Episode 92: Clinical Conversations: Obesity & Health Disparities - It's a Family Affair

Welcome to obesity a disease. The official obesity medicine association podcast exploring the many facets of the disease of obesity. Obesity a disease podcast is brought to you by the obesity medicine association a clinical leader in obesity medicine. I've been taken care of a young female patient that presented for evaluation of obesity. She had particular concerns about her legs that were large and painful. At her initial visit I diagnosed her with lipidema. My usual dietary recommendations sent her around consuming low carbohydrate or anti-inflammatory foods. Of importance is limiting refined carbohydrate sugar sweetened beverages and other sources of sugars as well as processed meats. For many patients this is a manageable strategy. However this patient does not have secure access to food. She relies on food from food banks friends and any place else that you can find it. Giving advice on what patients should do is easy part. The challenge for many patients is being able to carry out carry out that advice. This individual lives not only with food insecurity but also housing insecurity and relationship insecurity. These issues were not barriers that she freely offered but while taking her history they became apparent as we started to develop a treatment strategy. I didn't ask the right questions I would never know. She's not alone. Hi I'm Dr. Nick Pennings, chair of Family Medicine at the Campbell University School of Osteopathic Medicine and Executive Director of Clinical Education for the OMA. And with me today on the podcast is Kathy Earls MD and pH. Dr. Earls presented on obesity and health disparities as a family affair. Pediatric and adult considerations at the 2023 obesity summit in San Antonio, Texas. Dr. Earls please tell us about yourself. Thank you thank you Nick. Call me Kathy please. It's a pleasure to be here. I am a Chicago Illinois raised tower university educated. PDs for some by training and board certified in both Pediatrics and obesity medicine. Currently I'm an obesity medical liaison for Nova Nordisk and an assistant professor in the Department of Pediatrics at Moorhouse. I've spent the majority of my time really just edifying a whole lot of information regarding the disease of obesity and that includes pathophesiology, comorbidities, treatment and most recently a large portion of my time has been spent discussing the roles of social determinants of health and the impact on the disease of obesity. And a key part of that is the doctor patient relationship. It's an integral part of patient care. Patient trust and healthcare providers allows for more effective communications, more thorough evaluations and greater acceptance of and adherence to treatment plans as well as a greater likelihood of regular follow-up visits. However, that trust in providers and medical institutions is less likely to be present and minority patients. What do you see is the origins of that lack of trust? Yeah that's a great question. We unfortunately have a long and sorted path that's really laid groundwork for feelings of mistrust extends as far back as 19th century by the gynecologist Dr. J. Sims on enslaved black women following very traumatic deliveries in which the women suffered physical vaginal fistulas. He performed experimental surgery on these enslaved black women without their permission and without anesthesiologist. And then many are really familiar with the Tuskegee study and that's from 1932 in which over 600 black men with syphilis and thought they were receiving treatment were really just being observed for the lifestyle of the disease. And this is horrific for a multitude of reasons to of which it was unknown not only to the black men but to their spouses, many of who contracted these disease. And the second thing is the fact that there was an early and effective treatment for syphilis in 1910. We also have this story from Johns Hopkins that began in the early 50s in which a young black woman by the name of Henry and a Lacks presented to Johns Hopkins University with a very aggressive form of cervical cancer. Her cervical cells were obtained and they were used to make a series of treatments and vaccinations including the polio vaccine as well as COVID-19 vaccine. They were also used to study leukemia, AIDS virus and cancer worldwide. And additionally many pharmaceutical countries made millions. All of this was unknown to Miss Lacks and her family until very recently. And then we have current examples that the epidemiologist who worked at the CDC, Shavon Irving, who died after delivering a baby. She noticed a very tender lump along her C-section incision. It required lancing and draining. She had significant spikes in her blood pressure and nurse made a visit to the servings home to drain in his incision. And she also recorded the blood pressures. She suffered from chronic pain, headaches swelling in her legs and on January 19 she went in for her screen for postpartum preeclampsia which was came back negative. She went home and she died five days later. She collapsed in her home with cardiac arrest, Russia, the hospital and died. So we not only have these historical examples but we have very recent and present examples which lend themselves to continued mistrust within the black and brown communities. So more recently the COVID pandemic and widespread recommendations of masking immunizations generated new levels of mistrust in the healthcare system. Did that further fuel mistrust in the healthcare system among minority patients? Yeah, I would say that that further fueled the fire that had been set centuries before. Why people make up a small share of people who receive at least one dose? 55% of people who recently received the vaccination, that's about 48% compared to their share of the total population. It's about 59%. Black people in the other hand make up 10% of the people who recently received the vaccination which is the same as our share of people who received at least one dose which is 10% and it's smaller than that share in the total population which is about 12%. Hispanic people make up a larger share of vaccinated people at 21% and people who recently received the vaccination there 23% compared to their share in the total population. So the overall share of vaccinated people who are Asian, it's similar to the share of the total population. So you see the mistrust has been carried down to the lower percentages of vaccinations in black and brown communities. There the distrust lives on Nick. And a lot of that centered around the newness of the vaccine and I can see how seeing this is somewhat as an experiment and not wanting to be part of something that was at least perceived as being experimental yet. Correct. So do you see the level of trust in medical institutions getting better or worse and unxtmine minority populations? That's an excellent question. I really see medical mistrust persisting and it appears to be growing. The farmer company, Genotex, surveyed about 2,200 patients about half of them were considered to be medically disenfranchised because they didn't have really good access to mental care. And about 2/3 of medically disenfranchised black and Latin American people said they did not feel that the healthcare system treated them fairly at all. And about half said that they skipped their follow-up appointments or really stopped going to their provider because they didn't feel understood. And 1 in 3 do not by choice participate in clinical trials or get vaccinated due to this persistent lack of trust. So in addition to the mistrust of the healthcare system, what are some of the other factors contributing to the healthcare disparities? So social determinants of health have a really huge impact on health outcomes and this disproportionately impacts economically and socially marginalized communities, factors such as income, education, environment, and access to care all have to be considered when we attempt to provide treatment to get better healthcare outcomes. For example, prescriptions cannot be provided if you don't have ample finances or even transportation to pick up that therapy. There is a wonderful illustration and brought out by the Institute of Clinical Systems Improvement that depicts a person and it divides that person into percentages based upon what impacts their health care. And so the physical environment is about 10%. Health care is about 20%. Health behaviors like tobacco use, diet and exercise, sexual activity, that's about 30%. But the bulk of it has to do with social economic factors. Talking about employment, talking about social support, income. What's the community like in education? And those are serious issues. And that brings me to the patient that I saw and that the importance of being able to delve into those issues when you're coming up with a treatment plan. So what are some of the strategies that we can use as health care providers to explore those areas more and make sure that we're addressing those components of their care? First of all, Nick, I think it's a good idea to really sit back and admit our own bias and stigma towards our patients with obesity. And also admit the fact that many of us who were trained in my area weren't educated on the disease of obesity. In fact, we did not even learn that it was a disease. And then educate ourselves. And then secondly, ask for permission to discuss the disease of obesity with our patients, ask for permission and then provide education in an empathetic and non-judgmental fashion towards our patients. And then ask them what are they willing to change and then help in facilitating that change. So we're being more of a partner instead of a dictator in terms of our treatment towards our patients. And that's I think an essential component of motivational interviewing where we are engaging the patient and voking ideas from the patient rather than just coming up with a list of ideas that may or may not work for that individual, especially if we are not factoring in those social determinants of health when coming up with that plan. Absolutely. So there was a time when obesity was a sign of an ability to afford food and thus a symbol of health and wealth with the agriculture and evolution, advances in food, technology, highly processed foods became readily available at lower costs, but also with much lower nutritional value as well. How do health care disparities and consequences of food choices impact obesity risk? So if you don't have first income to obtain healthy food, then it makes it quite difficult to do so. But not just income, Nick. If you don't have access, for example, in many of our marginalized and disenfranchised communities, you will find a plethora of fast food restaurants. You can have a chicken restaurant, a burger restaurant, tacos, the whole gamut and you may have just one grocery store. And in that one grocery store, the abundance of fresh fruits and vegetables may be negligible. That makes it extremely difficult to have access to healthy food that will encourage healthy outcomes. A given example, Nick, when I was on full-time faculty at Morehouse School of Medicine, my clinic was on a street that had a lot of those fast food restaurants and it had one grocery store. And I would preach to my patients and their families to get fresh fruits and vegetables and eat them two to three times a day until I went to the grocery store. And then I was able to see firsthand that those fruits and vegetables were perhaps not as fresh as those that are provided in our community. So I had to change my recommendations. And I'd say, get enough fresh fruits and vegetables to last you one to two days. And I also had to increase my education regarding the impact of many of our fast food habits on their health, not just their physical health, but mental health as well and that of their children. And speaking of children, how does this particularly affect the pediatric population? Yeah. And as we can see, when we look at the curve of the epidemic of obesity in the United States, we can see that the curve for adults, which is trending upwards, particularly in black and brown communities, it also is reflected in the curve that is trending upward in the pediatric population. And that if you think about it, it makes sense. Children typically do not buy the groceries. That's one thing. Children are directly impacted by the income of that family. If a child also experiences gunshots, that increases their anxiety. That alone is associated with poor health outcomes. So it's a matter of a ladder of community safety or the lack thereof, the lack of family and social support, education, poor educational system. If you go to a school in which it is a crowded classroom and the lunch lacks any type of nutritional value and you are instead surrounded by fast food at every corner, then it makes it quite difficult to eat in a manner that will encourage healthy outcomes. And very often those foods have a flavor that is attractive to students or packaging that is attractive to kids. That also makes it more challenging to stop for healthier foods, which may not have that same taste appeal. Absolutely. How have school lunches and access to food through schools impacted kids? Has it been a beneficial thing or has it been a harmful thing? Well, it depends upon the school. It depends upon the community. Schools, public schools, for example, receive their funding from the neighborhoods. So if you live in a neighborhood that has a high income that has their expensive houses, then those schools will be better funded than some other areas in which there is overcrowding, there is public housing and the income in fact is lower. So let's say for one school that's in a economically more infused neighborhood, you may in fact have a lunch that is brought in. You may in fact have a vegetarian option. You may also have math every day and a foreign language every day in PE every day. There is if you go into another community that where the income is less, where there is less family support, where there is a significant amount of unemployment, then in fact, you may get a less quality lunch because of the income or the lack thereof that can be provided to sustain a healthy lunch in that particular neighborhood. So access can increase but the quality of the food is not necessarily better. Yeah, and I'd say access to fast food can increase. And then the other thing too, Nick, is that when we look at fast food in areas where the income is significantly higher, even that fast food is different. There is a pretty big difference between the caloric fat and the quality of the food and let's say for example, and I'm probably getting trouble with this, to polling versus the local wing shop. There is a difference in the fast food in these neighborhoods. There's also more access to grocery stores in some of our higher income neighborhoods. An example here in Atlanta, not too far from me, is that there's one neighborhood that has one grocery store, but it has 30 to 40 fast food within that strip. Then if you go to a higher income neighborhood, a bit away, instead we have some fast food options, which I said are a little bit higher quality than in those that we did do in the first neighborhood, but we also have numerous grocery stores. There's a public. There is a trader jove. There's a whole food, so there are options there as well as different options for fast food that are of a healthier nature. Yeah. With the advent of new high-pote anti-obesity medications, this creates some new and exciting opportunities for obesity treatment. However, their high cost is prohibited from any individuals, and while advances are being made in the treatment of obesity, are those advances also growing the disparity in access to treatments for obesity? Yeah, I wish I could say that the access is improving just at the same rate that we're developing these new and very beneficial anti-obesity medications. USJ. center just did a white paper that highlighted the benefits, potential benefits of increasing Medicare coverage for the new classes of the weight loss drugs and really estimated that increasing the coverage could save nearly a trillion dollars over 10 years and reduce healthcare costs and improve quality of life. The coverage could generate I mean over 175 billion in cost to Medicare in the first 10 years alone and then the benefits would extend beyond Medicare to the society at large. Certainly quality of life benefits and overall not just the cost of healthcare but ability to work and avoiding disability and other health consequences of obesity would be really important. Yes, the other thing too Nick about that is the paper suggests that covering the obesity treatments could not only reduce the overall healthcare cost but improve health equity since obesity disproportionately affects black and brown communities and lower income communities. Absolutely and so we have a long ways to go but are there some organizations that are making strides and improving racial and cultural disparities in the US? Yeah there are some of course the end of NAACP they work on a whole wide range of issues including voting rights and criminal justice there's a national urban league Asian Americans advancing justice and then there are also a series of leadership conferences on civil and in human rights this is really a coalition of about 200 national organizations that work to promote and protect the rights of all persons in the United States and they really focus on advocating for policy change and that policy change primarily deals with equality and justice. Right and those are many of the drivers of consumption and stress and all contributors to the development of obesity and the maintenance of obesity. So what do you see as some key future initiatives that are opportunities to address the racial and social disparities in the United States? Yeah so there are several initiatives that are proving to be quite impactful there's the heat initiative that stands for health equity action transformation and it was launched by several healthcare organizations and it's aimed to essentially eliminate disparities in healthcare access and outcomes it focuses on data collection policy advocacy and community outreach and then there are some other oh there's justice and equality and this is aimed at reforming the criminal justice system supports policies that look at the disproportionate incarceration rates of minorities and develops initiatives for bail reform sentencing reform and to promote alternatives to incarceration. Well that's great and one of the things that I see in medical students that are coming into medical school now was really a much greater focus on these issues and a much greater concern about access to healthcare and I find that very inspiring and hopefully that that translates into a future where these you know inequities are narrowed yes yes ideally so. So lastly one discussing obesity treatment with other healthcare providers what's your favorite bit of advice? My favorite bit of advice is perhaps dealing with to me what I see as one of the most difficult things to face when we talk about treating our patients with obesity if we do not recognize our own bias and stigma towards our patients with obesity then we're not going to be able to provide compassionate empathetic care towards our patients so really I believe the change begins with us as providers and how we show up towards our patients and I mentioned before I first asking for permission second begin the conversation provide education for our patients and then third see where our patients are willing to make that behavior change and then do what we can to assist them towards those endeavors and building self-awareness is extremely important there the power of our words as healthcare providers is really very strong and can have lasting impacts on our patients so I think that self-awareness is really key. Definitely and that's oftentimes more difficult we can read a book and memorize the information and just it and learn it and spit it back out but I would suggest that it's more difficult to look within and see what negative emotions we bring to the table when addressing our patients. Absolutely well thank you Kathy you can find Dr. Earl's conference lecture obesity and healthcare disparities it's a family affair pediatric and adult considerations in the OMA Academy where else can our listeners learn more about your work. Well you can learn more about my work from some publications that I've done a book that I wrote and by emailing me as well I'm always ready to provide education on the disease of obesity and treatment towards it as well. Well that's wonderful and I just sent a connection on LinkedIn to connect with you as well. Thank you. 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