The Medical Alley Podcast, presented by MentorMate

Race and Cardiovascular Disease in America: Obesity's Impact on Heart Health

Episode Summary

For the second year in a row, the Medical Alley Association is partnering with the Association of Black Cardiologists and the Preventive Cardiovascular Nurses Association to bring you a three-part content series focusing on Race and Cardiovascular Disease in America. In our first of two podcast conversations, we're joined by Dr. Fatima Cody Stanford and Dr. Emily Jones, who lend their expertise for a discussion about obesity, cardiovascular disease, and maternal health. The second part of this content series will be another podcast discussion, followed by a solutions-oriented webinar on Dec. 8.

Episode Transcription

Frank Jaskulke00:10

Good morning, good afternoon, good evening to all those out in Medical Alley. Today we have a very special edition of the Medical Alley Podcast that's done in partnership with the Association of Black Cardiologists and the Preventive Cardiovascular Nurses Association. It is always fun to get to work with association peers. This is the second time that we've partnered with these organizations to bring important stories, important information to what's going on in healthcare. And this podcast is the first in a three part series. We'll have one more podcast, and then we'll have a webinar that will conclude the series on December 8. So make sure you're looking out for the podcast or looking out for the webinar. If you're not already a subscriber, hit that button and make sure you subscribe. So today I am so pleased to have this conversation and to be joined by Dr. Fatima Cody Stanford, an obesity medicine physician scientist and educator at Massachusetts General Hospital and Harvard Medical School. And Dr. Emily Jones an associate professor of nursing and PhD program director in the Fran and Earl Ziegler College of Nursing at the University of Oklahoma Health Sciences Center. Today, we're going to have a conversation about obesity, cardiovascular disease and maternal health, and some of the new research developments, treatment developments. And maybe even we'll get into a little bit of public policy in this very important issue. So to both of you, thank you so much for joining us. Maybe what I'll start with is I'd ask Dr. Emily Jones, if you'd give us a quick intro on yourself and your work. And then Dr. Stanford I'd ask you to do the same.


Dr. Emily Jones01:50

Sure. Thank you for the warm welcome. I'm Emily Jones, and I'm currently a nurse, scientist and associate professor of Nursing. But my career started in labor and delivery. As a labor and delivery nurse, I cared for women with complications of pregnancy like gestational diabetes, preeclampsia, hypertensive disorders. And I saw that we offer great care during pregnancy. But when it came to the discharge instructions, far too often, those nursing discharge instructions sounded just like they did for anyone without a complication and pregnancy. And what I began to realize was, we weren't offering preventive approaches, approaches that would really think about preventing diabetes down the road or cardiovascular disease. And that's really where my research questions began to grow about lifecourse prevention care, starting postpartum. So the majority of my research has been in the space of postpartum cardiometabolic risk reduction and advancing maternal health equity broadly, but particularly for indigenous mothers in this country. The research that I lead has all been centered on relationship and community based participatory principles.


Frank Jaskulke03:04

Oh, fantastic. Thank you. I appreciate you sharing that background. And Dr. Sanford, if you would.


Dr. Fatima Cody Stanford  03:10

So my name is Dr. Fatima Cody Stanford, and I'm an obesity medicine physician scientist at Massachusetts General Hospital, and associate professor of medicine and pediatrics at Harvard Medical School. I'm one of the first fellowship trained obesity medicine physicians in the world. And so my work really revolves around treating patients with the disease of obesity across the age spectrum. As both an internist and a pediatrician, I care for patients from the range of two to 90. I've published over 170 peer reviewed articles and journals like the New England Journal, Lancet, BMJ, Nature, Cell, etc. And my work really spans looking at treatments for the disease of obesity, particularly focused on lifestyle and pharmacotherapy, and metabolic and bariatric surgery across the age spectrum. A lot of my work also focuses on disparities, looking at disparities that we see in the diagnosis and treatment of patients with obesity, particularly racial and ethnic minority communities here in the United States. And I serve as an advocate for patients with obesity, looking at issues such as weight bias and stigma, which are prevalent and pervasive in our society and actually most prevalent amongst healthcare professionals that care for these patients. And so a lot of my work really looks at how do we undo the stigma and the bias that exists so that patients would actually want to seek care from us, either as physicians or other health care providers. And so that's the work that I do. That's what's brought me to this work. That's what sustains me in this work. And I see my patients as my family, and I will fight for my family. And that's what I do every day.


Frank Jaskulke04:44

Thank you. Appreciate you providing that background, and I might stay with you for just a moment. There's been clearly a lot of research done in the last 20 years on this topic. And our knowledge, our understanding of the issue has advanced significantly. Could you give our listeners a little We'll perspective on how that knowledge has advanced and what kind of better understanding we have today.


Dr. Fatima Cody Stanford  05:06

Absolutely. I think that, you know, one thing that has become more pervasive in knowledge, although I still say we have a long way to go, is the recognition of obesity as a chronic disease. So obesity is a chronic relapsing remitting disease that can occur over the life course. And what a lot of people are unaware of is that obesity is actually a disease regulated by how the brain signals and there's two primary pathways in the brain that tell us how much to eat and how much to store. One part of the brain that's in the brain that tells us how to store little and eat little is called the POMC or the pro-opiomelanocortin pathway. And that pathway happens in the paraventricular nucleus of the hypothalamus. It tells us to eat less than store less. And people that traveled down that pathway produce high levels of something called BDNF or brain derived neurotrophic factor. And that's really great because those people tend to be very, very lean. I exclusively care for patients with overweight and obesity. And so they traveled down an alternate pathway, the brain called the AgRP, or the agouti-related peptide pathway. That inhibits the formation of that BDNF. And what that ends up doing is leading to expression of adipose or fat. And so it's not necessarily something they did to themselves. It's how their brain signals. Now, what we do know is that the body and the environment that we exist in can have major adverse causes. And we think about dye quality is as important physical activity is important. Unfortunately, lifestyle behaviors in and of themselves typically don't lead to significant weight loss or, you know, basically sustainability of that weight loss. And we've seen shifts in circadian rhythm, which means that we need to be awake when it's bright outside and sleep when it's dark outside and when we deviate from this, this actually causes significant more storage and actually the Nurses Health Study, along with the health professional study really demonstrated this when we compared nightshift workers to day shift workers. Medications that we prescribe for other issues can often lead to tremendous weight gain. And we do believe that 20% of obesity in this country is secondary to medications we prescribe for other issues — medications, like lithium, Depakote, Tegretol, Celexa, Cymbalta, Effexor, Zoloft, Paxil, Ambien, Trazodone, Lunesta, Gabapentin, Glimepiride, Metoprolol, propranolol, long term insulin, long term pregnazone, just to name of the ones I wanted to say at that moment. And these are all really, really important. And then I think we can't discount genetics and the role it plays. We know that if you're born to parents with obesity, you have a 50 to 85% likelihood of having the disease even with optimal behaviors. And so what we're looking at is almost half of the US adult population with the disease of obesity here in the US as defined by BMI, which is flawed, and we can come back to that another time. But about 20% of pediatric patients, which means anyone aged 20 and below.


Frank Jaskulke08:01

Staying with you for just a moment there because you said something that really struck me which was that parents who are obese, their children have a high propensity as well that it sounds almost like there's a generational piece there. Is that showing up in the research as well?


Dr. Fatima Cody Stanford  08:18

Yeah, absolutely. I'm gonna change one of your words I'm gonna eliminate — and so for those who may be listening, let's eliminate the word obese. Obese is a label, obesity is a disease. So we say a person with obesity, they have it but aren't defined by it. So that's one key thing. I want to make sure we change in our language. But yes, so let's look at the generation there's a generational piece. So the generational piece is more of an epigenetic piece, but it's also just kind of — I'm going to use dogs to explain this. I feel like people get this when I say this. So let's say we were to put a bulldog with a bulldog and mate them. You're gonna get a bulldog, right. So they're going to be no matter how like you can have a lean bulldog and a heavier bulldog, but they still kind of have the same kind of look right? You're gonna be able to identify it kind of stout kind of round, it is what they are. Now, if you were to mate a chihuaha with a chihuahua, lean little bitty dog, right. So that's why Taco Bell like to use it because it's cute and it's little. But if you were to make, let's say a chihuahua with a bulldog, I don't know really how that will work, you guys, but let's just say you're gonna get a hybrid of that, right? So when you think about that, it's not that they did anything, the Chihuahua or the Bulldog to look the way they are, it was just kind of the genetic pieces they were dealt. And so I'm not saying we're dogs, but if you explain it that way, people are like, oh, yeah, they do kind of look a certain way. And so if you have two people that have, let's say, severe obesity and you meet them together, the likelihood that you have like a very, very lean child is lower than then if you were to have just two very lean people. So often what you'll see and what I hear is kind of this this myth that I see as you know, you see families that have obesity walking around and you're like, I've seen these really negative stigmatizing things. Well, no one runs in this family or everybody's eating badly, but it's, you know, the cards they were dealt They didn't get the chihuahua genes, they got the bulldog genes. And it's not their fault. The kid can's go back and be like, You know what, I want a new mom and dad, let me go back and redo this again. But since we have that, then we have to treat it. And often these are the kids that are coming in at the age of two, already two standard deviations above the growth chart, not because they did anything wrong, because that's just what they were made up of.


Frank Jaskulke10:23

Oh, very interesting, and thank you for for describing it, then that makes it much easier to understand. And Dr. Jones, I might switch over to you for a moment is the other factor that we hear a lot about, and I think about you describe your work in prevention and realizing we weren't providing families with information. We weren't providing the moms information when they needed it or the right way. What about the broader factors that are around them the social or the environmental factors that a family might be conceiving in or that a mother might be birthing in and have to deal with? How does that impact the disease of obesity?


Dr. Emily Jones10:59

Undoubtedly, eco social factors impact rates of obesity and overweight in our society and around the globe. There's no doubt about that. One of the best ways I have to think about this actually came from a research participant once during a qualitative study where I was seeking to better understand mother's risk perceptions. And again, these particular moms were tribal citizens and indigenous women in the US. And one mom said, you know, when I think about my risk for getting diabetes, I don't know if it has more to do with the other people in my family have diabetes, and I'm genetically predisposed, or that I've just been in the same environment, I've learned to eat the same way my family eats. And I have similar physical activity behaviors as my family and I just don't know where to tease out the gene, or genetic predisposition, and maybe learned environment. And I think that that's a really important thing to bring up. But behaviors and those lifestyle behaviors, as Dr. Stanford already mentioned, only account for a certain percentage of control over a person's weight, and what that weight is going to be. So when we think about those social and ecological and environmental risk factors, that's really something we've only begun recently to pay serious attention to in this field of obesity science and weight management. The words social determinants of health or structural determinants of health are now part of our vocabulary in a way that they just weren't one to two decades ago. When we talk about determinants of health, we're really talking about root causes. The root causes of obesity are complex, but certainly conditions of socioeconomic disadvantage and poverty, resulting in food insecurity, maybe lack of access or affordability of nourishing foods or overnutrition of non nourishing foods. Those are root causes. Not all of the root causes. I think there's a lot of interesting work that's happening right now, particularly in maternal health and this field that we call the first 1000 days, which really captures that very vulnerable time period where pathways are being laid that impact the health have offspring and generations to follow. And what we're learning in this expanding science is that adverse childhood experiences, trauma, stress, chronic stress can literally be embodied in biological ways, and can impact the brain as Dr. Stanford, you know, started our conversation out by saying obesity is a disease that's regulated by the brain. And yet it's very complex, to say the least, to disentangle the social, and the environmental, from the biological sometimes, and it's those mechanistic pathways from the social and the ecological to what we're seeing in the body that we have a lot of work to still do to really illuminate what's happening there.  I'm hearing you say that we need to understand more and it's a component of it, but not the totality of it. Given what we know today, should we be investing more in say public health initiatives or interventions and addressing some of those community issues? Yes, we should. In my estimation, the policies that we should be pushing for harder than any other policies relate to those that are upstream in nature. So policies that are going to actually allow us to prevent metabolic diseases from occurring are so important, and historically have not been prioritized in this nation, and truly around the globe, as we see prevalence of chronic conditions that are non communicable like diabetes and heart disease. Prevalence keeps going up. People are living longer with them. But the prevalence and the impact on quality of life across the life course from childhood through older adulthood, if we can focus on upstream, community driven programming and interventions that meet people where they are, that address the cultural context of people's lives, that may actually begin to move the needle on our country's health outcomes when it comes to conditions that really are related to the disease of obesity.


Frank Jaskulke16:06

Well and to that end, if taking the premise of the public health side is one piece of it, I'm curious, and I'm sure our listeners listeners are too, Dr. Sanford, are there better treatments today? Or do we have better options? And if we do, how's the accessibility picture for them? I always think, right, you can have a great treatment. But if a person can't take advantage of it, it kind of doesn't exist. So where do we stand today?


Dr. Fatima Cody Stanford 16:35

I think you, first of all, I liked the way you framed that. If it's there — and I always tell my patients, if it's like a shiny ornament on a shelf which you can't get to, it's lovely, it's pretty to look at. But if you can't get to, it doesn't really mean anything. And so let's talk about the range of therapies that we could utilize. So we have lifestyle modifications, which is, of course has been there, it's always going to be there, it's part of what we would look at. And then of course, we have medications, or we call it anti obesity medications. And actually, believe it or not, the first medication ever approved in the United States was approved by the FDA back in 1959. So while there are newer classes of medications, medications have been around just most people didn't know how to use them. And to use them safely I think is another story. And then we also have metabolic and bariatric surgery. So those are kind of the three tiers. Now, there are devices that can fall somewhere in that kind of medication to surgical milieu that also can be utilized in there. These are FDA approved devices for the treatment of obesity. And so I guess if we want to kind of give the total picture, those are all the things. But let's talk about what's happening in this country currently in terms of treating obesity compared to other chronic diseases. What we do know is only 1% of patients that meet criteria for anti obesity medications actually received them. I published a paper in the Mayo Clinic proceedings last year around this time that demonstrates that. So only 1%. And then only 2% that meet criteria for metabolic and bariatric surgery actually receive that. So only 3% of individuals in the country right now are on what we call more advanced therapies, meaning beyond lifestyle modification. Now, I would lose my medical license if I did that for other chronic diseases. So let's say a patient came in with diabetes, they have poorly controlled diabetes, and I'm like, You know what, I think you just need to eat a little better and exercise more. And then they come in still with a very high blood sugar. and you're like, yeah, so you know, maybe you should add in some running, you know, okay, and then they come back, and then, you know, have you added more vegetables, you know, so we can keep doing that. The problem is is that their brain is defending a certain setpoint. And we don't treat it like other diseases. So we let this go on and on and on. And they come in to me at 65, 70. And then we have a really, really big problem. Or even if it's kids, we have these kids that you know, we just tell them to change into drinking low fat milk or something like this. And you're like, we have a severe issue. And so I believe in treating these diseases with the right tool for the size of the problem. We have a severe problem, severe obesity, we need the appropriate tool. If we have a mild problem, that smaller tool, right? So it's just about using the right tool. And often the way I kind of look at this is, and for those people that live in the northeast, this would make more sense, I am from the southeast, so I'll have to use an analogy for the southeast also, but all right, let's look at it I'm going to use something that will apply to the to the country at large. Okay, so let's say it's a hot sweltering day somewhere in the country and you go into a building. Probably you want air conditioning, I would presume. Would you want just a handheld fan? Or maybe you want like a whole thing that, you know, central air that you know, supplies the entire building. What we usually do for patients with severe obesity is we give them a handheld fan and we're like, okay, go use this and you're like, What am I supposed to do with this? But maybe we need to, you know, give air to the whole building. What I usually talk about here in the northeast, for all of my people that are used to a lot of snow is, you know, if we got two feet of snow, would you go give someone a teaspoon and tell them, you know, let's move the snow away? Probably not. Maybe. And I asked them, What would you use, they're like, oh, plow. Exactly. We use the right tool for the size of the problem. Getting to these treatments and accessibility, believe it or not metabolic and bariatric surgery is much more accessible than medications for the treatment of obesity. Most insurers including government insurance, Medicare, and Medicaid will approve metabolic and bariatric surgery, not all, but a large majority will. And very few will cover anti obesity medication. So we go from lifestyle, to surgery. And then we have this big doughnut hole, not the doughnut hole we're used to hearing about with insurance coverage. But I think it's problematic. And I think we treat patients with obesity in a different way. We're like, Oh, you have a disease, sorry, you must not be doing something, right? It's all the onus is on you. Whereas if a patient comes in with hypertension, or diabetes, or heart disease, we actually treat their disease and emphasize the lifestyle factors that go along with it. We don't necessarily just say medications, but if someone comes in with really poorly controlled hypertension, we don't just send them home and tell them to eat less and exercise more, which is often what patients with obesity get.


Frank Jaskulke21:22

So is that to say that part of the challenge is within the clinical community itself and changing their mindset to how they treat their patients?,


Dr. Fatima Cody Stanford  21:33

Yeah. Well and Dr. Jones, if I come back to where you started in your opening comments about seeing that prevention wasn't part of the work, I'm curious, do you think is that a similar dynamic to why we didn't have those sorts of discharge guidelines or other supports for those individuals? That's 100%. So actually, the professions known to actually demonstrate the highest amounts of weight bias for those in health care, physicians, nurses, PAs, physical therapists, we, as a group, health care providers tend to have very high levels of weight bias towards individuals with excess weight. And this is why they will often delay seeking care until things are really, really advanced. Because if you come in to the doctor and I basically ridicule you or and you know, accuse you of doing something that you haven't done, do you really want to come back to see me? But maybe you've experienced that your whole life. Maybe it started with your pediatrician. And then it also happened with your internist or family physician. It also happened when you went over to the orthopedist. and they said, Hey, you got to lose 120 pounds before I'll see you. And you're like, hey, wait a minute, I'm trying to get help. Nobody seems to want to help me. And everybody just tells me it's my fault. Would you want to go get seen? Probably not. But that's what people are experiencing. And I can tell you, I've seen patients that are coming in, in their 80s for their first appointment, and they can recount every experience in healthcare that was negative, deleterious to their progress. And they can go back to childhood, way before I was born, because they're in their 80s. And it's really, I can tell you, it breaks my heart. It breaks my heart to see that our profession — and when I say our profession, not just medicine, healthcare at large — does not treat patients. But a lot of this has to do with poor education. It's only this year in 2022, that the American Association of Medical Colleges is releasing core competencies surrounding obesity. We still don't see any core competencies in nursing schools, PA schools anywhere in the country. So if no one's being taught about it, how can they be expected to treat? But yet we learned how to treat everything else. We learn about diabetes, we learn about heart disease, we learn about sleep apnea. We learn about all of these things that are often caused by the obesity itself. And what I love about my work, particularly on the patient care side is that I literally have the only area of medicine where I'm actually deleting diagnoses from patient's charts. When I treat their obesity, they no longer may have diabetes, or it's in remission, or they no longer have high cholesterol, they no longer have fatty liver, they no longer have sleep apnea. And if I come to the problem of like, I have no idea how to build this patient because they no longer have any disease, that's a good problem to have. It's a problem that I can figure it out,. Believe it or not, they have a history of diabetes, you know, I can put that in history of fatty liver. That's that's a really easy problem for me to overcome. But who gets to do that? We're usually just adding, adding, adding, adding diagnoses, not pulling away because we don't treat the root cause. We treat all the stuff around it. We don't treat the key thing that's leading to all of these diseases, 14 types of cancers, etc., right? So hopefully that gives you kind of my thoughts.


Dr. Emily Jones24:46

I do think it's a similar dynamic. I also think, in the space of maternal health and life course health for birthing persons, we have really missed the mark in thinking about women and their bodies, and the bodies of all birthing persons as a life course, from a life course perspective, I should say. So that is to say that even though in this country, sometimes birthing persons really only first encounter health care settings and health care providers during pregnancy, but we can do a better job in this country about caring for these individuals before pregnancy and after pregnancy and not seeing pregnancy as a cross section in time that is completely self contained. But seeing it as just almost like removing a mask and looking under the surface to see, well what's actually in this biological body? What's going on under the surface? And how can we take our hints from what we're seeing during pregnancy — issues like gestational diabetes, issues, like hypertension and pregnancy, where those conditions had not unmasked themselves before? How can we then actually intervene in such a way with this individual, that this individual now has much greater chances of not going on to develop a condition like diabetes, or heart disease, or any of the many other various conditions that are linked to obesity. So that's certainly something that comes to mind. And I think that in general, a lens of prevention has not been supported in policy in this nation. And it's really not been where we've started.


Frank Jaskulke26:55

And I want to come back to the policy piece in a moment. But I want to pull on another thread of what you had shared there. I think probably to the lay public, it intuitively make sense that having preventative care and having better maternal health, and I love that that life course that you described, that that will lead to better health for the child that is born. But could you maybe for the audience expand on that and what that connection is, and what impact that disease of obesity can have on maternal health and on the health of the child when they're born.


Dr. Emily Jones27:34

We know that our external environments, from the food we eat to our exposures to stress and adversity, shape our future health in powerful ways. But in recent years, this field that I mentioned about the first 1000 days, and that's from the point of conception to the child's second birthday, roughly, we know that the nutrition in pregnancy impacts how bodies and immune systems develop. And that's in the offspring. And we know it influences these children's predisposition to diseases later in life. So there's evidence that suggests that the health effects of poor nutrition and adverse experiences early in life can pass down from one generation to the next. So how well or how poorly mothers are nourished and cared for during this time, and I would argue far before pregnancy, that all has a profound impact on the infant's health for a lifespan. So when you take a moment to soak that in, and by the way, there's a lot of folks in healthcare who don't know about developmental origins of health and disease, so it's not like this is a well kept secret in the world. There's a lot of folks who are not thinking about this intergenerational transmission of health or illness. But once you do see it, you can't unsee it in terms of thinking about more upstream intervention, that will make a difference not just for this mother and this baby, but for generations.


Frank Jaskulke29:18

I gotta say, that is a very profound thing to hear. And as you describe it, what you said about you can't unsee it, I would fully agree with that it. I mean, honestly, that is a very impactful message that the things we are doing today, we'll either pay a price for them or have a dividend for them for potentially hundreds of years to come. Yeah, very impactful. Maybe where I want to


Dr. Fatima Cody Stanford  29:47

I want to actually touch on something I'm really happy that Dr. Jones brought up this and she said something also really important. She talked about the first 1000 days which was from the time of conception to the second birthday, but I'm gonna I'll go with what something else she said. And this is really important. The most important prevention tool that we don't use is intervening with people before they conceive. Right. So if we know that if we're going into a pregnancy, a mom's going into a pregnancy with overweight and obesity, she has lots of inflammation in the body, this is changing the metabolic profile for the child in utero. And so then setting them up for this life course of disease that Dr. Jones mentioned. So if we could somehow intervene with mom and dad preconception to optimize their health prior to conceiving, we have a much better likelihood of actually affecting all of these things, from obesity, to heart disease, to diabetes, etc. But that's the prevention that no one's doing. Now, let's think about it. 50% of all pregnancies in the country are unplanned. It's probably going to increase post the Roe v. Wade decision by our lovely Supreme Court, and you guys can take that however you want, whoever's listening. But what we do know is that if that's what we're going into, people aren't necessarily planning. We're having people with not optimal health conceiving, and then what happens to the kids, and then the grandkids, etc. You know, this piece of epigenetics that I briefly mentioned earlier, is that that stress, that harm, what the patient's grandparents experience is passed down. And let's look at it this way. If a grandmother is giving birth to a female, the female is born with all the eggs she needs to give birth subsequently. If she has one of those eggs internally, if the grandmother's experiencing these stressors, let's say it's racism, trauma, etc., it has huge implications on the grandchildren. And actually one of the best studies looking at this was looking at the grandchildren of Holocaust survivors, versus those that were not under Nazi rule. And we see significantly higher likelihood of obesity, cardiovascular disease, sleep apnea and diabetes in those grandkids that were the descendants of Holocaust survivors versus those that were not under Nazi rule. And it just shows you that we have to recognize that this is intergenerational. So when we look at the higher prevalence, for example, of overweight and obesity and other chronic diseases in black communities, the stress of having been enslaved in this country, and how that's perpetuated down generations, is extremely pervasive. And so I can't go back to when my ancestors landed on the coast of South Carolina or Alabama, which is where it appears they came in through, to change all of that. And so here we are, right, hundreds of years later, dealing with the me or the me's of the world that now have to interact with our environment, which has changed, but still has some major issues that we have to overcome


Frank Jaskulke32:46

That connection you just made there, I'm hearing, when we talk about prevention, in this case, some of these new treatments and say the lack of accessibility to them maybe impacting prevention of future problems because of the connection between the family's health, their children's health, I mean that, yeah, that circle right there is very powerful in what you're describing. So maybe what I'd ask both of you then in closing, we've touched on it a little bit. There are a number of issues you've identified that are medical, clinical issues, issues that are societal issues and issues that have a public realm to them. A lot of the work that Medical Alley does, one of the levers that we pull often is in the public policy realm. So I'd ask each of you if there's a policy issue, or if there's something that, you know, the community should be thinking about that could have a more profound, say, generational impact on this topic of the disease of obesity. What would you suggest to us? Or what might you suggest to the community? And Dr. Sanford, just because you're unmuted at the moment, we'll start with you.


Dr. Fatima Cody Stanford  33:57

You know, I was gonna go first because I'm like, I'm on the edge of my seat. So I would say the first I would say the key policy right now that we've been trying to get through the House and Senate for now nine years is the Treat and Reduce Obesity Act. This act has bipartisan support, as you guys may have guessed. Obesity is not a partisan issue. It affects all people regardless of their political leanings. And this particular act seeks to do two things. Number one, we believe that people that care for patients with obesity who aren't just physicians, i.e. dieticians, other providers that deliver high quality care should be paid for those visits. That's what we think. Right now, if you're under Medicare, and you want to see a dietitian to work with them as you're trying to address obesity, that visit is not covered. That patient has to get diabetes to then be able to work with a dietitian and have that visit covered. So you have to get diabetes and then we're like, Oh, hey, let's give you a dietitian. Seems a little bit out of order. Just my thoughts, but that's the way things currently work. Second, under Medicare Part D, now, Medicare typically obviously focuses on older adults, but other communities can be, you know, in that realm of individuals. Medicare Part D has a complete exclusion for anti obesity medications. That is the the current status of affairs. We know Medicare sets the stage for what private insurers do and what Medicaid does. But until we can get this changed, then we're going to continue to see this problem that you asked me about earlier, accessibility continuing to be pervasive because if Medicare doesn't do it, everybody else is like, Oh, we don't have to do it. Medicare doesn't do it. Once Medicare says yes, oh, we need to probably do because Medicare does this. And so this is what the Treat and Reduce Obesity Act is seeking to do. And like I said, nine years of it you know, with 150, plus co-signers on the House side, but not enough to obviously take it to a vote and actually get it, you know, placed into law. And so I would say advocate, talk to your congressmen and women. I know, this is not something you may not think about doing. But I can tell you that the voice of the voter matters. And that's what we need to do. That's what we need to push for. I think people should have access to therapies. And right now, a lot of therapies are just inaccessible for most people.


Frank Jaskulke36:19

Thank you. Dr. Jones, if you would.


Dr. Emily Jones36:21

So right now, the United States is in a crisis when it comes to maternal health. And of course, infant health goes hand in hand. But in the US, women die more frequently in childbirth, or in the first year after delivering a baby than in any other developed nation. So we I am happy to say have seen some recent strides in policies that are shining a light on this issue and really contextualizing it as the crisis it is because it should not be happening. Recent CDC data shows us that in indigenous populations, 90% of maternal mortality is preventable. And in black moms, that number is 80% of cases that have been looked at carefully have been deemed to be preventable. So this leaves a lot of people, healthcare and non healthcare individuals alike scratching their heads saying, How can that be if these deaths are preventable? Why aren't they being prevented? And that takes us back to the structural reasons, the root causes, that these deaths could happen in the first place. So all the isms that we've talked about racism, sexism, the body shaming that happens related to body size that we mentioned earlier, bias related to appearance, there are so many structural reasons that the care of birthing persons is not optimized in this nation. And so my plug would be for even greater attention to the structural determinants of maternal health. And thinking about really using this moment in time where, for instance, we suddenly have 12 months coverage of postpartum health care. And that's part of the Biden administration put that into the COVID Recovery Act. So states red and blue like are embracing this temporary, for right now it's just five years, but that's more than women in this nation has ever had in terms of health care coverage in the postpartum period. And so I think there's an opportunity to study what is working and what isn't when it comes to optimizing outcomes during this really important and vulnerable timeframe, recognizing it's just a window in time, and there's an entire life course to think about, as we've mentioned. But for me, that's where our attention should remain until we see this needle moving.


Frank Jaskulke39:16

And that I think is a fantastic place to pause this conversation, I'll say, because it is certainly not done. I want to say thank you to both of you for sharing that insight, sharing that knowledge on what is such an important set of topics. I appreciate you taking time out of your day to spend it with us. And I hope to see you around again next time on the podcast.


Dr. Fatima Cody Stanford  39:38

Thanks for having us.


Dr. Emily Jones39:40

Thank you.


Frank Jaskulke39:41

And folks, that's been another episode of the Medical Alley podcast. Remember that this is the first of a three part series. We've got some additional conversations coming out for you. Make sure you're on the lookout for those. You can find them on on Apple, Spotify, Stitcher or wherever you get your podcasts from. And if you're not already a subscriber, do me a favor and make sure you hit that subscribe button. And do me one more favor, which is share this with just one person. If every listener shared it with one more person, we'd help get this message, get this important information out more broadly, and speed up the process of driving change that we need. So until next time, thank you and have a great day.