Economic Impact of Racial Health Inequities; Obesity and Cancer Risk

TTHealthWatch is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine in Baltimore, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week.

This week’s topics include the economic impact of racial inequities, use of housing vouchers to reduce severity of childhood asthma, metabolically unhealthy obesity and cancer risk, and exercise and infectious disease risk.

Program notes:

0:42 Economic burden of racial inequity

1:42 Impact of education

2:42 Death younger than 78 years

3:18 Housing mobility and childhood asthma

4:18 Baltimore housing partnership

5:15 Impact of antibodies to allergens

6:15 Disproportionate environmental exposures

7:15 Housing reparations

7:30 Leisure time physical activity, flu and pneumonia

8:30 Up to 600 minutes of exercise

9:25 Obesity, healthy obesity and cancer

10:25 Increased relative risk of obesity related cancers

11:25 Interrelated to decrease risk

12:05 End

Transcript:

Elizabeth: What’s the relationship between obesity, metabolic healthy obesity, and cancer?

Rick: Assessing the economic burden of health inequities in the United States.

Elizabeth: What’s the association of housing with childhood asthma symptoms and exacerbations?

Rick: And does leisure time physical activity change mortality from the flu and pneumonia?

Elizabeth: That’s what we’re talking about this week on TTHealthWatch, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I’m Elizabeth Tracey, a Baltimore-based medical journalist.

Rick: And I’m Rick Lange, president of Texas Tech University Health Sciences Center in El Paso, where I’m also dean of the Paul L. Foster School of Medicine.

Elizabeth: Rick, how about if we turn right to JAMA? I’m going to ask you to take the ball first on this economic burden of racial, ethnic, and educational health inequities in the U.S. JAMA this week is, of course, focusing a lot on this specific issue.

Rick: Right, and Elizabeth, this is the most comprehensive study I have seen. They’re looking at the year 2018, estimating what the economic burden of racial and ethnic health inequities is in the United States.

They took an interesting approach. Oftentimes, we talk about health disparities and comparing one group to another. Typically, you’ll compare Blacks to whites or Hispanics to whites. You know what? The whites really aren’t all that healthy either. So let’s talk about health inequities rather than health disparities.

Here is what they discovered. Using analysis of data from 2016 to 2019, they estimate that the economic burden of racial and ethnic health inequities is about $420 to $450 billion. Let’s look at education, whether you have a high school diploma or not, a high school or college, or more than college, whether you’re a college graduate. If you look at education-related health inequities, the cost of that is $940 to $980 billion.

If you parse it out, most of the economic burden is attributed to the poor health of the Black population — about 74% of the health inequities. Even the burden attributed to things like Native American Indians or Alaska Native Indians is higher than the proportion of the population. Most of the educational-related economic burden is incurred by adults that have a high school diploma or GED. Although they only make up 9% of the population, they bore about 26% of the cost. If we’re going to talk about addressing health inequities, we have to look at the racial, ethnic, and educational inequities in the United States.

Elizabeth: This outcome, of course, was not just the sum of their excess medical care expenditures, but also included this loss to labor market productivity and the value of their excess premature death, death younger than 78 years of age. I think it’s something we really need to focus on because we are experiencing a population decline and all of us are so inextricably linked to each other. We need everybody to be in there being productive and we also need them to be healthy while they’re at it.

Rick: Right. There is an editorial that accompanies this and says, “Listen, if you don’t want to make this argument on a moral ground — that everybody ought to have the same access to healthcare, and there ought not to be health inequities — you ought to at least make it on the economic argument. They make the point that income and wealth inequality is higher in the U.S. than almost any other developed country.

Elizabeth: Let’s then turn, also in JAMA, to this association of a housing mobility program with childhood asthma symptoms and exacerbations. This is kind of drilling down from the really big picture that you’ve just created, and taking a very specific circumstance — that’s this incidence and also severity of childhood asthma.

Their central hypothesis centers around structural racism. It has been implicated in the disproportionately high asthma morbidity that’s experienced by children who live in disadvantaged urban neighborhoods, or what they call “high poverty” neighborhoods. They wanted to look at whether participation in a housing mobility program that provided housing vouchers and assistance moving to low-poverty neighborhoods could reduce both asthma exacerbations and visits to emergency departments because of those exacerbations.

This was done here in Baltimore with a cohort study of 123 kids 5 to 17 years of age with persistent asthma. They participated in something called the Baltimore Regional Housing Partnership Housing Mobility Program. They were matched with another cohort of kids, 115 children in the Urban Environment and Childhood Asthma (URECA) birth cohort. Among these kids, their median age was 8.4 years.

They found that when they moved them, the vast majority of them were well below the poverty line. Only one of these kids continued to live in a high-poverty neighborhood during this course of this study. They found that 15% of them had at least one asthma exacerbation in a 3-month period prior to moving versus 8.5% after moving. Their maximum symptom days in the past 2 weeks were 5.1 before moving and 2.7 after moving.

They also looked at other things like, you have antibodies to things like mouse droppings and cockroach, and did you have a parent who smoked in your home? They also were able to look at those exposures to those kinds of allergens and cigarette smoking. They were able to say, “You know what? It doesn’t look like it’s these things; it looks like it’s stress reduction that accounts for this really positive benefit.”

Rick: This cohort of 123 kids moves from a low-income area to a higher-income area because of vouchers, and it reduces the odds of asthma exacerbation by 54%. You talked about structural racism. I’m going to take a step back because oftentimes our hair stands on end and we say, “What do you mean, structural? I’m not a racist.”

You know what happened in 1933 is the federal government established what’s called the Homeowners Loan Corporation because there were a lot of foreclosures. They said, “We need to stop these home foreclosures” and they “redlined” communities. They drew a red line around Black communities and said, “There is a high risk of foreclosures, so we’re going to make it harder to get loans.”

Suddenly you have a group where they have concentrated poverty and they’ve got disproportionate exposure to environmental exposures and poor housing quality. That just happens for the next 60 or 70 years. It’s not intentional, it just happens. As a result, because of this and other conditions, we have an increased risk of asthma and other chronic conditions. This was a really well-done study.

Elizabeth: I think so too. I would note that the editorialist also mentions a study we talked about before that looked at greening of vacant lots and also housing remediation, maintenance, and trash pickup in these neighborhoods that have a high degree of poverty and demonstrated a decrease in gun violence in those neighborhoods. There is something that we can potentially do within the neighborhood itself.

Finally, I would say this. I think a lot of us, since we have so much focus on this notion of structural racism right now, also tend to bristle when we hear reparations. We feel like, “Wait a sec. I didn’t do this. I’m not a racist. It’s not my problem.” I actually think that this place of providing housing reparations is a really great idea to try and to reduce some of these inequities.

Rick: Yeah. But what you’re doing is you’re just shifting public resources and providing housing opportunities that basically changes a family, changes their health, and changes their trajectory as well.

Elizabeth: Let’s turn to the BMJ.

Rick: This is looking at leisure-time physical activity and mortality from flu and pneumonia. This is a study of, gosh, almost 600,000 U.S. adults. We talk about leisure-time activity; I will remind our listeners that the recommendation is that people spend about 150 minutes per week of moderate-intensity aerobic physical activity and also two or more episodes of muscle strengthening. Does this really improve outcome — not just “Do you feel better?” but if you’re exposed to some condition like pneumonia or flu, is it protective?

Well, 600,000 people were followed for a median of 9 years. During that time, over 1500 influenza and pneumonia deaths were recorded. What they noticed was that if you met both of the guidelines, it decreased your risk of mortality from flu pneumonia by half. Even if you didn’t do that, let’s say if you just exercised 10 to 149 minutes, that decreased your mortality by 21%. The more you exercised, the better you did, up until about 600 minutes. Relative to muscle training, if you did two or more episodes per week, a 47% lower risk. If you did 7 or more, it actually increased your risk, although I’m not sure what that’s about.

Elizabeth: Where is the sweet spot with regard to the balance between cardiovascular and strength training activity?

Rick: The sweet spot — what I’d recommend is 5 days of aerobic exercise, 2 days of muscle strengthening and pretty much you’ve hit the sweet spot.

Elizabeth: Of course, I’m going to pin you to the mat here and ask you, how does your exercise regimen compare?

Rick: Well, Elizabeth, with regard to aerobic exercise it’s actually pretty good. You and I both ride bicycles. I do need to pick up the muscle strengthening though. I was thinking about that as we read the article. This is going to change my exercise behavior.

Elizabeth: You can poke me on this, too, because I too fall down when it comes to the weightlifting and keep on thinking to myself, “I really need to do this” and I just haven’t gotten around to it.

Finally, let’s turn to the Journal of the National Cancer Institute, this ongoing debate, “Gosh, is it possible to be obese, but metabolically healthy?” In this study, they are assessing this with regard to the risk of obesity-related cancers. They looked at normal body mass, overweight, and obesity jointly and in interaction with metabolic health status in relationship to obesity-related cancer risk.

Their N in this study was almost 24,000 among almost 800,000 European individuals. They gave these folks a metabolic score and that’s amid blood pressure, plasma glucose, and triglycerides. They also looked at, of course, obesity and they used the standard metrics to determine that.

They found that unhealthy obesity, where your baseline metabolic score was not good, was found in about 7% of their participants. When you had unhealthy obesity, compared with a metabolically healthy normal weight, there was an increased relative risk of obesity-related cancers including colon, rectal, pancreas, endometrial, liver, gallbladder, and renal cell cancers as well as these other obesity-related cancers.

Rick: Let’s add some additional information, which is that there’s some additive effect of what I’m going to call the “inflammatory state.” We’re talking about people that have high triglycerides, high sugars, and hypertension. The combination of the obesity and the inflammatory state accelerates the incidence of certain types of cancers.

Elizabeth: This study also shows that there still is a risk that’s associated with even metabolically healthy obesity. I don’t think there is any question that getting our arms around this propensity of people to become obese for a multitude of reasons is going to be really important for reducing the risk of all kinds of chronic disease, including cancer.

Rick: Right. It’s kind of a tripartite view: obesity increases your risk of having metabolic disorders, obesity increases the risk of having cancer, as does the metabolic disorders. They are all interrelated as you said. Addressing obesity will be central to decreasing the risk of cancer and decreasing the risk of metabolic disorders as well. I totally agree.

Elizabeth: I guess the other thing that this points out is that those folks who do have obesity ought to be scrutinizing themselves and making sure that they get all kinds of cancer screening promptly.

Rick: Yep, your point is very well taken.

Elizabeth: On that note then, that’s a look at this week’s medical headlines from Texas Tech. I’m Elizabeth Tracey.

Rick: And I’m Rick Lange. Y’all listen up and make healthy choices.