CEimpact Podcast

Fatty Liver Disease: Risks, Treatments, and the Role of the Pharmacist

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Fatty liver disease affects a growing number of patients, often progressing silently until advanced stages. This episode highlights what pharmacists need to know about recent terminology changes, risk factors, pharmacotherapy updates, and key counseling strategies to support patients. Tune in to sharpen your clinical knowledge and help identify, manage, and educate patients at risk for this increasingly common condition.

HOST
Joshua Davis Kinsey, PharmD
VP, Education
CEimpact

GUEST
Sarah Wheeler, PharmD, BCACP, CDCES
Assistant Professor
VCU School of Pharmacy

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CPE INFORMATION
Learning Objectives
Upon successful completion of this knowledge-based activity, participants should be able to:
1. Describe current terminology, risk factors, and stages associated with fatty liver disease.
2. Identify evidence-based pharmacologic and non-pharmacologic strategies that pharmacists can use to support patients with or at risk for fatty liver disease.

0.05 CEU/0.5 Hr
UAN: 0107-0000-25-219-H01-P
Initial release date: 6/23/2025
Expiration date: 6/23/2026
Additional CPE details can be found here.

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Speaker 1:

Hey CE Impact subscribers. Welcome to the Game Changers Clinical Conversations podcast. I'm your host, josh Kinsey, and as always, I'm excited about our conversation today. Fatty liver disease is becoming increasingly common, often progressing silently until serious complications arise. Yet many patients remain unaware they're at risk. In this episode, we'll discuss what pharmacists need to know about evolving terminology, emerging treatment options and how to support early identification in patient education and everyday practice. It's so great to have Sarah Wheeler as our guest for today's episode, sarah welcome.

Speaker 2:

Hi thanks, josh. Thanks for having me.

Speaker 1:

Yeah, thanks for being here. Before we jump in, I always like to let our listeners meet our guest. So, Sarah, take a couple minutes and tell us about yourself, your practice side and maybe why you're passionate about fatty liver disease.

Speaker 2:

Absolutely so. I am currently an assistant professor at VCU School of Pharmacy and as part of that I have a clinical practice site at one of the VCU health primary care clinics. Within my practice I get primarily referrals for type 2 diabetes, but I really approach my patients from a holistic cardiometabolic management standpoint. So I'm not just looking at their blood sugars, I'm looking at the diabetes and all the other things that that affects.

Speaker 2:

And part of that, especially in the most you know, past several years here has been liver complications and so as part of my cardiomyopatolic management of these patients, I'm always looking for complications like kidney complications, nerve complications and then, of course, liver complications. So screening for mazzled or fatty liver disease. And so a lot of people I feel like are not aware of this within my clinic my patients, my colleagues, and so really excited to be here to talk about that today.

Speaker 1:

Yeah, that's great. Well, thanks again for taking time out of your busy schedule. I know this is I used to be in academia and I know that this is summer, but summer is often more busy in academia than the actual school year, so I know that this is still a busy time, so thank you, okay. So, yeah, let's jump right in. One of the first things I want to tackle is the fact that I have called it now fatty liver disease multiple times, but there are more technical terms, so let's jump into. Let's just lay the foundation, remind everyone what fatty liver disease is, what other kind of terminology might be associated with it, and just to make sure that everybody's on the same page before we dig in.

Speaker 2:

Yeah. So I think probably most of the listeners are familiar with the term fatty liver disease, and really what we're going to be focusing on is previously called non-alcoholic fatty liver disease, and so this is something that was coined originally in the 1980s when it was first seen and essentially the disease histologically looked exactly like alcohol-associated liver disease, but then the patients didn't have any significant alcohol use, so at the time they really just named it for what it wasn't. So it wasn't because of alcohol, but it was a liver disease that looked like it. The problem over the last couple of years has been that that's really been a diagnosis of exclusion and there's a lot of stigma around alcohol and there's a lot of stigma around the term fatty and fat, and so I would say that there was really kind of a search for is there a better term for this? So one group, kind of in the interim, coined this term MAFLD metabolic dysfunction associated fatty liver disease and that partially met the mark. So we were bringing in the idea that this is driven by metabolic related problems, but it still included that fatty liver part. So we were getting there and that's a term you might still hear sometimes too In 2024, though, they did a Delphi process and figured out like what is the best approach for what do we call this disease and how do we define this disease and how do we identify this disease.

Speaker 2:

And so the newest guidance, kind of the greatest and latest, is that there's an umbrella term called steatotic liver disease and really that just means that there's fat buildup in the liver and then there are specific subtypes of fat. So there's now this spectrum that we recognize. On one end there's this metabolic dysfunction associated steatotic liver disease, and then there's also alcohol associated steatotic liver disease and in between there are people that have some of both of those things driving it. So you'll hear metabolic dysfunction associated fatty liver disease. So that's Maslod and that's sort of the new Maslod.

Speaker 2:

You'll also hear your alcohol associated steatotic liver disease, and then in between we have this MET-ALD. So it's this mix of the two and even within that it can be more metabolic driven or more alcohol driven. And so what the big difference is is now we say this MAZLD, it's steatotic liver disease. There's fat in the liver, plus there's a cardiometabolic risk factor and there's a spectrum of that as well, and so some of the other terms you might hear is mash. So for those of you familiar with NASH, non-alcoholic steatohepatitis mash is the new NASH, mazold is the new NAFLD, so really you might hear any one of these terms now.

Speaker 2:

But I think we've come a long way, because now we're diagnosing it for what it is. We're avoiding some of those really stigmas, and I think that it just really kind of more clearly defines that it's not these buckets of things right. There's a spectrum of disease.

Speaker 1:

Yeah, yeah, and one of the things that we'll dig into later as a potential challenge that we have in this space is kind of the acceptance from the patient. So I can imagine how removing some of these stigmas is probably a positive thing. So, yeah, well, that's great, that's a great overview, because, I have to be honest, it's been a long time since I've heard about fatty liver disease or you know, really kind of dug into it. So that's a really good review. So thank you. So let's jump into epidemiology now too. Let's talk a little bit about you know, you mentioned some comorbidities, the cardiometabolic issues. Let's talk about the epidemiology of the disease in itself.

Speaker 2:

Yeah. So I would say overall about one in three people worldwide have Masl.

Speaker 1:

Wow.

Speaker 2:

Yeah, it's very prevalent.

Speaker 1:

That's really significant.

Speaker 2:

Yeah, but I think, really importantly, less than 10% of our general population has the more severe version of that, the mash, and so we don't see maybe as much complications arising because of that. But then when we think about our people who are at higher risk for those complications, I'm really thinking about the people where we see other cardiometabolic complications, so particularly people with type two diabetes. Over 70% of them have Maslod and half of those have MASH.

Speaker 1:

Wow, wow. And I mean and that's significant because we also know that there's a large population of our patients who have diabetes that are undiagnosed. So that probably means that if that is undiagnosed, so is anything related to the liver, so yeah, so I imagine those numbers are even higher and more shocking than we think.

Speaker 2:

Yes, exactly yeah. So as obesity is continuing to rise, that's another big risk factor. Probably similar epidemiology numbers as with diabetes, and as diabetes continues to rise in prevalence, we're going to see Maslod and MASH being more and more prevalent in the patients we're taking care of.

Speaker 1:

Yeah, so you mentioned obesity is a risk factor, diabetes is a risk factor. What else do we see in someone where you may see a patient and think, oh goodness, I won't. They look like they're at risk or they might be at risk think, oh goodness, I won't.

Speaker 2:

They look like they're at risk or they might be at risk. Yeah, those are really the biggest two that I would be looking for. You know, the other thing that I think about is that Masl has this sort of bi-directional relationship with type two diabetes. So diabetes, like I said, is kind of my bread and butter. Clinically, there may be twice as likely to have Masl as the general population, and then you add on obesity and that's going to only increase that. Those are really the top predictors, um, and then, likewise, obesity and Masl are top predictors of developing prediabetes and type two diabetes, if it's not already present. So it's kind of the cyclical thing that they're feeding into each other.

Speaker 1:

Sure, sure. Okay, that makes sense. So I mentioned in the segue earlier that it's kind of a silent progression sometimes. So let's talk a little bit about that. Let's touch on the pathophysiology. How does it, when does it usually show up, that you see it if you're not looking for it, you know like what? Let's talk about that.

Speaker 2:

Yeah, so usually, like what let's talk about that? Yeah, so usually, like you said, it's not something that's going to be symptomatic until we've progressed to really severe stages of liver damage. So maybe when someone's getting to the point where they have cirrhosis from this, but most people are not going to have any symptoms at all. Pathophysiologically, insulin resistance is a really big driver, so that's why we see obesity and diabetes as so correlated with Maslow presence, and so that that insulin resistance is driving increased lipid lipogenesis and then that fat is accumulating in the liver. So that's where that steatosis is happening. Okay, the liver doesn't like fat in it, so those fat accumulations are toxic to the liver cells and then that causes inflammation and then that's really where we get into that mash, the steatohepatitis.

Speaker 1:

And you mentioned that sometimes you don't see symptoms later. What symptoms do you see when it progresses? What are we looking for?

Speaker 2:

Yeah, so if people have symptoms, they generally are pretty like vague and like general fatigue, maybe some slight abdominal pain. They're really not super specific symptoms.

Speaker 1:

Okay.

Speaker 2:

We're catching it really far down the line where we're having cirrhosis You're going to be thinking about like what are those like standard liver complications, right? So jaundice, maybe some of our lab abnormalities that we would see. But we can detect Masl before we see any of those lab abnormalities. A lot of people kind of, historically, where it was being caught was they'd have imaging done for something else and then you'd see on that imaging, oh, there's sympathetic stimulation, something happening, yeah, interesting, okay.

Speaker 1:

So we've talked a little bit. One thing I also want to mention is and I could be wrong with this, but I feel like from my reading and knowledge of it is that a lot of times patients think it's cancer, like when you're diagnosed with this. So let's be sure that we're drawing the line between. This is not a cancerous thing, right?

Speaker 2:

No, it's not a cancer. There is definitely a risk for cancer with it, though. So, as that damage is occurring in the liver and then we get to the point of having scarring and fibrosis and then jumping to cirrhosis, that can definitely place people at a higher risk for the hepatocellular carcinoma.

Speaker 2:

So it's not a cancer when it's diagnosed but, we definitely want to think about that, as one of the risks of people developing Maslida and MASH is that we could see them progress to having HCC Got it and even without going to cirrhosis they still have that risk. So even people that are not like maybe as severe MASH, there's still that risk of developing that cancer and then non-hepatic cancers as well. So we don't really know the mechanism of why those other cancer risks are higher. The HCC makes a lot of sense but it's definitely a risk factor and one of those down the line complications we want patients to be aware of.

Speaker 1:

Got it. Are there anything else like that? We kind of talked about how obesity, diabetes and stuff like that has kind of led to this. Is there anything we know they have this that we need to watch out for? If they didn't have hypertension before, are they going to have hypertension? Those kind of things. Is there anything that we're looking for after the fact?

Speaker 2:

Yeah, I think, just thinking metabolically, the biggest number one cause of disease in these patients is still going to be cardiovascular disease. So, even though it's a liver disease, that's usually not what is causing death in this population.

Speaker 2:

So I think, just being aware of what other cardiovascular risk factors does this patient have? Making sure that we're monitoring for those and treating them appropriately. If they're not on a statin, put them on a statin. Just because they have liver disease doesn't mean that a statin is not appropriate for them. And I think a lot of people get afraid to see oh, this patient has some sort of chronic liver disease and they're pulling statins off. And actually that's just putting them even higher risk for cardiovascular complication. Yeah.

Speaker 1:

Okay, so really it's a. The issue is if we're seeing them in this space. They've already progressed, like they already have some things going on, so we just need to make sure that those are being addressed and we're not progressing further. So I love the call out on the statin, because immediately the first thought is to pull off anything that affects the liver, and we know that they do. So, yeah, that's a good call out. Ok, so as we get into, what do pharmacists do? So why do we need to know about this disease? Why do we need to be aware of this? Why do we need to be aware of this? What can we do to help? So that's what I want to segue into next and really talking about, what are the opportunities for pharmacists? So, if you want to just kind of highlight some of those and then we'll go deeper into each of them, yeah, so I think one of the main things that we can do is identify patients that are at risk.

Speaker 2:

This might look a little bit different depending on your practice setting. There are some things that we can do in terms of lifestyle counseling, making sure that the patients are on medications that are going to provide benefit for the liver, and really just being aware of what is the latest and greatest evidence out there, because it is a really rapidly changing landscape right now.

Speaker 1:

Yeah, yeah, totally makes sense. So let's jump into each of these. I kind of have them broken down so we'll try to touch on them as much as we can. So actually, one of the first ones you mentioned was identifying at-risk patients. So what does that mean as a pharmacist, whether we're in an AmCare setting or an internal patient setting, inpatient setting or community pharmacy like what can we be doing? How can we be seeing these at-risk patients?

Speaker 2:

Yeah. So I think you know, for me in AmCare the biggest thing that I'm doing is I'm just incorporating it into my workflow of if someone has not had a formal screening done for this complication, then I'm doing that. There is a very easy, non-invasive test called a FIB4 index that's been recommended in our guidelines and all it is is like you go to your MD calc right, pull up your calculator and you put in the patient's age, their AST, alt and their platelet count. So it's labs that are being done regularly for these patients already and it basically stratifies patients into three categories. One would be low risk, and it's really really good at identifying those patients who are low risk. We don't need to do anything for those patients other than keep screening every one to three years.

Speaker 1:

To make sure it's not progressing.

Speaker 2:

basically, yeah, basically we're just making sure I think about it, like when I talk to patients I say it's just another screening for a diabetes complication. We wanna see have them go get their eyes checked. We wanna have them get their foot checked. We wanna have them do kidney tests. This is just one more of those screenings for me.

Speaker 1:

Yeah, that makes sense. So if you don't have access, if you're in a community pharmacy setting and you're not typically accessing that medical calculator, what should it be like? Oh, I have an obese patient, oh, I have a diabetic patient.

Speaker 2:

So those be the things that we're looking for disease state, risk factors and having a conversation with the patient to see if they are aware of the risk for this. If it's a conversation they've had with their primary care doctor is probably the place that I would start. I will tell you I had a patient within the last month that says I've had diabetes for over a decade and no one has ever talked to me about this. So I think it's newer in the guidelines.

Speaker 1:

It's something that's really not being, you know, regularly incorporated in the standard of care that, unfortunately, and so I think that in the community pharmacy setting, you can be that person that spurs the conversation and lets them know hey, this is something that is you should ask about check for yeah, yeah, yeah, and I mean that that is like perfection right there, the fact that it may not be talked about as much as it should be in the provider's sense, like with their primary care or with their specialists. Even so, that's even a greater opportunity because we all know pharmacists we see the patients the most often. They come in more than they see their doctors, so it's an opportunity for us to really be having those conversations. So, even if it's simply awareness, I think that's big and important. So, yeah, okay, very good.

Speaker 1:

So there are some specific lifestyle guidance and recommendations that can happen for these patients too, and that is again we know from our traditional practice setting. That's something that pharmacists can really help with as well. We can talk about diet and exercise and stuff. So what are some of the things that we need to reinforce with these patients from that lifestyle modification?

Speaker 2:

Yeah, lifestyle. I would say like the biggest focus for people with Maslod or MASH should be targeting weight loss. One thing that I didn't touch on earlier when we talked about pathophysiology, that I think is kind of like the crux of all of this is that even though there's this progression from mazold to mash to then we have mash with fibrosis and cirrhosis, you can go backwards on that, so this is reversible, even when you get into fibrosis stages.

Speaker 1:

That's right. I always forget that the liver is the rare organ that can like fix itself. So yeah, yeah.

Speaker 2:

So with weight loss we can. We can um at 5%, we can reduce the fat accumulation in the liver, so that's a good thing. We're not kind of continuing to drive that toxicity when you get to higher amounts of weight loss is seven to 10%. That's when we're looking at the point where you can reverse, even stay out of hepatitis and fibrosis. So really really focusing with your patients on targeting weight loss and targeting that five to 10% is enough to make a difference for you.

Speaker 1:

Wow, interesting. Yeah, very interesting. This just randomly popped in my head and I'm going to mention it, but I don't forget it again. But we talked about earlier the stigma of it and I think when you said it this time for whatever reason, it finally hit me. But is there ever a stigma? Maybe this is more of our challenge section, but that's okay, I'll jump ahead. Is there ever a stigma where people think that you've told them they have an STI because of it being hepatitis or something like that? Like if you, I wonder if that's where some of that stigma is. I don't know.

Speaker 2:

I haven't had that experience in my clinical practice and you know, honestly I don't use the big, you know, long medical terms with my patients necessarily. Right. And so a lot of times again, because we're in this transition point between the different terms, like I'll use both fatty liver disease and. I'll say you know and mazzled. I won't even spell it out for them necessarily, so I haven't run into that, but I think it's possible, right, you?

Speaker 2:

know you hear these other terms and there's overlap and you're like oh, it's alcohol and it's cirrhosis and cirrhosis is for people who are alcoholics.

Speaker 1:

And you think of hepatitis hepatitis A and B and C and you know that those sometimes have that stigma associated with them too, so you know you could, I could see a patient who doesn't hear everything and just leaves thinking that they've just been told they have hepatitis, you know which it is, but it's a different. It's a different version than what they're, I'm sure, thinking of in the mainstream. So, anyway, I just that just reiterates the fact that education, and from pharmacists is so important, because that's something that we can also help with. We can help them understand that there's differences between the types of liver disease that are out there. So, okay, sorry, I completely took us off. I told you we might go down the rabbit hole. Okay, so we were talking about lifestyle guidance and mainly watching their weight. What else is something else with lifestyle modifications that we can help with?

Speaker 2:

Yeah, so I think you know feeding into that weight, diet and exercise are kind of the bread and butter, right? So diet, you're thinking high fiber, whole foods, low saturated fat, low added sugar, cut out your sugar sweetened beverages as much as you can, All the things that we're we're normally counting on for diabetes and for weight management. Um, exercise, it's really nothing special. It's your 150 minutes moderate intensity once a week, or per week, Maybe, not all at once.

Speaker 1:

Once a week spend four hours.

Speaker 2:

Right. And then, even though these patients are, you know, again like non-alcoholic right it's sort of that like other end of the spectrum we know that people do use alcohol and that might not be the driver of their disease, but that having increased alcohol intake is going to put extra stress on the liver, and so we also want to make sure that we're recommending to minimize alcohol intake. If they get to the point where they have more severe, like moderate fibrosis, we really want to tell them to cut it out entirely.

Speaker 1:

Yeah, and again that's important, that's a space where we as pharmacists, thrive, in that we know our patients, we have, you know, those conversations that are more collegial and nice and less what's what I'm looking for technical I guess, and so it's important that we're also talking about those kinds of things too, with changes. So, yeah, great call out Okay. So we haven't really dug into a lot of the pharmacotherapy insight, but let's talk about that now. What are the current treatment landscape Like? What's the landscape right now with options for treatment?

Speaker 2:

Yeah, so right now there's only one drug that's FDA approved for MASH and it's specifically at risk MASH.

Speaker 2:

So even where the patient has MASH and moderate to advanced fibrosis, so earlier than that, for Maslod and for our earlier stages of MASH, there's nothing that has a specific FDA approval. With that said, there are other things that we can do that the evidence has shown helps provide some liver benefit for our patients. Okay, so, thinking about our patients that are at the highest risk, we have our patients with obesity, we have our patients with diabetes, type 2 diabetes in particular and we have shown that some of our drugs that we use in those two spaces improve our liver outcomes for people with Maslod. So in diabetes, kind of historically, pioglitazone was the go-to option. It is still recommended in our guidelines for people that have Masl and type 2 diabetes, but there's kind of limited phase two data for that, so we kind of leave it at. There's potential MASH benefits. Our GLP-1s is really where we have the most robust evidence and so good news is we can use them for both obesity and for type 2 diabetes.

Speaker 1:

I was going to say this is a good thing because they have a kill two birds with one stone. So yeah, this is great.

Speaker 2:

Exactly, yeah, so we've had kind of similar to the piagulidazone like phase two trials earlier. But more recently in April of this year, the essence trial gave some preliminary results. It was a large study, I think around 800, their first 800 patients that were enrolled and they showed that the semaglutide was superior to placebo for a mass resolution and fibrosis improvement. So we're kind of hitting both of those things right. We're hitting that inflammation as well as the fibrosis, which is really really awesome to see in as large of a trial as that is.

Speaker 1:

Wow, that's great. And not to catch you off guard, but you mentioned in our previous discussion, before we started recording, that you wouldn't be surprised if you saw an indication come out for semaglutide in the future.

Speaker 2:

So yeah, I wouldn't. I know that that's one of the things that the manufacturers are kind of targeting as an expanded label for semaglutide. So it's the one where we're the furthest along in our trials. So yeah, I mean, I don't know when it would be necessarily, but right around the corner, I'm assuming.

Speaker 1:

Yeah, yeah, no and that, but again, that's that. Yeah, yeah, no, but again, that's good news overall because it not only expands the options that we have, but it has with sleep apnea and lots of stuff. So again, we've had a podcast episode just on GLP-1s and how they're the magic bullet. So, yeah, it's interesting, okay. So one other thing is you mentioned a clinical trial, so that's another thing a pharmacist can do is we can stay up to date. We can make sure that we're up to date on the most common or the most recent terminology and lingo that's gone on within the space. And is there, you know, like we have a diabetes guideline that comes out every year. Is there a guideline for this or is it more or less still a work in progress?

Speaker 2:

There are many guidelines and that's sort of part of the challenge is that it feels like almost every year a different society has released a new guideline for this and as we're getting new evidence, that guideline has some of the newer evidence. I think the most recent ones that I've seen is in May. End of May, ada just put out a consensus report.

Speaker 2:

And then there was also a global consensus that came out, I think in April of this year. But I mean, aasld has one, aga has one, ace, the European guidelines everybody's got a guideline for Maslod, and that's what makes it really challenging, I think, to kind of stay up to date with is that you have different societies that have different. You know the state of evidence and so you're kind of trying to figure out, like based off of the new trials and based off of what this organization says, like what's the best approach for me and my patients.

Speaker 1:

Yeah, interesting. So really the take home here is is to be updated in general, like trying to use the most recent version. Whoever has the most recent studies and has has kind of come out with guidance there. So okay, yeah.

Speaker 2:

I think so, and then just being aware that, like, for example, the ACE guidelines were really targeting primary care and endocrinology providers and kind of getting at that idea of let's screen and let's identify early and let's catch those patients before they get all the way to where they're having symptoms. And then some of our other guidelines are more specialist targeted. So it's just going to depend on kind of what your needs are, what your practice setting is, and then I think like regardless.

Speaker 2:

Like you said, let's just pay attention to where we are publishing the guideline, what year this is from and making sure that it's incorporating the latest evidence or saying, okay, I know that this guideline was published here, but also this trial came out, so how does it fit together?

Speaker 1:

Exactly exactly. So to briefly touch on some of the challenges that we might see as pharmacists in this space we've already talked about there's limited FDA approved treatment options. Potentially that might be changing soon, but there's not limited options for treatment, because you mentioned several others. So that's something that we have to be aware of, but it's not like our hands are tied with only one drug option kind of thing. We talked about the terminology confusion. We're staying up to date on that, understanding that some of those are used interchangeably and that they mean the same thing, and also having those discussions with patients to ensure that we're removing any sort of stigma. If they are reacting to the alcoholic portion, hepatitis portion, like to remove that stigma for them with education.

Speaker 1:

And then, just again, in general, it's kind of hard to see where pharmacists fit into this, because it is a specialized disorder, but it also is super common, as you opened my eyes too. So it's not something that we shouldn't just be like oh, that only happens rarely, like we don't need to space. Pharmacists really need to be in this space helping to identify those iris patients. Right, yeah, okay, all right. So then, lastly, I guess is there anything else that we didn't really cover that you're like pharmacists need to know this. Anything that you'd share, and if not, that's okay. So my follow-up to that would be I always ask the guest what the game changer is here. So what do you feel like is the take-home point for our pharmacist listeners today?

Speaker 2:

Yeah, I mean, I think the take-home point here is that this is really moving from sort of like a rare condition that wasn't commonly identified to now it's the most common liver disease worldwide and that we had to previously use liver biopsy to identify this and now it is very easy to do with screening tools. So between the advent of our non-invasive testing and now treatments that actually have an impact, we can change from this like reactive okay, now we're just treating the symptoms or the complications of this disease to identifying patients at risk, starting therapy early and trying to even reverse some of that disease process so that we're reducing cardiovascular risk and reducing liver complication risk.

Speaker 1:

Yeah, that's great. Well, sarah, this has been so enlightening. I feel like, like I said, it's been so long since this has been something that I've heard about, talked about, whatever, so so enlightening to have you. Thank you again for your time. It's really great to see you. Thank you so much, josh. If you're a CE Plan subscriber, be sure to claim your CE credit for this episode of Game Changers by logging in at ceimpactcom. And, as always, have a great week and keep learning. I can't wait to dig into another game changing topic with you all again next week.