Fit for Duty podcast: Episode 6.

Hello and thanks for joining us for the sixth edition of the Fit for Duty podcast by Aetna International. As Global Content Marketing Lead here at Aetna, I've invited the incredibly knowledgeable Dr Sneh Khemka back to the podcast, to discuss cardiovascular disease. Now CBD and heart disease, that's to say disease of the heart or blood vessels around the body, are responsible for approximately 30% of global deaths. So it's little wonder that it's high on the health agendas of so many employers, health policymakers and individuals. The conversation today highlights heart disease risk factors, and the influence of COVID-19 on individuals’ lifestyle choices. We delve into the reasons why it's so hard to pin down exact numbers of people dying for CBD, and we look at the contributing lifestyle factors in varying regions around the world, the ways in which governments should step up their commitment to tackling heart health, and also ways that employers can help workers reduce their risk. We cover a lot of ground in this 30 minute podcast, and I hope you get a lot out of our discussion.

Today I'm joined by Dr Sneh Khemka, Vice President of Population Health Solutions and vHealth here at Aetna. Hello and welcome back Sneh.

Hi Lorien, thank you very much for having me back.

You're very welcome. It's a pleasure to have you back. We spoke a couple of months ago with regards to smoking cessation around the time of world no tobacco day. So, I was wondering if you could give us a little bit more background about your role, specifically your involvement with digital health, and also, I know that you're a specialist adviser to the World Economic Forum so a little bit more background for our listeners, please.

Yes, of course. So, for those of you who haven't heard a podcast with me before, my name is Dr Sneh Khemka. I am a surgeon by background and I returned to clinical practice, but I also have been involved for the last 20 years or so in the business of healthcare, and most recently for the last seven years at Aetna International. So, we have done projects that range all the way from helping governments to set up new healthcare systems in the Middle East, to go into career to help big companies with their digital health propositions there. And what we do a lot of at the moment is the stuff that had become really relevant during COVID, which is digital healthcare. So, digital healthcare is really about accessing health and care services without physically having to be in front of a doctor or a healthcare professional. So if you need to see your GP but because of COVID you can't get down to the clinic, we're the people to turn to. And we have this service called vHealth, which we deploy all around the world. It's big in India, in Thailand, in Singapore, in Dubai, but also across Europe. It helps you for primary care consultations, but also to manage your mental health, manage your wellness, manage any chronic diseases you may have and get access to help and services that you may otherwise struggle to get. So that's what the digital healthcare side of things is Lorien. You asked about the World Economic Forum, I'm part of the Council on the Future of Healthcare. It's an academic group that really looks at future trends and comes up with solutions on how to tackle global health issues, such as COVID and other things, and lead the way on policy for governments to follow us.

So thank you Sneh, that's wonderful. I really wanted to bring all of that incredible expertise to bear on the subject of cardiovascular disease and heart disease in particular. So according to the World Heart Foundation, cardiovascular disease, or CVD, accounts for nearly half of all non-communicable disease deaths around the world, which makes it the world's number one killer. So, we also understand that heart disease, including strokes, claims 17.9 million lives each year. I mean these are staggering figures, and that equates to around 31% of all global deaths. So, I really wanted to talk to you about this Sneh. I mean in terms of non-infectious chronic diseases, which can be as a result of either genetic or lifestyle or environmental factors, would you agree that the World Heart Foundation's assessment is correct in terms of how many deaths are attributed to CVD. In addition, you know we hear talk of heart diseases hiding in plain sight. So I also wanted to ask you why it's so important to bring people with CVD symptoms into clear view?

So there's a lot to talk about there, thank you Lorien. Let me first say, yes. So you know the World Health Heart Foundation and the World Health Organisation have got some statistics and who am I to refute the statistics, I do believe them. And as you say roughly 18 million people around the world die from cardiovascular diseases every year. And that represents about 30% of global deaths. Now, I just want to explain to the listeners what we mean by cardiovascular disease, because the term is bandied around. Most people sort of get it, but just to be very clear, this is where you get disease of the heart, or the blood vessels that go throughout the body. Now, that is obviously a huge system. And so most of the deaths come from heart attacks, where the blood vessels that supply the heart get blocked, and the heart is not able to beat properly. Therefore, it can't pump blood around the body, and it has those effects. But a lot of people are affected by strokes, which is something slightly different. Strokes, as we all know, is where either you have a bleed from one of the blood vessels, or a blood vessel gets blocked, which leads to the brain, and that causes a stroke. But don't forget that you can have blockages of blood vessels leading to all sorts of other organs. From the kidneys, to  the liver, to the eyes, to the lower limbs. It doesn't exist in isolation, it exists as part of a range of diseases. So people with high blood pressure, people with metabolic syndrome, people with diabetes. They all have a mix with cardiovascular disease. And so it's a multifactorial thing. Now the reason I'm telling you all of this is if you ask for clear statistics does cardiovascular disease account for 31% of deaths, yes, statistically, that's right. But it's usually never in isolation, it comes with other things. And so people with cardiovascular disease tend to have other conditions which cause the mortality rate to go up. So I think that's probably an under representation of the number of people who are dying from non-communicable diseases. And the problem is multifactorial.

So that's really why I think that they talk about heart disease as hiding in plain sight, because as you mentioned, there are so many comorbidities associated with it. And in terms of helping people to address this you know there are risk factors including tobacco use, unhealthy diet, physical activity, you know, most of us have had these risk factors drummed into us since a young age. But globally, it seems that these trends are not going in the direction that we would hope. Would you say that over the last 10/20 years, there has been a decreasing trend, or is there a fairly plateaued view? Again, with the caveat that obviously this is very difficult to distinguish because of those comorbidities.

Yes, so it depends where you live, is the quick answer to that. So I split the world into sort of the developed Western economies, and the still developing Asian Middle Eastern economies. And the trends are different depending on which part of the world that you live in. So, what happened if we take the United States for example, at the beginning of the last century, in the early 1900s, heart disease was very uncommon as a cause of death. And generally, it was more infectious diseases, rather than non-communicable diseases, which cause death. You used to think of the old infections like TB, typhoid, cholera, all those sorts of things. But then throughout the 1900s, by mid century, over the 50 years that intervened it had become the most common cause of death. So what happened in that time is people's lifestyles changed. And that was the stuff that you're talking about. Everybody started smoking, we got a lot more salt in our diet, we got a lot more processed foods and high fat foods, our cholesterol went up, we moved from very physically active lifestyles to sedentary lifestyles. And so by 1955, heart disease had become the most common cause of death. That persisted until about the 1960s. But since the 1960s, it's been decreasing. And there has been a marked decline, and that's because we became aware of the issue and we started doing something about it. So we started looking after our diets a bit more, we started to do something about smoking habits, we started to measure our cholesterol and introduce drugs that help to reduce cholesterol levels. We started understanding the importance of family exercise, and the importance of screening. And so we have seen a persistent decline. So that's the US, but if you look at other economies, say China or India, we're still seeing rises coming through and that's because the people who live in those countries are still experiencing some of the changes that the US had in the beginning of the last century. So moving away from non-communicable into communicable diseases, getting more sedentary lifestyles, changing the diet into a more Western high fat diet, rather than low fat Asian diet. And so we are getting increasing rates of cardiovascular disease in countries which are still developing in the traditional sense.

Say, as you said you can split the world, roughly, and we are using relatively sweeping, well I'm certainly using relatively sweeping generalisations. But if you were to take a view of the US, Europe, for example, and look at physical inactivity, diet, high blood pressure, tobacco use, high cholesterol, for example, obviously they all have a knock on effect in terms of their cumulative impact on the body. But if you are going to rank these risk factors for people and really give them a starting point as to how they can start to live more healthily and reduce their risk for developing heart disease in the future, how would you go about doing that?

Right, that's an excellent question. So, we know that there are certain things which make a difference and let me try and give you some quite human advice here. For the average person out on the street, let's take me. I’m a mid 40s male who drinks a bit of alcohol. I don't smoke but have previously, I have a diet that I try and manage but sometimes it's not as healthy as it could be, and I try to do exercise. So, I represent the average man who is at risk of cardiovascular risk factor. So what are the things that I would concentrate on for myself? So the first thing is I want to know what my cholesterol and my fat levels are doing. You need blood tests probably once a year, to be able to monitor that, and you want to have your total cholesterol under control. You want to have a high ratio of high density lipoprotein versus low density lipoprotein (HDL versus LDL). You want to have low triglycerides, because triglycerides are not good for you, and you want to generally be avoiding polyunsaturated fats in your diet. So you want to have good fats, you know the salts you get from avocados and things like that, and avoid the bad fats that you get from fried food. That's the most important thing; singularly that's the most important risk factor is getting cholesterol under control. Number two, behind that is don't smoke. Smoking is the second most influential factor in causing heart disease, and people who smoke will have a higher risk, and the more you smoke, the higher the risk. If you're a smoker, this is one of the first things that you just need to stop if you're at risk of heart disease. The third, interestingly, is psychosocial. It's about how much stress, depression, anxiety you have in your life. It’s about the housing that you live in. It's about the social determinants of your health, and the people you surround yourself with that actually comes in pretty close after smoking. It’s almost as important as smoking, so if you live with a lot of stress, depression, mental health issues, in a poor environment that is as bad as smoking almost. It's not as easy to act on, but it's an important factor. The next one is diabetes. So, I'm a South Asian individual, Indian by background. Diabetes runs high in my ethnicity. Type two diabetes, which often is associated with obesity, is the next biggest risk factor, and then behind that it's high blood pressure. So, getting your blood pressure under control, will really help. After that your family history,you can't do much about that but if you've got a strong family history you'd be much more conscious. And then behind that is obesity. Now, obesity is a relatively low risk, compared to say, high cholesterol. But of course the two are linked. And the big problem with the world, forgive the pun, is that obesity is now our single biggest problem. Bigger than COVID, bigger than smoking, bigger than everything else and that's because we are all getting fat and obese. If there's one single macro thing I want to tackle as a policymaker, it is obesity, because I think that will make the most difference in people getting cardiovascular disease.

Well, it’s certainly high on the government's agenda for the future in the UK. And I know that it's high on the agendas of a lot of other nations as well.

Sorry to interrupt you. Absolutely, so very recently in the UK we have seen announcements, really because of COVID. Boris Johnson, our Prime Minister has announced significant changes and it is a huge step in the right direction. He himself had COVID, as we all know, and he lost a stone and a half as a result of changes he made to his lifestyle after his COVID hospitalisation. And he's now brought that to bear and I really welcome it, I think it's so important. Take the chocolates away from the front of the supermarket, stop the advertising, regulate the food industry and the supermarket industry, make sure it's visible in restaurants and on packaging. It's absolutely essential stuff.

Absolutely. And I'm completely with you and so one of the things that I particularly picked up on there is it’s really important for people to know their numbers. And last year’s World Heart Day campaign really challenged people to pick up on one of four actions, which was to know their blood pressure, to stop smoking, to eat healthily and exercise more. So we've talked about how you would prioritise these, and the fact that just doing one thing is not necessarily enough. You've given a really candid illustration of your own life and circumstances and lifestyle behaviours and things. So, in terms of the other risk factors. There are also non-modifiable risk factors, we've touched on family history, diabetes, age, gender and you mentioned ethnicity again. So, are there any that people should really be concerned about? Health care is very personal, we need to be aware of our genetic influences and our family history, etc. Are there any that you would recommend that people pay particular attention to?

All of them, all of the above. But let's be human about this. There's always a balance that one needs to find in one's life, I mean if you become obsessed about these sorts of things, then you may actually raise your psychosocial risk factors. And so, the mantra is always about balance, it's about a balance of enjoyment but discipline, it's about doing the right thing on a regular basis but allowing yourself the occasional slip up. That's the only human way to deal with things, because the big thing about making sustainable changes in your life, if you try and do drastic changes you tend to rebound from them and they don't persist. You need to be doing something that works for you, over a 30 year period, not just over a 12 month period where you have a crash and you lose a lot of weight. So, you know, the good news is, if you do drink alcohol, regular alcohol consumption of a very moderate level, it's actually protective against cardiovascular disease. So the evidence shows that if you have one or two glasses of wine, a week or a little bit more in moderation, that that can actually be cardioprotective, to a certain extent. The other good news is that regular physical activity has quite a big impact and physical activity doesn't need to be going down to the gym and pumping weights, it could be 30 minute walk with the dog in the park, every day. Diets you've got to be conscious about, you know, balancing your diet, you may want fried chicken on a Wednesday, but make sure you have some fruit and vegetables on a Thursday. That's the way to do it, is always find the balance and make sustainable changes over time.

So in terms of sustainable changes over time, we've talked about the role of the UK government but what else can public health officials and health organisations be doing considering this is a long game? As you say it's not something to focus on for 12 months, 15 months, two weeks, you really need to make and apply changes to your life that are sustainable. So in terms of those agencies, what more do you think that they could be doing?

(19:29)

So, a huge amount. I think we are laggards, I mean globally I’m not pointing out one country here, that there is so much more that can be done so let me try and break it down a little bit. First, is we need to change the way that we look at food production. Salt is a big risk factor for getting high blood pressure and getting cardiovascular disease. If you think the extra sprinkle of salt that you put on your lunchtime meal is the culprit, think again. That's not the culprit. The culprit is the processed foods that you are presented with in restaurants and supermarkets. And so when we look at food production, we need government and industrial support and changing the way that we process food. Stop adding salt, stop adding sugar, stop adding fats, stop adding fructose syrup, corn syrup, stop adding all of those bad ingredients which still are very commonly added to foods to make them more attractive, to make them cheaper in production, therefore more affordable. That is a big, big issue, and until we start tackling that we're never going to really change this. So regulation of the food production industry to move towards much healthier food production is one. Two is, let's think about other ways of substituting meats in our diet. So moving to alternatives to meat and alternatives to processed meat in particular. So there's a huge amount of research going into the use of pea, lentil, soya and mushroom mycelium as a meat substitutes, which are now becoming quite commonplace. They're available on the supermarket shelf and these alternative food sources will be a big driver for change. Three is then regulation of how we're presented with food, especially where we buy it online or in the supermarkets. Clear labelling, clear signposting of things that are going to be bad for you. That's very important. Not presenting poor health choice foods to young people so that they start off well in life. And along with that food education, I think supermarkets and big food distributors should be responsible for funding the education of young people for healthy diets. Then, you know, when you look at restaurants and food outlets, let's change the pricing around healthy versus unhealthy foods. So don't make it easier to go and have fried chicken and pizza than it is to go and have a really healthy nutritious salad. Get to cost parity with government funding to allow us to get there. So that's the sort of food and food production side. Then, when it comes to public health planning, let's design our towns and cities to get people active, rather than inactive. Let's not make towns and cities designed for people to drive everywhere. Let's make it designed for them to cycle everywhere. It’s beginning to come through, some countries better than others. Let's make sure that they are designed so that we can go out on pleasant long walks with our family, rather than having to get into cars and go to amusement parks. That's a fundamental need to change. And then finally, let's change the world health systems,so the doctors are trained about keeping people healthy, and not just dealing with the disease when it comes. We need to shift from disease based health systems into wellness based health systems. So three fundamental parts of the system that need changes, starting to happen in small pockets, but a lot more is needed, and that's going to take 50 to 75 years to start to really affect.

Yeah, absolutely. And obviously that web of interoperability that you've just discussed really there and cause and effect has on a global level has the potential to benefit people hugely. So when we're looking at an employment landscape, and granted it is difficult at the moment because you know unfortunately a lot of people have either been furloughed or potentially out of work completely as a result of COVID, a lot of people are working from home which has really shifted the emphasis for corporate health and wellness away from the four walls of the office into to the kitchen table. So, what is it, do you think, that employers can be doing today to help look after the heart health of their employees?

So, that goes really to the question of, what is the employer’s role in the health care of the individual? And that’s changing around the world and again there's quite a lot of geographical variation depending on where you live. In the US, for example, it is very common that the employer is responsible for the health of the employee. They look after their health insurance, they pay for the health insurance, and that's how an individual has access to the healthcare system. Whereas if you take the UK or most of Western Europe, a lot more is associated with a government and the state. So, in America and what I'm seeing are models where, and we do it at our own company actually at Aetna and CVS, employees are given tools, resources, access to stuff that helps them with their diet. And that ranges from making sure that the canteen in the office, when people do go into the office, is stocked with healthy foods rather than unhealthy foods. That there is pricing parity so that healthy foods are cheaper to buy than unhealthy foods. It's about giving people access to support resources, such as nutritionists and dietitians and self help apps and things like that that help you to monitor your calories, in association with organisations like WW, which was Weight Watchers. Those sorts of things which really allow you to empower yourself to look after your health a bit better. The provision of on site gyms, or if it's not on site, then discounted access to gyms and other sporting activities, you know, whether it's just access to a bicycle through a voucher scheme or access to other training. One of the things we've got going on at CVS at the moment is you've got free access to online classes, fitness classes, during COVID, which I think is really really good. And then there are financial incentives as well, so you can get more money in your paycheck every month if you show healthy behaviours. You're exercising more, you're eating healthier, you're sleeping more. Organisations are increasingly moving towards that. So, in the US I'm seeing a lot of people go in that direction. In Europe, it's still a little bit early, in Asia it’s only just emerging, but I am seeing the employer taking a bigger and bigger role in making sure that you maintain your health, especially when it comes to food and diet.

And we spoke not too long ago Sneh about, as I mentioned at the top of the session, smoking cessation. And one of the COVID-related hopes that you had expressed at the time was for individuals to use the current health crisis as motivation to stop smoking, for example. And recent reports have shown that in the UK, for instance, a million people have quit smoking during the pandemic. That's the highest number in over a decade. So, it will be interesting to continue to watch health trends and to see whether the COVID crisis has a bit of a silver lining in terms of overcoming individual’s inertia, if you like, around healthy habits. And I wanted to also then talk about, you know, we've spoken extensively about high blood pressure and cholesterol and you know smoking recently. Why do those underlying conditions make a COVID infection worse in many instances?

Well Lorien, we've all got to hope that something good comes out of COVID. And if it's sustainable behaviour change and a million less people or more than a million fewer people smoking, that's only good. So, smoking, let's just talk about smoking. Smoking rates are declining across the world actually, and that's good. And that's because of government action you know some of the changes that have happened in the UK. For example, banning smoking indoors has made a profound difference. COVID sounds like it's going to be an acceleration for that change as well. The issue that is rising is people are switching to vaping and we still don't know whether vaping is good for you or not. There are different types of vaping, some of them are very really not good for you. But, young people are coming into an age where they start smoking and that's the bit we need to concentrate on. Your question about COVID, so I can't explain to you the pathophysiology, well I can to a certain extent but I won't bore you, but basically, if you have a lot of fat adipose tissue, the coronavirus is much more likely to attack those cells. They have a much better, much increased permeability to coronavirus and are more susceptible to attack and means you're more likely to store it. Plus, you don't have as good circulation, you don't have as good an immune response, and therefore you are likely to be hurt by the virus more. Also people who are fat or obese, you know, they are likely to have a reduced lung function, and therefore have a higher need for ventilation support. And once you're in a ventilator, that's tough to come out of. So those are all parts of a thing, you know, if you are well, you generally do better with coronavirus. If you've got poly morbidity, are hypertensive, obese, non-compliant, diabetic, asthmatic. Those are the people who really will suffer with COVID.

Say this year's World Heart Day campaign is entitled “Use heart to beat heart disease”. So the key messages are really about understanding what it means to live a heart healthy life, to act on that knowledge and to also use your influence as an example for others. It calls on health care providers and players to invest in positive change for heart health. And I wanted to ask you about, so during the pandemic, looking at people at risk of developing CVD, what should they really be focusing on at this time, to help avoid cardiovascular disease?

During the pandemic, people are much more savvy about their health. One of the things to come out of the pandemic is that everybody's thinking a lot more about their health and wellbeing. And that's a good stimulus, and hopefully that will remain after the pandemic has gone as well. But people are becoming much more literate about health terms, they're becoming much more educated about what are the health connotations and that is raising awareness and that is the single biggest thing is that people are now aware and educating. So they're thinking, what is my cholesterol level, thinking “hold on, I'll be smoking for 20 years now, should I be stopping?”, they’re thinking “I’d better measure my blood pressure every month and see what that's doing”. So people are much more savvy about it and I think that's the biggest thing that can change. As I said, it's about making sustainable life changes. So, you know, if you've been locked up at home, and you've only had an hour of exercise, you've taken that hour and you've been out jogging in the park. Can you continue that once lockdown is finished? Can you continue to be that active person for the next 15 or 20 years? And if you’ve changed your diet during COVID, for whatever reason, is that a sustainable change? So, for me it's all about making sure that they have sustainable change to keep healthy. But on the flip side of it, one thing that's happened during COVID is people are scared to go and see a doctor or go to hospital, and people with coronary cardiovascular disease have had problems, so people with angina, which is pre heart attack, or heart attack or stroke, what we have noticed in many countries is people have been so scared to go to hospital that they haven't access care. And that's been a problem because that leads to more morbidity and eventually mortality. And that's been an unintended but real side effect of lockdown.

Well thank you so much for answering that because that was actually going to be my next question, which is fantastic. So, I want to move on now to discussing digital health tech. So, in your opinion, what role, or what does the future hold in terms of digital health tech for helping people, individuals manage the symptoms of cardiovascular disease, to help them prevent it? And looking at the other risk factors we've been discussing.

(34:29)

So it's quite wide ranging. So on one end of the spectrum, digital health tech has changed how doctors use stethoscopes. So when I trained as a medic 25 years ago, listening to someone's heart and trying to hear a murmur was like finding a needle in the haystack. Using a stethoscope, and I often pretended I could hear stuff when I couldn't. Now we have digital stethoscopes, they're just beginning to come to the fore. But essentially it's a bit of kit, you put it on someone's chest, and instead of using your ears you can use a digital app on your phone to listen to someone's heart and it will give you a much more specific reading, so that you can tell there and then as a doctor that has someone got a murmur, heart valve problem or whatever it may be. So that's one side of it. The other side of it, of course, is how we as human beings are interacting with our world in a much more digital way. So everybody who's got a mobile phone in their pocket will know that their mobile phone can gather information on how far they've walked, ran,swam, how much they've eaten, how much they've slept, all of that sort of stuff. So suddenly we're gathering heaps of information about our lifestyles, which means that we know what's going on and we can act on it. But then you get into managing cardiovascular disease. So, rather than the traditional model that's happened in the past where you see your doctor every three months, they take a reading then, it's a point in time, you don't know what's going on with your blood pressure or cholesterol. Now, it’s a much more constant means of measuring it, and I can take my blood pressure and record it on my phone every single day. I can recall what I'm eating. If I have diabetes, I could be recording my blood sugar's twice a day, and it would be there. And so there are lots of companies and therapeutics out there that will monitor this stuff, and not just tell you on a three monthly basis but on a daily basis give you feedback for you to improve your health. And then the final part of this is of course the way that you access your doctor. So, rather than having to wait a year to see a cardiologist when you've been referred, with vHealth and digital health, you can now get much quicker access to a global network of cardiologists or GPs, whatever you need access to, so that you can get immediate advice, monetary treatment prescriptions and all those sorts of things. So the game has changed massively. And as we adopt digital technology, and the healthcare world allows digital technology to ease delivery, I see these things making a fundamental difference to how we deal with cardiac disease and cardiovascular disease.

And not on the flip side, but in looking at the humanity and the human involvement in looking after people with heart conditions and also to help prevent, I spoke with Caroline Payne, our VP of Customer Proposition and also Dr Hemal Desai, Global Medical Director here at Aetna recently about the importance of trust, humanity and compassion in the world today. And really, as a result of COVID and a lot of other things that have been going on in the world recently, and I won't go into all the detail, so I think just in terms of closing remarks and looking at how we can potentially apply those principles of humanity and compassion in conjunction with the wonders of digital health tech, in looking after people and their their heart health, do you have any any final statements or closing remarks that you'd like to make in that vein?

Well, it's a great point. So, are we moving to a nicer world where compassion in humanity, a greater factor? Certainly from an employer perspective I see that change happening, but specifically pointed to this question, we talked about psychosocial factors being the third most important factor in deciding when you're getting a heart disease. So, if we can alleviate mental health issues, such as depression and anxiety and stress and all of those other things that happen in the workplace and outside the workplace, we know by empirical evidence, scientific evidence, that that will make a difference in cardiovascular disease. So does a more humane society prevent heart disease? Absolutely. Will it be a big factor? I hope so. It will take humans quite a long time to change but my closing remark here is, if you think with your heart, and you act with your heart, then possibly you can look after your heart even better,

That's wonderful Sneh thank you, and it's a very nice introduction to our next conversation in a couple of weeks time, which is focused on mental health and World Mental Health Day. I really want to come back and have a discussion with you very much about mental and physical health parity and what affects the mind, affects the body and vice versa. So, if you would care to join me in a few weeks time, then I'd be really keen to pick this discussion up with you again.

It would be a pleasure Lorien. Thank you.

Thank you so much, great to talk to you.

Thanks for listening today and I hope you've enjoyed the podcast. You can subscribe to the Fit for Duty podcast by SoundCloud or other podcast software, and you can listen to archive episodes including “Turning the tide on tobacco”, “Tackling employee health and national healthcare trends” and “Corporate wellness trends in 2020 and beyond”. Join us again in a few weeks’ time when Dr. Sneh Khemka will be back in our virtual studio to discuss mental health disorders, which affects some 450 million people around the world, and will be focusing on preventative measures and advances in treatment. For those who don’t know us, Aetna International is a global health and wellness benefits provider, but we’re more than just an insurance safety net. Our skills lie in delivering the tools, services and resources that help drive healthcare costs down and people's physical and mental health and wellbeing up. That's something that's important to our corporate clients and our self-funded members and their families. That's why we currently serve almost 900,000 members around the world, from Shanghai to Seattle. Ultimately, we believe that when people thrive, their work and personal endeavours thrive too. For more information about us, you can visit aetnainternational.com.