Shireen: Dr. Margrethe Horlyck-Romanovsky discusses intra-ethnic diabetes disparities and how to optimize diabetes risk assessments for diverse populations. She also talks about how immigrant status, ethnicity, and race can influence diabetes risk in populations of African descent.

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. Horlyck-Romanovsky is a public health nutrition professional committed to addressing intra-ethnic health disparities among populations of African descent. Her mixed methods research examining intra-ethnic risk profile research in New York City compares risk factors, health behaviors, and disease profiles of African Americans, African born Blacks and Afro Caribbeans.

Welcome Dr. Margrethe Horlyck-Romanovsky.

Margrethe: Thank you so much for having me. It's a great pleasure.

Shireen: An absolute pleasure having you on. I want to kick things off by asking you, how did you get involved in research, exploring the intersection of diabetes, race, ethnicity, and acculturation.

Margrethe: Right. So how did I end up working up on this?

So, I, after career and nutrition, education implementation, um, I shifted gears and went back to graduate school, essentially because I was, um, largely frustrated by health disparities and sort of the lack of progress in addressing these issues. And while doing my doctorate, I started teaching at Brooklyn College and Brooklyn College was part of the city University of New York system, which is one of the most diverse university systems in the country. And, uh, Brooklyn College is situated, um, in Brooklyn and surrounded by many immigrants in US communities, including sizable, South Asian, Orthodox Jewish, Russian, Turkish, uh, communities in a very large Black Caribbean enclave. And that was really where all this work started.

I had sent my community nutrition students out into the world to conduct community assessment. And one of the questions they had to address was, uh, what health concerns does, uh, the community members rank the highest. And what do we know about the issue from contemporary evidence and as nutrition and public health professionals how might we help address this?

And the group assigned to speak with the Black Caribbean, Caribbean communities, largely Jamaican Trinidadians, Tobago, one Haitian, um, people from Guyana, Barbados, Venezuela, et cetera, came back to report and they listed type two diabetes and hypertension as major concern.

But the students also told me, which I didn't believe at the time, but when they searched the library databases, there was no evidence of the, the specific risks of diabetes and hypertension in Black Caribbean communities. And, uh, but they were right. Um, and in fact, despite the fact that Black Caribbean immigrants make up about a third of the Black population in New York city and, and unspecified but my guess is that the very large fraction of their children and grandchildren probably make up another third. That up until 2017, there was no data on the intra-ethnic differences in, uh, the Black population, as everyone was classified as African American or Black in epidemiological evidence.

My students really did an extraordinary job. And so, we started, uh, exploring and we realized this was the stomach issue that applied to most research about, um, people of color and specifically to people of African descent. And that, um, heterogeneity within the Black racial groups was invisible and largely undocumented. So just like a dietician, a physician has to accept the patient that arrives in their practice. A public health researcher has to take the urgent public health issue that presents itself. And quite frankly, this was not just public health. This was also a social justice issue that we had to unpack. And so that became the beginning of my dissertation research and, uh, the focus of my research lab, um, going forward.

Um, so that's how we ended up here.

Shireen: And so, help us understand what are intra-ethnic health disparities? Do these ethnic, intra-ethnic disparities manifest itself in diabetes. And if so, how exactly?

Margrethe: Right. So intra-ethnic health disparities means that there are people who are classified as the quote- on-quote, “same” in terms of race and or ethnicity, but that within these racialized categories, there are distinct groups, uh, who are different from each other in terms of lived experiences, health, status, and health threat.

Um, and so in the US, um, in medicine and in public health, we first divide people up by race and/or ethnicity, and then we examine how these groups differ and that's essentially the underlying issue that we're trying to uncover. Um, and, uh, this happens because, um, our public health data sets do not often contain an adequate sample to give us testable power.

So, we can't explore these intra-ethnic variations or the heterogeneity. So, generalizations essentially, um, comes from a lack of data and it, and quite frankly, it's a lack of willingness to draw adequate and representative samples because we've demonstrated with the, uh, people of, um, Latinx or Hispanic descent that because we have a large population, um, and it's well-represented across the country, our national surveys actually now over sample, uh, Latinx or Hispanic descent populations. And we have evidence of distinct health differences by nationality, genetic heritage, immigration history, et cetera. And so, uh, one thing I want to say about, um, intra-ethnic health disparities is that they're, um, often are not negative. Um, minority or immigrant populations, um, often have, uh, better health than the white or US born equivalent population.

So, it's not always, um, a negative that we have to identify, but we have to identify differences within groups. And so, uh, you asked for an example. So, in many cases we see minority populations as positive outliers. For example, as much as we have written about, um, the higher risk of diabetes or, um, an elevated risk of diabetes, uh, Sub-Saharan African, um, Black African immigrants have an overall far lower type two diabetes risk than African Americans or Black Caribbeans, but they have a different risk profile.

Um, but in essence, we know too little about this because we have, um, under-representation in our national surveys and, um, but in New York city we have, uh, we're in this unique position to actually examine the health of more specific groups because we're a city of immigrants and we have cultural enclaves, and we have access to, uh, large groups representing the diversity and heterogeneity and the racial and ethnic groups. And, and that's really invaluable. And that's what we're trying to, um, mobilize and, and use to sort of tell this much more granular story.

Shireen: And so, building off of that, what does marginalization of African populations in healthcare research really indicate about systemic flaws in the US health system and the food system? And then the second part of that is why should help the research really dis-aggregate that data on ethnicity and race? What, what value does it provide?

Margrethe: So, um, the way we do it right now by assuming homogeneity in all populations of African descent. And we do this in both public health and healthcare research and clinical guidelines where we're illustrating that systemic, structural, and institutionalized racism, racism is pervasive. Um, and this is particularly damaging when we, um, list race as a risk factor, right? Because race is a proxy for lived experiences. Uh, but for, for instance, the American diabetes association, uh, just issued their new clinical guidelines and they, as they've done for many years, um, they list race and ethnicity as one risk factor.

And if people have a, an elevated BMI over 25, uh, 25 or above, and they are of African American, Latino, Native American, Asian American, or Pacific Islander descent, there, they are already, um, identified as at elevated risk for type two diabetes. But the same is not true for other groups. Um, but we have to remember that, um, race is, is a skin color, right?

It is not actually a biological concept. Um, it is not the skin color that puts people at risk. And so, um, we need to get, um, so the reason why we should not aggregate data by race first, race is an important concept for, um, social reasons for, um, structural reasons and for lived experience reasons, but, uh, in medical and, um, epidemiological research, we have to be very, very careful not to aggregate by race.

Um, and that has been shown both, uh, in the regions of origin. So Sub-Saharan Africa, and then the Caribbean, and in the case of my research and, uh, also an epidemiological and clinical studies in the US is this, um, for instance, Blacks, Sub-Saharan Africans, uh, experience a higher risk of diabetes at a younger age, a lower BMI, and a lower waist to conference.

Uh, then we, um, see in sort of the general US population. So, in effect by, um, aggregating. African immigrants, African Americans, and African Caribbeans, we may delay detection of type two diabetes in some groups, uh, simply because their phenotype is not aligned with the US standard and delayed diagnosis of diabetes can lead to irreparable damage to kidneys, eyesight, and long-term risk of cardiovascular disease.

And as we've seen more recently, um, diabetes or, um, increases the risk of severe COVID-19 infection and death. And so that's in part also why we've seen, um, a higher burden of COVID-19, um, in minority populations and, and the Black populations in the US in particular.

Shireen: Let's um, let's go back to the research that you've mentioned, Dr. Horlyck-Romanovsky. Um, in your research in New York city, you found that foreign born Blacks experienced lower odds of obesity, but higher odds of diabetes than US born Blacks. How do you reconcile this increased risk of type two diabetes in the, in the Black immigrant population?

Margrethe: Well, you know, that's really at the crux of our work, the big “Why” um, with the, so they are three main drivers that we are currently exploring.

And, um, we can hypothesize that recent changes in low- and middle-income countries where, uh, we've seen a rapid increase in body mass or body weight. Um, that's in part, the result of, as you alluded to the food system that, or what we call the global nutrition transition, the global change of food systems that lead to increased consumption of, um, refined grains, sugar, plant oils, animal protein, and processed foods and sugar sweetened beverages.

These are essentially the changes that used to be associated with immigrating to the US. But now the global food environment has changed to make these food items more affordable and available, um, and displacing local foods and, um, also local food habits. And so, in fact, the healthy immigrant effect, which used to be true that immigrants arrived much healthier than the US population, that is diminishing.

Um, and then in addition to that, it's hypothesized that the, uh, this increased access is also leading to rapid increase in overall fat accumulation in populations in low- and middle-income countries and particularly of visceral, uh, hepatic and pancreatic fat that are the main drivers of the rising rates of type two diabetes.

Um, the other two things are, there's also evidence linking diabetes phenotype that we are seeing, uh, to transgenerational effects. So multiple generations, uh, experience translate into, um, health outcomes and current generations. So, for instance, the effect of famine or food insecurity in past generations can increase the risk of diabetes in subsequent generations.

The same is for intrauterine exposures. So, uh, while a woman is pregnant, the exposure of her lived experiences affect the, um, the fetus and their risk of diabetes. And then also the exposure to frequent infections in Sub-Saharan Africa in particular has also been, have also been implicated in the increased risk of diabetes, um, in subsequent generations.

And so that, all that paired with the rapid increase in overall, energy intake and fat accumulation is sort of the perfect storm contributing to, um, increased type two diabetes risk. And then I just want to, the last piece is of course, uh, immigration experiences themselves or present unique exposures to stress, uh, the people who get to immigrate are under extreme pressure to support themselves, support their families back home, uh, while experiencing the transition from being part of a, a racial majority to becoming a racial minority, uh, and they're facing racism and other types of prejudice under employment, uh, diminished, social standing, changing as food access, healthcare access, lack of social cohesion and such stressors really increase, um, the physiologic stress and also may increase the risk of diabetes and other chronic diseases such as hypertension.

Shireen: And I think that the main thing there is also that what we know to be true as obesity being a risk factor for diabetes, it seems like there's a multitude of other things, and it's just not the obesity by itself, that there are multitude of other things that can also put it at a higher risk. And like you said, I think the association that we draw today, uh, is more tied to that, to that BMI, uh, risk for the most part.

Margrethe: Absolutely. Absolutely. Yeah.

Shireen: So African Americans have a higher risk of diabetes at lower BMI, a different waist circumference cutoff, and a younger age than African Americans. Um, if diabetes risk assessments are not optimized to detect diabetes in African descent populations, what can be done here?

Margrethe: Oh, I think we have a lot of, we have a lot of work head. Um, but I think we, we have, um, we have several sort of immediate tasks.

This is a more global, uh, tackling of, um, and, and sort of an anti-racist approach to many things, including the screening criteria that we use. Um, but we really need to have this discussion on a more global level. And I mean that in the broadest terms. Uh, we have enough evidence to illustrate that there are significant issues with our current approach to race and risk, and we need more awareness among our medical professionals that race, risk, and skin color, um, are not primary risk factors, but that people's lived experiences, family history, medical history, and social demographic circumstances are far more important.

Um, and then we really need to also recognize that many of the, um, many of the screening criteria that we use, um, originate in populations that are not representative of the populations where they're being used. So, we've alluded to BMI, which is, it's a horrible measurement. Um, it's history is a fraud. It was, uh, was not used for population health or even medicine, but it's a really easy tool because it's easy to measure someone's, uh, height and weight and, and draw some conclusion about their level of risk.

Um, same thing goes for waist circumference. We have different phenotypes, um, across the globe, we cannot generalize. Um, so I think we need to re-examine, and we need to really look at the evidence that's emerging. There are several groups that are looking specifically, um, at this, um, intra-ethnic, um, diversity and heterogeneity to figure out how do we actually tackle this, um, story.

But part of it is making it visible, right? So, um, for instance, we've had other things that have been completely invisible until we tackle them. The example this year is, um, we're appalled in 2022 that once we see a, um, an illustration from an anatomy and physiology textbook with a Black fetus in the belly of a Black pregnant person, that somehow, we have never seen that that was invisible.

Um, and similarly we need to, we need to deconstruct uncover, um, where these guidelines come from. For instance, a hemoglobin A1C performs hardly in populations of African descent for and South Asian and Middle Eastern populations because of the presence of hemoglobin variant, deficiency, and other reasons, um, that it's really a very crude measure. And so, we, we need to re-examine how we are, um, what we're using to measure and how we're understanding, um, the diversity of risk, really in all kinds of people. So, I work really contributes to this growing evidence that BMI waist circumference, hemoglobin A1C and, and other screening criteria that are developed predominantly in white population can just not be universally applied and that we need to de, deconstruct, these white normative reference points.

Um, and then we really need better data to understand how else to predict risk and ensure early detection of diabetes. Um, to prevent his long-term devastating complications, regardless of what people look like. Um, so a more holistic approach to who is at risk.

Shireen: Certainly. So, with that Dr. Horlyck-Romanovsky, we are toward the end of the episode, um, at this point, how can our listeners connect with you and really learn more about your work?

Margrethe: So, um, my email is, is always a good, uh, communication point. I'm also on Twitter. My Twitter handle is my first name and DrPH so my, um, academic title. So, @MargretheDrPH. So that's my Twitter handle or, um, my email is, um, margrether@brooklyn.uni.edu. And I really welcome open debate and conversations about how we can tackle these complicated issues.

Shireen: And what we'll do is, um, in the show notes, we'll post all the social media handle, as well as the email address there so the folks can reach out to you. Um, and so with that, Dr. Horlyck-Romanovsky it has been an absolute pleasure having you on thank you so very much for your time.

Margrethe: Thank you so much for having me and thank you for listening to, um, what we had to bring to the table.

Shireen: Absolutely. And to our listeners out there, we want to pose a question to you, head over to our Facebook or Instagram and answer the following questions. What will you do to not generalize individuals of African descent? Heavy question, loaded question, head over to our social media on Facebook, on Instagram, find us there. We're @Yumlish, um, and answer this question on this podcast announcement, we will see you on our social media channel after this episode. Thank you again.

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