Aaron Carroll talks to Dr. Sherif Farag of Indiana University about his work harnessing the power of patients' own immune systems to treat blood cancers like multiple myeloma.
The Healthcare Triage podcast is sponsored by Indiana University School of Medicine whose mission is to advance health in the state of Indiana and beyond by promoting innovation and excellence in education, research and patient care.
IU School of Medicine is leading Indiana University's first grand challenge, the Precision Health Initiative, with bold goals to cure multiple myeloma, triple negative breast cancer and childhood sarcoma and prevent type 2 diabetes and Alzheimer's disease.
Dr. Aaron Carroll: Welcome back to the Healthcare Triage Podcast. Today, my guest is Dr. David Haas. He is the Munsick Professor and Vice Chair for Research in the Department of Obstetrics and Gynecology at Indiana University School of Medicine.
This episode of the Healthcare Triage Podcast is sponsored by Indiana University School of Medicine, whose mission is to advance health in the state of Indiana and beyond, by promoting innovation and excellence in education, research, and patient care.
We're going to be talking about gestational diabetes today. How is it different from other diabetes? Why is it important and what we might do about it? David. Welcome.
Dr. David Haas: Thank you very much. I'm glad to be here.
Dr. Aaron Carroll: So let's talk a bit. We'd like to talk when we introduce someone on the podcast about sort of how they got to this position. So how did you decide OB/GYN was for you and how did you get into this line of work?
Dr. David Haas: Sure. So it was actually one of the things I didn't want to do going into medical school. I told my wife, I didn't want to do pediatrics or OB/GYN.
Dr. Aaron Carroll: You made the wrong choice.
Dr. David Haas: And, you know, I got to the end of my third year, it was my last rotation and I realized that it had the three things I really loved. I loved to do surgery. You got to do a little bit of primary care and there's nothing in the world like catching babies.
Dr. Aaron Carroll: But how did you get interested in gestational diabetes?
Dr. David Haas: So I got interested in gestational diabetes because we just see a lot of women who have it and it's something that leads to a lifelong health consequences, in terms of gestational diabetes can be the first sign that a woman has difficulty with their glucose metabolism and how they process sugar. And then it can go away for a while, but then they have a high risk for it to come back later in life. Diabetes is a major public health crisis with obesity that's prevalent in the United States and the sedentary lifestyles and so if we can do something about it while a woman is pregnant and they're engaged in the health system, then potentially we could have a public health impact later on down the road.
Dr. Aaron Carroll: I guess we should back up for a second. What exactly is gestational diabetes and how is that different from diabetes in general or other diabetes?
Dr. David Haas: Well, gestational diabetes is what develops during pregnancy. So that's the definition of gestational diabetes, whereas Type 1 or Type 2 diabetes develops in childhood or adulthood and is, they're all related in the fact that the people have difficulty in processing and utilizing the sugar and the glucose that are in the bloodstream and that's what cells need to do all of the activities that happen inside the body and the processes.
And so what happens during pregnancy though, is that there are changes in a woman's body in the development as the baby is progressing and the placenta is getting bigger, that can make it harder for her to process the glucose and so they can become insulin resistant. So the normal insulin that their body produces, which helps drive glucose and sugar into the cells so that they can be active and do the processes that they need to do, that isn't handled very well and the mom becomes resistant to it.
Dr. Aaron Carroll: When in pregnancy does this happen?
Dr. David Haas: Typically it happens the later you get in pregnancy. So it's mostly a disease in the third trimester but there are signs that it can happen earlier in pregnancy and just develops on a continuous basis.
Dr. Aaron Carroll: How does it show up? I mean, do women notice that there's something wrong or is this something we try to screen for and pick up on a lab test?
Dr. David Haas: Well, we do universal screening now in pregnancy.
Dr. Aaron Carroll: For everybody?
Dr. David Haas: For everybody in pregnancy because the lowest risk group was so small, that they found that from a public health perspective, it was much better to just screen everybody so that we would pick them up. But typically there's not a lot of symptoms that go along with gestational diabetes.
As the blood sugars would tend to rise throughout pregnancy, you could get things like a lot of urination. So women would have to go to the bathroom a lot. They could get a little bit more swelling, but generally those are things that happen sometimes during pregnancy even when there's no gestational diabetes.
So it is something that it's difficult to pick up and a lot of people are surprised when they have it because they could be totally otherwise healthy and not have any symptoms of it.
Dr. Aaron Carroll: So why does this occur during pregnancy?
Dr. David Haas: So this occurs during pregnancy, mostly because of physiologic changes in a woman's body as the pregnancy develops. A lot of people, point to the placenta and the development of the placenta. It produces a substance called human placental lactogen, which is abbreviated HPL, if people hear of it that way, but it can interfere with a woman's ability to utilize the insulin that's normally in her body.
Dr. Aaron Carroll: And does it usually just go away once they've had a baby?
Dr. David Haas: Usually once the placenta is gone, then the human placental lactogen is gone as well. And so most women, even if they have relatively severe gestational diabetes where they're needing medication therapy, whether it's insulin or Metformin or other things, even if they have severe gestational diabetes, a lot of them the day or two postpartum, their blood glucose returns to normal values.
Dr. Aaron Carroll: How many women does this affect and how many women actually need an intervention with medications like you mentioned?
Dr. David Haas: Sure. So about 7% of women will have some form of diabetes during pregnancy; so about one in every 14 women. And most of those are gestational diabetes.
Dr. Aaron Carroll: Do they all need medication or what?
Dr. David Haas: Not all of them. The majority of women actually can be treated just with diet modification and with more physical activity. That's sort of the first line treatment and so we'll check women's sugars. We'll have them actually, they do finger stick glucose checks for fasting in the morning and then two hours or one hour after every meal that they have. And then we watch and see how abnormal they are. If they're too high, then we can modify their activity and their diet or if they medication because those behavioral changes aren't enough.
Dr. Aaron Carroll: So given that it seems to comes in late in pregnancy and it can go away a day or two after the placenta is gone, why is it such a big issue?
Dr. David Haas: We feel like pregnancy oftentimes is a woman's first stress test. It's a big strain on the normal physiologic processes and the ability of a person to compensate for those things. And so what we find is the things that happen in pregnancy, predispose people to conditions later in life. And whether this is the start of it, or this is just the place we pick up these bodily changes, is still open to some debate. But we know for instance with high blood pressure, that women who have high blood pressure problems in pregnancy, have a much higher risk of developing high blood pressure later in life, even if it goes away after pregnancy and also cardiovascular disease, in other respects.
Diabetes is the same way. Women who have gestational diabetes have up to a 70% lifetime risk of developing Type 2 diabetes later in life.
Dr. Aaron Carroll: 70%, so.
Dr. David Haas: 70%.
Dr. Aaron Carroll: Okay. So that would seem to be like, then this is a major risk factor for developing diabetes.
Dr. David Haas: It's the number one risk factor for developing Type 2 diabetes.
Dr. Aaron Carroll: Okay. And I want to go deeper into that but before I do, the pediatrician in me has to ask, is there an impact on the baby? Is there an impact on the child?
Dr. David Haas: There is. Depending on how well the blood sugars are controlled during pregnancy can impact the immediate health of the baby pretty quickly. Because even though mom isn't utilizing her insulin very well, the baby's just fine with its insulin. And so if her blood sugar is high, that goes straight through the placenta to the baby. Baby's insulin is fine but it has to put out a lot of insulin to keep up with all of that sugar coming in.
And so insulin also has insulin like growth factor. So babies tend to get bigger in moms who have uncontrolled gestational diabetes, and that can make the birth process harder, higher risks of things like having to be born by cesarean delivery, but also after the birth happens and the umbilical cord is cut, that sugar pipeline is gone and the baby's insulin though is really high. So babies can have low blood sugars, sort of counterintuitive, but the infants initially have low blood sugars so they can have issues with recovering from that and needing extra feedings and IV fluids. And long-term, we know that babies of moms who had diabetes, have a higher risk of diabetes and metabolic problems as well.
Dr. Aaron Carroll: So is that, do we know that that's causal? That's something along with something that they were exposed to in utero is what's causing that versus... Or could it be that whatever predisposed mom to diabetes to begin with, would make the baby more likely to have diabetes?
Dr. David Haas: I think that's still an open area of research. I know there's associations, but I don't know if there's actually the causal link that's been found yet.
Dr. Aaron Carroll: Because if I remember too, is there a high link of obesity as well?
Dr. David Haas: There is.
Dr. Aaron Carroll: Yeah and that's always fascinating because of course whatever social determinants life or even genetic factors, which would predispose moms to be obese and have diabetes, but you also wonder if there could be something in development in utero. Are people doing research in that area?
Dr. David Haas: They are. So there's a lot of people who are looking at whether there's epigenetic or other changes that happen from generation to generation that just have an additive effect on these health consequences.
Dr. Aaron Carroll: So given that you're concerned there for a baby's glucose level after they're born, like how long does that hypoglycemia risk exist? Is it just a couple of days or do you need to be worried for longer?
Dr. David Haas: No, it's usually pretty much within the first day that we worry about it and that's why we spend a lot of time on labor and delivery, optimizing mom's blood sugar. So they get their fingers get poked a lot more frequently if their blood sugars are abnormal because we really want them to have pretty steady blood sugar during the labor process, so that the baby gets exposed to the right concentration.
Dr. Aaron Carroll: So your treating mom with insulin, then right up into delivery.
Dr. David Haas: Sometimes if their blood sugars are too high, we treat them with insulin.
Dr. Aaron Carroll: All right, let's get back to mom. So first of all, we were talking about the fact that this seems to be a major risk factor for developing diabetes later in life. I'm assuming that's Type 2 diabetes, or is it any diabetes?
Dr. David Haas: It's Type 2 diabetes.
Dr. Aaron Carroll: Now we've identified a major risk factor in mom.
Dr. David Haas: Right.
Dr. Aaron Carroll: That she's going to get diabetes. Do we do anything about that?
Dr. David Haas: The goal is to prevent it. I mean, that would be the ideal. And so that's one of the things that we're doing with some of our research in the Precision Health Initiative Diabetes project is we're really trying to find out how do we predict women who are going to get gestational diabetes because then what we can do is try to figure out the right mechanisms and pathways that we can try to treat, to try to avert them getting gestational diabetes in the first place. Because if they don't get the gestational diabetes, then the thought would be that they have lowered that major risk factor. So, that's one of the things that we're trying to look at because if we can prevent it, that will hopefully have better downstream effects.
Dr. Aaron Carroll: So you're trying to prevent gestational diabetes.
Dr. David Haas: Correct.
Dr. Aaron Carroll: We're not even talking about preventing Type 2 diabetes?
Dr. David Haas: Right. We're preventing, at sort of both arms. So what we're doing with the diabetes project is in two phases. One phase is trying to better predict and prevent gestational diabetes and then phase two's group is really working on, in women who get gestational diabetes, how can we better prevent them from developing type two diabetes? So we're trying to attack it actually on both ends of the gestational diabetes.
Dr. Aaron Carroll: So what can we do to prevent gestational diabetes?
Dr. David Haas: Well, right now we feel like women who are in low risk are people who are at ideal body weight, who are active, who have healthy diets, but that sort of is a small percentage of people that get gestational diabetes. So what we don't know right now is how we can prevent it. So that's what we're doing active research in. Trying to figure out, from a genetic standpoint, from a behavioral standpoint, dietary, are there certain protein biomarkers that are strongly associated with the development of gestational diabetes that we could potentially see as predictive targets?
Dr. Aaron Carroll: So you're talking about looking for ways to prevent it with medication.
Dr. David Haas: Potentially.
Dr. Aaron Carroll: Okay because I mean, usually when we talk about preventing Type 2 diabetes, a lot of it is diet and exercise.
Dr. David Haas: Right.
Dr. Aaron Carroll: In which case I'm always, the population-based guy me is always like, that's good advice for everyone, not just people who are at risk for gestational diabetes. But you're going beyond that. You're actually thinking we might be able to find specific targets that we could actually develop medications for, that might specifically prevent gestational diabetes.
Dr. David Haas: Correct.
Dr. Aaron Carroll: Would those same drugs then be used to treat regular... I mean, I don't want to say regular dia... But those same drugs be used to treat other or Type 2 diabetes, or do you think there'll be specific to gestational?
Dr. David Haas: I think they could be used. It depends on the pathways that we identify. If they are similar to those that we identify in women who have Type 2 diabetes or even Type 1 diabetes, then those could be some that we would investigate in that area too.
Dr. Aaron Carroll: So, when we think that women get gestational diabetes and you were saying that it's the first stress test. Then my mind immediately went to, we've just unmasked the risk that now we've identified the women who are at high risk for diabetes in general and we should therefore try to prevent Type 2 diabetes.
But if we're specifically trying to prevent gestational diabetes with medication, is it that you think the actual development of gestational diabetes somehow changes a woman in such a way that she's then at high risk for Type 2 diabetes?
Dr. David Haas: That's a great question and that's actually an area of debate that we've had with experts in the field. There are some who believe that just women who have gestational diabetes really it's a spectrum disease and they've already been on this path and it just happens to be that this is the snapshot we've taken to identify it, because a lot of people don't get a lot of routine healthcare until they become pregnant and then they engage in the health system.
There are those who though feel the other way, that this is sort of that stress test and that they didn't have problems with their glucose before. This is really the thing that's tipping them over the edge and starting a cascade. So there's discussion on both ends.
If it's a total spectrum and that this is just the snapshot of diagnosis that we've come to, that is something we can't stop just in pregnancy, but we can try to maybe divert the course a little bit to improve their health long-term.
Dr. Aaron Carroll: Fascinating. Is this more common than it used to be?
Dr. David Haas: It's definitely more common than it used to be.
Dr. Aaron Carroll: Is that we're better picking it up or is that really, it's more common than it used to be?
Dr. David Haas: It's really that it's more common. We've been doing universal for a long time, but as the population in the United States has risen in the rates of obesity and sedentary lifestyle, that really has driven up the rates.
Dr. Aaron Carroll: Is gestational diabetes like a marker for the broader problem that we have, do you think? Or is it a specific entity that we need to get a handle on and doing so would actually reduce risk overall?
Dr. David Haas: I think it probably could be both, to be honest with you. I think that it definitely is a by-product of some of the behavioral things that we are doing as a society and some of the lack of activity that a lot of people are doing. But I think in general, I think we do have a potential here to impact health long-term for people and if this is the tool that we can utilize for women's health at least, that if you get, if you have this condition develop while you're pregnant, this is really the risk factor. And maybe this is what actually gets them to do something about it because you're right, everybody talks about diet and exercise. And at the end of the day, I think that we've become a little bit deaf to that as a society, because everybody keeps saying diet and exercise. Diet and exercise. So if this is what gets them off of the couch and gets them into some kind of a program, that's the goal, if it can impact public health in general.
Dr. Aaron Carroll: So do you... Is this the kind of thing that I think we're looking at, or there is evidence that says we can use this as a moment to-
Dr. David Haas: I think we're more looking at that. I think we're trying to capitalize on it as a moment.
Dr. Aaron Carroll: Right.
Dr. David Haas: We know from the diabetes prevention program that we can reduce the rates of Type 2 diabetes-
Dr. Aaron Carroll: Yes, exactly.
Dr. David Haas: ... If you engage in one of these healthy lifestyle programs. So what we're trying to do in our second phase really is take women who had gestational diabetes. So we've gotten this snapshot. We know that these women are at super high risk and engage them better in programs. Figure out what works with their lifestyle. Do more of an individualized, personalized precision kind of way to get them engaged in a program, whether it's with their family, whether it's at a YMCA, through Weight Watchers programs, a virtual online thing, but try to figure out what is the best way to engage people in these healthy lifestyles that can be sustainable.
Dr. Aaron Carroll: Are there disparities with this or does it affect all women about the same or are certain races or socio-economic classes more likely to be associated with gestational diabetes?
Dr. David Haas: The highest risk groups are women who are older when they're pregnant and also there are racial and ethnic distribution. So we tend to see a large risk of this in Hispanic women and in Asian women. And one of the really sort of striking things about gestational diabetes transition to Type 2 diabetes is it's particularly hard on Hispanic women in that 50% of the Hispanic women will develop this within five years of their pregnancy.
Dr. Aaron Carroll: Diabetes?
Dr. David Haas: They'll develop Type 2 diabetes.
Dr. Aaron Carroll: 50% of women who have gestational diabetes.
Dr. David Haas: [crosstalk 00:18:03] Will develop diabetes-
Dr. Aaron Carroll: Within five years.
Dr. David Haas: Within five years.
Dr. Aaron Carroll: That's horrifying...
Dr. David Haas: It's horrifying. Which is why this is such an important thing that people don't talk about.
Dr. Aaron Carroll: Like literally I'm like, I can't believe I did not know that and I can't believe that that's not front page news. That's horrifying.
We've talked about before and we've seen a lot of news and the fact that maternal mortality is a real problem right now. Is diabetes part of the reason for that? Or is it true true and unrelated.
Dr. David Haas: I wouldn't necessarily it's unrelated but I don't think that it's a major driver. Now we do know that women who have gestational diabetes have a higher rate of preeclampsia and high blood pressure in pregnancy and that is a driver of maternal mortality. And so it's sort of quasi related. It's sort of on that pathway because we know that people who have one complication of pregnancy tend to develop more.
Dr. Aaron Carroll: So I'm going to get back to the horrifying statistic because I can't like get that out of my mind. So I mean, any group that has a 50% chance of a bad outcome would seem to be right for an intervention. I mean, I just can't believe that that's not a public health crisis, that people are not saying we need an intervention.
If I said, "You have a 50% chance of developing heart disease in the next few years," we would have a drug and everyone would be on it yesterday. Knowing that, is there a real move to try to figure out how do we prevent this or get at least all of those people into a diabetes prevention program or something like it.
Dr. David Haas: There are a lot of health system based and community based programs to help.
Dr. Aaron Carroll: I mean just from an insurer's standpoint. I mean, [crosstalk 00:19:38].
Dr. David Haas: Insurance pays for a lot of these.
Dr. Aaron Carroll: Yeah, like it'd be a massive. I mean we discussed before too how prevention rarely saves money. But if I knew that there was a 50% chance of a bad outcome in a certain population that would cost me a fair amount of money in the short term, it would seem like that would be where I'd want to invest right now.
Dr. David Haas: Well, I think one of the problems is we don't have a drug.
Dr. Aaron Carroll: Right.
Dr. David Haas: We don't have the magic pill that's going to prevent diabetes.
Dr. Aaron Carroll: Right.
Dr. David Haas: Maybe we can find one.
Dr. Aaron Carroll: Right.
Dr. David Haas: Maybe in all this research that we're doing, we can find one. That's part of the grand challenge is to prevent a chronic disease. Maybe we can do that. But I think that there are a lot of programs that people are trying to engage in. Insurance companies will help pay for some gym memberships and things where you can make lifestyle modifications but I think it gets back to then people disengaged from the health system until they get older and they just don't, the momentum is really hard to maintain.
Dr. Aaron Carroll: Even when you tell people flat out, there's a 50% chance in five years you'll have diabetes.
Dr. David Haas: Yeah.
Dr. Aaron Carroll: Yeah. That's amazing. I mean, because again, it's like I think we scare people with numbers a lot but that number is truly scary. That needs no fudging.
Dr. David Haas: Right.
Dr. Aaron Carroll: That's an absolute risk. Like, that's just, that's just amazing. So what are you most optimistic about? Where do you think the best bang for the buck is? Or what do you think is going to make a big difference in the future?
Dr. David Haas: In the future, if we can prevent the women from getting gestational diabetes in the first place. I'm very excited about a lot of the collaborative work that we're doing with some investigators down at IU Bloomington and in computer science and a lot of interdisciplinary people, that are coming at this from a lot of different ways.
Whether it's we put a Fitbit or activity tracker on everybody, and that helps motivate them during their early part of pregnancy or trying to do some interesting work with how do we look at nutrition content and can you take pictures of your food and figure out what your nutrition is?
We're looking at proteins in the blood that could be used as biomarkers, we've got genetics. So I think it really gets me excited that we're trying to approach this from multiple aspects and then really smart computer scientists are going to try to throw this all together and come up with some really good predictive models and looking at pathways and proteins we could potentially use as early predictors, so that in the first trimester, during some of the early screening tests when they get blood test to see if they're anemic, or if there's any increased risks for baby, they could get a test that would say, this is your risk of gestational diabetes and we need to do these things to help lower that risk.
Dr. Aaron Carroll: So not to be a naysayer, but since we just finished a few minutes ago, talking about the fact that when I tell people they have a 50% chance of risk of developing diabetes in the next five years, that that doesn't seem to be a motivator enough to prevent them.
Dr. David Haas: I'm an eternal optimist.
Dr. Aaron Carroll: Well, that's great. I'm just like, but I'm thinking one, maybe we do need a drug. I mean, maybe it is that... I love the idea of trying to attack the small angles. Believe me. But it's just, I am struck by just this conversation about how difficult it is to try to get people to change their behavior, even when their risk is truly known. But a drug is sometimes easier for people to wrap their heads around, especially if you're only taking it during pregnancy.
Dr. David Haas: Right. And one of the things that I think is interesting about this grand challenge is it's not only has disease state teams, but it's got a lot of extra research pillars and a lot of them have to do with drug discovery. And they have to do with different core laboratory facilities that can help find these pathways and help discover these drugs. So that's why with a lot of these large pregnancy cohorts that we're recruiting, we're recruiting 500 more women here in Indiana, to look at these things and collecting a lot of specimens. And we can find these proteins or these pathways that we could attack with a drug.
And as part of this large endeavor of the Precision Health Initiative is we'll have partners who can think at these problems really carefully and say, "You know what? This is potentially druggable," and maybe we could develop a small molecule that we would obviously have to then test to make sure it's safe in pregnancy because that's a big hurdle to get through because you not only have one patient, the woman, you've got the baby development too.
And so I think there are potentials to do that. And yes, it's so much easier and if I could tell every woman who had gestational diabetes to just take an oral medicine, it may not be as effective as lifestyle but you're right, it is easier to take a pill every day.
Dr. Aaron Carroll: I'm not trying to talk people out of lifestyle change. I mean, there's nothing more we could do probably for public health in general, than to get people to improve their lifestyle. I mean, that's been shown again and again. That I remember writing a column years ago, there was, you know, if you just make this simple lifestyle changes of, if you... 30 minutes of moderate activity, five days a week, stop smoking, don't drink too much and eat reasonably well. And that's like 50% of all chronic disease, right there. It's like would be more than any drug that we could take.
But we've known that for so long and we just have so much trouble doing it and I'm certainly not advocating that we find a drug, but given there's a reasonably short window to try to change people's lives and we've got evidence in our face that this is so hard to get people to change their behavior. I agree. We've got to try every avenue, which is why, certainly it sounds like you're doing that but it's such a hard problem to lick.
Dr. David Haas: It is.
Dr. Aaron Carroll: Sometimes I think I would say, "Well, we should raise awareness and we have, make sure that women get it," but it sounds like we do universal screening. It sounds like everyone is going to get checked for gestational diabetes, if they are pregnant and they're getting health care.
Dr. David Haas: Correct.
Dr. Aaron Carroll: Having said that, it's probably a good idea for everyone to still engage in improved lifestyle. I mean, all the things that I mentioned that make people healthier in general, also make for healthier pregnancies and babies, it sounds like as well.
Dr. David Haas: Absolutely. You know, optimizing health before you get pregnant is really important and we have a real struggle with getting people in for preconception care, where we can talk to people about, "Oh, you know what? Your sugar is high now. We know that that's going to increase your risk of problems in pregnancy." Or, "Your blood pressure is high now. Let's work on that before you get pregnant." Or, "Your obesity is going to put you at a high risk during your pregnancy and even afterwards." Just because you're done having babies doesn't mean you don't need to have healthcare and particularly for women with gestational diabetes, you're supposed to see a primary care doc and get your blood sugar checked every one to three years.
Dr. Aaron Carroll: You know, you're so right and that's an excellent point. I think we made a video not long ago about a lot of the warnings about alcohol use and pregnancy don't resonate well with women because they're brought up when get pregnant, as opposed to making healthy lifestyle choices even with alcohol are important before pregnancy, after pregnancy; it's part of women's health in general, and that we shouldn't make it necessarily a pregnancy thing.
I think you're right, the healthy lifestyle and making good choices is a women's health issue. It's not just a pregnancy issue and probably focusing on that would result in a lot more health for women in general, even during pregnancy.
I think another thing to focus on as well is that pregnancy is not just a women's health issue. Other people are involved in pregnancy and so, should we involve more than just the to-be mom?
Dr. David Haas: I think we have to. I think family health is really important and I think that may be one of the reasons why we failed in the past with some interventions is that we haven't focused on the entire family unit. It's one of the pieces that we have with our phase two prevention of Type 2 diabetes is some of the programs that we're engaging in are family-based, where women can come with their partners, with their kids and do it as a family. Because if you can get the family into a healthy lifestyle, the hope is that it would be sustainable because everybody's going to try to fall off the wagon a little bit and there are going to be days when it's like, "I just don't want to go for that run. It's cold outside." But if your kid then says, "But we're supposed to go for a run today." Or, "We're supposed to go for a walk in the park." Or the partner can say... You got to keep feeding off of each other. Things tend to work better when you've got partners going through this stuff with you.
Dr. Aaron Carroll: All right. Well, this has been fascinating. David, thank you for joining us.
Dr. David Haas: Happy to be here.
Dr. Aaron Carroll: And hopefully as these studies gather more data and you have more to talk about, we hope to have you back.
Dr. David Haas: Absolutely love to be back.
Dr. Aaron Carroll: Again, thanks to Indiana University School of Medicine who's sponsoring this podcast and whose mission is to advance health in the state of Indiana and beyond, by promoting innovation and excellence in education, research and patient care.
And if you'd like to support the show, you can go to patreon.com/healthcaretriage. We'd especially like to thank our research associate Joe Savitz and of course our surgeon, Admiral Sam, and all of you to can help make the show bigger and better.