Medically Speaking #1

Welcome to Medically Speaking, a podcast of Self Regional Healthcare. This is our first podcast and I'm super excited to have Dr. Jamel Felder with us today. I'm going to give you a little bit of background on Dr. Felder. Dr. Felder is a native of Florence, South Carolina. She currently lives here in Greenwood with her husband and family and she is one of our pediatricians at Self Regional health care. She's married to Dr. Alan Pasinger, a personal friend of mine, and a farmer over in Newberry County as well. Good guy. And Dr. Felder earned her bachelor of science degree from Duke University and her medical degree from Medical University of South Carolina down in Charleston and completed pediatric residency at East Carolina Brody School of Medicine. She's board certified in both pediatrics and obesity medicine, and we'll be talking about those topics today. She also has a Certificate in Diversity and Inclusion Training and has been working at Self Regional since 2005. So welcome, Jamel. So glad to have you here today. Thank you, Dr. Logan, for inviting me and I'm very excited to be on this first podcast. Great, great. And again, I'll introduce myself real quick, Matt Logan. I'm the CEO here at Self Regional. I've been with Self Regional for 18 years in a variety of roles, some clinical, some administrative, and excited to start this podcast series. And Jamel, super glad that you can be our first guest today. So with that said, I thought we would just maybe kick off with a little, some questions. So we're going to be talking today about pediatrics, some, and some about obesity, and some about how it seems like some races may be more affected by the obesity pandemic or epidemic than others. So I really appreciate your insights on that. So maybe we'll start with what are some just basic statistics on children with obesity? Okay, so I'll talk about the highest rates of obesity among children from 2 to 19 years old in the United States. So the highest rates you may not know, but are in African-American girls at 29.1% and Hispanic boys at 28.1%. And that's been stable, that those minority groups are the highest in obesity rates. And then in South Carolina, overall, for all children, we're ranked ninth for obesity rates in children 10 to 17, and that rate is 20%. Okay, so yeah, definitely some significant impact on our communities, for sure. So with that said, what would you say are the most impacted groups with obesity overall? And we're looking at, like, say, the state of South Carolina. Okay. Well, I do have some stats on that. So the adult obesity rates in the country are as high as in African Americans at 49.6%. So, you know, half of black adults struggle with obesity. And then that cohort of black adults, the most highest group is black females at 56 percent. And then in South Carolina, that also pars out with the highest rate being in black adults at 45 percent, followed by Hispanics in the country at 44 percent and then whites at 42 percent. Gotcha. Gotcha. What are some treatment options, for example, like say for obesity or some lifestyle modifications that could be made by people who struggle with obesity? So when I went to get my board certification in obesity medicine, I did a course at Harvard called a Blackburn course. And basically, we haven't been taught this, how to treat obesity. We weren't even really taught about obesity when I went to medical school. And, you know, now changing the narrative about obesity, that it's a chronic disease just like cancer, high blood pressure, diabetes, is where those of us who are board certified are tasked to now do. Basically, you know, we talk calories in, calories out, eat less, move more. And that just doesn't work. You have to have a behavior modification piece, and you have to kind of sit with families and figure out the social determinants of health that may be affecting their behaviors that are causing them to be obese, as well as the lack of understanding on how they can make those changes. So some treatment options are stratified, of course, but you start with lifestyle modifications, you know, helping people eat better, you know, understand more about their nutrition and exercising certainly is a vast piece of that. But the main stay of treatment should be how we treat all our other chronic illnesses, and that's with medication and possibly with interventions such as bariatric surgery, if need be. But I think the main thing is to have honest and open conversations with patients about their status on whether they're overweight or if they're obese. And sometimes doctors have a hard time saying those words because people can take offense to it. And so you have to be careful how you bring those conversations up. So, Jamel, what would you say, from your perspective, what is health equity and how does obesity affect health equity? So I'm going to give you the healthy people, people, healthy people, 2020 definition. Health equity is, it requires valuing everyone equally with focused, ongoing societal efforts to address avoidable inequalities and justices to eliminate health disparities. And basically, why I wanted to read the definition is because it's kind of esoteric, but now I can kind of break down what that means. And so when I do talks and, you know, I've done several of these lectures, you know, we talk about equality versus equity. So if you can imagine someone riding a bicycle, which is the picture I always show, and everybody has the same access to the same bicycle, then that's equality. And so sometimes we get into a mindset of, well, it's available. It's there. You have a bike. You have a way to ride around if you choose to. Equity, on the other hand, is tailoring that bike to everyone for their specific needs. So if you're a child, it's a kid sized bike. If you are disabled, it's a bike where, you know, you can sit in a maybe three wheeled bicycle where you could have your hands on some of the bicycle handles. But you also are able to be in a seated position. If you're a female, maybe the bike set is lower than if you're a taller male. So I like to always give that graphic because then that can give you a picture of the difference between equality and equity. Now, as far as how that plays into obesity, where I always tell people there's a reason why the onus of that statistic lands in black Americans. So for you know, you can't just say it's because they're black, which is one of the reasons why we need to get away from identifying, you know, me and you have talked about this before about why we in medical school have to say in our histories, you know, a 60 year old black male. But what we have to do is peel that back and figure out what is happening in those communities, why they have the higher rates of obesity. It may be, I will share some stats for social determinants of health. So for African-Americans, they have a higher uninsured rate. They're less likely to have a PCP. They're more likely to live in a multigenerational home. they're more likely to have, we have higher unemployment rates and higher poverty levels and higher food insecurity. So when you take all of those pieces together, there are things that have happened socially, economically that are interfering with able to have health equity around certain diseases. Okay. So it sometimes may not be something physiologically different between, say, one race or another, but more some of the social factors that people maybe grow up in that affects their, I guess, their decisions or how they end up along the health path, either healthy or not healthy path. Would you say that's accurate? That is very accurate. And in fact, 20% of an individual's health is attributed to clinical medicine. So what we do in our clinics, hospital settings, but 40% is attributed to social or economic factors 30 health behaviors that we may pick up to cope with said uh social or economic factors i'll get to that in a minute and then 10 is physical environment so like if you live in a um you know a run-down place with you know lead in your water so that's the physical environment um but there are certain uh zip codes in certain cities where that's where you live and so um so that's only 10%. But if you can imagine that you live in those kind of areas where you get lead coming out of your water, and then that obviously should probably is a high poverty level. And then you, as a coping mechanism, decide to overeat or drink or smoke or what have you to cope with that. I'm not saying it's right. I'm just saying that sometimes we develop health behaviors that are not conducive to overall good health in the long run because of sometimes that's coping mechanisms um and as humans we all you know some sometimes we do that and then um the other social and economic factors poverty unemployment um and cyclical poverty uh generational poverty meaning that's all you've known from my grandmother was you know we lived in poverty then my parents and And so looking at some of those structures and how we can intervene in those aspects are ways that we need to move forward in medicine. Now, we're not social workers, and I know people want to say that that's not our job as medical professionals, but I beg to differ. And if you're going to help a family or a child or an adult tackle some of these complex chronic health illnesses, you're going to have to get at the root of the causes of why it's occurring. Yeah, I agree with you. I think getting to the root cause is really key in addressing that root cause of why are we in this situation. And, you know, as I think about that, Sue, from your perspective and your knowledge and training and us as a community here in Greenwood, South Carolina, and the surrounding communities that we serve, like what can we do as health care professionals and also as a community, you know, whether it be from the city or county governments or whatnot, what should we be doing? What can we do to make the biggest impact on health equity and specifically around obesity? If you could just name a couple things in your mind that we maybe could help focus on to really move the needle. So I think, I love that question. I think focusing, because you don't want to have all the bad stuff and no solution. So I'm definitely solution driven. So one of the things that I think is the main thing is education. So I don't think there's enough discussion about obesity. There's not enough discussion about how in a health care setting, how do we make changes around obesity? So I've had several people come to me and say, well, I go to my doctor and he says, lose weight and I'll see you in three months. Well, you you and we also need more time to, you know, to kind of deal with these complex, complex issues. But that's not really what we're talking about. But giving people tools. So not just saying lose weight. Well, how do you lose weight? You know, sitting with somebody and trying to figure out what it is they're eating, how much they're eating. You know, maybe you need to focus on eating a Mediterranean diet more different than what we typically eat as black people. But there are people that are switching their eating habits because it's healthier. It's better for your body. But also, you know, explaining that there are treatment options. So not just saying lose weight and I'll see you in three months. Try to partner with that person and try to figure out what is the biggest roadblock into making those changes. You know, is there something that's hindering them they don't understand or they feel like they've been dismissed And so they feel ashamed and they don't come back in the three months because they go home, they don't have any roadmap on what to do, they steadily are gaining weight, and then they don't want to come back to hear that again. Well, you didn't lose weight this time, keep at it, and, you know, the same cycle. So I think we have to transform the way we take care of people struggling with obesity. I think we have to eliminate the stigma around it. There's no stigma around cancer. or high blood pressure it's a chronic disease um now there are multifactorial reasons of why someone may be um struggling with obesity but the compassion the empathy all the tools that we use to take care of those type of patients as well we need to transfer that over to obesity so that was mainly education we and on both sides health care professionals patients the community now as far as other things communities can do you know we could um i think there was supposed to be a plan where we were supposed to have a walkable bike pad plan um i'm not sure where we are in that but you know have more safe walkable areas places where um people feel safe to come and play exercise um you know you have to have uh i remember one time one of the parks had a metal slide so the kids couldn't get on that in the middle of summer because it's too hot so you know just thinking through things like that um safe clean you know kept up parks that people can move in and also just giving people other options aside from lifestyle modifications because there are other options for treatment other than those things you know this just kind of got me thinking a little it when we're talking about community things, and education specifically. So are there some statistics that show that as the level of education increases, there is also an improvement in health equity? Like, for example, if, I don't know, if you attain a high school degree versus if you attain a couple years of college versus if you attain a bachelor's degree. I know around a lot of, like, even, like, mortality, there's, like, almost a direct correlation between level of education and length of life is there are there similar uh statistics um or data around obesity and other health equity uh with health literacy things like that as with a correlation with education and uh obviously in health there are those um studies have been done but still across um social economic status um and education um african-american females still have the highest rate um of obesity um and so there's something outside of that that's also um causing that statistic to hold steady among all um education levels um and social economic status And now that you say that, I did want to just say a small thing about maternal mortality after having infants and infant mortality. And that's still, for some reason, blacks are highest in those categories. So black mothers that are postpartum, no matter what their socioeconomic status or education, are at a higher risk of having a demise after the delivery, no matter what socioeconomic status they are in. And so, you know, there are other issues here. So some of those, I'm so glad you're getting to those. So some of those are bias in treatment and in health care and the fact that, for instance, like for maternal mortality after having an infant, sometimes infant mothers or African-American mothers are told to go home or this is just normal. And by the time they come back, it's too late. And that happens, unfortunately, too frequently. So there are other factors that, and I know that's not necessarily the question you asked me, but I think it's important to recognize that sometimes, unfortunately, when we're coming to the health care arena, sometimes we aren't treated the same. Just this week, I was telling one of my friends, there was the American Academy of Pediatrics put out a newsletter every day, every other day, and there were three headlines on one particular newsletter this week. One was about lead levels and how they affect IQ in children, in black children. The other one was the still increased preterm birth rate that is higher in our developed country than most developed countries or the other developed countries in the world. We're still high with our preterm birth rates. And they were saying that there were still gaps in care based on racial and ethnic groups. And so, you know, there are some other deeper issues that also plague our communities more than others as well. Jamel, what do you think that we should be doing at Self Regional Healthcare and really healthcare systems across the country to address these possible inequalities in care and to ensure that we're providing that high level care for every single patient, regardless of their skin color, their gender, their race, or really anything else that we could have bias around? How do we really tackle that? Well, that's a good question. And I'll just have to say thank you for your efforts of pushing diversity and inclusion to the forefront of self-regional health care. It's in our mission statement that we want to treat everyone the same and offer excellent health care. And I think in order to do that, you have to train folks as far as looking at implicit bias. Not all the time, but you have to call it out and make sure that people aren't using that. And it's an unconscious thing. It's not something that people are doing on purpose. It's that the brain is a magnificent thing and that it quickly can put things in categories based on previous experience, previous social media or TV ads or whatever. And so you may be thinking that you're treating someone with non-biased care, but you've had all of these things that have entered your brain over the course of your whole life and your whole life experience that you're not really aware of, that you have an implicit bias towards them or that racial group or women or any other thing that you could have a bias it could be weight bias it's you implicitly have a bias against someone who is in the obese category so what you have to do is kind of recognize that you have to do some self-reflection but I think educating your staff your health care team on that it exists and that it's not really you trying to be mean to somebody you're just not aware and so what and we're in a fast-paced environment in medicine, you know, visits are tried to be quick and fast and try to move people along. But in order to make sure that you're given that equitable care, that takes some time. It also takes recognizing if you are getting in that mindset of, oh, I'm, this is a bias here. This is a blind spot that I have. So the first thing I would say to do the training so that people noted that it exists. Secondly, I think, you know, making people aware of some of these studies that I'm talking about, you know, people could say, oh, yeah, yeah, there's implicit bias. But, you know, if it's something in your specialty, you know, oh, really, this is, you know, this is good to know. I wasn't aware that, you know, X, Y, and Z or, you know, African-American women were the highest category for obesity or black mothers have increased episodes of maternal demise after birth or preterm birth rates. You know, so I think education, you know, I sound like a broken record, but education, training your staff, but also making sure that you have a good diversity and inclusion program, the work that Cilento and you have done with making sure that diversity and inclusion is a part of our strategic plan going forth, I think is most important as well, because it not only affects the health care that you give, but also the place that where people work and you want people to feel included. And I had one professor tell me when I got my diversity inclusion training is that diversity is being invited to the table and inclusion is feeling comfortable in your seat and at the table. So I think we have to make sure that people feel comfortable in their seat. And when they do that, they can give the best care to the patients that are coming. Thank you, Jamel. So, you know, as I think about exactly what you said, the part of the things that come to mind is like the culture that we have at our hospital, right? So I kind of think so you hear the word culture a lot, or I certainly do is like we want to whatever culture, the inclusive culture or the, you know, the happy culture or whatever, you know, it's almost like becomes a little cliche. I heard once that culture really is a combination of core values and then behaviors that support those core values. And, you know, as I think about, like, our hospital system here in Greenwood and the surrounding counties, you know, to really get to that inclusive level, I really think it kind of fits, right? So our core values are quality, integrity, compassion, and respect. And if we can develop behaviors consistently around those core values, we will deliver quality, high quality care with integrity, compassion, respect. I think we're going to be at a good place. But I don't know. What are what are your thoughts on that? So I think we are at the baby steps of diversity inclusion, to be honest with you. So there are different, so diversity 1.0, 2.0, 3.0, there's a framework. And when you're starting something new, firstly, you have to recognize there's a problem, which we did. We created our diversity inclusion work group and has done a lot of work since 2017. But I think we have a lot more that we could do. But I think when you're starting and you're at the beginning, you just keep putting one foot in front of the other and you keep trying to move the culture towards where you want it to be. So do I think we have done some stuff? We have done lots of stuff. We have made great strides as far as moving our culture towards being more inclusive. But I think we can definitely work on getting that culture to the feeling of that culture to be I don't think everybody feels comfortable in their seat. I guess if I'm going back to what my professor said, I'm not sure that everybody feels comfortable in their seat. And so I think that's the second step. You know, we started the process. I think we need to make sure that everybody is comfortable in their seat. And I can't say that we're there yet, but I think we can move towards it. It's a huge endeavor to try to, you know, try to tackle diversity and inclusion. It almost is, you know, one of these cliche words, like you're saying, just like culture. and sometimes people have a negative connotation around diversity inclusion because um if you think about um if somebody else is included that i'm losing something um and that's the wrong way to think about it um everybody comes from different backgrounds and cultures and everybody has something to contribute um i think you're a better institution if not everybody's saying the same thing. People can say something differently and give you a different perspective that you've never even thought of before. And I think that's when you can say that your culture is inclusive. When the think tank and the think speak is not the same, you've included different voices from people from different backgrounds and cultures and you have everybody in on it. That's when you've So kind of, yeah, that's diversity 3.0. Yeah, I know. I really personally enjoy hearing a lot of different people's with different people's backgrounds, perspectives on things, because I 100% agree people definitely see it from a different perspective, depending on kind of how they were brought up. Right. And I think it is important to have a mix of people at the table when decisions are being made. So I definitely agree with you. And I think we are on a good path. I think we are, like you said, we've started and we still have work to do. But I know we're going to be in good place going forward. Oh, I know we are. I mean, you know, I think you and I have talked offline that it takes a couple of years to see change. But, I mean, I'm very confident that you can change the tide. I have very much confidence in that. Oh, well, thank you for saying that. So I did want to touch on one other thing just to kind of get back on the obesity topic for a second. So around treatments specific to obesity. So you mentioned there's some medicines. Maybe we could talk for a few minutes about like specifically like what medicines or what's the role of medication in obesity treatment, as well as behavioral modification, as well as potential bariatric surgery and which patients should be considering bariatric surgery versus more of a medical or a behavioral treatment options okay so you know piggybacking on what i just said about changing this uh this changing the tide on treatment and obesity so we have to kind of get away from just telling people to move more and eat less that just clearly is not working the obesity trends have increased over the last decade and over the pandemic have really gotten And everybody jokes about the pandemic 15 or whatever it was for you personally. But that was because it was a high stressful time and cortisol levels increase your need to want to eat. So we were all in a stressful time and a lot of people self-soothe by eating. And so that post pandemic. Well, now we're moving and transitioning to endemic. But a lot of people did gain a lot of weight over the pandemic. So those obesity rates that were already high. I was going to say I put on about 15 myself, but just saying, but go ahead. I did too. So I mean, yeah, so, um, but, but I think we, so those obesity rates were high pre COVID. And then we went through this big stressful thing together. Um, and so a lot of the obesity had, those rates have increased. Um, and so, yeah, so we have to stop telling people to back from the table or making a judgment about what they're doing or not doing, um, because they are obese. And so when I, before I went to the Harvard course, I was of that mindset, right? Because we didn't learn a lot about obesity in med school. Um, and we weren't taught about, and there weren't a lot of treatments. Obesity medicine is a very young field. Um, but we're going to explode here shortly. I'm so excited to be boarded in that specialty. But so there's a couple of treatments that I want to talk about first for adults and the thing is they're not really indicated for obesity so that's one of the things that people who practice obesity medicine we're trying to get these acts passed with legislators to make sure that people insurers payers will cover obesity treatment so that's one thing that's lacking we don't cover these treatments and so these medicines are high cost So there's still only a certain segment of the population have access to it and then can afford it. So that's one of the other issues. But there's a new medicine, Terzepatide, Mongero injection. It's indicated for type 2 diabetes, but studies have shown that people can lose up to 25 pounds on that medicine as a side effect of them using it for diabetes. And so what's exciting to people who practice that specialty is that the root cause is obesity. If we can get that treated, then people can get off their diabetes medicines. They can get off their hypertension medicines. They could potentially not go on to have heart attacks, strokes, and the like. And so any medicine that can help people lose weight up to 25 pounds, that's pretty exciting for obesity medicine. So that one's Mongero, very expensive. It's a weekly injectable, fresh on the market this year. So, you know, sometimes you kind of have to wait for the masses to be able to get those. But very exciting in that it has a combination. It works on two different receptors that decreases food intake and slows your gastric emptying and helps with your insulin levels as well. So that's how that works. And then there is a new medicine, well, it's not new, but Casemia is Phentermine and Topamax together. That's been out for a while. It has this year been FDA approved for teenagers. So you can treat teenagers with Casemia down to age 12. That's huge. We don't have any medicines that are really specifically FDA approved for teens. Pediatric people have to use those drugs off-label. all the time. But they help the teenagers, and that's the reason why they fought very hard. A lot of people lobby in my group of obesity medicine specialists to get some of these drugs FDA approved for kids. And so, Phentermine is Adipex, and Topiramate is Topamax. And so, we've used that for quite a number of years in combination to help teenagers, as well as adults to lose weight um phentermine you know people have the side effects of that one um and it's it's um in certain states you can't use it for long term but um when you help somebody with high blood pressure medicine and three months rolls around and their blood pressure is normal you don't take them off um and that's what we have done and kind of ham you know put our hands behind our backs when we're treating obesity while we say you have to um you know not supposed to use for long terms. Topamax has its drawbacks too. Some people get fog with it, so they can't, you know, they get a really kind of haziness with their thinking. And so some people don't like that. And again, you know, payment options, all those kind of things also hinder who has access to those things. But to have a drug that's FDA approved for teens is wonderful. So like I said, we're in the infancy of obesity medicine, but I think as time goes on, we're going to see a lot of change. And then bariatric surgery is indicated for anyone who has a BMI greater than 40, out the bat. So if someone has a BMI greater than 40, they can be referred for bariatric surgery. And then greater than 35. So there are a lot of people who have a BMI greater than 35, and they have to have one comorbidity. So diabetes, high blood pressure, severe obstructive sleep apnea something like of that sort um that qualifies so greater than 40 or greater than 35 in a comorbidity and then for children we use percentiles to describe obesity um so anybody and so the percentile for children is anybody greater than the 95th percentile is considered obese now you wouldn't be considered for bariatric surgery until you're at the 120th percent of the 90th percentile so 95 here you got to be up here and that is um class uh to obesity and childhood obesity is there an age where someone i just as we're talking i'm just thinking like okay well gosh i wouldn't think an eight-year-old at a high obesity level who hasn't been through puberty yet should should qualify for bariatric surgery is there an age that at which i would say 12 it's cut off 12 as young as 12 i would say as young as 12 but i don't think many bariatric surgeons across the country would do that so there is a um uh practice guidelines um but i don't have that memorized so i think 16 is probably when they would look at it okay okay but there's a 2018 so it's a older guideline it's been out for four years um and so but i don't it's it's not out to the masses yet. You know, sometimes we've, you know, straggled behind our practice guidelines. All right. Well, Jamel, listen, gosh, thank you so much for, uh, for talking with me today. Is there anything else that you want to touch on today before we wrap up? No, I think that's, um, I think that's everything. I would say that if we can, um, give some, uh, you know, like you said, have compassion around treating people with, um, obesity. I think that would be what I would want to end with. They're people just like we all are, and we all have our different struggles. And, you know, a lot of people struggle with obesity, and it's getting more and more common. The stats aren't turning around, and we have to figure out a way to help people and not just dismiss them and say, go lose weight. We need to do more than that. And if I can get that across, then I think my goal here has been accomplished. so thank you for inviting me thank you dr felder personal friend really appreciate you being here uh today and um and thank you all for joining us for this very first episode of medically speaking and we hope you'll join us for future episodes thank you