Social Determinants of Health - Modifiable Risk Factors - Obesity and Energy Balance

Social Determinants of Health in Cancer Care

This episode was originally released September 29, 2021

In this Social Determinants of Health (SDOH) episode, Dr. Jacquelyne Gaddy (UNC-Chapel Hill) speaks with Dr. Marvella Ford (Medical University of South) and Dr. Jennifer Ligibel (Dana-Farber Cancer Institute) on obesity and energy balance as modifiable risk factors and how clinicians can respectfully engage with their patients on this topic. View COI.

TRANSCRIPT

LORI PIERCE: Hello. I'm Dr. Lori Pierce, the 2020-2021 president of the American Society of Clinical Oncology. Thank you for tuning in for this discussion on social determinants of health and their impact on cancer care. The purpose of this video is to educate and inform. It is not a substitute for medical care and is not intended for use in the diagnosis or treatments of individual conditions. Guests on this video express their own opinions, experiences, and conclusions. These discussions should not be construed as an ASCO position or endorsement.

For this series on the social determinants of health, we invite guests with a wide range of views and perspectives. Some of these conversations may be provocative and some even uncomfortable. But ASCO is committed to advancing equitable cancer care for all individuals, every patient, every day, everywhere.

I dedicated this vision to my term as ASCO president, and these conversations bring many voices to the table, voices that we need to hear to move forward and find solutions. We hope you learned new ways of thinking about these issues and we invite you to join us in working toward a world in which every person with cancer, no matter where they live or what resources they have, receives high quality equitable cancer care. Thank you.

JACQUELYNE GADDY: Welcome to the ASCO Social Determinants of Health Series. I am Dr. Jacquelyne Gaddy, and I'm a current third year fellow in the Division of Oncology at UNC Chapel Hill. With me today is Dr. Marvella Ford, endowed chair of cancer disparities from the Medical University of South Carolina and South Carolina State University, and I also have the pleasure of having Dr. Jennifer Ligibel, director of the Zakim Center for Integrative Therapies and Healthy Living at Dana-Farber Cancer Institute.

In this episode, we will be discussing obesity and energy balance as modifiable risk factors, and how clinicians can respectfully engage with their patients on these topics. Dr. Ligibel, we've had some time talking together. And I want to start by actually just getting an introduction of how we can actually relate cancer and the outcomes of cancer with this topic today of obesity.

JENNIFER LIGIBEL: Sure. This is definitely a topic that we've learned a lot about, especially within the last few decades. We recognize that obesity is an epidemic, not just in the United States, but everywhere. In the US, many adult populations across various states have a prevalence of 40% or more of the adult population having obesity. And this rate is rising around the world. And we've known for a long time that obesity increases the risk of a lot of diseases, heart disease, diabetes. The connection between obesity and cancer is something that we have recognized more recently.

And in fact, in 2016, the International Agency for Research in Cancer reviewed all of the data looking at the relationship between excess adiposity, whether it was measured through BMI, through body composition and the risk of developing cancer, and found that there were 13 different cancers for which there was a clear and consistent relationship between higher levels of obesity and higher levels of cancer.

We also know that there's a relationship between a number of factors that contribute to excess adiposity, things like inactivity and poor dietary quality and excess cancer risk. We also know that individuals with obesity face increased challenges after cancer diagnosis. There are higher incidences of things like surgical complications, neuropathy, and other side effects of cancer therapies. And for many diseases, individuals with obesity at the time of cancer diagnosis have an increased risk of cancer recurrence and mortality as compared to leaner individuals.

So we know that there is a strong relationship between obesity and the risk of developing cancer and the risk of dying from cancer, as well as suffering increased toxicity from cancer treatment.

JACQUELYNE GADDY: Thank you for that, Dr. Ligibel. That gives us a really introduction into this important topic. And Dr. Ford, if we can dive a little bit deeper, I know this past summer for our ASCO conference, I had the pleasure of listening to you as you presented. And I wanted to specifically ask you to address what you discussed in regards to inflammation and its relation to cancer and obesity.

MARVELLA FORD: Yes, absolutely. So as Dr. Ligibel just noted, there is an association between being overweight and likelihood of being diagnosed with cancer, and also, the cancer treatment outcomes. What we have seen is that there's an underlying association between bile inflammation. The same bile inflammation that is linked to heart disease is also linked to cancer. And the good news is that there's something that we can do about it. So when we talk about the modifiable behavioral health risks, this is one of them.

What we're seeing is that physical activity can actually reduce levels of bile inflammation in the body, which is great news. And Dr. Ligibel and others around the country are leading the way in developing physical activity interventions for people who are diagnosed with cancer so that we can intervene early on to develop strategies to improve their cancer treatment outcomes.

You know, that leads us to the broader question of physical activity for the general population. How can we increase physical activity for everyone to reduce cancer risk? And I think there are some very attainable goals that we can set and there are some strategies that are achievable that we can accomplish in that arena.

JACQUELYNE GADDY: As we think about the social determinants of health and why we got started with this, and Dr. Pierce did an amazing job of putting that at the forefront of ASCO's goals this past year during her presidency, before we dive even deeper, Dr. Ford, I want you to address specifically, you had a wonderful figure. And I can kind of see it in my mind right now in regards to the race maps when addressing obesity, and again, tying that back into its relation to cancer.

MARVELLA FORD: So when we talk about obesity, what we don't want to do is get into a blaming-the-victim kind of approach where, oh, these people are just so overweight, that is exactly what we do not want to do. It's really important to look at the social determinants of health and the contributors to overweight and obesity. Because people are working with what they have available to them. And so the map that you're talking about really highlights the social determinants of health in relation to obesity.

And so what we saw-- I showed a series of maps-- is that obesity in the US, it's associated with race but it appears to be driven by socioeconomic position. So areas that have lower levels of income, education, you know, upward mobility is what we used to call it, have higher rates of obesity. And a lot of that is due to what's in those communities. And so if you drive around those communities, whether they're rural or urban, you see a lot of fast food places. You see a lot of food deserts.

Food deserts are not just a purview of inner cities, urban areas, rural areas where you would think, well, that's ironic because food is grown in the rural areas. But rural areas can also be food deserts. And so in my work at the Hollings Cancer Center, we're focusing a lot on the I-95 corridor of South Carolina, which ranges from North Carolina at the top, to Georgia at the lower end. And I know that's been an area of interest to many in our state.

And what we have seen is that it's one of the poorest and most medically underserved areas of our state. And if you just do a visual exam, if you drive on the I-95 corridor and just get off on some of the side roads, you see just a dearth of healthy foods, grocery stores. There are convenience stores. There are gas stations. I call it gas station food, convenience foods, where you can eat to fill up. But it's not really healthy food and it's not life-affirming, life-promoting, life-enhancing food.

And so this is what people have available to them. We have seen this with the impact of COVID-19 on the school systems. What we're seeing is that the schools, even if they're closed due to COVID, they still have to remain engaged in food distribution. Because for a lot of the children, the meals that they had at school may have been the only meals that they had that day. And so kudos to the school systems around the country for continuing to distribute healthy food to the children even when school is not physically in session, even when they're in a hybrid model or a virtual model. And on the weekends, they're sending kids home with backpacks full of healthy foods.

I just spoke with a principal on Friday. One student tested positive at a local high school, and so she had to inform the other students who were in contact with that student that they had to get sent home. And one young lady was crying and said, but I want to stay in school. And there are a lot of reasons, and one of them is food security, being able to eat healthy foods and having access to healthy foods. Healthy foods can help to reduce inflammation in the body.

But we also know that there are stressors that are associated with the social determinants of health that also raise levels of bile inflammation, stress, stressors. What are the stressors associated with the social determinants of health? The same stressors that we're experiencing in this pandemic. The pandemic is really highlighting the stressors that many people in the US have lived with on a daily basis for decades.

Job insecurity, food insecurity, housing insecurity, educational insecurity, not knowing whether if the rent increases by $30 in one month, it may not seem like a lot, but if your budget is already stretched really tight, you may not be able to make a $30 increase. And then, if you and your family are living in your car, how does that impact healthy eating, and how does that impact stress?

And so all of these factors combined, there's kind of an interactive multiplicative effect on increasing levels of stress and stressors that people are facing. And again, the good news is that physical activity can help to lower those levels of bile inflammation. And I think we just need to be cognizant of where people are when we develop interventions and start with where they are in what's available and accessible to them in order for the interventions to really be successful.

JACQUELYNE GADDY: Thank you for that, Dr. Ford. And I think you touched on a lot of different barriers that I know I can attest as a fellow and been in training for so long, and I know Dr. Ligibel can also likely attest to that as well. I'm from Buffalo, New York, a rather urban environment. And you know, my mom raised me as a single parent mother. So many of these barriers that you're describing I either experience personally or definitely have close friends, et cetera, that did have these barriers.

Dr. Ligibel, I want to ask you in your day-to-day practicing, outside of the barriers that Dr. Ford addressed, what do you tend to see on a day-to-day basis that are common barriers that patients face when they're battling obesity?

JENNIFER LIGIBEL: I think that's a great question. And I will say that one of the things that we've been doing through ASCO for the last few years through our work in the obesity initiative is trying to learn a bit more about what's happening in practice. What are patients hearing? What are doctors saying?

And so in 2019, we conducted a survey that went out to all of ASCO membership asking anyone who actively participates in clinic, whether they were a physician, a nurse practitioner, a chemotherapy nurse, kind of all through the entire health team, do you talk to your patients about physical activity, about nutrition, about their body weight and how that may be connected to cancer?

Now this was a survey, so the people that responded were very interested in this topic. And most of them indicated that they did talk about these topics with their patients. But they noted that they felt like they didn't have a lot of training in what's the best way to bring up these topics. And we asked them specifically, what do you think are barriers to patients making healthy lifestyle changes after cancer diagnosis?

And one of the things that they said, certainly, barriers in terms of transportation and resources. There's just-- many places don't have physical activity programs to send their patients to. But they also talked about that patients weren't aware that this was an important part of their health, and that this really needed to be a message that was echoed many times, not just by one provider.

So we followed up that survey to providers and asked patients, what are you hearing about nutrition and exercise from your cancer care providers? And not surprisingly, because this was patients that were also interested in this, they all said they wanted to hear about this. And only about half of them actually got any kind of information about a healthy diet or exercise or weight management from their providers.

And so I think that there's clearly work that we still need to be doing, trying to figure out, how do you help providers talk about these things with their patients? How do you help patients make these types of healthy lifestyle choices after cancer diagnosis? Because there are a lot more barriers than for someone who's thinking about making changes in their activity before cancer diagnosis related to their cancer. They may be more tired. They may have side effects like neuropathy or lymphedema.

In addition to all the things that Dr. Ford talked about, cancer creates a lot of economic uncertainty for people. And that can contribute to not thinking that you've got the resources to be able to make these healthy lifestyle changes. So I think there's a lot of work to be done both in the messaging and then having the services available to people to make it easier for people to choose healthier foods, to have the ability to exercise in a safe place. We have a long way to go to really make these things be accessible to our patients.

JACQUELYNE GADDY: Thank you, Dr. Ligibel. Dr. Ford, you have talked about this during this conversation. And you have previously mentioned this as far as your research is concerned. As we consider the solution, because that's the biggest part, right? We can talk about the problem all day, and I think we tend to do that a lot in research. But what is more important and most important in my eyes are what are we going to do about it? As we think about all of the things that Dr. Ligibel just mentioned, what are the parts from a structural racism standpoint that are lacking, that you think A, is a problem-- so we need to identify it-- and then also, as we transition into the last part of this conversation is, what are we going to do about it?

MARVELLA FORD: That's a really great question, because that's really the ultimate question, right? What are we going to do about it? And so I think that you and Dr. Ligibel have alluded to the fact that we want to make sure that the interventions are successful, these physical activity interventions. And so that means starting with where the patients are.

If we are working with a patient population that already was struggling financially before a cancer diagnosis, we have to recognize the impact of that on their lives of the cancer diagnosis, on their economic stability after. And even people who had really great jobs before a cancer diagnosis, depending on where they worked, they may or may not have the benefits that would continue to sustain them over time, over the course of the cancer treatment. So their lives may take a drastic shift as well.

And so I think that what we want to do is recognize what the patients are going through on a daily basis. And it would be wonderful to be able to offer at our cancer centers, people come for treatment. Can we do physical activity at the cancer centers? I know some are starting to do different types of exercise. But this would be something that they could bring their children to, they could bring their families so they wouldn't have to worry about child care. I know our cancer center at one point offered Middle Eastern dancing, or belly dancing. And it was just great. People could bring their kids. I participated. Even before my own breast cancer diagnosis, I participated.

And it really helped the women to regain mobility and use of their arms, being able to raise their arms over their heads after a breast cancer treatment. And so it really-- I think the exercise could be tailored to the needs of cancer patients as they recover. And as they continue to go through treatment and recover, you can tailor the specific types of exercise to their needs.

Most of our cancer centers have some type of wellness facility. And so I know that at our wellness center, we have a physician, Dr. Jennifer Harper, who started a physical activity program for breast cancer survivors. And it's gone on for, I think, at least five years. And so it's really great if we can build on the resources that we have in our centers, and our cancer centers, out in the community. If we partner with local schools, have gyms. A lot of them open up after hours to the community members so they can bring their children and everyone can exercise together.

But we could bring in people with training with cancer survivors to work on physical activities that are specific to certain types of cancer to help improve outcomes for those cancer types just by partnering with local schools. So I think there are a lot of things that we could do, making use of existing resources in our communities, doing a lot of partnerships, partnering with fire departments, partnering with people in the community who can become champions and can help drive it.

JACQUELYNE GADDY: Thank you for that, Dr. Ford. And lastly, Dr. Ligibel, we talk about-- in the Black community, a common thing that we mention is the Brown tax. But then when we consider the intersectionality of the Brown tax with those that are obese and that stigma that's associated with it. Lastly, what do we do to try to address that stigma? Because I think patients come in, they're already fearful about their diagnosis. And then some are fearful because the color of their skin. And now they're obese as well. How do we tackle that as providers and trainees?

JENNIFER LIGIBEL: That is a phenomenal question. And there are many data that show that people with obesity are less likely to seek medical care. They're diagnosed with cancers at a later stage. And a lot of that is due to that feeling of, I don't really want to engage with the system. I don't feel good when people are talking to me about my weight. And I think this is a place where we really need some concentrated training.

There are many subspecialties where this is already being worked upon. And I think that this is, again, something that as an oncology community, we need to think about how to treat our patients with respect and create an environment where people feel comfortable. Because therapeutic partnership with your cancer provider is so important, that people have that sense of being cared for. And I think this is really something that we can work on together.

JACQUELYNE GADDY: Dr. Ligibel and Dr. Ford, it's been a pleasure working with you before this and during this. I want to thank you both for taking time to speak with me today. And I want to thank you for joining us for this episode of the ASCO Social Determinants of Health Series. To keep up with the latest episodes, please click Subscribe. Let us know what you think about this series by leaving a review or by simply emailing us at [e-mail]. Thank you.

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