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Clinical Conversations: Obesity Treatment for Low-income Patients

Learning Objectives
1. Identify ways to engage low-income populations with healthy nutrition
2. Describe ways cultural and racial differences impact perception of healthy weight
3. List reasons why care for low-income populations may struggle with obesity
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Obesity Medicine Association (OMA) offers clinicians evidence-based obesity management techniques using the four pillars of clinical obesity treatment: Nutrition, Physical Activity, Behavior, and Medication. Learn more

Audio Transcript

Mark Labriola: Welcome to Obesity: A Disease, the official Obesity Medicine Association podcast exploring the many facets of the disease of obesity. I'm Mark Labriola and in this episode obesity medicine specialist and OMA clinical education director Dr Nicholas Pennings interviews Dr Caroline Apovian, a speaker from Overcoming Obesity 2019 about overcoming barriers to treating obesity in low-income populations. Obesity: A Disease podcast is brought to you by the Obesity Medicine Association, the clinical leader in obesity medicine.

Nick Pennings: Welcome to the OMA podcast. I'm Dr Nick Pennings, chair of family medicine at Campbell University School of Osteopathic Medicine and executive director of clinical education here at the OMA and we are at Overcoming Obesity 2019 Conference in Boston, Massachusetts and I'm here with Caroline Apovian. Dr Apovian and is a nationally and internationally recognized authority on nutrition metabolism and obesity medicine has been in the field of obesity nutrition for nearly three decades. She's a professor of medicine and pediatrics at Boston University School of Medicine and director of the Center for Nutrition and Weight Management at Boston Medical Center. Dr Apovian has written over 10 books and 200 peer reviewed articles involving original research on obesity and nutrition. She is immediate past president of the Obesity Society and one of the founding creators of the American Board of Obesity Medicine. And welcome, it was very nice to listen to your lecture today on obesity treatment in low-income patients.

Caroline Apovion: Thank you, there were many questions afterwards. So a lot of interest in the field of not just the obesity but as it relates to disparities.

NP: It is, it's a very challenging topic, especially since many of the interventions for obesity may be fairly costly.

CA: Yes, they they're costly. They're not any more costly than treatments for other diseases. But if third-party payers and insurance doesn't cover them, for many reasons, one of which that we need to get it out there that obesity is a disease then yes, then they're perceived as more costly than others.

NP: Right, right, the mother of all disease it seems in many ways. So one of the things that is often talked about with respect to that is that healthy foods are more expensive than less healthy choices. Do you agree with that? Are there exceptions to that belief?

CA: Well, I think it's a complicated question. Yes. If you know, go to your very expensive markets such as—I don't want to, but I'm going to say it: Whole Foods—then yes, you know, fruits and vegetables are, can be expensive, and lean protein such as salmon steaks and tuna can be expensive. That is very true. And you can go to a convenience store and get a liter bottle of soda pop for $1. So you can get pizza for very inexpensively and you know fast food, but that's not really the entire matter. You can also, if you go to the right place, you can get fruits and vegetables that are not that expensive. But the problem is, is that healthy choices are not there for our urban population in food deserts. So that's where the problem is: you can't go to a convenience store and get fresh fruits and vegetables, and that is the problem—not whether or not you know, fruits and vegetables are more expensive than other foods, less healthy foods. It's about how access to those.

NP: So both cost and access have significant barriers. Exactly. Yes.

So obesity rates are typically higher in lower income groups, but gender and racial impact is not uniform, for example, women of lower income households are disproportionately affected by obesity. Why are women in impoverished circumstances particularly at risk?

CA: I think women bear the brunt of economic disparity. And they are taking care of themselves and their children and their spouses and run the risk of, you know, not taking care of themselves. So that's one issue. I think that women tend to have higher rates of disordered eating. Certainly, in that respect, more so than men do. And maybe that's a tribute can be attributed to the differences you see in women in particular, than men in lower income households having issues. Another question was raised well do men in lower income groups? Are they, their jobs, hard labor? And is that reason why they have lower obesity rates could be, we need to look at that. That's a very important point that that needs to be studied, because men and women of higher income groups are at desk jobs. So maybe we need to look at that. But I think for a lot of reasons women of lower income households are disproportionately affected by obesity. If you look at African American women that have the highest rates of obesity prevalence in the United States, it has to do with not just being a woman, but being an African American woman, being a black woman. What is that about? It's not just different. You're a woman. It's probably genetics, cultural, and socio-economic. So we have to look at that.

NP: And so what role do those cultural influences and perceptions about excess weight influence those racial differences?

CA: Yes. So I think I alluded to a bit in, in my talk that women of color you know, their perception is that if you lose too much weight, you are not healthy, you don't look good. And we don't have that in the white cultures. We don't really have that, that perception. So that may really influence women of color, and their perception of what is a healthy weight. I think, I think African American women feel that a bigger weight is a healthier weight. That's true. You know, you just see it all that I see. Half of my patients are African American women, actually. And I get that from them all the time, that they don't want bariatric surgery because they don't want to look like they're emaciated. Right? I don't see that being talked about in in white populations.

NP: So there are different perceptions, but maybe also some physiologic differences. Well, you've published research on disparities in weight loss in different races in response to bariatric surgery. Can you explain what you found, what your thoughts are on why different races respond differently to bariatric surgical interventions?

CA: Yes, these are these are very important questions because we, our research can impact how the future of obesity treatment in this country and elsewhere if we see… we can corroborate what we found that African Americans don't lose as much weight as whites and Hispanic populations and then they regained more weight and at earlier stages than whites do with that's what we found, then we have issues with whether or not bariatric surgery is the best treatment for a certain population. It still may be because, you know, even though African Americans don't lose as much weight as whites after bariatric surgery, specifically the Roux en Y gastric bypass, it still is great weight loss, it's still, you know, 26% weight loss. We can't do that with any other medication, with a medication, for example. So it still may be a viable option. It's just that in the African American population, we need to be more vigilant, most likely after bariatric surgery after the nadir to make sure that there is less weight regain, and when there is weight regain, we also see in Caucasians at least remission a relapse of type two diabetes and African Americans it doesn't seem to be related to the weight loss. There's something about, about diabetes and African Americans. It may remit after surgery. But certainly there's more relapse. And we have to research that. And we may have to be more vigilant about adding medications after the nadir of weight loss in African Americans, even more so than we do in Caucasians, so it's just about, you know, understanding the pathophysiology and the treatment and we just don't have enough information yet.

NP: And perhaps maybe a little less emphasis on the amount of weight loss and a little more emphasis on the metabolic benefits that are realized from the intervention.

CA: Yes, that's very true. It's just that in African Americans, the metabolic benefit doesn't seem to be as great either as in Caucasians.

NP: Does that seem to apply to all bariatric procedures?

CA: We didn't look – we have an 11–year database. And at the time that we researched this, we didn't do enough sleeve gastrectomy. But my suspicion is that the data is going to look the same after sleeve gastrectomy. We're starting to realize slowly that the sleeve gastrectomy doesn't have as much benefit as the Roux en Y gastric bypass. I think people are starting to realize this and their research, going to the data, is going to manifest itself eventually.

NP: What role does insulin secretion and insulin resistance play in the variability of weight change in different racial groups?

CA: Well, so it's very important to remission of diabetes after bariatric surgery. And in fact, it can be very helpful to figure out what surgery the patient should undergo or help the patient figure out what surgery is best. So, Dr Showers′ group at the Cleveland Clinic have data suggesting that if your diabetes is extremely severe or had has been manifest for years and years and you're on insulin, that you're really not going to see remission after bariatric surgery. And if you're not going to see remission after bariatric surgery, then do the less, the least aggressive procedure. So do the sleeve gastrectomy. If you have diabetes, that has only been manifests for a few years, and you want to see remission, then both surgeries would do a good job but perhaps the Roux en Y gastric bypass might be better because you're going to the remission will be you'll have it for a longer period of time. And if you're in the mid-range, then I would go for the Roux en Y gastric bypass to get the best remission rates. So, that kind of tells you a little bit about where some of the, the more you know, progressive surgeons are going with these 2 procedures.

NP: And the different procedures have different metabolic effects, though too, right? Where you might see more of an effect on grehlin with a sleeve gastrectomy where you might see more of an effect on the ileal break GLP1 with a Roux en Y?

CA: Well, I don't think that … What does that mean for treatment, though? I don't know

NP: Well, perhaps if somebody has diabetes, is that significant? Right? Do you want to improve GLP1? One response in that situation?

CA: Well, I think the devil is in the details. Because, you know, if that were true, then we would be doing the Roux en Y gastric bypass for everyone with diabetes and obesity, and we don't so I think we have to look at duration of diabetes also. And just because, you know, I think you have to look at it in context of the duration of the disease and not just what's happening with the GLP1 levels.

NP: The ability of beta cells to recover and improve and function. Okay. So, can you tell us a little bit about maybe some innovative ways that might be able to overcome some of the economic barriers to healthy eating. That's one of the efforts that you've made here in Boston.

CA: Well, yes, here in Boston, we have a food pantry at Boston Medical Center. We've been up and running with that food pantry since 2002. And we're feeding 8000 families a month, all philanthropic, the food pantry started by some by restricting to mothers and children, like WIC, and then we immediately almost immediately be received so much more funding from philanthropy that were able to open it up to all families. And we now also have a demonstration kitchen, which is overlooking the cafeteria and the food pantry. It's a beautiful facility at Boston Medical Center. And we've been teaching families how to cook the food that they're able to get at the food pantry for several years now. And we have a dedicated RD chef who runs the demo kitchen. We have a dedicated technician who runs the food pantry. And we've also been able to develop a rooftop garden on top of Boston Medical Center that that basically grows fruits and vegetables and feeds the food pantry and also our cafeteria, believe it or not, with salads and vegetables, so we are able to really feed patients at Boston Medical Center. We have a lot of patients who are food insecure. We don't ask about salary or anything like that, we simply—the provider gets an idea that the patient is food insecure from the history and can write a prescription to the food pantry and no questions asked. So, they just have to be a patient at Boston Medical Center. And we are a model for other hospital systems all over the United States that would like to do something similar. So, we are very proud of this and it has really enhanced our ability to help patients with their obesity and other diseases.

NP: It sounds like a tremendous effort. And one of the things that I think was unique or distinctive about what you do is it's not a food pantry that's just about canned and boxed foods, that the access to fresh vegetables and fruits that are available through the food pantry is an important part of that. What do you think other food pantries can do to increase their access to fresh fruits and vegetables?

CA: Well, what we've done yes, we do provide a lot of fresh fruits and vegetables in addition to whole grains, lean proteins and some canned food, we have, as I said, we have the rooftop garden that provides a lot of those fresh fruits and vegetables in addition to philanthropy. So a large shopping, shopping for example, provides us with fresh fruits and vegetables as well. So it's not just the rooftop garden. But I think that there are ways of doing that, of working with farms around the area to provide produce for your food pantry. So there's a way to do that, that I think we become a model, so I think that that's a very important part of this.

NP: Well, thank you. That's very interesting insight and we appreciate you giving us your insights on a very challenging problem that faces all society today, and particularly a challenge for obesity medicine specialists to address.

CA: Yes, we also sell our own produce and produce from other farms in the area every Friday in our lobby for, you know, big bunches for $1. So very inexpensive. So this is for the general population as well. So that's another way of, you know, enticing people who would like to have a healthier diet to do so by providing fruits and vegetables at cost.

NP: And I'm in a farm area and yet much of the farm produce, that's foods that are produced, are shipped someplace else and not reaching the community. So I think connecting the farms to the community is very important. That is very important. I agree. Well, thank you for your insights today.

CA: Thank you. Thank you for having me. It was a pleasure to be here.

Mark Labriola: Thank you Dr Pennings and Apovion. For more information about obesity medicine, podcasts, and other resources from the clinical leader in obesity medicine, please visit obesitymedicine.org/podcast. Love this episode of Obesity: A Disease? Head over to iTunes to subscribe, rate, and leave a review. The views expressed in this podcast episode are those of the show hosts and do not necessarily represent the opinions beliefs or policies of the Obesity Medicine Association or its members. Please check back soon for another episode of Obesity: A Disease.

Audio Information

Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

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