunities here on the, but you know, that's the case for everything. I guess really all year round, there's always a holiday around the corner. Yeah, always, always, that's right. So, so maybe before we start, I think it might be worthwhile just to kind of the high level, because you kind of mentioned the why, you know, why have this conversation, but I suppose for, for some folks, I think very few who might not really understand what ADHD or ADD is, I think most people have this stereotypical presentation, but do you think it's worth defining what maybe the medical terminology is loosely, and the different variations of that kind of stuff? Yeah, so I mean, we're not psychiatrists, so I don't know the exact terminology, like you said. But I know there's ADD versus ADHD, right, and common thought is at least with sugar, and the reason why we don't give sugar to children is that they'll start quote unquote acting out, right? They'll start becoming hyper. These will start doing things that are out of characteristic of their baseline. And so when you look at ADHD, right, that hyperactivity disorder is in there, I believe you have to have two out of three situations, and I don't exactly know what the criteria are, but I know a teacher, a parent, and then I think maybe out in the community might be the third one, where I think you have right, I think it's got to be in multiple different environment settings, right? Can't just be at home, okay? It's just being school. Maybe in multiple different environments, but I think maybe I was, let me just backtrack a little bit. I think you talked about the hyperactivity part of it. I think, so most people think about the inattentive type as the most common presentation, and then we've come to learn that there is a hyperactive type, which I think if you talk to parents, that's the premise of this discussion here today, and this is kind of the official diagnosis where psychiatry or NIH and stuff will describe three types, right? Intentive presentation, and that's essentially the person who can't stay on task, right? They're easily distractable, they can't focus, they can't finish, therefore, you know, a lot of fresh college students, medical students, or we'll claim that these are challenges, but I think we've talked a little bit off the record, or maybe even on the record before, about how really distractability is one of the main reasons for that, but I digress. And the second type, which you're talking about is a hyperactivity where you're just jumping off, just from couch to couch, and just cannot calm a child down, and this can be a company with lack of finishing one task, because you're just jumping from one to next, but this is the hyper-focused, hyper-vigilant type of presentation. And then the last type of presentation would be combined, and that's the one that becomes really challenging, because you have these stages where you go from one to the next, and you're like, wait, but you're not, but you are attentive, and you're really hyper-focused on task, and you get something done for the same time. And those are the ones I think, you know, medically and clinically become the most challenging, and they're typically, I would say, diagnosed later on in life, just because it's hard to catch, you know, for the reasons that we just mentioned, so I think that's kind of a quick overview. Anything you want to add on to that before we dive into the correlation, if you will? Yeah, no, I think those are good points. So again, I think one of the things I want to bring up, too, is the reason why we are truly going through the papers that we will is that there was actually a single study done in the 1970s, where a doctor removed sugar from children's diets, and he started to notice that their behavior improved. Later on, we find out that it wasn't truly just sugar that he removed, it was more about additives, food coloring, preservatives. And so, you know, for the next 20 years, there was this correlation that, oh, it's sugar that is changing these kids' behaviors. And the paper wasn't really focused as much on, or at least, I guess, the theme that came out of the paper wasn't solely focused on the preservatives, food coloring, additives like it should have been. Right. So this is good, right? We had a finding, and then somebody went back 20 years and said, well, in fact, you know, what we believe to be true isn't actually true. But for some reason, the messaging carries on, right, for a long, long time, and that's the one that's hard to break. And you'll tell us why. So get into it. Exactly. Yeah. Yeah. Absolutely. So we've got three papers here, right? So we're going to go to our soap formats. We just got done with the subjective. So objectively. So first paper here is called Effects of Diet, high in sucrose or aspartame. I always want to say aspartame for some reason. I like that better. That sounds cooler. But aspartame on the behavior and cognitive performance of children. So again, right now we're going to look at does sugar affect behavior and cognitive performance in children. So this was a double blind study done in 1994, right? This is not recent. This was done almost 20 years ago. And then it was basically they took two groups. They took children, 25 children who were in their age range of three to five years old. And then 23 children who were six to 10 years old. And all these children have been described as sugar sensitive by their parents. So what they did was they had each group in different diets. Okay. There were three different diets. And essentially these three different diets were placed for three consecutive three week periods. Okay. So after every three weeks, they would change up the diet right away. And then after three weeks, change up the diet right away again. So what was the diet? Okay. So three different ones. The first one was it was high in sucrose with no artificial sweeteners. The second one was low in sucrose with an artificial sweetener. And the third diet was low in sucrose with a placebo sweetener. Okay. So those were kind of the three different tiers there. All of the diets were essentially free of additives, food coloring, and preservatives. Now this was in the New England Journal of Medicine. I think the reason why I got in such a prestigious journal is this was pretty involved study. Like everything was controlled. They had dieticians go to the house, remove all other foods. They trace the food with other compounds so that they could get urine samples to ensure that they were eating the right amount of sugar, the right amount of food. Now on average, they were eating about five grams per kilo of body weight. Right. So let's say the average is probably, I mean, more than 10 kilos, right? Like 15, 20 kilos maybe for some of these kids. So you're looking at 100 grams of sugar in this diet, at least the ones with a high in sucrose. So that is way above normal in a typical diet. So 100 grams of sugar, I mean, I don't even think we get, I definitely don't at least, but that's a lot. So the parents were then asked to monitor and assess behavior and cognitive tests. Now there were a bunch of them. I did not know any of these tests, but going through them, they basically assessed cognitive ability, you know, attention, focus, doing some problem solving, behavioral tests. They'll look at motor skills. They'll look to see if there are any tremors, they'll look to see if there's any hyperactivity. So it kind of ran the gamut and I, you know, looking at it from a glass, there are probably eight to 10 tests that they looked at in combination. But overall, they found no difference. They found no difference in any of the diets in any of the children ranging from three to 10 years old. High sugar, low sugar, there was no difference in the cognitive abilities or the behavioral abilities of the children. So that's the first one there in the New England Journal of Medicine. Cool. Awesome. Yeah, I think for those aspartame, or aspartame as we're calling it now, that's typically equal, I think, or neutral suite, or I think, right, those are the ones that the brands that people are going to see. It's a lot of heat for a lot of different things and is responsible for really ADHD to, as you mentioned, from according to some people, and cancer, and dysbiosis, and lumbabloid. Got my co-op. Yeah, yeah, exactly. Exactly. All right. So that one is as a negative finding, what we'll call it, it would say, okay, but, you know, some people might say, well, it's more than 20 years old. Do you have anything more recent for us? What is the current evidence suggest for this? You know what? I got to look at the dates, actually, on this second one, but there is a meta-analysis that was done in JAMA, called the Effective Sugar and Behavior on Cognition in Children. Now, of course, the way medical societies work is you got to pay just to get the full text, so that's unfortunate. So I kind of get the full text on this JAMA one, but essentially they did 16 studies, and I'm pulling it off right now to see what year this was done if my internet gets any faster. You might beat me to it. Yeah. This looks like this is also the 90s is as a wall rage, the first author. Um, you know, this thing forever to go. Yeah. It looks like the one that you referenced in JAMA is maybe actually fun JAMA. Yeah. Also, 1990s, yeah. It's interesting. I think most of the studies are actually done in the 90s and early 2000s. Yeah. Um, but essentially this meta-analysis, right, 16 studies also show the same thing. No association, but they did say that you can't rule out any small effect that sugar or substitutes may have on children or subsets of children, right? So now we're looking at particular children with any type of special conditions, whether it's genetics, whether it's mental health. Um, so, you know, further research would need to be done on that in a particular subset. But overall, if you're looking at like a generalized population, this meta-analysis show that there was no effect on one of the same kind of things that we looked at the first study. Okay. So another null finding anything else with regard to that. So I guess maybe at this point, well, actually what we'll do is maybe we'll kind of bring it together towards the end, um, if we can answer the questions because people are going to probably wonder, okay, well, what does cause it, right? I think we always have to propose an alternative, um, or at least we think we do. But um, you said you might have mentioned you had one more. Yeah. Absolutely. So, so this third one is not looking at cognitive and behavioral correlation with sugar. It's actually looking at how we perceive kids who take sugar from a mother's perspective. So this title was called Effects of Sugar Interaction Expectancies on Mother Child Interactions. Okay. So they took 35, 5 to 70 year old boys who again were reported to be quote unquote sugar sensitive by their mothers. So the mothers were then assigned to an experimental, which was the large dose of sugar or a control which was the placebo, but in actuality, all the children got a spartome. So what the researchers did was that they videotaped the mom and child interacting, um, after these children got their diets, right, after they got their high dose of sugar or they got their placebo. And then they were questioned, um, about the interaction as well. So what they showed at least through videotaping was that the mothers in the sugar expectancy group, so the ones that were supposed to get the large dose of sugar, they were, they rated their children as more hyperactive. And they also, and the researchers also noted that the moms were more controlling and in a way of more physical closeness, more criticism, and they would actually talk to their kids more, uh, more so than the moms would with the placebo group. So if this is more of kind of just a behavioral study or at least looking at that aspect of this old debate of the sugar cause hyperactivity. So is it more perception? It's kind of what this paper is answering. Right. It's kind of the anticipatory response, right, especially like after Halloween, you're like, oh, God, they're going to be jumping off the walls and then maybe you're a little bit more keen to that response. Yep. Exactly. Interesting. Yeah. And so those were, those were kind of the three that I pulled up, so yeah, no, I like that. I think this is something that, you know, I know you mentioned that you have folks that are, that are in your circle or some version of that and they've got children and this is a concern. And I think it's a valid concern as a parent because I think a lot about, of course, we think a lot about nutrition in my own food and then now responsible for another life form. And so I have to think very much about what I'm going to put in front of my child. And it's essentially about building these habits, right? And so at the same time, we've talked about being balanced and can't control all the environments, right? Can't go to school and at the lunch and be like, no, can't serve this, can't serve this to my child, right? That's, that's not also realistic. And we talked about, you know, when they go to a birthday party or something like they're going to be, they, there's, might be cake there. There might be whatever. And so we have to be able to find that balance. And so these fear-based messaging, particularly with something like this, right? So I think one of the things that I feel to mention when I was describing the multiple types is this is a neurodevelopmental disorder, right? And we, I think ultimately kind of what, what I'm getting from what you're describing and also from what we've learned is that we don't truly know one cause for this, right? I mean, we think genetics play a role. We're questioning whether or not our environmental factors, such as sugar plays a role. And a lot of people have asked that question and are looking at it as well. And there are some associations. I do think there was a study that I do remember at some point looking, I could not quote it to you, but maybe I could find it. It was much more recent. I want to say in the last three to five years, which was a meta-analysis looking at sugar, sweetened beverages maybe, or actual sugar consumption and the effects of, or its correlation with ADHD. And it did, it did find that there was an association with children who did consume more sugar, had a higher prevalence of ADHD. But that, it's very important when we were talking about fourth, the correlation doesn't necessarily mean causation. And I think what has been documented more often than not are the effects of sugar on the brain. And that's not to say, so that equates to ADHD, right? Because ADHD is a, is a unique process that what we're saying is we don't necessarily know the sugar can manipulate that. Again, that's not the same thing as the sugar doesn't affect the brain in some way. In fact, sugar is the primary preferred fuel source for the brain. Sorry, you were going to say something today. No, no, yeah, so I think it's important to note here too, right? Hyperactivity in the chronic sense would be the ADHD, which is what you're talking about right from the near development. I think these studies are looking more at the acute, acute bouts of hyperactivity, right? And I think a lot of parents think that too. They'll say, oh, I give my kid a piece of chocolate, boom, they're going to like start being hyperactive. So I think it's important to note, at least for the audience, that hey, there's kind of two distinctions here with hyperactivity. There's the acute, which is you give kid a piece of chocolate or candy and they become hyperactive right after versus you consistently have high sugar in your diet. Does that lead to a near development issue, such as ADD, ADHD, down the road? Right. I mean, who knows how long, right? I think that's, that's what you're talking about, yeah. And I think my sense is at this point, the answer to that is questions we don't know, right? I think we can expect, I mean, is that, is that kind of your takeaway as well? Yeah, no, I totally agree, right? It's so interesting that it was a 1970s paper that showed this link and now we know this link at least in the acute sense is false, right? And from what I mentioned in this objective sense is I see a lot of people talk about the acute sense, like, oh, I don't want to give my kid candy at four o'clock because then they're not going to be able to go to sleep, which we like face off these papers, we know is not true, right? We are falsely associating, giving candy to this increase in activity that we perceive. But it's interesting, if you read a lot of these blogs and you read a lot of the research out there too, it shows that most of the time these kids are having candy, it's going to be around an exciting time, right? It's going to be at a birthday party. It's going to be, maybe at a birthday gathering. So they're already going to be excited, they're already going to be happy, right? They're going to be proactive. Right. They're going to be stimulated. So it's not necessarily sugar itself doing that, it's the environment, right? And I think one of the blogs I read was, hey, parents, just take note next time that if there is candy around or you're thinking that this might make them hyperactive and stimulated, instead just look at the environment and see, you know, whether it's actually that. Right. Because again, it's funny how we only tell children not to have these suites because they're, you know, they're going to get stimulated, but when it comes to adults, we don't really say anything. Yeah. So no, no one ever talks about that distinction, right? So I think it's just, I don't know, because it's just kind of like a old wise tail just to get kids to eat healthier. It doesn't seem like that based off, you know, kind of this 1970s paper. But yeah, I mean, that's, that's kind of my assessment of the whole thing is that, again, I think we do need more research. When we look at 90s and we look at aspartame and artificial sweeteners, I mean, now we're starting to research that a little bit more. So going back, hey, what effects did those actually have on the study and, you know, what not? So I think it's cool to kind of resurface this a little bit. Yeah. No, I do agree. Yeah. I think that those are some really awesome points that you made. I mean, I think again, about the fact that if we're doing candy, but the same time Elmo's on the back right, I know that again, my child has difficulty winding down, going to sleep. And I think that's, that's much the case with us as well, right? I think, again, diet plays a role, but at the same time, we talk about putting, you know, these softwares on our screens to dim the light and, you know, you got the blue blockers glasses, we talk about, you know, doing relaxation techniques, whether it's hot shower, cold shower, whatever, all the kind of stuff, wind out routine. And the idea is that maybe it's a accumulative effect for multiple of those things, rather just one specific thing. There is no magic pill, magic bullet, magic candy bar. The other thing I will say just to play devil's advocate for a second is there might be some individual variability. And I'm not here to say, and I don't want to speak for you here, but, but I do think we've talked about that, hey, you do have to be mindful of, hey, like sometimes, you know, the studies might show a certain thing, but your body doesn't read that paper or your body hasn't read the textbook and your biology behaves or your child's biology behaves a certain, a different way. So to your point about, you know, we're not giving any parental advice here, but to your point about, hey, let's just be mindful about, hey, what is it? And can we disentangle that from the environment and the stimulation and the parties and all that kind of stuff? And if that, in fact, is the case, then maybe some adjustments are in order, right? I think that that's kind of the piece that I'm taking away from that. Yeah, absolutely. Like, I think about all the time with people who are lactose intolerant, right? So let's say they do no dairy at all for like six months, and then they introduce a little bit of dairy. I mean, that little bit of dairy is going to wreck their stomach versus somebody that does a little bit of dairy every single day, and then they have a bigger amount of dairy one day. They might not feel that effect as much because they've got microbiome or whatever is kind of already used to the mechanisms of digesting that dairy product. Same thing kind of goes for a kid. I mean, you might have a kid who eats, let's say, 20 grams of sugar a day, one day goes up to 60 and you don't really notice a difference because they're already based like kind of having some sugar versus a kid who has no sugar at all, pretty strict diet, let's say. And then they have an increase about a sugar. I mean, who knows how that's going to affect and just kind of like that second paper said, you can't really rule out even a small effect of sugar in a subset of children, which I think comes down to that genetic variability. For sure. Awesome. And then, I guess, so a lot of this is looking at the acute thing and I guess I was looking at it more of a chronic response, which I do think is what we're talking. But I think that that becomes way more complex. Yeah, I'm going to have to look at more papers to actually see that. Yeah, yeah, yeah. And I think, honestly, I think at some point maybe you and I were talking about different things. But I think that that's the one that becomes really challenging because, you know, it's pathological versus physiological responses, essentially is what we're talking about. And yeah, it is interesting. Hopefully, it puts some people at ease and makes people a little bit more informed. I know it's made me a bit more informed about how I'm going to think about these things moving forward. So let me ask you, what's your what's your plan here? Right? Yeah. Yeah. What are you going to do? I don't think this, you know, dissuades me from giving a particular food in any sense to my child moving forward or even myself at a certain time of the day, right? I mean, we talked about, you know, even if you told me, or any of the literature supported that it does, in fact, cause an acute hyperactive response or whatever for a sustained period of time, I would argue is that let's just say that we're enjoying candy or dessert, something sugary at dinner time as a family with my child, then, you know, that bonding experience will create a relaxation response. How do we measure that? Right? And I think one of the things that we've talked about before is that food is, especially I think in our culture and a lot of other cultures across the world, it is a language, right? It's a way for people to come together at the table. It's not just like input fuel, output, you know, phosphocreatine or carbohydrates and that kind of some, and triglycerides, it's a way for people to come together. And you know, again, things that we talked about when we look at the blue zones is one of the foundations that they have is people have these close relationships. And I hope I'm still making sense a little bit. I guess what I'm trying to get at is, you know, how do we measure the other side of it? What are the positives that are coming from it and does that out way, the potential negative if you were, or if anybody was to be able to show it? So I would argue that is, you know, I wouldn't be convinced. I think much like anything else, just assessing the situation on an individual level. For me, my family, whoever people I'm working with directly and giving them the same guide is that, hey, see what the response is and how things are going. And if they're not going according to the outcome, whatever that outcome is that you want, then change your variable and see what happens. Yeah, I like them. Yeah, I would say it's kind of the same for me. I mean, obviously we're not pediatricians. So from a medical standpoint, there's not much that, you know, we would tell our patients. But definitely from parenting standpoint, right? Like your father, I'll hopefully be one in the next couple of years or so. And I always think about parenting. And it's funny because I remember me being a child, I had such a sweet tooth. I mean, I would literally search for candy around the house. And I was very hyperactive. And I mean, I still am. I'm a huge extrovert. I'm pretty, I'm pretty out there and stimulated all the time. And so read these papers, you know, I remember just a lot of times growing up being like, oh, you can't have this candy because, you know, this is, this is how you act, right? And I was always told that. So it's funny looking at these papers and be like, hmm, maybe there wasn't actually that link for me. Maybe it was just because I was always stimulated. I was always looking for something to do, but I just also loved candy, right? And so for a long time, I haven't had the best relationship with like sugar. I've always binge did or I've always stayed away from it, right? And after kind of getting this knowledge, I've learned that, hey, I can actually shape my relationship with candy and understand that, hey, I can have this. It's not going to cause me to be crazy, but I don't have to go overboard and make it all or nothing. And so that's what I look forward to at least when I have kids is having them enjoy, you know, as well, just like you said, but teaching them as to why they shouldn't have sugar every day, and but not making this the hyperactivity, the scapegoat, but more so understanding, you know, about health, obesity, you know, all the things we touch on this podcast. And I'm a big proponent of always teaching, you know, kids wide kind of like what Ben Greenfield talks about, having them eventually become teenagers and adults. They're going to have to make these choices one day. So, you know, even at whatever early age they can start to comprehend these things. So that's kind of that's kind of where I think of this stuff. Right on, I love it. On that note, I think, oh man, I will disclose. I just had three truffles before we started. So maybe I'll, you're ready. I don't know. One could argue, maybe that's why I wasn't on the same page as you in the beginning, but who knows. Hey, we hit two birds with a stone, some chronic acute one through page. I think I think it was a good episode. Awesome. Now I didn't, I didn't ask you in the beginning. And so it'd be rude of me to not bring the list was up to date on what's going on with you. You talked a little bit about the the tri-demic. Is that what you call the tri-demic? Tri-demic? Tri-demic? Tri-demic, man. It's a weird time. Tri-demic, you know, interesting. Aside from that, what's the word? Any any trips coming up? I know people are excited to follow you journey on that. Yeah, yeah, yeah. So we're going to where my god, I guess, I like a blank for a brain fart, a Mexico City and Columbia end of December. Right. So that will be a fun trip. But yeah, not much else. I've been a lot more active on Twitter. So people can follow me on Twitter before it disappears. They're thinking Twitter might just go under. Everyone's resigning right now. Oh, yeah, but I'm blue check verified. I'm now famous. No, I paid for it. Yeah, so that's that. Oh, lastly, man, I don't know if you watched Broadway musicals, but Hamilton. So me and I just watched on Disney Plus. Unfreakable, like absolutely the best Broadway. Best Broadway show I probably will ever see in my lifetime. And I've only seen Aladdin. But still, it was incredible. Like I was not expecting that. I never understood the hype, you know, for like the last two years. I thought it was just a colonial American history boring music. You know, it's like rap music. It takes you through all the emotions. You're learning a lot. I was absolutely three hours of just unreal. Yeah, I don't understand how they come up with this stuff. Honestly, it's incredible. I'll just watch all the listeners out there if you have. Yeah, I will put that on the list. And while we're at it, another one in Disney Plus. The series just got released limitless. One of my favorite super. Chris Hemsworth is, I think, starring it. And somebody that we listen to and we quote someone frequently is Peter T is one of the longevity experts talking about essentially longevity. All the things that I think we're interested in. So we'll be sure to check that out. And maybe we'll do like a little recap at some point. A review for folks. So two things for the upcoming weekend for people to check out. As they enjoy some desserts and cakes and candy or whatever makes you happy. All right, thanks again for listening to another episode of The Progress Note. Now, if you're a parent or maybe you're just an unobserver of a child getting candy, be sure to see whether that child is actually getting stimulated and becoming hyperactive. I think it would be a cool experiment now that we know what the data shows. So Thanksgiving comes and then Christmas, New Year's. Make that a part of your experiment. So I think it'll be cool to see. If you know any parents who would be interested in learning about this topic, please be sure to send them this podcast. We are on Apple Spotify and all other major platforms. And if you are enjoying this podcast, please, please, please, for whatever platform you're on, leave us a review and a rating. It really helps us in terms of expanding our reach and getting these episodes into the hands of many. And as always, the medical disclaimer, everything discussed in this podcast is for educational purposes only. It does not constitute the price of medicine and we are not providing medical advice. No physician, patient relationship is formed. And anything discussed in this podcast does not represent the views of our employers. We recommend that you see the guidance of your personal physician regarding any specific health related issues. And for our listeners out there who celebrate Thanksgiving, wishing you a very, very happy Thanksgiving, and see you later.