Shireen: Dr. Ashley Butler talks about the intersection of race and ethnicity and the prevalence of diabetes and childhood obesity. She further explores social determinants of health in the impact of childhood obesity. She explains implicit bias, how it exacerbates existing health disparities and discusses upstream factors and policies that impact health.

Podcasting from Dallas, Texas. I am Shireen and this is the Yumlish podcast. Yumlish is working to empower you, to take charge of your health through diet and exercise and reduce the risk of chronic conditions like type two diabetes and heart disease. We hope to share a unique perspective and a culturally relevant approach to managing these chronic conditions with you each week. 

Dr. Ashley Butler is a fellowship trained associate professor in the department of pediatrics, section of psychology at Baylor College of Medicine and serves as a licensed psychologist at Texas children's hospital. Welcome Dr.Butler!

Dr.Butler: Thank you, 

Shireen: Dr.Butler, diving in, what drew you to the field of psychology and pediatric health disparities research?

Dr.Butler: Well, I was drawn to the field of psychology actually as a high schooler in the 11th grade. And I remember one of our assignments was to actually research various career potential options that we might be interested in. And so I at the time chose to look into mental health careers, both psychiatry and psychology.

And actually in my high school graduation, you know, they have little books where you write out what your career goals are, what you want to do, how much money you want to make, where you want to live. And I actually wrote a psychologist down in that book that I still have, but I wanted to be a psychologist, but really didn't know exactly what I would be doing in the field of psychology.

Probably there were two major experiences that I had that really guided me to focusing on health disparities in particular for racial and ethnic minority groups and socioeconomically disadvantaged families. One being when I was an undergraduate student or an undergraduate student in psychology in New Orleans. I had the opportunity to volunteer with one of my professors there and actually worked at the VA and he was doing a lot of therapy research. I researched various therapy techniques for our patients at the veteran's hospital there, and just really became aware that certain groups, more vulnerable or marginalized groups, do have a lot of barriers to accessing mental health services in particular. You know, I was interested there, but you know, through some other experiences, I really wanted to work with children and families. And as a postdoctoral fellow here at Baylor, back in 2010 and 2011, just really delving into the research. Seeing the very significant disparities in health outcomes. So thinking about, you know, children, minority children with certain chronic conditions are more likely to die from those chronic conditions. Their families are more likely to have a lot of burden from those conditions. So I really became interested, you know, back then with just seeing the heavy information about the numbers with regard to death and burden with certain chronic conditions and really wanted to, I set my sights out on focusing on research in that area.

Shireen: And speaking of chronic conditions, a lot of work that we're doing is in diabetes over at Yumlish. Tell us about how race and ethnicity really impact the onset and management of type one and type two diabetes in youth. 

Dr.Butler: So really race and ethnicity have somewhat of a different relationship with type one and type two diabetes. So they're, they're really kind of, you could think of them differently. So in particular, for type one, we know that individuals with type one diabetes are racially and ethnically diverse, but there are differences with regard to the management of type one across race and ethnicity, as well as health outcomes.

So we know that African-American and Latinx children and individuals with type one diabetes in particular are less likely to enhance, to have the advanced technologies for diabetes management, such as continuous glucose monitors or insulin pumps. And we also know that health outcomes tend to be worse for African-American and Latinx individuals with type one diabetes.

For type two diabetes it's a little bit different where we know that there are racial and ethnic differences in the onset of diabetes or who gets type two diabetes. Individuals of color, Native Americans, African-Americans, Latinx individuals are more likely to – they're overrepresented among individuals who have type two diabetes. And then there are some differences with regard to health outcomes as well, that are similar to those for type one diabetes. So for example, having more significant complications later on in the disease course, such as amputations, we know that they are more likely to have those. 

Shireen: Let's talk about childhood obesity for a moment. How do social determinants of health really impact challenges? 

Dr.Butler: So social determinants, you know, there's a lot of talk about social determinants these days, a lot of different definitions, but you know, I think of social determinants of health as sort of those things that are within an individual's environment, the way that the things, you know, the places where they are living on the regular basis, where they're working. For children, where they are playing on a regular basis. It's kind of those things you think of outside of the traditional healthcare setting or their medical appointments. And we know that there are differences in terms of social environments. So for example, we know that iIndividuals live in communities where there's less access to healthy foods, there's less grocery stores, more options for things like fast food and less healthy food options. We know that is associated with higher rates of overweight and obesity. Also things just such as the sort of walkability of a neighborhood or the safety of a neighborhood that relates to, you know, more ease of physical activity.

We know that when communities have fewer of those options, that that's also related to childhood obesity. So there are these things within an individual social environment that could impact the onset of childhood obesity. 

Shireen: Okay. What is the role of implicit biases in exacerbating these disparities?

Dr.Butler: So implicit biases, you know there's also a lot of talk about implicit biases these days. And so really when you think about it, the definition is really having a preference for, or against one thing or someone or something like racial ethnic group, for example, or preferences for or against socioeconomic status of an individual.

And so biases really can be positive or negative. But when we think about disparities, it's really when there's a negative bias against a racial or ethnic group or a socioeconomic group. So for example, with biases we know, you know, there's a lot of evidence that tells us that there is bias against African-Americans among healthcare providers that really occurs. you know, a lot of times people say. “Oh, you know, healthcare providers, they are, you know, in this profession, they're good people. They care about others, you know, they're really in it for a helping role, right?” So there's a lot of like, well now they don't have implicit biases,  But we know that studies show that healthcare providers actually have levels of implicit bias against African Americans for example, that are the, at the same rate as everybody else in our country. 

And so even when those biases are occurring outside of a person's awareness, so they don't know that these things are happening, the biases really can lead to poor communication, between patients and providers. Where providers may tend to dominate the conversation. They share less information when they encounter an individual with diabetes, for example. And they actually, you know, the other piece is more emotional where they actually may show less empathy towards an African-American patient. And then what ends up happening is patients are less satisfied with their care.

And we know that satisfaction, having a strong relationship with provider trust and provider is going to be important for patients to continue in their care, to follow recommendations that are being provided, you know, and also it's important because, you know, because patients need to provide their healthcare provider with information too, so that treatments can be adjusted based on the family’s circusmtance. 

We know that because implicit bias affects our communications. There's poor communication that happens. There's, you know, that's where the breakdown occurs and could exacerbate the disparities. 

Shireen: So we've got a loaded question for you. What is really being done and what else can be done to mitigate these health disputes?

Dr.Butler: So I think that, you know, there's several things. One, you know, some provost organizations really are embarking on ways to target social determinants of health and implicit bias. You know, there are organizations where they're delivering training to their providers to increase awareness. Just a lot. Like I said, a lot of times the thought is, well, you know, implicit bias isn't happening and it's not affecting me or  impacting my patients. So there's training to increase awareness of just how the brain works and that, you know, there's people, a lot of times people say, “if you have a brain, you have bias,” right? So it's increasing awareness and then also teaching mitigation strategies. So what are things that organizations could do to better standardize care to help reduce potential biases that may be happening. To also deliver ongoing assessment, to look at places in care where there may actually be vulnerability to implicit bias playing out. So like I mentioned, with regard to differences in terms of technology being prescribed to certain groups, you know, being able to really know if that's happening, there needs to be really good assessment happening within organizations. So organizations I think are doing those kinds of mitigation techniques for implicit bias. 

And then with regard to social determinants of health, you know, there's some data in more general pediatric settings, not necessarily in diabetes, but where you could actually screen folks for social determinants of health that may be impacting diabetes management, where you can ask them questions such as you know, are you having difficulty keeping food at home? Are you running out of money before you have the money to buy more? And in the healthcare setting, you could ask patients that and then help better understand if social determinants are something that's impacting management and then adjust by either doing things like connecting them to community resources to help reduce the impact of that particular social factor on an outcome or on management. But also sometimes, you know, asking about that could help providers tailor or adjust the treatment regimen that may be helpful as well. So there are I think different strategies that organizations may take to targeting social determinants. 

And then I think there are some there from an organizational or policy perspective, there are also new incentives, for example, through Medicaid, where, you know, there's some possibility for organizations or for patients to be able to access certain social resources because social resources are something that’s impacting their health. So for example, insurance can be used, for example, for if a health plan decides that grocery delivery is something that if the person lives in, what they call a food desert, There's no access to healthy foods that they can easily get. You know, that the health insurance could be used to cover a grocery delivery to a family with diabetes

And one of the challenges in  healthcare settings is of course, when you think about social determinants, health care providers are really trained to, you know, provide medical treatment, right? There may not, they may not have had a lot of training with regard to identifying social needs. And then if, even if they do uncover that. What are they, what are they going to do about it? And so that takes time to be able to talk to families about that. Determine what social determinants might be fact, diabetes management that's really complex when that starts to happen. So there are also incentives being rolled out where providers can actually account for that in their dealing, in terms of working with individuals with diabetes. So that can sort of help eliminate that barrier too. You know, taking the time that's really needed to assess and address social determinants. 

Shireen: And in fact, when you're talking about this as that's one of the things that we do is when we identify that through the USDA, you know, to question  the questionnaire, identifying that food access and at Yumlish what we do is we refer them to those resources. But what I'm hearing from you in which I love is that players can actually come together and say, let's identify this and find a sustainable way to close those gaps.

Dr.Butler: Absolutely.

Shireen: I love that. And that is, something happening more on the federal level is to get payers to do that more. Let's switch gears now to talk about diabetes and also obesity. And then what kind of effect. What kind of effect does that have on the wellbeing of minority families and their children? And then also, what suggestions do you have for families struggling with diabetes and sort of this overall burden of obesity? What would you say to them? 

Dr.Butler: So we know that diabetes, you know, it is a very demanding condition for children and their families. And so we know individuals and families where there is diabetes, that they can be burdened financially, emotionally with their mood.. You know, there is, you know, there could be distress associated with the day-to-day management of diabetes. There could, you know, there's even things like depressive symptoms. So things like having difficulty sleeping, you know, loss of interest in, in daily activities for individ, for the person with diabetes, as well as those who are caring for an individual with diabetes such as parents. And we also know that it can negatively impact, for example, parents and their work environment, because they, you know, could disrupt some of their things in the employment setting.  as well as it can impact the school life of a child, for example, with diabetes. So there are many areas in a person's life that could be affected.

And then in terms of suggestions, you know, I think one of the biggest that could be thought of is how diabetes is not something that can be managed alone. The burden can really be reduced when the individual with diabetes, as well as their family members have sufficient support, you know, searching, searching for and asking healthcare providers about diabetes supports in the community can be something that could be very helpful at helping individuals think through their support system and how can they expand their support system. I think, you know, probably historically it was thought that the person with diabetes has to learn to manage, you know, manage it on their own, but with  something as complex and as high demand, you know, as diabetes is that we know that, you know, building a support system around the individual with diabetes is the, the way to go. 

Shireen: I want to now touch upon some upstream factors and even policies that impact health. Can you speak to that and help us understand what that looks like today and then who are the key players in these conversations and what can we really expect?

Dr.Butler: That's a good question. I think, you know, more and more, you know, as we think about the social determinants or those upstream factors that are impacting diabetes management and outcomes, there is a call for the healthcare and other social systems to not be siloed, kind of in their approach to addressing health. You know, there really needs to be more collaboration and engagement across both healthcare, as well as social sectors. And so I would say, you know, some of the key players, you know, even include things such as sort of transportation, the transportation industry, for example, and thinking about, you know where with diabetes live and, you know, are there, is there easy access to the healthcare where, where folks are receiving their care? You know, that's one way you could think about it. So individuals, not all individuals have their own individual, reliable transportation to get to medical services so that better planning in the community. Helping understand where individuals may be living in communities that are, that have high rates of diabetes and thinking about where they are seeking health care and making sure that there is transportation access is one thing I think about,

The other thing is kind of like what I've mentioned with regard to, you know, there could be greater collaboration among payers. So thinking about it, we know that there potentially food insecurity is something also transportation is something that could, that payers could be involved in, in thinking about, you know, are there partnerships, are there partnerships. You know, being very creative – like Uber or Lyft – to help patients get to their medical appointments. Could there be collaboration with businesses? Like we mentioned with healthy groceries, could there be better partnerships there so that we know if food insecurity is something that's impacting an individual with diabetes so that they could actually use their insurance coverage to access healthy groceries?

Similarly, from a business perspective, you can even think of exercise and physical activity options. Could payers be more involved in helping an individual with diabetes access, exercise programs that are generally, you know, maybe they may not be easily affordable for an individual?

So I think, you know, there are these opportunities to work across programs and in the business sector and the transportation industry and the food industry to better address a chronic condition like diabetes, 

Shireen: Anything else as far as public insurance is concerned? The Medicares and Medicaids of the world? What can be done? 

Dr.Butler: So that's why, like I was saying earlier, I think better insurance coverage, so that are better options for providers to be able to feel for addressing the complexity of social determinants of health would be something, you know, because when you think about it, you know, providers may be spending more time with those patients. So, you know, being able to bill insurance companies for that would be important. 

And then, you know, it could end up being where there are also other supports needed in the healthcare setting, because there's a question that comes up is the physician with their expertise in managing disease. Is that really the right person who should be addressing social determinants of health? Are there other types of individuals, more things like lay patient navigators who could be working within the healthcare system, who would be better resource to help patients either, you know, link to community resources or even, you know, just communicate bridging that communication between the patient and the provider around how social determinants are impacting their disease management so that the provider can adjust treatment regimens accordingly.

I think that Medicaid and Medicare being able to really think about that and, and provide it, you know, incentives or allow providers to be able to feel in that way, I think would be tremendous. 

Shireen: I would certainly appreciate that if I'm thinking of food access, my, of course, with all of my biases, I would say the dietician, right? Have that person, when we're talking about food insecurity, community health workers, they think have a stronger role to play in this. Certainly. So I think lots of opportunities there, but just waiting for Medicare, Medicaid, sort of CMS has set those standards. 

That's lovely. So with that, Dr. Butler toward the end of the episode, how can our listeners connect with you and just really learn more about your work?

Dr.Butler: So I am actually on Twitter at @amButlerphd. You can find me there and you can also find me on LinkedIn as Ashley Butler, and you can follow me there. 

Shireen: Sounds great. Well, thank you so much for your time, Dr. Butler, it’s been a pleasure having you on today's episode. 

Dr.Butler: Thank you.

Shireen: Thank you for listening to the Yumlish Podcast. Make sure to follow us on social media @Yumlish_ on Instagram and Twitter and @Yumlish on Facebook and LinkedIn. For tips about managing your diabetes and other chronic conditions and to chat and connect with us about your journey and perspectives. You can also visit our website Yumlish.com for more recipes advice and to get involved with all of the exciting opportunities Yumlish has to offer. If you like this week's show, make sure to subscribe so you can hear more from us every time we post. Thank you again, and we'll see you next time. Remember your health always comes first. Stay well.

This episode is part of our series dedicated to national childhood obesity month for the month of September. With this episode and the rest in the series, we hope to increase awareness around childhood obesity and connect you with experts to help you better prevent childhood obesity and support related initiatives.

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