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Bill Klaproth (Host): Welcome to Oasis Rheumattainment, a podcast with Dr. George Munoz, Chief Medical Officer and Founder of both AOTRC and American Arthritis Rheumatology Associates Care Center, including the Oasis Institute, a fully integrative multidisciplinary clinic in Aventura located in Miami, Florida. And on this episode, Dr. Munoz talks about the disparity of COVID-19 morbidity and mortality in Hispanics and African Americans, as we explore the why and the role of integrative medicine in addressing this inequity. Dr. Munoz, as always great to talk with you and thank you for your time.

George Munoz, MD (Guest): Bill, it's so good to be here once again talking about relevant topics that really are affecting society, America and really, global effects.

Host: This is so timely right now, the COVID-19 pandemic has put a spotlight on the racial and ethnic disparities in healthcare access and outcomes with minority status tied to more severe disease. Right?

Dr. Munoz: That's what we're finding.

Host: Yeah, this is an interesting topic and something we all need to be aware of. So, let's start the podcast by going over a recent study, and then we'll get your take on it Dr. Munoz. So, a recent study from your Alma Mater in New York City at the Icahn Mount Sinai Hospital looked at this very question and gastrointestinal tract inflammatory bowel diseases. And these auto-immune diseases include Crohn's disease and ulcerative colitis. Both represent chronic autoimmune disorders with high morbidity, potential mortality, and requiring complex and advanced biological treatments like for rheumatoid arthritis, psoriatic arthritis, and systemic lupus erythematosus. Now disparity of severity has been seen in these autoimmune conditions in Hispanics and African Americans.

And during the pandemic between March, 2020 and March, 2021, we now have data reporting on Crohn's and UC in these minority populations and the severity of COVID-19. So, the study looked at primary end points, including adverse COVID-19 outcomes, defined as hospitalization or death due to COVID-19 and severe COVID-19 defined as a composite of intensive care unit admission, mechanical ventilation and or death. And the results showed that Hispanics and African-Americans had significantly worse outcomes than non-Hispanic whites and non-African-American controls. So, Dr. Munoz, what do you think about this study? Give us your brief overview on these findings.

Dr. Munoz: Sure Bill. They looked at approximately 3000 patients with IBD, inflammatory bowel disease that included the groups that you just mentioned, Crohn's disease and ulcerative colitis. And they looked at the group and used what's called statistical modeling to analyze the results and outcomes. And basically what was seen in summary was that there was a significant disparity in the COVID-19 outcomes in the IBD patients based on race and ethnicity, mediated only in part by their other comorbid conditions, such as obesity, hypertension, et cetera.

These findings really underscore the clinical importance of considering social determinants of health and looking at higher risks in our patient populations, such as these minority groups. And really looking at what are our health policies needed to bridge the gap and improve healthcare access and outcomes for all.

So, these inequities and outcomes, this is not new. This is something that we've been seeing now for decades. And is it a surprise? No, it's not because nothing has changed Bill since I trained in medical school and residency in New York City. And I've been down here over 35 years in Aventura, Miami, Florida.

Host: So, as you said, these inequities and outcomes, you're not surprised by this. You're saying this is not new. This hasn't changed at all.

Dr. Munoz: It hasn't changed at all in a significant degree to result in outcomes change. What we are now developing is more awareness, but awareness alone is not enough. Awareness has to become action.

Host: Absolutely. So, let's talk about some of that action and some of the different ways of thinking about this, including integrative medicine. So, where does integrative medicine come into play here?

Dr. Munoz: I think that is a very important point Bill, because integrative medicine has the ability to interject itself within conventional medicine approaches and modalities and simply prescribing drugs, but looking at the whole person as to why they don't keep their appointment. Why couldn't they, you can't just say they're noncompliant. Maybe there was a transportation issue. Maybe there had to be someone else in the family that was cared for. Maybe there was not enough money to pay for the Lyft or the Uber to get them to the appointment. Maybe they don't own a vehicle. These things have to be addressed because access is multi-tiered, multi-dimensional, multifactorial.

And we have to look at our patients in a more holistic way and understand what are their challenges, in order to succeed with the treatment plan that perhaps has been set out without looking at realities of life, economics, socioeconomic, transportation, other medical conditions that can be effecting the primary condition.

In this case, the primary condition was COVID infection and being able to survive or not. Why didn't some of these people survive? Because they had other comorbid conditions such as diabetes, obesity, high blood pressure, many of them not well controlled. There's the travesty. Looking at whole life approaches, whole person approaches, can make a dent without necessarily having to add more drugs for every issue or every comorbid condition.

Host: So, when you talk about comorbidities, such as diabetes, obesity, high blood pressure, things like that and many of them not well controlled as you mentioned, you're saying that these all contributed to the worse COVID-19 outcomes. Is that right?

Dr. Munoz: Absolutely. And this is a societal and public health issue and it's not new. For example, why is it that in underserved inner city areas in city A,B, C, or D in America, it's literally a desert with respect to healthy eating and the ability to have food that is low in salt, low in trans fat, is anti-inflammatory instead of pro-inflammatory and doesn't make you gain three pounds within the week of consuming it. Why? And why is it so cheap in comparison to healthy food?

Host: So funny you bring this up. So, I heard of a radio station that's doing a kind of a telethon to build a grocery store in an inner city neighborhood. Because it's just like you were discussing or talking about Dr. Munoz, it's a food desert. People have no grocery store close by where they can buy fresh produce and healthy foods. The nearest one is 30 minutes away. Who's going to drive 30 minutes to go grocery shopping? You're going to go to the local little five and dime store that's got crap in it. And that's what these people eat all the time. So, no wonder they have hypertension and diabetes and other illnesses. Because they're eating crap because they don't have any good food choices.

That's an unfortunate aspect of what's happening in this country today. And that's why this topic is so timely today, as we talk about this. It's just the disparities in health outcomes from zip code to zip code is striking.

Dr. Munoz: This has to be addressed at the local government, state government, neighborhood to neighborhood, street to street level. It's a national problem, but we need to embark now in infrastructure addressing these needs. Infrastructure, access, and appropriate moneys being directed to help mothers, children, families, and moving on up the chain into adolescents, young adults, adults, and then adults with families.

The cycle needs to be broken. If this isn't done, then the burden of healthcare just keeps escalating. The conditions and autoimmune conditions keep increasing. The morbidity and mortality from the comorbid conditions of obesity, hypertension, and diabetes keep on increasing. Stroke, heart attack, kidney failure, dialysis, cancer. And will this be our last pandemic? Possibly not. We need to be a healthier population. And that means all people, not just those that have money or resources now. It's got to include everyone.

Host: So, I know you were just mentioning a few things there. Where do we start to tackle these COVID-19 results and disparities? And the other is we've been talking about food deserts and things like that. How do we tackle these disparities?

Dr. Munoz: There are many strategies, but number one is education. With education comes empowerment. With empowerment comes the ability to come up with individual plans. Individual food gardens, educating our kids and young families, having local gardens, having earmarked farms for the inner city where education, distribution, access and fair pricing comes in so, that people can afford to pay for food that they need and not be stuck in the fast food, high trans fat, high salt, bad type of fat food that fills you, but it's devoid of minerals, vitamins, and micronutrients and fiber that are all necessary in well-balanced, anti-inflammatory whole foods. So we need to teach this. We need to get the access. We need to get people proactively involved in their day-to-day life and self care. And then this has to be taught generation to generation.

Host: And then thinking big picture could this strategy be applied to autoimmune diseases in general?

Dr. Munoz: Totally. It is in total alignment because we now see that the number of auto-immune tests increasing every decade signifies that the population is developing the predisposition for auto-immune diseases. And we know that the cancer risk is increasing. And this is all related to environment, stress, poor eating, micronutrient, vitamin deficiencies not being addressed, lack of adequate exercise. We need to get moving literally. We need to improve the access of whole foods that are devoid of chemicals. And why is it that you have to have a certain socioeconomic status to be able to afford a good lifestyle? I'm not talking about excessive things. I'm talking about the need for daily sustenance. We need to get to these basics and not waste money and time on superfluous things and really focus on what our population, our children, our young mothers and families and the elderly need.

Host: So, as you're talking about this, are these integrative medicine modalities expensive though? That's what everybody's going to ask. Well, how expensive is it? It's just going to cost us money. Who's going to pay for it. So, are these modalities expensive?

Dr. Munoz: No, they're not. That's what is mind blowing here. For example, teaching people stress management, breathing techniques, meditation; there is no special equipment. You don't have to subscribe to a monthly plan. You can be taught. You can be taught for free. You can download apps, load YouTube, watch them and learn these types of activities. Yoga, breathing, meditation, exercise. What about vitamins and supplements? We want good ones. We want ones that are devoid of contaminants, hopefully made here in the US and not in places where we can't control for heavy metals or other adulterants. So made in the USA, affordable, based on what the individual needs.

Good, healthy diet. Exercise, you don't need to belong to a Fab Five Gym. Basics. Getting down to basics, walking, running, cycling, having good, safe places to exercise in schools and communities. What about the food in school? That accounts for an important part in nutrition for our underage, minor children all the way from preschool to 18, to high school. Well, that food has to match what we've just said. It cannot be what's the best contract that the school system, the school board has opted for and is settling for. No, it has to be of the highest standard for our children, our future. These are things that need to be addressed.

Host: How soon can we begin to influence children in these health approaches. It sounds like the sooner the better right?

Dr. Munoz: Absolutely. You know, as a parent of five, my youngest right now is 18 and she's getting ready to go to college. I remember going to their schools when they were in pre-K, the first grade, the second grade, the third grade, all the way through sixth, I did this with her older brother, and taught the children, the teachers year after year on what this healthy eating looks like. So, that after a year or two, they knew how to not only put together a healthy meal, they really were teaching their parents, insisting to them, to their guardians and parents, what they thought they should be eating on a regular basis and what should be eliminated or reduced significantly that had low yield in terms of sustenance and was excessively high in the things we talked about, sugar, salt. Anti-inflammatory foods were identified and also mind-body interventions. They learned how to do breathing and meditation when they were four and five years. And by the time they were in the second, third grade, anytime I'd see them out in the community, they'd always sample me, show me what they remembered and did.

And it was amazing. So, here's the point. The younger, the better and young kids can teach the parents and the parents can reinforce this with their other family members, and this can be a growing pandemic of health instead of COVID.

Host: A growing pandemic of health. I love the way that sounds. So, this study was very interesting in what it showed. And like you said, you weren't surprised by the findings. You know this, not a lot has changed. So what should patients do or ask their physicians and providers considering the study findings?

Dr. Munoz: I think that patients should ask their physicians to create a time, a separate visit even, where wellness, disease prevention, lifestyle, stress reduction, exercise, vitamins and supplements are discussed. Not during the first visit when your doctor's trying to figure out what your problems are, not during the second visit when your doctor figures out what the problems are, has read all your test results and is now giving you a treatment plan. But from the third visit on, it's up to patients to request this and respectfully demand this because it's part of the whole person approach that everyone merits to have, in addition to simply having a system where prescriptives are the answer to every problem, question or issue. No, we need to start having a whole person integrative approach that really looks at all these domains of health and not disease management, but rather prevention and health maintenance or health achievement.

Host: So, to use your words, we need to start having a whole person integrative approach. Not focus on disease management, but rather prevention and health maintenance. Is this where it all begins then this should be the start?

Dr. Munoz: Yes, this is the start. For example, with exercise, team sports for youth, getting involved in your local community centers, the YMCAs, the centers that have activities for all ages, gyms. Having a regular routine, movement, exercise, sweating, moderate intensity, three to five times a week. Those reduce the chance of heart attack, stroke and cancer significantly and mortality. There's no one pill that does that. Exercise does that. Combine that with good sleep, combine that with stress management, combine that with an anti-inflammatory well-balanced dietary plan. I won't even call it a diet. Put in a little intermittent fasting once in awhile, meaning eat early, go to sleep and don't eat till almost lunchtime. That gives you an intermittent time period of fasting where your metabolism can reset, helps weight loss, helps with pre-diabetes or diabetic tendencies, and always do these things though in conjunction with and after consulting, your doctor, don't do these things on your own, but always involve your physician to make sure you have the ability to do these things safely.

Host: And that is good advice, no matter where you live. Dr. Munoz as always, thank you, so much for the thoughtful conversation, education and knowledge. We really appreciate it. Thank you again.

Dr. Munoz: Thank you, Bill. And I look forward to our next meeting.

Host: And I the same. And we thank you again, Dr. Munoz, and this is the Oasis Rheumatology Podcast featuring Dr. George Munoz. And for more information, call (305) 682-8471, that's (305) 682-8471. Or visit theoasisinstitute.com. Once again, theoasisinstitute.com. Thanks for listening.