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Hypertension, Obesity, and COVID-19

Educational Objective
To understand how COVID-19 is affecting obesity and hypertension
0.5 Credit CME

New data show unfavorable US trends in hypertension and obesity, with communities of color doing worse. National Institute of Diabetes and Digestive and Kidney Diseases Director Griffin P. Rodgers, MD, and National Heart, Lung, and Blood Institute Director Gary H. Gibbons, MD, discuss the implications for COVID-19 outcomes and public health. Recorded September 10, 2020.

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Transcript

>> Howard Bauchner: Hello and welcome to Conversations with Dr. Bauchner. It is Howard Bauchner, Editor-in-Chief of JAMA, and this is one of my most unique conversations. I am joined by two leaders at the National Institutes of Health. Gary Gibbons is the director of the Heart, Lung, and Blood Institute. He has been since 2012. He's a board-certified cardiologist, and his budget is about $3 billion. He has about 1,000 employees in NHLBI. Gary, welcome.

>> Gary H. Gibbons: Thank you, Howard, pleasure to be here.

>> Howard Bauchner: And Griff Rodgers, who is the director of the National Institute of Diabetes and Digestive and Kidney Disease, board certified in hematology. He's been director since 2007. He's also a member of the JAMA editorial board. His budget is about to $2.1 billion, and he has about 700 employees. And they've written a remarkably powerful editorial to accompany two papers that we published, one yesterday, one last week. The title of the editorial is "Obesity and Hypertension in the Time of COVID-19" by Griffin Rodgers and Gary Gibbons. The two articles that they're commenting on, and that we'll discuss today, the first is by Paul Muntner and colleagues entitled "Trends in Blood Pressure Control among US Adults with Hypertension, 1999-2000 to 2017-2018, and then, "Trends in Obesity Prevalence by Race and Hispanic Origin, 1999-2000 to 2017-2018." And Gary, I thought I'd start by just summarizing the data that you allude to in the editorial and just to talk about it. I found it so, so disturbing. Muntner estimates the proportion of adults with hypertension who had controlled blood pressure, increased from 31.8% 1999, to 48% in 2017, remained stable to 2013-2014, but then declined, declined from 48.5% to 43.7% over that four-year period. Gary, were you as disturbed when you saw these data as I was?

>> Gary H. Gibbons: Yeah, no, Howard, I think you're exactly right. This is a very concerning trend. We know one of the success stories, I believe, in biomedicine, is the reduction of cardiovascular death over the last 50 years or so, in part, related to effective control of risk factors. And we know and have abundant evidence that lowering blood pressure works, prevents strokes, heart attacks, heart failure, etc. we've known that for a few decades now, and we've done, particularly the NHLBI, had a leading role in enhancing awareness in the public about "the silent killer," as it used to be called back in the 70s and 80s. And so, there have been guidelines for, again, decades, as part of the JNC tradition, to try to really galvanize the public and practitioners that controlling blood pressure is important. And yet, as you're pointing out, we have less than half our population that's controlled. And so there are lives that will be lost as a result of that. And it's particularly concerning in light of the fact that the NHLBI sponsored the SPRINT trial, which, I think, is one of the milestone trials of the 21st century, in showing that even more aggressive lowering blood pressure prevents strokes, heart attacks, heart failure, and saves lives. So, the data is getting stronger and stronger about how important blood pressure is. It is frustrating that the control rates seem to be lagging.

>> Howard Bauchner: Gary, the other thing, and then Griff, we'll get to the obesity data. The black/white differences are more pronounced than ever before, and they're very pronounced around who has access to regular care and who doesn't have access to regular care. I do also want to make sure that people recognize that the definitions used to represent control was identical during the reporting period, even though there were some new definitions introduced. There is a sensitivity analysis based upon the new definitions, but these comparisons are apples to apples over the years. Gary, can you just comment on the black/white difference and access to care. Obviously, they often go together. But I'm wondering if you could say a few words about that.

>> Gary H. Gibbons: Yeah, that is another element of the disturbing trend, and who seems to be most adversely affected. And indeed, that has a social dimension to it, in which, I think it lays bare some of the social determinants of health that is feeding into racial and other health disparities. And so, really, since it's a matter of doing what we know works, what we already have evidence, it's really back to how do we deliver quality care to all Americans? And this is really a canary in the coal mine. It's telling us we have a problem here in making sure that all communities are getting evidence-based care.

>> Howard Bauchner: Now Griff, the data around obesity, I don't think, will surprise people. When we talk about an epidemic, or a pandemic, obesity has become a worldwide problem. It is a pandemic. So, I'll read the data that you summarize in the editorial. Again, 1999-2017 increased the prevalence of obesity, increased from 27.5% to 43% for men and 33% to 41% for women. And the prevalence of severe obesity, BMI greater than 40, increased from 3.1% to 6.9% for men and 6.2% to 9.7% for women, and again, a number of subgroup analyses, the prevalence of both are greater. That is, obesity and severe obesity for non-Hispanic black women, 56.9% and 18.9%, respectively, and Mexican-American women 49.6% and 14.5%, and white women, 39.8% and 11.3%. We've been at it for a decade, Griff. I mean, we talked about it at our editorial board. Is it intractable? Can we not solve this problem?

>> Griffin P. Rodgers: Well, it is a problem, in fact, one of the -- let me just highlight one additional subset analysis that was reported in the Ogden paper. They looked at individuals between 6 to 11 years in adolescence in which the prevalence had also increased from 15.8% to 19.3 and 16% to about 21%, respectively in those two groups. And this is particularly concerning because we know that severe obesity is a major risk factor for type-II diabetes in youth, which is a more severe course and responds less well than treatments for diabetes later in life. But the second point, in adults, again, we're just seeing this general increase in this epidemic of obesity, as you pointed out. I mean, we're in the midst of a pandemic now, and obesity, you know, if you were to kind of put this in the communicable disease, it would, obviously, be right up there front and center, because obesity is such a risk factor for so many other conditions in adults, cardiovascular disease, nonalcoholic fatty liver disease, which, by the way, is now becoming the more likely cause of cirrhosis. I just got off of a Zoom meeting in which we were reviewing data on obesity as risk factors for certain types of cancer that has been published recently in JAMA. Unlike hypertension, in which there are really a very large number of therapies available, which is, as Gary indicates, very disconcerting, therapy, either pharmaceutical therapy or behavioral modifications, telling people to eat better and exercise more, just has not been as effective as we'd like. And again, this is a condition because of the social context and the other related aspects about eating and exercise and sleep, by the way, which is sort of the third leg of that stool. We're up against some great forces that we have to compete against that makes this almost a seeming intractable problem.

>> Howard Bauchner: Gary, what I found so disturbing about the hypertension data is we can diagnose it. We have effective treatment, and they're not even expensive. I mean, that's what's remarkable. I mean, obesity is so complex. I mean, you know, I'm trying to lose 10 pounds. It's hard. But physicians are good at hypertension. We can make the diagnosis. We can treat it, and it is inexpensive. Do you have a sense of what's happened over the last five years, Gary? I mean, you've talked to so many people. You fund so much research.

>> Gary H. Gibbons: Yeah, I think one of the other elements that you alluded to that I'd like us to, at some point, give greater attention to is what some might call the science of health delivery. That is, as you point out, it's not that the clinicians don't know what to do or don't have the tools. It does raise the question as to how effectively does our system control a risk factor, and particularly in those who, quite frankly, are on the lower socioeconomic means, and really, I think it's more of an indictment of our delivery system, less about our providers and their knowledge than anything. Similarly, it is a challenge in these communities of color in particular, that they have access to the lifestyle that we know can promote a healthy blood pressure. And so, as Griff was alluding to, if you're in neighborhoods that don't provide access to fresh fruits and vegetables, and yet, have high concentrations of places with high-fat and high salt, it's going to be harder to have -- you're going to have more high blood pressure, and is going to be harder to control. So, it's really a multi-level, multi-pronged element to this. Now one of the things that we did fund relatively recently, Ron Victor [assumed spelling] did a trial in which he actually showed that if you got into barbershops in these communities of color, that, indeed, that was a more effective way of getting the word out and getting the peer buy-in to controlling blood pressure. And so, you probably can't tell from my video that black men spend a lot of time in the barbershop, and it's actually a major conduit of information. And so, for him to leverage that for health education in communities is, again, a strategy. Mobile technologies have also been used. So, there's still things we're trying to do in terms of the science of health delivery that may make a difference.

>> Howard Bauchner: Now I always think of obesity, trying to help people who are trying to lose weight as just so remarkably complex, Griff. There isn't it a drug. I mean, there is bariatric surgery for people who are morbidly obese and what defines who should get surgery is changing, I think, because of the effectiveness of surgery. But nevertheless, I find it to be so much more complex than some other medical conditions. What do you think the future of trying to move towards better weight control for the entire US population ... where do we need to go?

>> Griffin P. Rodgers: Well, I think, you know, we clearly do have to think differently. I mean, there are people who are able to -- if you look at some of the behavioral studies that NHLBI and NIDDK and the other institutes and, you know, other agencies that fund it, it is quite clear that almost anything that you do, as long as there is good support for it and encouragement and having people work in groups in which there's group dynamics to encourage this, you will see that people will lose weight, but after some point, it is absolutely clear that, you know, humans have evolved to defend weight loss, and a number of compensatory mechanisms kick in to make it, you know, more difficult, for you to lose the next incremental pound, in fact, doing the same thing, you begin to regain weight, and under those circumstances, you know, people can become quite discouraged, and they just give up, and that weight just comes back. But if you look at the series of what happens, you know, some people will return and maintain that weight loss, but the greater majority will have a very slow slope going back up at the same, you know, caloric intake or reduced caloric intake. So, understanding what those differences are, and again, some of it is biological. Some of it is social and environmental, I think, something that we need to go after. You did raise an important issue, and that is bariatric surgery, and I alluded to this fact that kids, youth, with obesity, is a great risk factor for type-II diabetes, and they're really refractory to therapies that we use for adults. What seems to work is bariatric surgery, both in terms of the restitution of normal pancreatic function and insulin sensitivity. It also reduces the risk of hypertension and cardiovascular risk factors, but of course, that's not something that we want to prescribe to large numbers of people out there. And so, we're actively involved in studies, trying to better understand what are the biological underpinnings of why people lose weight and sustain weight and have sustained improvement in metabolic and cardiovascular parameters after surgery. As you probably know, many people begin to lose weight, you know, or at least their metabolic and cardiovascular numbers, actually improve within hours or days before they've lost substantial amounts of weight, and what it is intrinsically that's causing that is yet to be determined. It's probably multifactorial. But we're actively engaged in supporting and conducting studies to better understand that. So that, ultimately, people may benefit from bariatric surgery without having to undergo surgery.

>> Howard Bauchner: Yeah, I mean, I think of these as almost like the twin evils around population health. If you made me czar, health czar, I would say we're going to focus on two conditions at the population level, hypertension and obesity. It is not lost on people who are watching this that the two of you are Black men in America, and you touch on structural racism in the editorial, and I really appreciated that you were willing to talk about that. It's been a very painful six months. I can't really understand what it's meant to Black America. I can try, but I am not Black. And so, there's a long history of slavery, and you touch on structural racism. How did the two of you think about that vis-a-vis your Institute, personally, vis-a-vis hypertension and obesity? Griff, do you want to go first on this one?

>> Griffin P. Rodgers: Yeah, well, as I think we alluded to in the viewpoint, this is the context under which people live their daily lives. And so, if you're in a, you know, in an environment that doesn't have access to fresh fruits and vegetables, doesn't have a safe place for kids and adults to exercise, lacks resources in terms of easy access to healthcare facilities, you know, these have sort of a reinforcing effect, and I think, policies that have been going on for years, decades, perhaps, have, you know, reinforced this, in terms of educational attainment, employment attainment, and that's why I think you mentioned COVID. This brings us in sharp relief, because the same risk factors and the same things that put people in these type of environments are also risk factors for being -- inability to social distance, to be our front-line employee that will be publicly facing, and therefore, at greater risk of exposure, and then, of course, if they have hypertension, cardiovascular disease, diabetes, obesity, they're at greater risk of suffering more severe complications and even mortality from the condition. So, I think, you know, this just puts this, you know in the need to do something at a more urgent pace.

>> Howard Bauchner: Gary, how do you think about this?

>> Gary H. Gibbons: Yeah, no, Griff described it quite well. I think, you know, we cited a paper that related to redlining, a policy of, in essence, disinvestment in areas that were predominantly African-American or communities of color, and that's been in place for decades. It kind of promotes that racial segregation. In our cardio study, the cohort study, it's been shown that the individuals who were born in racially segregated neighborhoods and stayed in racially segregated neighborhoods had higher blood pressure over time. And so, clearly, when we think about predisposing factors those social dimensions do get under the skin. It was shown that, for example, that those redlining neighborhoods also had more preterm births, and that's where the social potentially has a biological underpinning, because we know how much the seeds of chronic disease, whether it's obesity or hypertension or cardiovascular disease, begins in utero. And so, there are things that if you're born preterm, the blood vessel vasculature, the elasticity, the elastin that's laid down in your blood vessels is different. The stressors that come from that birth, both for mom and child have an influence. And so, that starts to set up. We know your epigenome and your microbiome and everything that then puts you on a trajectory, such that you may, indeed, have more of the 95th or the 105th percentile on your obesity and blood pressure. So, all those things intertwine both the social and biological, and we're just now understanding that the biological transduction of those social determinants. So, those are things that really work together and reinforce these inequities.

>> Howard Bauchner: When you think -- you had mentioned before that the knowledge about hypertension and how to diagnose this and treat it is relatively good, and the Muntner article really highlights what we think is a failure in the delivery side of care, which I would agree. I mean, for me, and I've written about this, everyone should have health insurance in this country. To me, that is what we need to do, and that would improve access, and in the Muntner article, regular access to a physician, your blood pressure control, was infinitely better. To me, this has to happen in my lifetime, hopefully, within a year or two, but when you think of your institutes, so, both of you lead just remarkably influential, national and international institutes. Eighty to ninety percent of your funds go to extramural funding. How do you think about parsing out those dollars between lab-based science, clinical research? Do you feel like you need to move each of the institutes in the direction of delivery, or is that not where you want to go? I'm just curious about how you think about that. I know you both have advisory boards.

>> Griffin P. Rodgers: So, certainly, we, several years ago, started a new subunit within the NHLBI called the Center for Translational Research and Implementation Science, and part of the reasons we did that was to start to address that sort of distal end of what we call translational research. Everyone's familiar with bench to bedside, and T1 and T2 as you get, say a therapeutic agent into the clinic and the patient, but it's that end mile where you now need to go from efficacy toward making sure that it reaches patients in the real world, where they live in the communities and practices, and that's an area that I think, and NIH has not traditionally invested quite as much in. And so, that's one of the commitments we've made that gets to the space of the science of delivery and implementation science, and doing things again, in a rigorous and systemic way, to test strategies as an extension of what we do. So, we've seen that as part of our mission, and it's still, I don't know, a very modest part of our overall portfolio. At the end, the engine will always be discovery science on the front end and the clinical research. But we like to see that more seamless, and also, the thing is, it dovetails with trends in healthcare where, I think, related to the things that you do here at JAMA are talking more about value-based care and really looking at things more holistically, as opposed to per procedure or per visit, per se, and if we take that more holistic view, I think that helps us think about the patient at the center, the community in which they live, and how holistically we can get better outcomes.

>> Howard Bauchner: Well, I mean, the good news is that the NIH budget has really grown over the last three or four years from $32-33 billion. I think next year, it's supposed to top 40 billion. I hope some of those additional funds have flowed to your two institutes. Griff, how do you think about this balance between discovery science, which Gary articulated, and sort of the backend, you know, T4-T5?

>> Griffin P. Rodgers: Sure, yeah, no, absolutely. I mean, I completely agree with his formulation there, and, obviously, we think basic science is critically important, because you really don't know when the next -- what that discovery is going to lead to five years from now, 10 years from now, and beyond. And so, one has to have a pretty good balance of basic science, translational work, and clinical work and clinical studies. I just want to, you know, again, first echo Gary's points, but also just maybe shift a little bit, just to point out that we work together and the kinds of things that he's articulated is in both of our institutes' strategic plans for the future. We're also realizing that some of these seemingly intractable problems, like obesity and cardiovascular disease, really is going to, you know, they don't occur in isolation. So, most people who have hypertension also have diabetes and they may be obese. And so, some of the things that we talk about that are in the environment that may be conducive to one may be conducive to more than one, and we've taken this opportunity to fund these natural experiments. And so, for example if there are policy changes within a particular city or district or state or region, we use an opportunity called a time-sensitive approach to allow people to apply very early in advance of these policy changes to get baseline data to see whether, in fact, once these policies are introduced, over time, whether that changes not just one parameter, say childhood obesity, but whether that has an influence, for example, on hypertension or other things. So, for example, one could look at the introduction of light rail system or a decision of a particular school district to allow high-school students to -- well, of course, not now, but to sleep in an extra hour before the school start time. Or you may remember, a number of years ago when the mayor of New York decided that these jumbo --

>> Howard Bauchner: Oh, the jumbo drinks.

>> Griffin P. Rodgers: -- drinks would no longer be allowed. Of course, that was actually overturned, but we actually funded some of those studies, so that investigators could get information early on. One final thing, though, is again, we have to kind of go beyond just working together, but we have to go across agencies. So, for example, we've been working with, in conjunction with a number of institutes, NHLBI, to work with, for example, the Housing Department, to see whether their voucher programs have put people in more affordable houses in different places may have health consequences that one would predict, based upon what we talked about, the social determinants of health. So, we're going to have to sort of work with other agencies, transportation, education, housing, and really conduct these natural experiments, to see what these effects will be.

>> Howard Bauchner: Yeah, I've had a number of guests on the show who've decried that we haven't been better at understanding natural experiments and just trying to -- and obviously, they're not clinical trials, but life isn't a clinical trial. And so, you can derive an enormous amount of information, as you said, and they're more likely to reflect the real world about what happens to someone's life when you change the way they commute or they get to school or what they drink or they eat. So, it's interesting that you've commented on it specifically. Gary, the gains in cardiovascular disease, you've been at the NIH before 2012, although that's when you became director, over the last 20 years are extraordinary. I mean, the number of lives saved, the advances in cardiovascular disease, but it appears to have plateaued over the last three or four years. Do you have a sense of why it's plateaued? Has it just got more difficult? Or I've always thought because it's been combined with the obesity epidemic, you've probably saved many more lives, but it's hidden because of the obesity epidemic. Do you have a sense of why we're seeing a plateau in cardiovascular health?

>> Gary H. Gibbons: Well, as you point out, Howard, it's probably a bit multifactorial, as you say. We have an aging population that also, with a great increase in some of the risk profile of this cohort, with obesity and diabetes, as Griff has allude to, but I'm also concerned that if you look at some of the curves, again, there's a footprint of geographic disparities there, as well. The American Indian population over the last 20 years is getting worse. There are parts of rural America, actually, particularly women, in lower socioeconomic status in particular, in rural communities. Again, African-Americans, a rather stubborn kind of decline, if not a little bit of an upturn. So, some of that aggregate curve and plateauing sort of obscures the fact that there's some populations that are actually going the wrong way, as well as those who are still benefiting from a lot of the good progress we're making. So again, it comes back to one of the ways to get that curve going down is to expand who gets the benefit of all these advances and ensure that those who are getting a disproportionate burden get a disproportionate benefit related to what we know. And that's going to take special outreach. In addition, I think we do need to get better, that we need greater advances in problems like heart failure, and Griff has made -- there's been a lot of great advances, but there are things that, you know, we still have too many people dying with heart attacks, even on statins and state-of-the-art care. I think we still need some breakthroughs in how we can more effectively arrest this disease, and part of it, I believe, is actually starting earlier. That we've always attacked it as an affliction of the elderly. I think we have to start, now that we have new tools, including polygenic risk scores and biomarkers to say should we start to intervene earlier, since we now this is a cumulative effect of decades? Could we, in fact, really shift that curve down if we got more aggressive earlier? That's more ambitious, but I think those are some of the opportunities I think, still lay ahead.

>> Howard Bauchner: Gary, you had mentioned SPRINT, and JAMA had published, you know, the major publications were split between JAMA, New England Journal, and we publish subsequently two or three papers from SPRINT. When you think of the scientific discoveries funded by your institute in the last three or four years, what do you think have been the major successes, and Griff, I'm going to ask you the same question. I'm curious, when you think of the science portion of your Institutes, I mean, SPRINT was remarkable. I think it's settled the issue that you really want blood pressure in the 120s not the 140s. But are there other things that come to mind, Gary, that you think really represent the next generation of science?

>> Gary H. Gibbons: Wow, that's a tough one, Howard. That's like asking me which of my three children do I love the most.

>> Howard Bauchner: Sorry. [Laughing] Don't answer that question. [Laughing]

>> Gary H. Gibbons: You have a lot of people listening. So, I already put the chip out there on SPRINT because I think that one is remarkable in its scope and meaning and potential public health impact, not only in this country, but around the world. It's really tough to say. As you also know, I think you share certain interests and what we're doing in the blood place space with sickle-cell disease.

>> Howard Bauchner: Sickle-cell disease, yes, you've written for us.

>> Gary H. Gibbons: And, again, I think the very promising initial areas, in terms of curing that, and my good friend, Griff, is one of the leading investigators in that space. He's been a pioneer for decades. And so that, I think, is very exciting. He mentioned sleep before. We actually are the host to the National Center for Sleep Disordered Research at the NHLBI. It's really a trans-NIH initiative. To pardon the pun, but I think that's one of the sleeper areas, the sleeper areas of research, where it has such broad implications, and yet, I think we're still just scratching the surface. For example, finding out how common sleep-disordered breathing is in pregnancy and how that's associated with adverse pregnancy outcomes, including preeclampsia and other sorts of disorders, and now we're doing an intervention to see that if you improve sleep, CPAP, etc., can actually help both mom and child. So, those are very exciting things that we're doing. So, it would take you another three hours, Howard, but those are some examples.

>> Howard Bauchner: Griff, NIDDK, some great successes, I mean, type-I diabetes, type-II diabetes, but I'm curious what you think of the science portfolio over the last three, four, five years, what emerges as you think one of the great funding achievements of NIDDK?

>> Griffin P. Rodgers: Well, again, as Gary mentioned, we have so many different constituents, and you know, I hesitate to say one is better than the other, but since you did mention type I diabetes, and it kind of segues into something, a comment that Gary just made, I think that's been one of the great success stories in two aspects. One is because we have developed a way to sort of understand the genetic risk of this, probably, at this point, just based upon, you know, decades of actually studying, you know, the pre-existing risk factors, genetic risk factors to this. Probably we know more about the genetic risk, probably, you know, somewhere around 85 to 90% of the attributable genetic risk is known for type I diabetes, and that has, therefore, led us to begin to diagnose those individuals who are at extremely high risk. And this has given us the appreciation that the disease actually exists, or the condition exists, before people develop severe dysglycemia. This has actually led to the development of prevention trials, one of which was reported about a year and a half ago, in which, you know, just the therapy for anti-CD3 has reduced to the development of diabetes by two years, compared to a placebo, in individuals at extremely high risk. Just think about that. That's two years in which you don't have to check your blood sugar. Two years you don't have to give yourself insulin injections. Your parents can sleep at night. That's a major accomplishment. But at the same time, developing, you know, these developing these artificial pancreas technologies, which, again, results from the confluence of a number of different basic science discoveries, translational work, bringing in computer scientists, mathematicians with algorithms to sort of put all this together in something that a pump will kind of use your iPhone or other, you know, device to calculate and reproduce the effects of what your kidney does -- I mean, what your pancreas does. That has really been a big benefit. And again, I could probably give you, you know, a list of other conditions, but I just want to say that that may be the direction of the future, in that we're going to be able to, you know, develop a risk-factor score for people and maybe intervene at people at extremely high risk before the development of the disease.

>> Howard Bauchner: I wanted to make sure we finished on some positive scientific information, since the struggle around hypertension and obesity, and obviously, the way it's influenced COVID-19, the pandemic, particularly for different groups of individuals, is so powerful. So, I've been talking with Griff Rogers, who's director of NIDDK, and Gary Gibbons, who's director of NHLBI. They've written an editorial to accompany two papers. The title of the editorial is "Obesity and Hypertension in the Time of COVID-19." The papers are by Paul Muntner and colleagues, "Trends in Blood Pressure Among US Adults with Hypertension,1999-2000 to 2017-2018." Very concerning, disappointing results in the sense of less control now than five years ago, and then, by Cynthia Ogden and colleagues, a research letter entitled "Trends in Obesity Prevalence by Race and Hispanic Origin, 1999-2000 to 2017-2018." Gary and Griff, I want to thank both of you for joining me today. You direct just remarkable, remarkable institutes, and your leadership in American medicine is so critical. Thank you for your remarkable service over the last two decades.

>> Griffin P. Rodgers: Well, thanks for having us on the show. We really appreciate it.

>> Howard Bauchner: Bye, Gary, bye, Griff. Stay healthy.

>> Griffin P. Rogers: All right, you too.

>> Gary H. Gibbons: Thanks, Howard. Take care.

>> Howard Bauchner: Bye-bye.

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