This episode discusses physical activity and its role in preventing chronic disease, featuring an interview with Dr. Lucas Carr, an associate professor of Health and Human Physiology at the University of Iowa and leading researcher in lifestyle interventions and health behavior change.

The views and opinions expressed in this podcast are solely those of the student hosts, guests, and contributors, and do not necessarily reflect the views or opinions of the University of Iowa or the College of Public Health.

Lauren Lavin:

Hello, everybody and welcome back to Plugged In to Public Health. Today, we’re diving into an incredibly relevant and personal topic for many of us, physical activity and its role in preventing chronic disease. Our guest, Dr. Lucas Carr is an associate professor at the University of Iowa, and a leading researcher in lifestyle interventions and health behavior change. You may have seen his recent work featured in The Gazette, where he and his team advocate for asking patients one simple but powerful question, how much do you exercise? In this episode, Dr. Carr walks us through how exercise could be treated as a vital sign in healthcare settings, and the behavior science behind habit formation, and why helping people find enjoyable sustainable ways to move their bodies is at the heart of prevention. I’m Lauren Lavin. And if it’s your first time with us, welcome. We’re a student-run podcast that talks about major issues in public health and how they’re relevant to anyone, both in and outside the field of public health.

Now let’s get plugged in to public health. Plugged In to Public Health is produced and edited by the students of the University of Iowa College of Public Health. And the views and opinions expressed in this podcast are solely those of the student hosts, guests, and contributors. They do not necessarily reflect the user opinions of the University of Iowa or the College of Public Health. Hello, everybody. Welcome to the podcast. Today, we have Dr. Carr joining us. And Dr. Carr, could you just introduce yourself and then talk a little bit about your career, what you do, what you research, just a little bit of background for the listeners?

Lucas Carr:

Sure. Yeah. So, I’m Lucas Carr. I’m an Associate Professor in the Department of Health and Physiology. My research focuses mostly on… I do a lot of intervention work, so planning, implementing, evaluating lifestyle interventions. And most recently, starting to verge into implementation science as well.

Lauren Lavin:

We’re going to be talking a little bit about a paper that you recently published, and it’s about physical activity. So, what led you to focus on physical activity and the role it has in preventing chronic diseases?

Lucas Carr:

Yeah. So, originally, as an undergrad, I was an exercise science student. And I just had some general interests in exercise and sports, like I think a lot of people do. Our major in our department, exercise science major is one of the larger departments, undergraduate programs at the university, with over 700 students.

Lauren Lavin:

Oh, wow.

Lucas Carr:

Yeah. There’s just something that’s interesting about it. As I continue on in my education, I was learning just more about the health benefits that come from engaging in regular physical activity. And it’s just striking to see how many health outcomes can be improved by doing this one thing. But what’s really interesting is how few people do that one thing. And so, I just really became interested in not so much the physiology of exercise, but really more the behavior of physical activity and exercise. I’m really just always wondering why some people are so good at sticking to this thing and doing it so regularly, and then so many people don’t.

Lauren Lavin:

Yeah. No. That’s actually a really fascinating question. So, how has your perspective on health behaviors evolved throughout your career?

Lucas Carr:

Yeah. That’s a good question. I think I still see this in a lot of my students now, where we have this mentality that, as health promotion specialists, that maybe our role is to tell people what they should do, which I think that’s not necessarily our role. So, I guess to your answer, my perspective has evolved in that I would like to help anybody who is interested in receiving help, but I don’t believe that it’s my responsibility or role to tell people that they have a problem or that they should change in some way. I think that goes beyond what we’re supposed to be doing here. So, my research earlier was really focused on sedentary office workers and certain niche populations like that. But I was starting to find that that population tends to have all of the resources that they really need to engage in healthy behaviors if they want to.

And I was feeling like I was the person who was trying to drag people into these interventions and drag them across the finish line. And that’s not really what I want to be doing. I’ve since shifted my research focus to work with people in the community who are looking for help, but don’t really know where to go. Or people who are looking for help and just don’t really have the resources available to them. That’s where I want to have the impact for my research.

Lauren Lavin:

Yeah. Have you found any common denominators in what drives people to be physically active or have better health behaviors than others?

Lucas Carr:

We had a study that we looked at personality differences. And we found that, like many things, one of the most consistent predictors of success in life, and finances, and health is this facet of conscientiousness. People who have just really strict routines. There have been studies. There’s a National Weight Control Registry, has done some studies looking at people who have been successful at losing at least 30 pounds and keeping it off for at least a year, and trying to understand what makes that group so unique. And it’s a lot of that. It’s people who are able to really stick to a routine consistently, whether that’s their personality or if they’ve just really taught themselves and trained themselves how to do it. That’s what’s most important.

And so, this is maybe another thing that I’ve evolved on is really considering and thinking about physical activity and really even healthy eating as more of a practice than anything else. We practice all kinds of things. It takes years to get good at anything, but we don’t really think about cooking as a practice, yet we’re supposed to do this multiple times a day for the entirety of our lives. It’s probably a good thing to practice.

Lauren Lavin:

Yeah. I’m a yoga teacher. And we call it like a yoga practice, because this idea that you can’t master it and you constantly have to get better at it. So, I’m definitely familiar with that. And I was also listening to a podcast recently with, it was Dr. Huberman, so the Huberman Lab one. And they were talking about how you need to view exercise as a practice, and not something that you go and do and master. I really like that. You talked a little bit about sticking to a routine. Do you think that’s a skill that people can develop or is that just an innate personality trait?

Lucas Carr:

Hey, I really think it can be. There’s two levels of thinking. There’s the active level. If you’re actively trying to make a change that requires energy, pursuing something on a regular basis, that can work to a point. But what really tends to lead result in long-term behavior change is more of the non-conscious processes, the habit formation stuff. And there’s been some research on habit formation and how to go about creating effective habits. But surprisingly, it’s really limited. There’s been a couple of papers trying to figure out how long does it take to establish a habit. What are the key features that are required to establishing habit or quitting something that is habitual, like smoking or substance abuse? And we just don’t really know enough about it.

But there are some things that we do know. I’ve played around with this a little bit myself. I teach a class on health behavior change. And we do focus on habit formation and non-conscious processes of thought. And what seems to be really, really important is the cue in how we design habits. If you want to start a new habit, it does require active energy and thought in designing this. And then I think it takes practice and repetition. And with practice and repetition, we can develop habits. We do this all the time. It’s just a matter of designing this in a way that benefits us, rather than something that just happens to us.

Lauren Lavin:

Yeah. That makes sense. So, now we’re going to turn our attention to that recent study that you published. So, could you provide an overview of it and how it links physical activity levels to the risk of chronic disease?

Lucas Carr:

Yeah. So, the study that we published is in preventing chronic disease. And this was sort of a labor of love, a long-term project that I’ve been working on with some colleagues for the last few years. So, back in 2018… Well, I’ll go way back. In 2007, the American College of Sports Medicine established an initiative called Exercise is Medicine. And basically, what that suggests is because of all the known health benefits that come with physical activity, it is recommended that healthcare providers treat physical inactivity like a vital sign. And what that means is just like when you go to the doctor, they always measure your heart rate. They always collect your weights, and your temperature, and those things. The recommendation is we should be doing that for physical activity as well. Something that is really easily measured, and we should be doing this for every patient during every visit.

Unfortunately, most healthcare settings, organizations don’t do this. And one of the big reasons is there’s not a whole lot of money in exercise and prevention work. That’s one reason. So, fast-forward to 2018, I had just been promoted here. And I wanted to really consider what did I want to do with my work and my scholarship. And what I really wanted to do was make this focus towards clinical populations and focusing on people who actually needed help. And the only way to identify those people is to ask people about their physical activity. And so, I worked with some folks in our family medicine clinic. Dr. Britt Marcussen is a provider in family medicine. I reached out to him and asked, is there any opportunity for us to begin screening patients for physical inactivity in family med? And Britt has a dual appointment in sports medicine and family medicine, so he’s a person who I didn’t really have to sell him on this idea. He was already in.

And he said, “Yeah, we could do this.” So, in 2018, we started really, really small and we started screening patients, just the patients who come in for annual wellness exams in family medicine. So, it’s only 10% of all patients who come to family medicine, but we started there. And we’re doing this with the intention of looking at the relationship between patients, inactivity rates or activity rates. And a lot of the common risk factors and comorbid conditions that are measured and entered into our electronic medical records data. The EMR data set is massive. There’s so much data in there, much of which goes unused. And so, we want to just basically connect the dots. Then COVID happened, and so we had to put a pause on everything.

And then finally, when we got to the other side of that in 2022, we decided, okay, let’s go back to this and let’s start looking at this data. And so, we did this study. And we wanted to connect physical activity, the patients’ screened physical inactivity rates, to as many outcomes as we could possibly connect it to. And the study we did, we included a couple people from the College of Pharmacy, Dr. Cole Chapman and Dr. Mary Schrader. They helped us. Cole is really good at being able to access data from the EMR, which is not an easy process. You would think it would just be simple just to download this data. It’s really not that simple. So, we had come up with a lot of rules on how to do this. And essentially, once we had his help, we were able to get this big data set and start looking at these relationships.

And what we found was not really surprisingly. But we found that patients who were physically active or meeting the physical activity guidelines were at lower risk for 19 different comorbid conditions that we knew or already knew that these were related to inactivity. This study really just took a concentrated effort to really look for patients at Iowa. If we screen them for inactivity, what does that tell us about their overall healthy and wellbeing? And it tells us quite a bit, actually. And so, it really supports this argument that we should be treating this as a vital sign. We should be screening patients for inactivity. And if we do that, we identify people who are inactive, then we should at least be offering them opportunities to improve their physical activity if they’re looking for help.

Lauren Lavin:

Yeah. Great. So, I want to circle back to the exercise vital sign. So, how do you measure that? What does it look like? And how does it differ from other physical activity assessments?

Lucas Carr:

Yeah. It’s really crude. It’s only two items, two questions. It’s crude by design. It’s meant to be implemented into the healthcare setting, so it can’t be super, super long. If we want to do a really good job of measuring physical activity, we might have people wear a monitor, or at the very least we’d have a pretty comprehensive survey that takes them some time to answer these questions. But you don’t really have that luxury in this kind of setting. We just need something that’s really quick and that helps us determine yes or no, is this person meeting the physical activity guidelines? So, it does a pretty good job of that. It’s sensitive enough and specific enough to really identify people who are not meeting the physical activity guidelines. It is limited in that, the two questions are, one, how many days per week do you engage in moderate to vigorous intensity physical activity?

The person answers how many days per week. And then on those days, how many days do you engage in… or how many minutes per day do you engage in activity at that level? So, you answer those two questions. If you multiply the result, it gives you minutes per week of moderate to vigorous physical activity, which it’s just the aerobic physical activity. It doesn’t ask any questions about muscle strengthening activity, which is a really important part of the physical activity guidelines. So, it is limited in that way, but that’s what it looks like. A person at Iowa, when they come in for the annual wellness exam, they would probably complete that on a tablet. Either prior to check in or when they do check in, they would do that while they’re sitting. So, it’s pretty quick.

Lauren Lavin:

And then my other question that came to mind, is the goal of this research to try to draw a causal link between exercise and reduction in disease occurrence? Or is it supposed to serve as an indicator, like, “Because we know this about you, we could assume these other things?”

Lucas Carr:

Yeah. We use it as an indicator. It’s just a screening tool at this point. There would be potential ways to start looking at causal relationships. If you were to ask this question every time a person comes in and really treat it as a vital sign, then you would be able to look at their patterns of physical activity over time. And you could probably look at those relationships versus patterns of risk factors, other things that are measured over time. And you could probably start to make a case for looking at some causal relationships. We haven’t looked at it in that way. We just look at it as a screener. Just like if you come in, you have your blood pressure taken, your blood pressure’s high, your doctor’s going to say something about that, like, “We need to get this under control.”

That’s the same way that we should be looking at physical activity. So, the key is, what do providers do with that information? Do they prescribe the person exercise there on the spot or do they refer them to a specialist for additional help? So, that’s the other part of my research that we focus on.

Lauren Lavin:

So, have you thought about what that would look like, what an exercise prescription would look like, or what the connection is to those services that they need in an ideal world?

Lucas Carr:

Yeah. So, the American College of Sports Medicine does have some really good tools that’s available. They were designed specifically for providers to use in the moment. There’s a one-page exercise prescription tool. It’s like a provider fills it out, signs it just like they would any other kind of prescription. And that would include some information about how many days per week are they going to exercise or how many minutes, what are they going to do? Some providers, the evidence suggests that not all providers feel comfortable doing that, because they just don’t get a lot of training or any training on exercise counseling when they become a doctor.

And so, what we have done is we’ve designed… Actually, in our electronic medical record system here, we’ve connected the exercise vital sign to a health coaching referral scheme, basically. So, if a patient reports low activity, they’re automatically asked a follow-up question. Yes or no, would you be interested in meeting with a free health coach who can help you achieve some of your health-related goals? If they say yes, then the provider gets alerted. They get nudged to add some health coaching instructions to the patient’s MyChart and their after-visit summary report. So, when you go home, they get that little printout. There’s a little QR code there that the patient could scan and they could connect with a health coach in that way.

And so, that’s the other part of my research is we’ve designed a full health coaching training program in our department, in HHP, where we train students how to be a health coach. And then as part of an internship, we connect those students to these patients from family medicine, to give them free health coaching resources. And that student works with that person over the course of 12 weeks and helps them. It could be physical activity, but really they could talk to them about anything. It could be they want to improve their diet or they want to reduce their sugar intake, or they want to improve their stress.

Health coaching is a very open type of process. Whatever you want to do is fine. It’s not prescriptive in any way. So, that’s the way we’ve designed this, because we realize that we can’t just screen people for inactivity, we do have to do something with that information.

Lauren Lavin:

Wow. It sounds like you’ve created a really well-thought-out system. Two follow up questions. One, has this been applied anywhere else? And two, I’m a health policy PhD, so I think a lot about insurance. So, do you think about the reimbursement portion of this for the exercise prescription in particular?

Lucas Carr:

Yeah. So, the first part, has it been done anywhere else? There are some examples of places that, from the screening standpoint, there’s not very many. In the United States, there’s probably a handful of large hospitals like us. Kaiser Permanente in California was the first to do this. University of South Carolina in Greenville, they do this. There’s one at NYU. Intermountain Healthcare in Utah. There’s like five or six, basically. In the Midwest, really not very many at all. And then the follow-up, connecting that screener to an actual referral system, very, very few. We are very unique in that way, which is great. And our goal now is to take this… We have a pilot study that we’re just wrapping up right now to evaluate the effectiveness of this program. If we do connect these patients to coaches, do they become healthier, basically? And we’re finding that they do indeed.

They improve a lot of health behaviors. They improve their ability to regulate those behaviors. They actually lose weight. They report significant improvements in quality of life. So, there’s a lot of really good findings that are coming from that. And so, now that’s like, that’s where my research is really going now. So, we’re pretty unique in that way. The second part, the reimbursement parts, that’s a tougher one to answer. We just did a study. We just published a study looking at billing codes, like the use of billing codes related to exercise. And we did an internal study at the university here. And this was just published in the last month or two. But we basically found that for providers at the University of Iowa, there are some recommended billing codes that you can use. If you are counseling a patient on exercise, there are some billing codes.

It gets really tricky, though. Those billing codes are usually only reimbursable by people like the MD or nurse, or maybe a PA, people who tend to not have enough time to counsel on exercise, really. The people who would have the time and the expertise to do it, like health coaches, currently, the system is not set up for them to be able to bill for these types of services. But there has been some movement in this direction. There are some codes. And you would know this better than I do. I’m not a policy expert. But there are some codes that are moving through these stages, like code one, code two, code three, basically.

As the evidence builds, it looks like there will be some billing options for health coaches specifically. It takes time for that to catch on. I don’t believe that our hospital employs health coaches, for example. So, it would be like referring them to external coaches to… I don’t know how that works exactly. So, I think that’s where it’s going, but it’s just not there yet.

Lauren Lavin:

Yeah. But body of evidence, like what you’re doing, is really helpful in moving that needle forward. So, thanks for doing stuff like that. I didn’t think I touched on how many people were enrolled in this study. How many were?

Lucas Carr:

So, we ended up with about 7,000 patients. That was the number of people who actually had an exercise vital sign on file. But then we did a comparison of those individuals against similar patients who came in for a similar visit. We wanted to compare them, because that’s a piece that doesn’t tend to get done. We found that if you compare people who were getting screened for inactivity against a very similar patient who was not screened, we found that the screened patient cohort was generally healthier than the unscreened. And that’s probably a result of the fact that we only screen people who come in for those annual wellness exams. That’s kind of like the worried… Well, I’m one of these people. I go into the doctor all the time, more than I probably should. That group is a little bit healthier than the unscreened population.

But even within that group, there’s still the worried… Well, even within them, if we parse them out into completely inactive, doing some activity, but not sufficient amount to meet the guidelines or meeting the guidelines. Even within that group, we still saw those relationships between physical inactivity, and those 19 different risk factors, and co-morbid conditions. So, if we were to actually screen all patients and have all this variability amongst all these patients, we would probably see more relationships. And the strength of those relationships would probably be even stronger.

Lauren Lavin:

Are you still collecting data on this study or expanding it past the family medicine?

Lucas Carr:

Yeah. Now, at this point, I think the last time I checked in… Over 60,000 patients have been screened for inactivity.

Lauren Lavin:

Oh, my [inaudible 00:23:59].

Lucas Carr:

Which sounds like a lot, but it’s actually not. Family medicine, for example, they see 30,000 patients a month. That’s one clinic. I mean, it’s a big clinic, but it’s one clinic within this massive hospital system that we have. And if we were to screen every patient at every visit, we would have millions and millions of data points. And that’s what actually Kaiser Permanente in California does. And they have published some interesting papers. When COVID came out right away, they were able to connect their physical inactivity data to COVID outcomes with data sets with over a million data points.

And they were able to make connections showing that patients who are physically active have far superior outcomes when it comes to COVID-19. So, we’re still collecting, not necessarily for research purposes. I mean it’s a clinical workflow. Family medicine has committed to continuing to screen patients for inactivity with the intent of connecting as many patients, inactive patients to health coaches that want to have this.

Lauren Lavin:

That’s great. So, the research indicated that individuals engaging in 150 minutes of moderate to vigorous exercise per week had the significantly lower risk. So, from a scientific or research perspective, what does this actually look like in real life? What are people doing to hit that 150? If someone’s listening to this and is like, “Okay, I want to make sure that I’m doing that,” what does that look like?

Lucas Carr:

Yeah. That’s a good question. It can look a million different ways, basically. You mentioned that you teach yoga. And yoga would absolutely count towards a person’s physical activity levels. When we talk about moderate intensity, the best way I can describe it is doing anything that gets your heart rates beating a little bit faster than normal. It gets you breathing a little bit faster than normal. You might start sweating a little bit. But it’s not necessarily like running a marathon either. The low end of moderate intensity activity, if you’re walking, is walking at a very brisk pace. So, it’s like three and a half, four miles per hour. If you’ve ever walked on a treadmill and you get to that point where you’re not quite sure if you should be walking or jogging, it’s this weird pace, that’s moderate intensity. And so, it’s that pace that pushes you a little bit.

And because it does that, your body will naturally respond to that heightened level of stress. And that’s how the body gets stronger. And all the systems that are involved in making that happen are the beneficiaries of the physical activity exposure. So, we know that brain health, and heart health, and lung health, and muscles, and immune system, like everything, improves as a result of this stress that you’re putting on the body. So, it could be anything. The most common activity people do is walking with their dog or doing those things. But it can also involve going to the gym and doing traditional exercises. It can be yoga, it can be gardening, it can be really anything that is physically active in nature and gets your heart beating a little bit faster.

Lauren Lavin:

Yeah. I always say to people, the best kind of exercise is the one that you want to do. However you get your body moving, there’s so many different ways. And especially if you are listening to this and you’re at the University of Iowa, the group fitness that they offer here is really great and a really easy way to start. If you’re uncertain about even what to do in a gym, I feel like that’s always a great way to start.

Lucas Carr:

Absolutely.

Lauren Lavin:

You recommended that healthcare systems routinely assess patients’ physical activity levels. What challenges do you foresee in implementing this practice beyond the…? I mean, you could talk about the University of Iowa, but even beyond that, if other places wanted to adopt something like this?

Lucas Carr:

Yeah. I mentioned one of the big challenges of doing this routinely is making this argument that it’s worth it, that it works. That’s what we’ve run into. Family medicine, thankfully, was willing to do this on a small scale as we’ve approached other clinics at the university here to say that you should do this, too. Because obviously, if you’re a patient that’s going to see a cardiologist, the recommendations are that for anybody who has at least one cardiovascular disease risk factor, they should be receiving some sort of behavioral counseling help to improve their physical activity and to improve their diet. That’s what the United States Preventive Services Task Force has said. And they’ve made that statement because of the evidence that shows that if people are connected to a program, there’s a moderate benefit to participating in those programs.

That’s all well and good, but most cardiovascular clinics, like cardiology clinics, don’t even screen the patients for physical inactivity. So, if you don’t measure it, then you certainly can’t manage it. So, what’s really challenging is building up the evidence base that this works. And that there are systems in place that can easily and quickly identify patients that are inactive and that we can connect them to supportive resources. As I mentioned, there’s not a lot of money in prevention work right now, just with the way that our system is set up. That said, there are some billing code options available out there that can generate a certain amount of money. They’re not going to be like surgery, but they will generate revenue to cover some expenses. So, I think the big challenges are financial and then also just building support within a hospital system that this is important and something that should be done. Those are challenges that take time.

Lauren Lavin:

You almost need medical champions to drive the work in each location?

Lucas Carr:

Yeah.

Lauren Lavin:

Some good goals to work towards.

Lucas Carr:

Yeah, absolutely.

Lauren Lavin:

So, I always like to see if I can draw an actionable tip for people that are listening to this. So, based on your personal experience and your research, what practical advice would you offer to anyone listening that’s looking to reduce their risk of chronic disease through physical activity?

Lucas Carr:

Well, I think you kind of said it yourself. If you want to do it through physical activity, it’s really just about finding the things that you most enjoy. We tend to repeat things that we enjoy and we tend to avoid things that we don’t like. We have these New Year’s resolutions that we’re going to start exercising, we’re going to start going to the gym, which can work. There’s nothing wrong with that. But if you really don’t enjoy that, and it hurts, and it doesn’t feel good, and the likelihood that that sticks long-term is not great. So, I would say think about what you like doing the most and go with that. I despise treadmills. I don’t like running, and so the things that I do are… I like to play sports. I play soccer in a men’s league and then pickup games.

When we actually have snow outside, I do a lot of cross-country skiing. I do a lot of biking. I’ll probably go today, because it looks like it’s nice enough. And I’m genuinely looking forward to doing that. It’s not like a drag to me, so it just happens to be physically active. I look at it more as something that I enjoy.

Lauren Lavin:

Yeah. It’s a lot of trial and error, and so people should try things out. And chances are you’ll find something that you like doing.

Lucas Carr:

Agree.

Lauren Lavin:

Okay. Final question. All of that information was great. I have a lot of little bits that I’ll probably be chewing on for the next couple of hours and especially when I come back to edit this. But our final question is always just fun, low-key. Doesn’t have to relate to anything that we’ve talked about. But what are you currently reading or watching right now and would you recommend it?

Lucas Carr:

Yeah. What I’m reading is a book by a guy named Rick Rubin, who was a music producer. Produced the Beastie Boys and all kinds of just great artists. And he wrote a book called The Creative Act: A Way of Being, which is a really fun, simple, easy read. It’s just super, super enjoyable. I think it’s both useful and entertaining, so I would highly, highly recommend it. I’m going to have my graduate students read it, if they will do so. I think it’s great.

Lauren Lavin:

I’ve heard of that book. And it’s on my list of reading that’s a mile long, but I don’t have time for it, you know?

Lucas Carr:

Yeah. It’s a [inaudible 00:32:31].

Lauren Lavin:

So, I need to move it up. Well, thank you so much for being on the podcast today. I really enjoyed it. You’ve been a great guest.

Lucas Carr:

Thanks for having me. Appreciate it.

Lauren Lavin:

That’s it for our episode this week. A big thank you to Dr. Carr for joining us and sharing his insight on how we can make physical activity more accessible, measurable, and meaningful in both clinical settings and everyday life. Some of my big takeaways, physical activity doesn’t have to be complicated. It just needs to be consistent. Whether it’s gardening, biking, or group fitness, what matters is building a routine around movement that feels enjoyable and sustainable. Dr. Carr’s work shows us that treating exercise like a vital sign isn’t just possible, but it’s really powerful. So, this episode was hosted and written by Lauren Lavin, and edited and produced by Lauren Lavin. You can learn more about the University of Iowa College of Public Health on Facebook.

Our podcast is available on Spotify, Apple Podcasts and SoundCloud. If you enjoyed this episode and would like to help support the podcast, please share it with your colleagues, friends, or anyone interested in public health. Have a suggestion for our team? You could reach us at cph-gradambassadoratuiowa.edu. This episode is brought to you by the University of Iowa College of Public Health. Until next week, stay healthy, stay curious, and take care.