 Good afternoon, ladies and gentlemen. Welcome to an insight, an idea with Dr. Dean Ornish. I am Nancy Gibbs. I'm the editor of Time. Talk about someone who needs no introduction. Dr. Ornish is obviously a physician, a bestselling author, an advisor to princes and presidents, and a fervent and artful evangelist for a complete rethinking of how we approach health care. In our session today, the idea we are exploring is about lifestyle medicine. And so the obvious place to start is to define what you mean by lifestyle medicine. Well, thank you. I'm very appreciative for the opportunity to be here today with you. So thank you. Lifestyle medicine is, I think, the most important trend in medicine today. And its lifestyle is treatment. We all know that lifestyle changes can help prevent disease, particularly heart disease and diabetes and things like this. But this is lifestyle as treatment. And what my colleagues and I have been able to show over the last 37 years or so is that if you make big enough changes in lifestyle, not just diet, but exercise, stress management, things like yoga and meditation, and perhaps most important, how much love and intimacy and support you have, that our bodies have this remarkable capacity to begin healing. And much more quickly than we had once realized if we can treat the underlying cause, which to a larger degree are these lifestyle choices. And so in a series of studies over many years, we've been able to show that, first with heart disease, that even severe heart disease can be reversed, even within just a few weeks. And the more you change, the more you improve. We then did studies showing that men with early stage prostate cancer could slow, stop, and even reverse the progression. And if it's true for prostate cancer, it'll likely be true for breast cancer as well. We're planning a study on that now. That type 2 diabetes can be reversed in most people simply by changing lifestyle. And we found that when you change your lifestyle, it changes your genes, hundreds of them, over 500 genes in just only three months, turning on the genes that protect us, turning off the genes that cause these chronic diseases. And most recently, we found that even the aging process can begin to reverse at a cellular level. We did a study with Dr. Elizabeth Blackburn, who got the Nobel Prize about five years ago, for discovering telomerase, the enzyme that lengthens and repairs telomeres, the ends of our chromosomes that control how long we live. And we found that telomeres tend to get shorter over time. And as your telomeres get shorter, your life gets shorter. We found we could actually lengthen the telomeres. The only intervention that's been shown to do that. And so we tend to think of advances in medicine as being a new drug, a new laser, something really high-tech and expensive. And we're finding, in our studies, we use these very high-tech, expensive state-of-the-art measures to prove how powerful these very simple and low-tech and low-cost interventions can be. Do you think it is human nature that makes us tend to privilege the high-tech intervention over the more simple and instinctive, or do you think that's driven by economic incentive? Why do you think that is that we always go to the new technology or the new drug, as opposed to what you're talking about? Well, I think it's all of that. I think, certainly, we all would love a quick fix of somebody to give a magic bullet or wave a magic wand and say, you're cured. And some things are like that. Antibiotics for treating certain conditions can be really curative in that way. But we also have this kind of fascination with technology. It seems like it's very powerful and glittering and fun and all of that. And people have a hard time believing that it means that something as simple as my lifestyle could actually reverse these conditions and, therefore, prevent them. And even more interesting is that, with all this talk about personalized medicine and so on, it was the same lifestyle intervention for all these different conditions. It wasn't like there was one diet lifestyle program for a reversing heart disease and another one for diabetes and so on. It was the same for all of them. And we also found something that surprised me, was that the more people change, the better they got. In every way we could measure, no matter how esoteric the mechanism one, at any age. And that's a very empowering message to give people. Well, I'm going to want you to go through each of the four that you mentioned. But I'm curious first, just because this is, it still counts as something of a radical idea. And it's not where you started out in your journey. How did you get to this idea? Well, it is radical in a sense of radical means to get to the root of something. When I lecture sometimes I show a cartoon of doctors busily mopping up the floor around a sink that's overflowing but nobody's turning off the faucet. And when you get put on diabetes medications or blood pressure pills or cholesterol or any drugs, and the patient says, how long do I have to take these doctor? And the doctor says, forever, right? It's like, how long do I have to mop up the floor? Like forever, well, why don't we just turn off the faucet? And so it's really about radical in a sense of getting to the root of what really causes these conditions. And we find that when people do that, they get better so much quicker than we had once imagined. And did you start out thinking you were going to be a more traditional doctor before you found your way into the branch of medicine that you're essentially inventing? Well, I got interested in this because I was suicidally depressed when I was in college. I almost killed myself. I was so depressed. And I wrote about this in a couple of my books. And there's not time to talk about it here, but fortunately. But it was basically I felt like I was stupid and that I didn't know anything. And now that I was in a school with a lot of really smart people, it was just a matter of time before they figured out what a mistake they made in letting me in. But I also had this kind of spiritual vision with all the cliche kind of Cecil B. DeMille special effects just to make sure that I realized it was a vision. And it was like nothing can really bring lasting happiness. So the combination of feeling like I was never going to mount anything because I was stupid. And even if I did, it wouldn't matter anything. It was like, well, I know what I'll do. I'll just kill myself and then I can find peace. And that got me interested in an ecumenical spiritual teacher that I was working with and began changing my diet. And he said, if you just change your diet and eat a plant-based diet and exercise and love more and walk and do these things that you'll get better. And I began to experience that sense of when you quiet down your mind and body enough, however you do that, that you feel more peaceful. But not because those techniques brought you peace. That's our natural status to be peaceful unless we disturb it. And I think in one of the ultimate ironies, we end up running after all these things, and if I just had more money or power or sex or beauty or accomplishment or whatever, then I'd be happy. And once you set up that view of the world, generally, however it turns out, you're not happy. And that's what I wasn't happy. Until you get it, you're not happy. If someone else gets it, you're really not happy. And even if you get it, it's very seductive. It's like, ah, I got it. Now I'm happy. But it doesn't last. It's like, well, now what? Or so what? Big deal. So this teacher was a man named Swami Sacha Dhananda. And people say, what are you a Hindu? He'd say, no, I'm an undo. The undo button on the computer has been always my favorite. And our bodies have this remarkable capacity to undo a lot of that damage. So I began to get little glimpses of what it meant to feel peaceful, not because I got something I thought I needed, but I just was quieting down what was there already. And so I was able to do well enough to get into medical school. And then when I was in medical school, I was learning how to do bypass surgery with Michael DeBakey, the eminent heart surgeon. And it was, again, an example of high-tech medicine at its ultimate at the time. And we cut people open, we bypass their clogged arteries. He'd tell them they were cured. And more often than not, they'd go home and do all the things that caused the problem in the first place. They'd smoke and eat junk food, not manage stress, not exercise. And then, often, their bypassers would clog up. So we'd cut them open again. I said, there's got to be a better way. So that's when I took a year off between my second and third years in medical school, put 10 men and women in a hotel for a month. And that began kind of a lifelong journey for me. So there are four elements. So let's do those one at a time. Because I think people want to understand, when you say the more you embrace each of these, the greater the progress, the success. So I want to know how radical a lifestyle change we're talking about. So let's start with diet, which is the most obvious. It's the one probably you were first identified with. What kind of a diet change are you talking about for people? You're right. It's the one I'm most identified with. And it's the one I'm probably least interested in. But it's so kind of funny how that tends to happen. OK, I promise we'll end up with the one I know you're most interested in. It's basically a Whole Foods plant-based diet. It's also low in sugar and refined carbs. And it's naturally low in fat. I mean, fat is not the primary goal. It's mainly fruits, vegetables, whole grains, legumes, soy products in their natural forms, which are low in the disease-causing substances in high end. There's literally hundreds of thousands of protective substances that you find in foods like that. And it's also moderate exercise, walking a half an hour a day, yoga and meditation, or whatever way used to manage stress, and more love and support. And the more you change, the more you improve. So on the diet front, we've been having a great big conversation this year about fat. One of the most talked about covers we did at time was about eat butter. And the rethinking about fat versus sugar and what's the villain, where are you on the fat, good, fat, bad spectrum? Yeah, that wasn't my favorite Time Magazine cover. I didn't think it would be that way. But the theme of that issue, or the theme of that article, which has almost become a meme because it's been repeated so often in this echo chamber that people begin to believe it, is that Americans have been told to eat less fat. They're fatter than ever. So clearly low fat has failed. So I went to the USDA database, and I said, is that really true? Clearly Americans have been told to eat less fat, but are they eating less fat? And it turns out that every decade since 1950, people have been eating more fat, actually 67% more fat, more sugar, 37% more sugar, more calories, 800 calories per person, and more meat, 57 pounds more meat. So we may have been told to eat less fat, we're eating more fat, more sugar, more calories. And so it's not surprising that we weigh more. So sugar is important, fat is important, but animal protein seems to be particularly important. I did all these debates with Dr. Atkins before he died, probably of heart disease. That's another story. And he was always the low carb guy, and I was pegged as the low fat guy. Unfortunately, those labels kind of stuck, but animal protein, there was an article that came out by Levine in a journal called Cell Metabolism last year. And they found that people ate a lot of animal protein, independent of the fat and cholesterol and sugar, had 75% increased risk of premature death from all causes, a 400% increased risk of cancer, and a 500% increased risk of diabetes. So I think we need to move beyond individual components, low fat, low carb, you know, it's all of that. And so, and to me an optimal diet is a Whole Foods plant-based diet that's naturally low, both in fat, in refined carbs and high in the good carbs and enough of the good fats, the omega-3s and so on. So if there's a meme around exercise right now, and you're right, that each of these always has its fads and trends. So the one right now is not your half hour of walking, it's the one minute workout or it's the seven minute workout. So can you talk about that? No, I think it's true, these studies are showing that if you really do intense exercise for short bursts, that gives you many of the benefits of longer, less intensive exercise. But it's also true that, you know, just walking in half an hour a day, and not even all that fast or even all at once, can cut your risk of premature death in half. So a little goes a long way. And the consistency is more important than the duration. And I wrote a book called The Spectrum, which was based on this finding that the more you change, the more you improve. And part of what I've learned is that even more than being healthy, people want to feel free and in control. And so instead of, I chaired Google Health with Marissa Meyer from 2007 to 2009. We were trying to come up with all these complex algorithms for personalizing diet and lifestyle interventions. And one day I said, you know, I think we're really going about this in completely the wrong way. Instead of making this so complicated and telling people what they should be doing, let's ask people how much they want to change and then support that degree of change. So then it's much more compassionate. You can't fail because if you go on a diet, chances are you're going to go off it. And then you have all those toxic emotions. You know, I failed. I mean, the whole language of behavioral change has this kind of moralistic quality. You know, I cheated on my diet, you know, good foods and bad foods. And once you call foods bad, it's a very small step to saying I'm a bad person because I eat bad foods, you know, and it's all over there. And say, look, food is just food. But some foods are healthier than others. So I categorize foods from the healthiest to the least healthy and say, what matters most is your overall way of eating and living. So if you indulge yourself one day, it doesn't mean you cheated or you're bad, just eat healthier the next. If you don't have time to do an intense workout one day, do a little more the next. You don't have time to meditate for an hour, do it for a minute. Whatever you do, there's a corresponding benefit. And that way you can't fail. Now, I know from our fascinating conversations leading up to today that the one of these four that you are most animated by is about love and support, which I would have said is the one that people may have the least control over. So how does that one work? Well, you know, we tend to think that the time we spend with our friends and families are kind of the luxury that we do after we've done all the important stuff. But what the studies are showing that it is the important stuff, you know, that study after study has shown that people who are lonely and depressed and isolated are three to 10 times more likely to get sick and die prematurely than those who have a sense of love and connection and community. And, you know, Nicholas Christakis at Harvard found that if your friends, I mean, we are so interconnected that if your friends are obese, you're 45% more likely to be obese. If your friends, friends are obese, you're 25%. And if your friends, friends, friends is obese, you're 10% more likely, even if you've never met them. Now, how does that work? Because we're just so interconnected. You know, people used to criticize my work and say, oh, this is so California, this is so touchy-feely. And I'd say, no, no, no, look at, I've got the, you hear the quantitative arteriograms and the cardiac positron emission tomography and radionuclide ventriculography, blah, blah, blah. And then one day I said, you know what? It is touchy-feely. That's what makes it work. Because we are touchy-feely creatures. We're creatures of community. That's been a running theme throughout Davos this year, is that we are all interconnected and we rise or fall together. And we, you know, part of the value of science is that it can raise awareness. And many people aren't aware that the time that we spend with our friends and family and loved ones is the most important predictor of your health and survival, more than smoking, more than diet, more than anything. I wrote a book called Love and Survival about this back in 1998. There are hundreds and thousands of studies showing that, again, if you spend time with your friends and family and loved ones, that's probably the most healthy thing that you can do. But a lot of the conversation we've been having this week about connectedness and it's important is technological, it's virtual connectedness. And so I'm wondering whether you think that the capacity to stay in touch with friends and family electronically enhances this part of our lives or gets in the way of it because it is so easy than to in a way be isolated in our little virtual world where there isn't actually any genuine contact. How does that work? Well, technology is neither good or bad. It's how you use it, as you know. It's just another form of power and it can be used to connect us when I'm traveling and I can FaceTime with my wife Anne and our kids. It's a beautiful thing, you know? If I'm watching, especially my 14 year old Lucas and his friends and they're all sitting together and they're all texting and they're not even talking to each other, that's a kind of a way of using technology to isolate each other. So it really depends on how we use it. But studies have shown that virtual support groups are very powerful and the best, of course, is when you can be with someone face to face. There's an energy, I think, that gets transmitted that we don't necessarily know how to measure, but you can feel it. And I think that energy, that intimacy is healing. You know, the word healing comes from the root to make whole. The word yoga is from the Sanskrit to meaning to yoke, to unite, to bring together. Now anything that creates intimacy is healing. These are really old ideas that we're rediscovering. You mentioned a second ago about the Touchy Feely, California doctor. So I'm gonna ask you to do an exercise. Channel your critics. Channel my critics? Channel your critics. And those who say that this is a bunch of unscientific Touchy Feely stuff. What is the, what's the charge? You mean over time, like in the history of these things? Oh God, I don't think I've ever been asked that question before. Well I'm gonna give you a chance to answer them. Okay, okay, I will channel my inner critic and my inner rebuttal. Well I remember when I was an intern, I was at Harvard's Mass General Hospital. And I was on the wards in one of the, the attending physician at the time who was like world famous, wrote the standard textbooks. He said, Dean, you really think the mind affects the body? That's like the stupidest idea I've ever heard of. And I looked at him. I said, have you ever had an erection? You know? It's like, it's like, things that just seem so obvious to me are like considered radical, you know, we're like, cause they didn't fit within the conventional wisdom of what we've been led to believe. And of course the whole idea that heart disease could be reversed. You know, people thought that was a crazy idea when I started doing this work 38 years ago. And I was a medical student and I said, well look, you can reverse heart, you can cause heart disease and like dogs and cats and pigs and rabbits and monkeys if you make them smoke or eat junk food or not let them exercise or make them stressed and isolated, why can't, and you can reverse it, why would people be any different? Oh no, it can't be done. And so we did the first study and then people, it was kind of an eye-opening experience for me about when you're doing something that's true and I didn't realize cause I was a medical student I didn't know enough to know how disruptive it really was. I just thought, well let's just try it. One of the nice things about being a medical student is you'll do things you wouldn't do if you knew better. And so when we showed that it was reversible people didn't believe it. But beyond that there was a visceral reaction that was way out of proportion to just like a scientific skepticism. And I began to realize that when you're doing something that doesn't fit the conventional wisdom that's truly disruptive, it's threatening to the order that paradigm or that belief provides. And so it goes beyond just this particular issue it's like the whole fabric begins to feel like it may come undone. And it creates that kind of visceral sense of chaos that people want to like just put it down. And so over time we did a series of studies with increasing randomized controlled trials increasing evidence. Now that idea that heart disease is reversible has become mainstream. Other people have replicated that work. So then the skepticism and the criticism went, well you know you live in California it's an altered state, they'll do anything there this will never play in Peoria. And why would you want to do that anyway? We can just take some Lipitoris of statin drug and that'll take care of it. And this pervasive idea that taking a pill is easy and everyone will do it. But changing diet and lifestyle is difficult if not impossible turns out not to be true. And the drug company's own data has shown that less than half of the people who are prescribed statin drugs were taking them just three to six months later. And why do you think that is? Because they're fear based. We don't really think about it but it's like take this pill forever. It's not gonna make you feel better hopefully it won't make you feel worse to prevent something really awful from happening years down the road like a heart attack or stroke that you don't want to think about so people don't think about it. I mean for a few months, for like six weeks after someone's had a heart attack or stroke or something really bad they'll do pretty much anything that the doctor tells them. And then they get off it because fear is not a sustainable motivator. And that's just true in politics. I mean Al Gore talked about this eloquently earlier this week, you know that when he first did an inconvenient truth it was like everybody's buying fluorescent light bulbs and driving smaller cars and then people kind of forgot about it because the idea that the species might get annihilated is just goes all the way back to the Superman comic books I read as a kid in Jor-El trying to get everybody to stop krypton from exploding and nobody wanted to believe it it's too awful to think about something really awful might happen so people stop thinking about it. So fear is not sustainable but joy and pleasure are. And when you make these changes most people find that they feel so much better so quickly. It reframes the reason for making them from fear of dying which is not sustainable to joy of living which is, their pain goes away. They, you know if they have heart disease I mean people who literally couldn't walk across the street they can't have sex, they can't work they can't do all the things that are fun and within a few days to a few weeks they're pain free in most cases and they can do all that and their brain gets more blood they think more clearly they have more energy that the latest data is showing through a process called neurogenesis and neuroplasticity you can actually grow so many brain neurons in just a few weeks that your brain can get measurably bigger particularly the parts of your brain you want to get bigger like your hippocampus that controls memory you know when you get older you kind of people tend to forget names and things like that like where did I put my keys you know so these things are so much more dynamic that's really what makes them sustainable because there's no point in giving up something that you enjoy unless you get something back that's better and although the adherence to stat drugs is so bad we've trained now over 60 hospitals and clinics throughout the country and we're getting 85 to 90% adherence after a year to a very intensive lifestyle program to reverse heart disease and people thought that'd be impossible and the reason is twofold one is that they feel better and the other goes back to what we talked about earlier the sense of love and community that our support groups are not just support groups in the sense of you know exchanging recipes and types of running shoes it's a we create a safe environment that enables people to and encourages them to very intentionally let down their emotional defenses and talk openly and authentically about what's really going on in their lives without fear that someone's going to make fun of them or give them glib advice or the usual kinds of things now in the past you know if you had two or three people growing up in a neighborhood that you know that people knew you you know they didn't just know your nice resume they knew where you messed up and you knew that they knew and they knew that you knew that they knew and they're still there for you and there's something really primal about being seen and heard and that you're you know warts and all and that people are still there for you and so our support groups are trying to wait to recreate that and people will say things like you know and I'm amazed at how quickly we can do that even within the first or second support group people say things like I might look like the perfect father or perfect mother but my kid's on heroin or drugs or whatever I mean look like I'm really successful but I'm not and someone else will say instead of saying oh well why don't you send them to a drug rehab program you know it makes you feel more distant they'll say gosh we try to get people to talk about their feelings because our feelings are really what connect us and to say gosh that feels terrible or gosh I'm so sorry or gosh my kid has another problem or I used to have a drug problem they might say whatever it is and suddenly you don't feel so alone and ashamed and embarrassed you feel it doesn't fix the kid on drugs or whatever it is but it fixes that something even more important which is that profound sense of isolation and alienation and depression you know I've given the matriculation lecture at the army war college the last five years where they trained the future generals and joint chiefs of staff from all four branches of the military and I talked about the power of love at the army war college which had that go over it was actually well received I thought I'd have kind of a bit of a doctor strange love quality too but Stan McChrystal the four star general former four star general made a video that gave me more street cred which was a lot better than the kind of the West California doctor going there talking about these things and but you know one veteran kills themselves every hour 24 hours a day one active duty soldier kills themselves every day 365 days a year and more in the country as a whole the number one category of prescription drugs the last 20 years are antidepressants there are a lot of lonely depressed isolated people out there with the disruption of the social networks that used to get people that sense of community so in one sense when I listen to you this it sounds it sounds so obvious that I can I can feel better my rampant memory loss can be reversed that that heart disease and certain kinds of cancer all all can be turned back and I can stop aging it all sounds so irresistible that I have to say then what are the obstacles to widespread adoption of the arguments that you have well the biggest obstacles and how do you see that changing well it is changing that's what's so cool Nancy is that I used to think in kind of my naivete that if we just did good science that will change medical practice and to some degree it did but not nearly as much as I'd hoped and through our non-profit preventive medicine research institute beginning in 1993 to answer the question is will this play in Peoria, you know we began training hospitals and clinics around the country, you know UCSF, the Cleveland Clinic Scripps, you know but also community hospitals in Omaha, Des Moines South Carolina where they told me gravies of beverage and shit is a three syllable word you know those kinds of things and we found that we could get 85 to 90% adherence in all these different sites bigger changes in lifestyle better clinical outcomes Highmark Blue Cross Blue Shield which was covering our program began to provide it in West Virginia, Nebraska and Pennsylvania they got the same outcomes and they cut their overall cost in half but the painful lesson for me was that a number of those sites closed down not because of the science or the efficacy or the cost savings but the lack of reimbursement so that set me off on it and we were going insurance company by insurance company it was very hard to get people to do things visionary they insurance world doesn't select it selects for people who like to kind of manage risk that's why they go into it so I realized if we could just get Medicare to pay for it then most of the other insurance companies would follow suit and Bill Clinton when he was president was very strongly supportive of this we worked with Hillary asked me to work with the chefs to cook for them so and then I became one of his consulting doctors and remained that way since 1993 but also Newt Gingrich when he was speaker of the house came to one of our retreats with his daughter and he became very strongly supportive there wasn't a whole lot of things that they agreed on at the time and 20 members of the senate 30 members of the house across the political spectrum members of the heads of the AARP and most of the major medical societies got behind it and I thought well great you know this will we'll get this unfairly quickly 16 years later Medicare agreed to cover our program and they created a new benefit category actually got an act of congress pass to give them the statutory authority to do that so now that Medicare is paying for it the good news is most of the other insurance companies you know Mark Bertolini the CEO of Aetna was here earlier their Aetna is paying for it and well-pointed and most of the Blue Cross Blue Shield plans and others and so we're really trying to create and we are creating a new paradigm of healthcare if it's reimbursable then it's sustainable you know as the wrappers say it's all about the Benjamins and now it is and so and if it's reimbursable it not only changes medical practice but even medical education and there's a convergence of forces that after doing this for almost four decades it's finally the right idea at the right time because at the same time that the limitations of high-tech medicine are becoming increasingly documented I mean for example studies have shown that if you're not in the middle of having a heart attack that angioplasties and stents don't work you know that bypass surgery only works for a very small percentage of people who have the most severe disease maybe one or two percent we spent almost 80 billion dollars just on those two operations which were essentially dangerous, invasive, expensive and largely ineffective for treating prostate cancer the New England Journal of Medicine had a large study one out of 49 men who's treated for early stage prostate cancer benefits the others often end up in diapers and because they're incontinent or they're impotent and can't have sex so we main people in most personal ways and yet only one out of 49 people benefits from that we found that we could actually stop or reverse the progression of early stage prostate cancer by simply changing lifestyle it's like people say why are you doing this radical intervention like why don't you do something more conventional like cutting people's chest open instead of you know walking, meditating, eating vegetables and so on the same is true for type 2 diabetes so if you get your blood sugar down with drugs chronic diseases that are increasingly a huge global health well yeah I mean half of the American population already is either diabetic or pre-diabetic and United Healthcare estimated it's a 3.3 trillion dollar cost that's clearly not sustainable getting your blood sugar down with drugs doesn't prevent the horrible complications of diabetes like amputations and blindness and kidney failure and heart attacks and stroke any one of which would be awful but an aggregate are truly awful but if you can get your hemoglobin A1C your average blood sugar down below 7 you can prevent each and every one of the human costs and the economic costs so at the same time that the limitations of drugs and surgery are becoming clear particularly for chronic diseases the power of these very simple lifestyle changes is also becoming well documented through our studies and others and now that we're moving into the era of Obamacare whatever you think about it it's turning all the incentives on their ear so in the past in a fee for service environment the more operations you do the more money you make in the Obamacare environment here's X amount of dollars to take care of somebody you get to keep us left over so interventions that involve lifestyle medicine are now the most valuable because now Medicare is paying for this and they're paying it at a high enough level that it makes it really attractive and they save money on the back end because we're reducing the utilization now because we're running out of time you have in this room and throughout this building an extraordinary collection of individuals and leaders of in government and in private business if you wanted this room and those watching to take away one idea one personal change but one change about how they approach those who they lead what would that be well in simplest terms eat well love more stress less and move more any one of those things would be good but again I'm trying to get away from a reductionistic one thing but to say if you can do all these things to the degree you can do them you're going to feel better you're going to look better and you're going to be a lot happier Dr. Dean Ornish thank you very much great pleasure