Healthcare Triage Q&A with Dr. David Haas

This November, Heartland Study lead researcher and HHRA board member (ex-officio) Dr. David Haas joined Healthcare Triage podcast host Dr. Aaron Carroll to discuss the possible impacts of rising pesticide use on public and obstetric health. The Healthcare Triage podcast is sponsored by HHRA research partner the Indiana University School of Medicine, whose mission is to advance health in the state of Indiana and beyond by promoting innovation and excellence in education, research and patient care.

Eaters Deserve More Complete Information About Nutrition and Health Impacts on Food Labels
Multiple lines of evidence point to consumer food choices as major contributors to diet-related disease, and poor health and fitness. In a peer-reviewed journal article published today, authors Chuck Benbrook and Robin Mesnage cite studies indicating that “Some 90% of the estimated USD 4.3 trillion in annual health care costs in the US is triggered or made worse by poor food quality and diet-related disease.” Benbrook is the founder and former executive director of the Heartland Health Research Alliance (HHRA). The authors recommend novel metrics on both the nutrient density of food, and how to more accurately and usefully characterize the degree of food processing and its impacts on public health. The article is open access in the journal Foods and entitled “Enhanced Labeling to Promote Consumption of Nutrient Dense Foods and Healthier Diets.” The core nutrient density metric is a ratio: the percent of daily nutrient needs satisfied by a serving of food relative to the percent of a 2000 calorie daily diet taken up by the serving of food. This single metric is unmatched in comprehensively reflecting the nutritional quality of food. A graphic option to convey the metric on packaging is presented in Figure 3 in the new paper: A novel graphic is presented in Figure 5 to which integrates both the nutrient density and food processing metrics and graphics in a single graphic, shown below. The impacts of ultra-processed food (UPF) on public health outcomes is among the hottest topics in nutrition, medical, and public health journals, and media coverage on food quality and health outcomes. At the request of the journal, the authors developed a video abstract that explains the paper’s goals, methods, and key findings and recommendations. The authors conclude their paper with these observations: Transparent and accurate food product-specific ingredient and nutrient composition data should determine the content of nutrition health labeling. Efforts to soften the message should be resisted in light of the overwhelming need for new food labels that help bring about substantial improvements in food nutritional quality and dietary choices. Benbrook and Mesnage’s paper builds on public comments HHRA submitted in response to the US Food and Drug Administration (FDA) proposed rule in 2023 to update the definition of the term “healthy” on food labels. The proposed role would require foods labeled “healthy” to contain minimum amounts of foods recommended by USDA’s Dietary Guidelines, and to limit saturated fat, sodium, added sugar and other less healthy nutrients. Entitled “Food Labeling: Nutrient Content Claims; Definition of Term `Healthy’”, the comments recommended new nutrition/health messaging on the front of food packaging. Co-authors of comments included the chair of HHRA’s Policy Advisory committee Dr. Kathleen Merrigan, HHRA science advisors, and other experts working on how changes in farming systems and technology can increase the nutritional quality of food: Dr. Hannah Flower, Dr. Donald R. Davis, Dr. David Montgomery and Anne Biklé. In the comments, the authors introduced “NuCal” as a name for their new system. Resources HHRA February 2023 comments to the FDA. Benbrook and Mesnage (2024). Enhanced Labeling to Promote Consumption of Nutrient Dense Foods and Healthier Diets, Foods. https://doi.org/10.3390/foods13213377 Video Abstract: “Enhanced Labeling to Promote Consumption of Nutrient Dense Foods and Healthier Diets”
HHRA Weighs in on Key Pesticide Issues Under Review by the National Organic Standards Board
HHRA and ORG-Tracker, represented by Dr. Chuck Benbrook and Dr. Brian Baker, submitted comments to the Agricultural Marketing Service at the USDA in advance of the National Organic Standards Board (NOSB) meeting in Portland, Oregon, from October 22nd to 24th, 2024. Drs. Benbrook and Baker will both attend the conference and deliver public comments. ORG-Tracker is a project carried out by HHRA. It aggregates pesticide residue data from inspections of organic farms carried out by certifiers. The tables generated by ORG-Tracker utilize the results of certifier testing to compare residue frequency and risk levels to food produced on conventional farms. The team is working to more effectively highlight gaps and challenges faced by certification agencies to answer questions like What crops should we be testing, and where? Is a pesticide residue found in an organic sample likely caused by accident, pesticide drift, or an intentional and illegal application? How can we modify organic programs to better mitigate risk? The comments delivered to the USDA discuss risk-based certification, pesticide residue testing, and policies impacting the incorporation of so-called inert ingredients in the biopesticides approved for use on organic farms. They argue for a more rigorous, comprehensive, and health-focused approach to risk oversight. Regarding residue testing, they advocate for more expansive and effective data aggregation to inform consumers and the organics community. Finally, for inert ingredients, they recommend further review of current policy, including increased transparency of ingredients in pesticide products. Thank you to Drs. Benbrook and Baker for your advocacy and hard work! The three sets of comments are posted on HHRA’s website as part of our policy program: Comments to the NOSB on the Risk-Based Certification Discussion Document Under Consideration During the October 2024 Meeting in Portland, Oregon Written Comments on the NOSB Discussion Document “Residue Testing for the Global Supply Chain” Comments on the Inert Ingredients in Organic Pesticide Products Proposal dated August 13, 2024 Drs. Benbrook and Baker also submitted and presented comments at the Spring 2024 meeting of the NOSB, which are available on HHRA’s Policy and Regulatory Reform page.
Dr. Kimberly Yolton joins HHRA board
Dr. Yolton is a developmental psychologist and epidemiologist serving as Professor of Pediatrics at Cincinnati Children’s Hospital Medical Center. Her interests include exposures and experiences that may alter a child’s developmental trajectory from infancy through adolescence. She collaborates on research projects on typical child development as well as those focused on the impact of exposures to environmental toxicants, opiates and stress during early development.
Paul Hartnett, HHRA’s Executive Director
Paul Hartnett has served as HHRA’s CFO since our founding . With the departure of Russell King, Paul has now joined the board and Executive Director. We thank Russell for his service and wish him the best in his future endeavors.
Heartland Study Enrolls 1,000th Mother-Infant Pair
July 19, 2024 – In June of this year, the Heartland Study achieved a major milestone, enrolling its 1,000th mother-infant pair. Enrollment is now at 50% of goal. The objective of the Study is to help fill major gaps in our understanding of the impacts of herbicides on maternal and infant health. Currently in Phase 1, the Study is focused on evaluating associations between herbicide concentrations in body fluids and tissue samples from pregnant women and infants, and pregnancy/childbirth outcomes. Phase 2 is designed to evaluate potential associations between herbicide biomarkers and early childhood neurological development. Much appreciation for the mothers enrolled, and the entire Heartland Study Team including scientists, support staff and clinicians for this tremendous achievement, and for our funders to making this work possible. Read more about the study including peer-reviewed studies published in Chemosphere and Agrichemicals at our publications page. The investment required to conduct this study exceeds $1 million each year. You can support this important work by making a donation here.

Carroll: Welcome back to the Healthcare Triage Podcast! Today we have a returning guest David Haas. He’s the [Robert A. Munsick] professor of obstetrics and gynecology and vice chair for research in the department of obstetrics and gynecology at Indiana University School of Medicine.

I hoped you might first, like we always do, talk about what you do and how you got there? What made you decide you want to be a doctor? Then into OB/GYN and from there to get involved in research and in the areas you’re interested in researching?

Haas: I never really had that sort of lightning bolt moment that said I wanted to be a doctor. It just sort of came to me one day in high school and I thought, sure, that sounds like a cool thing to do. It sort of happened that way and everything went well for me then during medical school as I was going through my rotations. As you know, you know you rotate in all sorts of different specialties and really it wasn’t until the end of my third year, when I got to the OB rotation and didn’t really have any desire to do it, but it had everything I wanted in medicine. It had some primary care. I loved to operate and then there’s just nothing like delivering babies and so it was exactly what I wanted to do.

When I came home halfway through the rotation and told my wife she said “you know you’ve been happier in this rotation when you’ve come home and more excited to talk about your days than you had on any other rotation” and so she sort of figured I was going to lean that way too.

During residency I just wanted to answer the “why questions.” There were so many things we didn’t know, so I really got bit by the research bug in that way. Trying to answer those questions about why we do things, the way we do things, and how can we improve outcomes?

Carroll: So what do you like to focus on in those areas with respect to trying to improve outcomes? What specifically are you interested in?

Haas: I am a general ob gyn so I like all of obstetrics and gynecology, but in the research area I am mostly focused in obstetrics in improving pregnancy outcomes and reducing risks so that at the end of the day everybody’s goal is a happy mom and a happy baby. If we can achieve that and if we can find ways to help us achieve that for this new family, that’s really the goal.

Carroll: One of the things that has been making the news recently and I’ve been reading about is plastics and concerns about some different kinds of chemicals or exposures and how those would relate to pregnancy. I know you do work in this area, specifically something called The Heartland Study, so I was hoping you could tell us a bit about that and a bit about whether I should be worried about these things.

Dr. David Haas is an ex-officio member of HHRA’s Board of Directors and one of the Co-Principal Investigators of The Heartland Study.

Haas: The Heartland Study is a new study that we started just about a year ago. We’ve recruited over 100 women here at IU. So far the plan recruitment is to recruit 2000 women and we’re really trying to expand into the whole state because we want rural women who are pregnant to also be in this cohort as well. It’s really about environmental exposures. It’s not necessarily as much plastic, but it is pesticides. Really looking at how farmers are waging this war against weeds and against insects and other pests and what are those chemicals that are helping increase crop yields doing to our health? So what we’re doing is recruiting a cohort of women that’s going to be multiple sites across the Midwest. We are really trying to understand and measure these pesticide levels in pregnant women’s urine and then also look at the pediatric outcomes and follow these kids out for several years to look at what kind of developmental impacts the exposures may have.

Carroll: When we’re talking about pesticides and exposure to them, is it that these mothers live near farmland where water runoff or other things are leading to their exposure, or is it that it gets on food in general and no matter where you live you’re going to get exposed, or is it something else?

Haas: Short answer is yes to all of those. We know that these are sprayed on crops and they get into the environment that way, but most of the exposure for women, for instance in a downtown urban area, is going to come from food. We also know some of these environmental exposures happen just in dust particles that travel around. So there’s a lot of different ways that people can get exposure and that’s one of the reasons why we’re doing the study and taking really detailed histories of what you eat. We’ve worked with some of our environmental health folks here at IU in the past looking at how we can understand where your water source is. Are you on well water? Are you on city water? And what are the ways that you might be exposed to these things? We know that exposure is really common and we want to understand what those concentrations look like for women and for their babies, and what potential impacts it could have on the pregnancy outcomes.

Carroll: So are you just doing questionnaires or are you actually having to travel and test people’s food and water and what they’re consuming?

Haas: Right now it’s with questionnaires, however as we move along in the project it’s something we may think about. If we’ve got pockets of participants who are in different areas we may go out and measure those things. We would have to get funding for that but that is something that’s in the back of our minds to do.

Carroll: Are you also looking at air quality and things like that, or is it for the most part just food at the moment?

Haas: Most of it is food. However, we’re getting addresses for all of these participants so we’ll be able to go into public ag databases and other air quality databases to look at some of those things based on their location physically. We’re looking at the various common outcomes that we look at in pregnancy preterm birth growth restricted babies: preeclampsia, gestational diabetes, and then how the babies will grow and develop. That’s the phase two component of the project.

Carroll: Are you expecting to find that there are serious problems? I mean, is this one of those where I’d be horrified to learn that people are consuming chemicals and then there are bad outcomes, or are these things incredibly rare and you’re trying to fix things at the margins from other work that’s been done?

Haas: We know that a lot of these substances are very prevalent in the urine, particularly in women in Indiana since we are such an agricultural state. There have been some association studies that have pointed to potential exposures with increased risks of some pregnancy outcomes that are things like growth restricted babies and shorter gestational length. So what we want to do is, in a bigger study and a little bit more robust of a study, to measure these concentrations to see if it’s just any exposure or if there’s a dose effect exposure that the higher your concentrations of these chemicals in your urine are the worse your outcomes might be.

Carroll: Do you envision that the outcomes from this would be telling people to eat or live differently, or would be to change regulations and how we actually use some of these chemicals?

Haas: It is very possible that some of the information that we are able to gather from this could definitely inform public policy and could inform people’s choices. We want to make sure we have good rock solid data before we start to get into any kind of other public education and advocacy work. But that is part of our funding agency who’s funding this project, the Heartland Health Research Alliance. They definitely have an eye to that next step, as to how do we get science translated into society?

Carroll: Is there a lot of variation between how farmers use these chemicals? Or I mean to the point where you need to know, okay it’s not just that you ate a lot of vegetables, but that you eat a lot of carrots and it’s this kind of carrot and that carrot comes from this farm?

Haas: We aren’t capturing which farms these things come from, although that may be a component we need to look at in the future. However, our dietary questionnaire is pretty detailed about which vegetables and which components and how much of your diet is quote unquote organic and where does that come from.

Carroll: How many moms and babies do you have to enroll in order to get some good data on this?

Haas: We are planning to enroll 2,000 women and mother-infant pairs, so we are at the very beginning. We will be recruiting other hospitals through the Midwest likely in the next year or so. We’ve just recruited a hospital system in Wisconsin to help us as well. We’re also working with Franciscan Health down on the southside of Indianapolis. It’s going to be a large cohort and nothing like this has really ever been done in the Midwest. We are also looking at some samples that we received from the nuMoM2b, which was a really large [10,000-participant] first-time pregnant women study. We’re analyzing those specimens right now to see what the exposure may have been when nuMoM2b was done back in the 2010 to 2013 range. We do know that the usage of these pesticides is going up as they’re trying to counteract resistant weeds, so there’s a lot of work and a lot of interest.

Carroll: Are you looking for outcomes just around birth, or are you going to follow babies further out once they are born?

Haas: Once they’re born we’re definitely going to be following the babies. That’s one thing I’ve always struggled with in obstetric research, is that the minute we hand the babies off to the pediatricians we sort of stop. So there’s a lot of push nowadays in obstetric cohorts to follow these kids out longer term. In The Heartland Study we’re absolutely going to plan following these kids for at least three years of life and see how it goes.

Carroll: How do you get women to enroll? Is it that they have to be taken care of by certain physicians or certain places, or is this the kind of thing with pregnant women no matter where they are no matter what they’re doing?

Haas: Now that we’re talking about collecting things at a distance, patients could get more involved in research. For many of our projects we will take anybody who wants to sign up. A lot of our cohort studies like Hoosier mom’s cohort, like The Heartland Study, are listed on the research at IU sites. For the all-in for health, those kinds of recruitment sites anybody is welcome to reach out to us here at the department and we can definitely get you enrolled. Particularly for The Heartland Study we want rural participants. We’d love to have at least 20 to 30 percent of our participants be out in the Heartland, in the farming communities, in rural communities. We know that there’s exposure in downtown Indianapolis, but we also know there’s exposure, and looking for how much of exposure, is a difference in rural areas. We’ve had all of these great processes that we’ve not necessarily perfected, but we’ve really improved upon how we do distance research. We can send things to you so you can send us your bio specimens back. There’s a lot of remote work that we can do for participants in various areas of the state and even if we have to see a participant physically to take their blood pressure or to do something like that, we can figure out ways to get that done. There’s a push through the CTSI and IU health and other health systems to see how we can get research resources in other areas of the state that we could have various hubs around to really make this a more robust research endeavor.

Click here for the full interview on Healthcare Triage Podcast