All About BMI and Living at a Healthy Weight with Dr. Robert Bales

Podcast Transcript

Nada Youssef:   Hi, thank you for joining us. I'm your host, Nada Youssef and you're listening to Health Essentials Podcast by Cleveland Clinic. Today, we're broadcasting from Cleveland Clinic administrative building here in Beachwood, Ohio and we're here with Dr. Robert Bales. Dr. Bales is a family physician and an assistant professor of family medicine here at Cleveland Clinic. Thank you so much for being here.

Dr. Robert Bales:  You're welcome. Thanks for having me.

Nada Youssef:   Please remember before we begin, this is for informational purposes only, and it's not intended to replace your own physician's advice. Before we start, I'm going to ask you off-topic questions just for ice breakers. All right, so first one, if you could be cast in a movie of your choice, what movie would you choose and what character would you play?

Dr. Robert Bales:  I'd have to say Star Wars.

Nada Youssef:   Star Wars?

Dr. Robert Bales:  Yeah.

Nada Youssef:   All right, and which character?

Dr. Robert Bales:  Probably Han Solo.

Nada Youssef:   All right, that's cool. How about if you could choose only once place to go on vacation for the rest of your life, where would it be?

Dr. Robert Bales:  There's an island called Bequia, it's in the Grenadine chain. It's a very tiny Caribbean island just north of Grenada.

Nada Youssef:   Nice, so you want to be secluded?

Dr. Robert Bales:  Yes.

Nada Youssef:   Sun and water, perfect. Then what aspect of your personality adds the most value to the world?

Dr. Robert Bales:  Probably my energy.

Nada Youssef:   Your energy?

Dr. Robert Bales:  Yeah.

Nada Youssef:   High energy?

Dr. Robert Bales:  Yeah, I am.

Nada Youssef:   Let's go.

Dr. Robert Bales:  I don't stop.

Nada Youssef:   Good, that's excellent. All right, well let's go ahead into discussion. We're going to talk about BMI and obesity so first of all, let's talk about just the definition. What exactly is BMI? What does it stand for?

Dr. Robert Bales:  BMI stands for body mass index. It's a calculation. We take a person's height and a person's weight. We convert that into metrics, so centimeters and meters, or kilograms and meters, and we calculate weight per body surface area. It's measured in kilograms per meter squared. It's calculation. It's easy because in my office in family medicine, we can measure your height, we can measure your weight, and we can get this BMI calculation. Essentially, it takes basically taller people should weight more, so it sort of normalizes height across people. The 18 to 25 is considered normal. Up to 28 is considered okay. Over 28, so 28 to 30 is considered overweight, 30 to 40 is how we define obesity. Above 40 is something we call morbid obesity. Under 18 is anorexia. We can also use it on the low end of the scale.

Nada Youssef:   Sure, so for the BMI, you are taking measurements like the height and the weight and then age? Is that considered in there at all?

Dr. Robert Bales:  For this, it's adults so adults over 18. There are scales for children. When we look at growth charts in children, from newborns on up through adolescence, we do chart out their BMI so length versus weight but it changes-

Nada Youssef:   The scale is different.

Dr. Robert Bales:  It changes almost yearly, so there's actually a graph we use for that one.

Nada Youssef:   It changes yearly, how come?

Dr. Robert Bales:  Because as kids grow, they tend to have less weight per height. It's a little bit of a different thing. We look at a curve rather than, so when we're talking about BMI in adults, that's the 18 to 25 and 30 and 40.

Nada Youssef:   I do remember my two little kids at the pediatric office, it's always a scale to show the length of everything from head measurements to length to height, okay. Great, so it is used on kids, just kind of like a different measurement. I want to ask if it is accurate, BMI. I've heard that it might not be accurate because it doesn't measure muscle mass and if so, why is it still being used?

Dr. Robert Bales:  Right, so it doesn't tell you anything about body composition. There are people, particularly competitive body builders or power lifters who carry a lot of muscle mass, whose BMI will be high because they weight more, it's not really a good-

Nada Youssef:   Indication.

Dr. Robert Bales:  Indication of what their body composition is. For the vast number of Americans, it's a good rough estimate.

Nada Youssef:   Okay, so you'd call it a rough estimate but not too accurate, correct?

Dr. Robert Bales:  It's more accurate outside the normal range. If somebody has a BMI of 50, you can pretty much tell that they're carrying a lot of extra body fat. Where if somebody has a BMI of 28, does getting is down to 27 mean much? Probably not. Then underweight, so if somebody's got a body mass index of 16, that's clearly in the anorexic zone and that's pretty accurate too. You can't really have such a low body mass and be carrying a lot of fat.

Nada Youssef:   Okay, so for athletic people that do have a lot of muscle mass, there are other BMI measurements?

Dr. Robert Bales:  Well, there are other ways to measure body composition. BMI is BMI, you need height, weight, and that's it. You can measure body composition. There's several different ways to do it. The latest is a thing called plasmography, where you stand on a scale that has metal plates and you hold onto a hand thing, and they measure the electrical resistance of your body. The idea is that fat is an insulator and it will change the electrical resistance. That's all I know about that. You now know everything I know about these scales, but you will see them advertised. You can buy them for home. A lot of gyms have them. The caliper testing is probably the standard tried and true method of an exercise physiologist goes and measures skin folds on different parts.

Nada Youssef:   That's the fat measurement.

Dr. Robert Bales:  That's the fat measurement.

Nada Youssef:   That's when it pinches your fat.

Dr. Robert Bales:  Right, and I think you take 12 or 15 different measurements to calculate body fat. You can also do underwater weight, and I'm not sure if we do that at Cleveland Clinic but I have heard of it being done as where you weigh somebody in a pool and so the less you weigh in a pool, the more fat you have because the more it floats you up.

Nada Youssef:   Very interesting.

Dr. Robert Bales:  Like I said, I do know we do do the caliper test at Cleveland Clinic. I don't know if anybody does underwater weigh.

Nada Youssef:   Underwater weigh. How about, is there some kind of body pod, like a dexascan? I've read something about that.

Dr. Robert Bales:  I think that's more along the lines, well, dexa is to measure bone density. Your dexascan would be for osteoporosis, but there is a body pod, which I'm not really familiar with that technology.

Nada Youssef:   Okay, it's newer technology. Okay, if someone's considered overweight or obese, what is the first step? Let's say I'll go to the doctor to check my BMI, I'm 30, what do I do?

Dr. Robert Bales:  The first line treatment is diet, exercise, weight loss. Also, setting what's your target.

Nada Youssef:   Goals, yeah. Okay. Let's take these and kind of dissect them. First, the diet. Right now, with the abundance of food around us, we have highly processed foods, we have a lot of sugar, we have a lot of cardboard boxes, what is healthy?

Dr. Robert Bales:  Okay, so first I heard this recently and I can't remember where I heard this quote but somebody was talking about the standard American diet.

Nada Youssef:   Yeah, the SAD diet.

Dr. Robert Bales:  S-A-D. I really think that's true. In this country, low quality food is cheap and high quality food is expensive. Most Americans do eat a pretty poor diet either because financially they can't afford it or because out of time constraints. It's hard to work a job or work two jobs and come home and cook a meal from scratch and get the kids to basketball practice, or softball practice, or dance. We all lead these sort of crazy, busy lives. I think we cheat ourselves on our diet and getting more takeout, more fast food or just things we can put in the microwave.

Nada Youssef:   Yeah, so convenience and cheap equals unhealthy, right?

Dr. Robert Bales:  Yes.

Nada Youssef:   Okay, so what do you think about something like the diets that are out there right now? One of the big ones I always talk about is ketogenic diet, high fats, very low carbs, and basically almost no sugar, right? What's your take on sugar, fat, and carbs in this whole diet thing?

Dr. Robert Bales:  The keto diet is a whole lot like the Atkins diet from what 10 years ago?

Nada Youssef:   Yeah.

Dr. Robert Bales:  What it does is it puts your body into a state where you're burning calories because you're not getting any sugars in so you've got to convert either fat or muscle to sugar. You become ketotic. They work, I find most people can't do them for very long.

Nada Youssef:   Yeah, it seems like a short-term thing.

Dr. Robert Bales:  Because they're so restrictive and it's 100% or nothing. You've got to either hit them every single day, or they don't work. If you can do it, they work, you will lose weight.

Nada Youssef:   Hard for the long-term.

Dr. Robert Bales:  They're hard for the long-term because they're so restrictive.

Nada Youssef:   Right. What do you suggest? What is the diet that you would recommend?

Dr. Robert Bales:  The diet I favor most is along the lines of the Mediterranean diet. Mainly fruits and vegetables, with whole grains, whole nuts, protein comes from seafood is probably the best, protein that comes from nuts and soybeans, you know, legumes. Minimize the red meat.

Nada Youssef:   Is soy good for us?

Dr. Robert Bales:  Soy is good for us.

Nada Youssef:   Soy is good for us?

Dr. Robert Bales:  Yeah.

Nada Youssef:   Okay. I want to talk about drinks, because you see energy drinks and healthy diet drinks, every brand has some kind of diet going with it but then you hear about what diet actually is in the sweeteners and what it actually does to the body. What do you say to the people that are trying to go healthier and they're going for diet drinks?

Dr. Robert Bales:  If we're talking about carbonated sodas or carbonated energy drinks, we generally recommend people not consume those. Even diet sodas have, there's some effect on increasing weight in people who drink regular amounts of diet soda. It may be sort of a decisional balance thing where people, "Okay, I'm having a diet soda so therefore I can have the large fry," so we're making trade offs. There may also be something to stimulate appetite-

Nada Youssef:   From the sweetener?

Dr. Robert Bales:  Yeah, because it tastes like sugar, it may stimulate your appetite.

Nada Youssef:   Our body doesn't know the difference, it just knows it's taking in something really sweet.

Dr. Robert Bales:  Right.

Nada Youssef:   Okay, so you're talking about like someone taking it daily, soda or diet is just as bad.

Dr. Robert Bales:  Right. We're really concerned about the energy drinks. There has been some reported issues of heart problems in people who consume high quantities. People who a drinking, six, seven of these cans per day.

Nada Youssef:   Wow, that's a large amount.

Dr. Robert Bales:  It's a lot of caffeine.

Nada Youssef:   That is, yes.

Dr. Robert Bales:  And a lot of sugar.

Nada Youssef:   Right, tons of sugar.

Dr. Robert Bales:  The other drinks you see out there, there are healthy drinks. One thing I see a lot of is a meal replacement shake. The label should read like a balanced meal with some fats, some carbohydrates, and some proteins. I usually tell my patients these are okay to have, particularly if you can't get lunch. If you're going to go through a drive-through to get lunch, I would rather you have something that's more of a balanced meal in a shake. As long as it's not high in sugar-

Nada Youssef:   I wanted to ask you this, so sorry to interrupt but are you talking about store bought shakes because a lot of times you go to the store and if it's blueberry-flavored or apple cinnamon, it's all-natural flavors or added sugar, or are you suggesting do this at home, add your own avocado and add spinach and make your own thing?

Dr. Robert Bales:  Either/or. If you buy them online or buy them from the store, you really got to read the labels and know what's in these and make sure there's not a lot of extra additives but you can actually make your own sort of smoothies out of kale, and spinach, and avocado. There's lots of recipes online but I would rather somebody have one of that than sort of resort to fast food particularly for lunch.

Nada Youssef:   Sure, for a fast, convenient lunch, sure. What about a drink like let's say amino acid, I don't know if you call them supplements or shakes or drinks that people drink with water, sometimes on a daily basis? Again, there's a lot of weird labels on the back that when I look at it, I have no idea what I would be taking in.

Dr. Robert Bales:  Right, and I think of those more as sport-centered things. The original one is Gatorade, which was designed for the Florida Gators football team to rehydrate them while they're playing football in Florida, not designed for driving around, running errands, chasing kids, and drinking. Then there's also pre-workout, sort of intra-workout and post-workout drinks that for somebody who's a moderate to competitive athlete may be the right thing for them.

Nada Youssef:   Okay, so these are okay as long as you're moving on a daily basis and you're using your muscles.

Dr. Robert Bales:  Right. I run triathlons, okay, so the longest one I do is a six-hour swim, bike, run. You lose a lot of fluids, a lot of electrolytes, so we use electrolyte solutions and sugar supplements during but not while I'm walking around in my day-to-day life. A lot of people who do strength training, it's recommended to take in some protein within 30 minutes of your strength session, and that can be broken down branch chain amino acids. Protein, it could be a chicken breast. There is some benefit to recovery by taking in some protein post-workout, post-strength workout. Depending on what you do, your nutritional needs may vary, especially when you get into long endurance racing.

Nada Youssef:   Sure, so let's keep talking about exercise if that's okay because I mean looking at obesity right now, most of us have a nine to five job, sitting in a cube, we don't get to walk around much. Is this another reason, the sedentary lifestyle is causing obesity and how much exercise should we, is a half hour a day okay to just walk?

Dr. Robert Bales:  Sure. Americans are definitely not a walking culture. We will drive two blocks to the convenient store in our cars. A lot of our infrastructure is not set up to encourage walking. Most neighborhoods don't have stores you can walk to. A lot of neighborhoods don't have sidewalks. The recommended minimum exercise is a 150 minutes a week. That works out to a half an hour, five days a week, of moderate exercise, which is a brisk walk or faster. If you can walk and hold a conversation, that would be a brisk walking pace.

Nada Youssef:   Okay, so half hour walk, every day, at least five times a week.

Dr. Robert Bales:  Mm-hmm (affirmative).

Nada Youssef:   That's it, and that will get you, okay.

Dr. Robert Bales:  That's minimum.

Nada Youssef:   Yeah. That's not it but it's at least what you should be doing.

Dr. Robert Bales:  If you're talking about burning off excess fat and calories, you're going to have to do more.

Nada Youssef:   Okay, all right. Let's talk about genetics. Do genetics play a role how our body processes food into energy, how much fat is stored? Could that be genetic-related?

Dr. Robert Bales:  Could be, that's really kind of hard to sort out with some rare exceptions. Your genetics come from your parents and most people are raised by their parents so you're raised in the same environment as your parents and if your parents are not active and are sedentary and overweight, then you're likely to be, and it's really hard to separate is that from the way you were raised or is that from the genetic code you inherited? It's hard to separate that one out. There are certain very rare genetic syndromes that do lead to overeating but exceedingly rare.

Nada Youssef:   What you're saying is environmental factors or how you're raised how mom brings home pizza every other day and they're always drinking Coke and stuff like that, that could be a factor versus it just being genetic.

Dr. Robert Bales:  Right.

Nada Youssef:   Okay.

Dr. Robert Bales:  It's probably a combination of both.

Nada Youssef:   Okay, it could be a combination of both. To break the cycle, just work out, eat healthy, stay away from energy drinks.

Dr. Robert Bales:  Right.

Nada Youssef:   What about stress? Stress seems to be a culprit of a lot of things, overeating, under eating. I mean cortisol is a hormone that plays a huge role in that, correct? Can you talk about that?

Dr. Robert Bales:  Right, cortisol is your stress hormone, it's one of your fight or flight hormones, our adaptation to stress is highly variable. Some people feel stressed out and just work more, work more, work more and don't take care of themselves. Other people feel like if I'm stressed out and I go do my workout, even half hour, 40 minutes, my stress level comes down and I'm more productive. It plays into sleep too, so if your stress level is high, you're less likely to get a good night's sleep.

Nada Youssef:   Yeah, and then if you don't sleep, you're going to be really stressed out.

Dr. Robert Bales:  Right.

Nada Youssef:   It's like a cycle.

Dr. Robert Bales:  It's a cycle. I talk to people all the time who I fall asleep okay and then four or five o'clock in the morning, I wake up and as soon as I wake up, I'm thinking about work, and they can't go back to sleep.

Nada Youssef:   What do you say to those people? There's a lot of people that are workaholics, that just work all the time and can't shut that off.

Dr. Robert Bales:  You have to convince them to change that. Whether it's periodically schedule vacations or on your daily calendar, put your workout in as an appointment and actually just schedule your workouts as part of your daily routine.

Nada Youssef:   Just like meetings, put time in there, half hour for a brisk walk?

Dr. Robert Bales:  Mm-hmm (affirmative). I have a fair number of patients who travel a lot for work, so they're flying either domestically or internationally and when they land at their destination and they have business meetings and the company is paying for them to be there, it's hard not to just work, and work, and work, and same advice, on your daily schedule, put in 7 to 8 AM, that I'm gong to hit the gym at the hotel and walk on the treadmill for a half an hour.

Nada Youssef:   And take your naps, right? Sleep, so let's talk about sleep a little bit, because we underestimate sleep and what it can really do for our body. The hormonal changes that can come from not sleeping enough, can that make us over eat or crave junk food? I've read that.

Dr. Robert Bales:  It can. There's sort of a flip side to that too is that obstructive sleep apnea is weight-related. The soft tissues on the upper respiratory tract system tend to collapse when people weight more. We see a lot of people who are overweight also have obstructive sleep apnea, so if they're stopping breathing multiple times, hundreds of times per night, then they're not getting that regenerative sleep. In talking to people who are overweight, that's another thing you want to look into is do you have sleep apnea?

Nada Youssef:   Right, so how many hours of sleep should someone make sure that they're sleeping at night because again, that's another thing, we work a lot, kids, life is busy, sometimes get five hours, sometimes we get eight or nine, what is-

Dr. Robert Bales:  A good target is six to eight.

Nada Youssef:   Six to eight hours?

Dr. Robert Bales:  Mm-hmm (affirmative).

Nada Youssef:   Okay, so six to eight hours would be normal and that wouldn't change any kind of hormones or anything like that in the body?

Dr. Robert Bales:  No.

Nada Youssef:   Okay. How about some side effects from some medicines that people take or any kind of medical conditions or even thyroid, could that all effect obesity?

Dr. Robert Bales:  Sure, so underactive thyroid is related to weight gain. One thing, if you go see your family doc and say I'm overweight, they should at least run some blood tests, check out thyroid, check your kidney, liver, check a sugar, make sure you're not diabetic. People with diabetes gain weight because they can't process the sugars properly. That's sort of the weight causes the diabetes and the diabetes makes the weight-

Nada Youssef:   Another cycle.

Dr. Robert Bales:  Another cycle. Certain, we call them atypical anti-psychotics, they're used often in second or third line for like depression treatment, can stimulate appetite, can cause weight gain, can elevate your cholesterol, so anybody on these certain classes of medication should have periodic blood testing.

Nada Youssef:   The blood testing is to check the sugar for diabetes?

Dr. Robert Bales:  Mm-hmm (affirmative), and to check the cholesterol.

Nada Youssef:   Cholesterol, okay.

Dr. Robert Bales:  As well. Heart disease is a big deal with obesity is that obesity is related to heart disease, related to the increasing number of people in the United States becoming diabetic. Increasing problems with arthritis. If you weight 350 pounds, you're putting all that force through your knees.

Nada Youssef:   Sure. I know we talked a little bit about cholesterol right now, we did talk about diet earlier but I want to go back to it. Something like saturated fat and cholesterol, we've heard many different things and a lot of our dietary guidelines used to say stay away from meats, and to stay away from fat, and saturated fat, now coconut oil is not that bad for you, something like the keto diet, what is your take on that?

Dr. Robert Bales:  Well, the keto diet, you're tricking your metabolism.

Nada Youssef:   Yeah, but you're eating a lot of fat, right? You're getting a lot of fat, or could be saturated fat from coconut oil and things like that.

Dr. Robert Bales:  Really, you should have some protein, some fats, some carbohydrates and each one has good, better, and best so we heard a lot about corn syrup during the Super Bowl but we do tell people to avoid products sweetened with corn syrup. Same thing with fats, fats that come from not, avocados are better for you, cold water fish tend to be better so the omega-3's.

Nada Youssef:   Stick to good fats that come from avocado, like wild caught salmon, things like that, nuts and things like that.

Dr. Robert Bales:  Where the trans fat is not so much, things people tend to use for frying.

Nada Youssef:   No fried chicken. I've been reading about fried chicken too. That it's increasing heart attacks or cancer, all kinds of stuff, which makes sense. Who's at risk for obesity? We said it could be genetics, but it could be environmental factors, could be both.

Dr. Robert Bales:  Could be both.

Nada Youssef:   What about psychological factors such as depression? Because that's a big one too.

Dr. Robert Bales:  People with major depression or major depressive disorder are more likely not to take care of their own personal health because of their mood disorder.

Nada Youssef:   I see, so that's where that comes in.

Dr. Robert Bales:  You can be sedentary. Some people are the other way and they don't eat when they're depressed but mood disorders definitely play a role and should be looked into.

Nada Youssef:   Yeah. For treatments, we've talked about lifestyle, behavioral changes, being educated on better food choices, so you recommend to go to your primary physician to do the BMI test, to do some kind of physical, what should be the first step?

Dr. Robert Bales:  First, see your family doctor.

Nada Youssef:   See your family doctor.

Dr. Robert Bales:  See your family doctor, your general internist. They should run some basic blood tests. They should take some basic measurements. One measurement that we probably don't use enough is waist circumference. If you measure your waist one inch below your belly button, that's a good measure of are you losing abdominal fat. If you start an exercise program, start a diet, and you're losing inches around your midsection, even if the scale doesn't change a whole lot, that's actually a good sign.

Nada Youssef:   Tell me why the midsection, is it because that's the stubbornest fat?

Dr. Robert Bales:  Well, that tends to be the fat we associate most with disease, is truncal obesity. That's where you tend to carry most of, most fat gets deposited there. If you're losing inches around your midsection, which is a little bit higher than your belt line, then that's a sign that you're losing fat, especially if you've gone from being sedentary to now maybe doing some strength training, you put on a little muscle, the BMI may stay the same.

Nada Youssef:   Right, and that's another thing because the muscle mass.

Dr. Robert Bales:  Muscle mass, right, will skew that a little bit.

Nada Youssef:   Okay, good. Let's say healthy diets, increasing daily activity still doesn't work, and let's say someone's obese or morbidly obese, are there prescriptions or weight loss surgery that people can consider?

Dr. Robert Bales:  Yes. There's four medications on the market specifically for weight loss. These would be pills, you take it once a day.

Nada Youssef:   And it just makes you not hungry or it helps you shed fat, what does it do?

Dr. Robert Bales:  No, they cut your appetite.

Nada Youssef:   They cut your appetite, okay.

Dr. Robert Bales:  They curb your appetite. Then there's the Bariatric Institute that those are the doctors associated with the weight loss surgeries. We offer that. It's usually a process to get to that point of you've done the medical dietary exercise, not seen great results, maybe you've tried a medication and then you progressed to see the bariatric surgeons.

Nada Youssef:   Sure, great. Well, before I let you go, did you want to talk about the findings that you have with you today?

Dr. Robert Bales:  There is an interesting paper, it was published in The Landset in August of 2016, which took 239 clinical trials, combined the data from 239 clinical trials and found that in people who never smoked cigarettes, that increasing BMI was associated with all causes of mortality.

Nada Youssef:   All causes.

Dr. Robert Bales:  All causes. We're seeing increased cancers, definitely heart diseases, diabetes, arthritis, but they looked form trials across the world and they were finding this increase in all causes of death.

Nada Youssef:   And you said non-smokers, never smoked, that's a huge factor, yeah.

Dr. Robert Bales:  Non-smokers, right, so we took smoking out of the equation because we know that diseases related to smoking-

Dr. Robert Bales:  Are very prevalent.

Nada Youssef:   Right.

Dr. Robert Bales:  This just isolated BMI better.

Nada Youssef:   Sure. That's big news, I think. Again, anything you want to tell our viewers or listeners before I let you go? Any tips, tricks?

Dr. Robert Bales:  I think first start with your family doc. Exercise, you've got to enjoy it. That's the thing. If I tell you to go run a 5K and you don't like to run, you're not going to do it. You got to find something you like to do. That can be, there's adult soccer leagues, there's men's basketball leagues, there's-

Nada Youssef:   There's water aerobics if you feel like, any kind of Zumba, jazzercise, all kinds of stuff.

Dr. Robert Bales:  There's all kinds of things but you have to have fun doing it, otherwise you're not going to sustain-

Nada Youssef:   You're not going to go tomorrow.

Dr. Robert Bales:  Right. Try different things, find what you like.

Nada Youssef:   Eat a Mediterranean diet, moderation.

Dr. Robert Bales:  Mediterranean diet, watch the sugars that come from drinks.

Nada Youssef:   Yeah, sugar intake.

Dr. Robert Bales:  Calories that come from drinks, we don't always count them.

Nada Youssef:   Sure. Thank you.

Dr. Robert Bales:  You're welcome.

Nada Youssef:   Thank you so much for coming in today. It's been a pleasure and for more information or to make an appointment with a Cleveland Clinic family physician, please call 866-320-4573 or you can go to www.ClevelandClinic.org/medicineinstitute and to listen to more of our Health Essential podcasts from Cleveland Clinic experts, make sure you go to ClevelandClinic.org/HEpodcast or you can subscribe on iTunes. For more health tips, news, and information, make sure you follow us on Facebook, Twitter, Snapchat, and Instagram at ClevelandClinic, just one word. Thank you, we'll see you again next time.