[Goutham Rao] okay folks I think we'll get started we're a little slow gathering this morning but that's okay hopefully a few people will join us while we go through some of the preliminary information so welcome we are nearing the end of the series so just our usual reminders please don't disclose any PHI during case discussions these are the usual reminders about contact information for support a little bit about Cardi-OH which you've seen before and this is a smary slide of the team today I'll be facilitating as usual we have one case that's going to be presented by Rose from Cleveland Clinic and Mentor Chris Taylor and Adam Perzynski are going to be our didactic presenters today and Karen and Marilee will discuss a really interesting and very challenging case as well so usual disclosures there's no change from from last week and I think we guys can take it away Chris I think you're starting.

[Chris Taylor] Great thank you so much it's a great opportunity to talk a little bit more about contextual factors for lifestyle this is an idea that we had kind of following up from some of our discussions around the continuous blood glucose monitoring and how to really kind of interpret some of those some of those data within the context that might be functioning behind it it so I will get us started this morning and then I will pass it off to Dr Perzynski so our objective is talking about lifestyle behaviors assessment and context behind behind what the lifestyle behaviors are and how they might influence cardiovascular risk.

so one of the common questions I always get is around what our kind of foundational guidance is for nutrition and we're looking all the way back to the 1940s our recommended dietary allowances were established really as a function of World War II and the draft we were drafting individuals to go fight in the war and when you take general citizens and then in quick training hope that they'll be able to go out and serve as soldiers we were identifying basically nutritional risk that existed in the general population and that's when they really started to create the idea of we need an actual standard of what nutritional status should be and it really kind of led to the beginning of our dietary guidance you see the basic seven over on the left hand side and how this has kind of evolved into the concept of essentially what you the buzzword would keep hearing of plant-based which regardless of where you look across the spectr of our history of dietary guidance we're looking at plant-based that make up the foundation fruits vegetables whole grains and and then with our dairy and protein foods and then fats and oils used sparingly.

but we have this historical perspective around dietary patterns dietary recommendations and we're translating these into what Americans eat and setting the stage in terms of where we are and how we might be making recommendations towards dietary behavior change taking a look at the healthy eating index score which is basically a metric of how well Americans are doing in relation to the recommendations for the dietary guidelines for Americans so this healthy eating index score is a score 0 to 100 but what it ultimately is telling us that Americans are overall not passing the class for diet quality and we'll see this across the total population but also within our different racial and ethic groups.

and to understand a little bit more just looking at the total diet the background lines are the maxim points that we have within each of the scales so total fruit and whole fruits make up basically 10 points for fruit intakes vegetables get 10 points and it's broken down for total vegetables but also greens and beans to get that diversity in the diet whole grain dairy fatty acids all around at max of 10 points but you can see the areas where we're struggling the most so these give us opportunities to provide more specific guidance in areas when we're trying to promote healthy eating within our patients to either prevent or treat cardiovascular disease. the fatty acid the fatty acid subcomponent for a little bit easier translation is the relation between saturated fat to unsaturated fat so a higher proportion of saturated fat is going to then bring that score down a lower diet quality. so for every one of these the lower the score the lower the diet quality and then these would be within the components that we're trying to encourage more so more fruits, more vegetables, more whole grains, dairy and then under our moderation categories these are the areas where we want to limit intakes.

so we want to so you can see the context in which we would be making recommendations to try and help improve dietary intakes and we're seeing that a lot of the international guidance that we see from the dietary recommendations of other countries very much mimic the types of recommendations that we have from our own dietary guidelines so it's a lot of the the similar fruits, vegetables, whole grains, the plant-based diets so the applicability of the dietary guidelines that we have here and how they translate out into other populations means that we're applying these to different cultural food ways but we're looking differently at what are the staple carbohydrates that might be consed within a target population so a subgroup might not conse a lot of bread or grains but they might conse other starchy vegetables or starchy carbohydrates as their primary source.

vegetables and fruits we just see a different cadre of foods that contribute to these groups where we may have more apples and bananas in one group but you may have a more diverse type set of fruits and vegetables within another target population. the same thing with our protein sources may be animal-based may have groups that are more aligned towards a vegetarian diet so their plant-based sources are going to be more in the beans, peas and lagoons so how do we then create opportunities for them to meet dietary recommendations across their different kind of cultural approaches to eating.
and the one the thing that I thought became a very interesting element for us to kind of bring forward especially when we've been talking about using the continuous blood glucose monitoring and identifying what's happening across the day and and how to respond to those changes that are happening throughout the day that what what those patterns are have an underlying story of physiology and lifestyle and this concept of ecological momentary assessment really means that not only what you eat is leads to a total day but it's also the s of their parts so the synergistic addition of what did you have in the morning afternoon in the evening as a snack in between all of those are going to have impacts that then lead up to a total day but are also going to help us understand the context in which certain behaviors happen.

so what are those roles of snacks throughout the day the timing of eating the meals versus kind of snacking occasions how does that help us better understand what individuals are doing that give us what that ultimate kind of final intake actually would be and these are often then anchored to other related lifestyle factors so if they're being active what are the times of day where they're more active versus less active so that context of their circstance is really going to then drive what they eat what they do how active they are how inactive they are and this might be anchored to travel travel time so how many how many times do we talk about we got to run from one place to the other and we're stopping and grabbing food we're eating in the car on the way which then is going to impact the types of foods that someone's eating for dinner if they're going to be eating while driving and taking kids to a particular event or having to get home working late or or that or when they have to care for others what kinds of time do they have for meal preparation.
so understanding that context behind what behaviors are may help us better facilitate the behavior changes that we're looking for in lifestyle so it's not only the what individuals are eating and how that influences their cardiovascular risk and their diabetes risk but what are the factors that drive why they're eating what they're eating so that we can we can understand the context in which people are making their decisions and there is a whole there are a whole bunch of different wearable devices now that really help us understand what are the times when you are inactive and active you can you can track how your heart rate is throughout the day and identify those times where you are being more active versus less being able to track those inactive times which may also then be related to the times you're eating and snacking so the ability to pull this type of data together becoming a different source of information for us as we as we continue to provide more personalized approaches to facilitate lifestyle behavior change.

so I pulled together a handful of resources that'll be helpful looking at ways to implement lifestyle behavior change and also some resources for nutrition education to help with that Improvement in overall diet quality and with that I will pass it over to Dr. Perzynski.
[Paul] Dr Taylor this is Paul if I may if we can do it briefly on slide nber 12 I'm fascinated with the data at first glance you're inclined to have warm fuzzies because we're doing well when it comes to seafood and plant sourced protein but yeah the next one back slide nber 12 there you go seafood and plant protein that looks good but I'm wondering is that advertent because people are making choices or is that inadvertent because plant protein is part of processed food I'm just wondering why we seem to be quote unquote doing so well in that particular category.
[Chris Taylor] this is the one category that is it's somewhat misleading partially because with seafood the recommendations are 8 ounces a week and that the way that the consption data is captured is on a daily basis and then they do this as a population level so the seafood and plant proteins is the one category in here that somewhat over represents how well we're doing because of how little seafood we actually conse regularly that those episodic intakes the way that this is assessed makes us look like we're doing a lot better than we are and our plant proteins our leges are actually relatively small as far as is the prop proportion of people that conse them and the quantity so this is the one category within here that's actually kind of almost an overestimation of how well we're doing which is another indication on what our total scores actually look like.

[Paul] Very good thank you.

[Goutham Rao] Hey Chris could I ask you just a quick question as well so this this is a healthy eating index from Adam [inaudible]I think in Washington that he developed many years ago is this still based on your work with the dietary guidelines advisory committee is this still a valid measure of healthy eating given changes in patterns and things that have been going on recently.

[Chris Taylor] Yeah so this this would actually be developed by the center for nutrition policy and promotion as a direct result of the dietary guidelines so that's that the metrics that are used within each of the food groups are based on the recommended patterns that are developed from the evidence based analysis.

[Goutham Rao] Great thank you, okay Adam take it away whenever you're ready.

[Adam Perzynski] Loving this discussion so I'm going to talk a little bit about community structures I think there's a real nice intersection even with some of the exact measures between some of the example data that I'll show and so like you know I think about this a lot because a good bit of my work is focused on on neighborhood conditions and so we know from lots of research that neighborhood conditions influence cardiovascular disease and diabetes onset and management but then I'm going to talk a little bit about food retail environments people some some of you most of you have heard about this concept of deserts I think less often people think about food retail environment so I thought that would be nice to talk about as a contextual factor and then maybe I'll also share like a an anecdote or two from some other work I've been involved in.
so the Centers for Disease Control has for quite a while been distributing this value for most areas of the United States called the retail food environment index or there's a newer one that's the modified retail food environment index they're really very very similar. the image in here is kind of nice like it's an example of how this would be constructed for a person and then the equation is also there and it's really just the nber of fast food and nber of convenience stores divided by the nber of grocery stores plus the nber of produce venders in the denominator for any given area so that could be like a census tract or a block group or a zip code or a county oftentimes it's reported for small areas like census tracks which I think is what I'm going to show you.

so the there was a paper quite a while ago on California that linked diabetes prevalence and later linked diabetes incidents and management to the modified retail food environment index this was one of the first analyses out of California that showed a pretty substantial difference in the prevalence of diabetes based upon this sort of purely contextual factor of like what kind of food retail environment a person lived in so a really sort of heavy structural influence on the on the prevalence of disease.

so if we look at this for Ohio we reach a a sort of really interesting map these I think are census tracks so like and Ohio is this really interesting state where like we have some counties that are like one census tract so like and then you have places like like Cleveland, Cincinnati, Colbus where there are hundreds of tracts within the city so the a tract isn't always the same thing the like you can see like Ashtabula County out there in the far Northeast is basically one tract the maybe it's two. the and so what you can see is like a lot of heterogeneity both in the rural areas and the urban areas in the score here and also the the red is like the red is worse in this map dark blue is is best. the these patterns look a little different than than other patterns because retail environments don't tract perfectly with socioeconomic conditions.

but if we so if you dive deeper and we look just at cities there's this great paper by Darcy Freedman and another a nice group at at Case Western and they did a really elaborate survey study of folks in both Cleveland and Colbus and conducted this path analysis whereas the primary outcome they used the healthy eating index that Chris was talking about and they looked at these multiple ecological layers so these contextual layers of dietary behaviors and so they looked at you know at the far left they looked at the built environment so at things that are sort of approximate that modified food retail index and then they looked at what they called individual factors which is like a person's response to a scale about whether they see themselves as a person who eats healthy and whether they feel that they have control over eating healthy in their life or whether that's something that's outside their control.
and they also asked like whether they felt that the people in their household and their family provided support to them for eating healthy in that sort of center box and then they also asked about food shopping behavior so how far they traveled on average to get food from the place where they most often buy food and then how frequently they buy food and they linked all of this to how whether how and whether people ate healthy and then also to how much money they had in their household.

and one of the there so I there are two slides here and this one is for Cleveland and this one is for Colbus and there are some really notable differences between Columbus and Cleveland in this analysis and the biggest difference is that in Colbus how much money you had seemed to matter a lot more for most of the factors in the model so that the household income was a much bigger predictor of people's eating behavior your overall and we were able to explain like I think the the r squared in the Colbus analysis was roughly like 0.28 or almost 0.3 so 30% of the variation in people's healthy eating behavior was explained by these ecological factors and how much money was in their household.

but in Cleveland what we found was that the r squared is only 0.15 so it's like it's like half and also money seemed not to be a big part of it. the there's some speculation in the discussion section of the paper that like well maybe much of this is because like Cleveland has a much higher rate of poverty and has a much higher rate of people using the Cleveland food bank and food assistance than in Colbus that was one of the sort of speculative points from the discussion such that if you're able to get your food from other food ways like that are our various Public Assistance programs then your income matters less in terms of your food acquisition but that still doesn't explain the differences in food choice that are that are found here and that that income does not like seem to influence food choice in these individual factors in Cleveland which is a really sort of interesting finding.
but you know so part of this you know this this statement at the top differences can be hyperlocal it really is important to think that in a big and diverse state like Ohio where we all work in different places of the state and this this this ECHO discussion kind like the context that we're in is very very different and patients live and move through these contexts in their own ways.

and so here's where the the story that I like to tell a little bit I have a one of my projects resulted in a spin-off software company and the company that I founded sell software to a national company called rolling strong, rolling strong was founded by a gentleman by the name of Steve Kain and Steve is a a former truck driver like over the road truck driver who was really unhealthy and one day after work he had a heart attack and almost died and he decided to stop trucking and start a health and wellness company for truckers with the idea that it's possible to live a healthy lifestyle as an over the road trucker.
which and if you think about and one of the things Steve likes to say is that like if you think about a job where it seems almost impossible to live healthy it's being an over the road trucker like think of the food retail environment that truckers are dealing with like truck stop food just hardly sounds like it meets all those categories that Chris talked about and like also what is the exercise facility right like it just seems really really hard.

and so Steve actually drives around like his business is fully mobile it's a it's a semi truck and he he and his team like drive around the country doing demonstrations for trucking companies about how truckers can eat healthy and live healthy and he provides health and wellness coaching for truckers like sometimes times while they're while they're on a break and on a over the road shift they can call and have a health coaching session and so and you know he's had tremendous success in doing this and so like it's one of my favorite stories that like differences can be hyper local but like the resilience of like small pockets of communities to be able to sort of push back against these contextual structures is really one of my favorite things right like no matter how bad like work in environments can be like they can be very unhealthy we're all sitting here staring at screens right now we're not really the pinnacle of health and wellness this morning across Ohio on our ECHO session but no matter what we're doing like there still is the ability to sort of like find some some healthy food pathways and healthy eating pathways so I really love that story because I I think differences can be hyper local.

I'm almost going to wrap it up here I really love this with that said the structural elements are very very powerful and food environments are powerful so people who live in poor food environments are far more likely to conse more weekly servings of sweetened beverages like soda. there people who live in poor food environments they simply conse more fast food so high salt high caloric density food and fewer vegetables and if we look at at like an entire state like Ohio if we think about just those like food environment influences in Cleveland and Colbus just that one pathway from that complex model the neighborhood influences account for millions of additional unhealthy meals every week right so like like we're having millions of additional unhealthy meals simply because of the structures of our communities.

the I this week was asked to review a paper about one particular solution to this so improvement is is possible. the effort to improve availability and a reduced cost of healthy food is generally associated with some small improvements and similarly the paper that I'm reviewing is on the California sort of unhealthy food tax and it's like potential cost effectiveness and in general it's sort of the same thing efforts to like reduce the availability of unhealthy food are a little bit helpful.

partnerships between your clinics and healthy food outlets are generally like your patients would really love that if you partnered with a farmers market or healthy food outlet and there are some small improvements in the data there but I think this point about having an activity based understanding and the Chris's point about about like thinking of things in an ecological momentary assessment framework and I always love you know like how many people are eating snacks in their car because of how their job is and what is what is the health and nutritional benefit of those snacks that they're eating in their car or their truck because of how their job is structured. the I think those activity based understandings are really really important.
and then lastly I think this paper is really about obesity from National Academy of Medicine but I think this sort of four quadrants approach highlighting the areas in which Improvement are possible improvements are possible is really I think this is a sort of really nice illustration of how many different pathways to Improvement we have right so the top left is really sort of like focused on these structures of like well how do we improve like these retail food environments and then but then there are also things that deter us from eating healthier and so like we can reduce those deterrents in the top right quadrant.

the bottom left quadrant is really focused on policy level things maybe like the California or the you know the entire nation of Mexico has unhealthy food taxes I don't know if you've ever seen you pay a really heavy if you if you go shopping and buy like a a two liter bottle of coca cola in Mexico and it's sitting right next door to the on the shelf to the Coca-Cola zer you're talking a like a threefold difference in the price so like Coca-Cola zero is going to cost you like maybe the equivalent of like1 US dollar and that two liter because it's also vole based their soda tax is vole based so it escalates with the greater vole. the the the regular Coca-Cola that's full of of calories and sugar will cost three to four times that amount based upon that tax on the shelf in Mexico.

there's a group at the population Health Center at Oxford that has evaluated the effect of that tax on children in Mexico City and found a dramatic reduction in childhood obesity and hypertension and just tremendous positive benefits to that sort of like what is probably the world's like heaviest duty like sugar tax so like that bottom quadrant like policy advocacy can be super effective and can influence big changes for many many people.
and then at the bottom right I also think like community capacity and here's where I think about about my friend Steve Kane like empowering community members and groups of workers and people in neighborhoods and your patients and entrepreneurship and promoting Behavior change can also be effective and I think like the message of of the National Academy of Medicine here was that we can make improvements on all these fronts at the same time and really drive ourselves toward healthier healthier lifestyles. I think that's all I've got so if you have questions for Chris or I additionally we'd be happy to talk some more.

[Goutham Rao] Thank you Adam any questions for for Adam or Chris.

[Karen Bailey] This is Karen question Adam and Chris I love this presentation by the way and one of the things that you know as a dietitian I think about are I live in a rural area so I have patients that come in from food deserts and even though they want to eat healthy there's a problem of just the you know access to a grocery store that offers a variety of healthy foods and you know our our system our capitalistic system is not going to fix that very easily because the store is not going to move into a rural area if they're not going to make any money because only 3,000 people live there and they're all low income.

so then I I thought you know nutrition education is very valuable and important we have Americorps around the United States they go into these communities they teach kids about healthy nutrition they show them different vegetables my one of my kids is in Americorps so I've learned a lot about that but you know the other piece of it be besides that education is maybe having subsidized grocery stores in rural areas because you're not going to get our rural residents to go out and start planting gardens not all them are going to do that that's what they used to do back in the day everybody had a garden that's just what they used to do but times have changed.
so what you know Adam or Chris what do you know about subsidized grocery stores and is there I see there's been some studies on them but what do you think is the value and really kind of promoting you know that as part of a community effort in certain areas where there's food deserts.

[Adam Perzynski] Chris I'm I'm happy to start here I think like the political environment for that is like super super challenging that feels like sort of like a big like almost capital P policy solution and I think those are those are those require like a lot of heavy duty like political buy in and bipartisan for and it that can be very very challenging especially for small rural areas which are often disenfranchised and don't have great political representation.
I think you know in in other sessions Goutham has talked about this from like a food justice standpoint often in urban areas but I think like rural food justice is a similarly challenging topic. I think maybe my favorite approach here which maybe feels a little unsatisfying is community supported agriculture and community share associations are super effective so yeah maybe not everybody wants to engage in like planning a community garden but there are some farmers who are deeply interested in selling their produce to their neighbors and we'll plant more produce of different types but maybe like but the economy of that is like you know the the the folks in the community are going to have to to band together to support that.
and so you know community share associations across the country have been very very effective at provisioning healthy food. it's a little bit seasonal the but you know these like I you know I don't know about the rest of Ohio but like out in Geauga County there are these that a lot oftentimes they're sponsored by a single farmer or two and the farmer says like look you can be in my egg Community Share Association or you can be my produce Community Share Association and you have to front the money which is really tough so that if you confront $500 for the season like every week you're going to get like two giant bags of produce from from June through November.

the and like and you don't have to pay like that one time payment and then like and so you're taking on the risk with the farmer because whatever grows grows whatever doesn't grow grows if it rains a lot or like you you know you might get a lot of radishes in June. the that you may you may eaten a be eating a big box of kale the in some ways that's one of the reasons they're effective.

the egg share associations are you know I think eggs are a big part of of Chris's diagram and you know over vegetarian diets are super healthy. the and egg shares are also super great and really reduce the cost of of obtaining eggs and other healthy foods so that's probably like my favorite example of like a community resilience strategy that can be really good. most of these end up drastically reducing the cost of produce that like you spend so much less on produce if you're in a CSA. we used to have one at Case Western where you could go pick up the farmers would bring the food like to the campus. you had to pay up front but like you'd go you know there'd be couple hundred people standing in line every week on Thursday or Friday to get their bag of produce from the farm that they would drive into the cities like I think these are generally popular and well received it's not like the big policy solution you're looking for but I think like these sort of intermediate food ways are probably the more like like the solution that's more likely to to to solve that.
[Goutham Rao] Thanks Karen, Chris has kindly offered to defer his comments I'm sure he's got some great comments just to clarify there are subsidies for grocery stores and Adam was in indicating in urban areas but those subsidies are for the capital expense of building the grocery store and it's usually a tax deferment over 10 years not for the actual food that's inside and so this is why this is controversial and ineffective because they can sell whatever they want in these grocery stores they are selling unhealthy foods for the most part. the study from Chicago showed that people eat the same foods they just eat more of it and buy it at a lower price when the grocery store moves in.

the other thing is because they lose the the it gets phased out often the grocery stores will leave once they once they no longer can get the tax subsidy. they kind of blame you know retail theft which is kind of hard to imagine from a grocery store you know people stealing groceries but these are some of the claims that they make. but your point about rural areas is really important I haven't heard of anybody subsidizing any sort of rural grocery store so so let's go back to Andy for a minute before we wrap up.

[Andi Christopher] Just a reminder that our May webinar is coming up and you can register through our website or through the QR code all past and present ECHO clinics are available to you on our website and then a post clinic survey has been emailed to you please complete that by tomorrow also for our final wrap-up clinic we will be answering any outstanding questions you have so please feel free to email them to me or add them to your post clinic survey.

[Goutham Rao] Thank you Andi so that final session which will be in two weeks I think Karen is leading our session next week but is an opportunity for us to tie up any loose ends any questions that we didn't get a chance to address it usually winds up being a pretty interactive and an important session so please start to think of some of those things over the next week or so all right thanks everyone have a great day bye
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