Howie and Harlan are joined by Brita Roy of NYU Langone Health to discuss her work drawing on the existing assets of a community to improve health outcomes. Harlan reports on new research on the dangers of sugar substitutes; Howie reflects on the growing openness to the lab-leak hypothesis for the origins of COVID-19.
Harlan Krumholz: Welcome to Health & Veritas. I’m Harlan Krumholz.
Howard Forman: And I’m Howie Forman. We’re physicians and professors at Yale University. We’re trying to get closer to the truth about health and healthcare. This week, we’ll be speaking with Dr. Brita Roy. But first, we’d like to check in on current health news. And Harlan, there was an article that came out earlier this week about erythritol, and it reminded me of the fact that several years ago, you gave up Diet Coke, and you’ve been, much earlier than most people you started to talk about what is in our food and whether we know enough about it. So can you tell us about this article, what it means, and what we should be thinking?
Harlan Krumholz: Sure. Yeah. You’re kind to remember this piece that I put in The Wall Street Journal, maybe the most popular piece I’ve ever written, where I talked about quitting diet drinks, which my daughter, Hannah, had been advocating for a long time for me to do. So she was the one really ahead of the curve. And at that time, I had been reading an emerging set of studies that had been indicating the possibility that these additives that were replacing sugar were actually doing us no favors and maybe causing certain derangements in our metabolism and could ultimately be causing harm. I had a sense that the studies that had…came out, if anything, were negative, and that these were largely inadequately studied.
And we worry so much about medications. We put them through a lot of evaluation. The FDA has a very strict set of criteria that leads them to decide whether or not something can enter the market or not. But for food additives, it’s completely different. And by the way, our current commissioner, Dr. Califf, is very interested in this issue. And when you think about the exposure of the population to these chemicals, it’s much greater than for any medication. And yet we do this without really understanding them.
Erythritol is a sugar alcohol. And so this is a type of carbohydrate that’s commonly used as a sugar substitute in food and in beverages. And they’re derived from natural sources, but it can also be produced synthetically. And they’re loaded up into these treats to make them sweet, but they lack the calories that regular sugar do. And for a long time, I think people thought that, well, maybe they would be better. And you may have heard erythritol, xylitol, sorbitol, mannitol. I mean, these are all sugar alcohol. Sometimes you’ll see a keto-friendly product in the supermarket. And then if you look at the ingredients, you’ll see a lot of these.
So what brought this to bear was an article that came out that was published in Nature Medicine, one of the strongest clinical or strongest scientific in clinical journals that are out there. Came from the Cleveland Clinic from a group that’s been looking a lot at issues around diet. And this group has published a fair amount of work around the mechanism by which red meat might increase cardiovascular risk. Well, in this case, they’re looking at this artificial sweetener.
And they were pulling together various different epidemiologic studies that have been conducted where they had characterized populations and followed them over time. And they had the ability to measure erythritol within the blood so that they could put them into different groups. People had a high amount, people have medium, low, and so forth, and then look at how it was associated with cardiovascular events, death, nonfatal microinfarction or stroke, for example, over time. And then what they did also, they had one group that was sort of a volunteer group that they were able to make these measurements and also to look at other aspects of their physiology, like how did their platelets work?
Well, when they ran this study, they saw that the amount of erythritol in your blood, especially... Let me just say there was a real distinguishing mark between... They put it into quartiles. So they have one, two, three, four groups. And the group that had the highest amount had the lowest survival in the most number of these events compared to the one in the quartile with the lowest. But quartile one, two, and three were kind of clustered together, and this one that had the most, the last quartile, really was markedly different in these studies. And then they looked at it among various different subgroups.
And in every subgroup they can imagine, age, sex, whether they have hypertension or diabetes or what your lipid levels were, they kept finding this to be true, that there was this increased risk. And then they went and said, “Well, let’s look and see what this might be doing to the body.” And they found in the end that erythritol enhanced what they call platelet responsiveness. So sort of like the propensity or ability of the platelets, these acellular substances in blood that help with blood clotting, they seem to get them activated. They saw the erythritol enhanced thrombosis formation in these individuals. And so they left saying here were some epidemiologic information that suggests there may be some risk associated with this highly common additive.
And then also when they started looking mechanistically, the underlying potential reason that this might occur, they started looking and seeing that maybe there was some relationship between this substance and blood clotting and even the causing of thrombosis. And this was for a prolonged period of heightened thrombotic risk. So this led them to conclude that we should pay attention and that this is potentially a big concern for patients. And I think ultimately, a lot of us reading this say that this means that this deserves further scrutiny. But I think it does bring back this issue of additives where there’s a lot of different biological effects and we haven’t really studied adequately, I think, there will potentially impact on people’s health.
Howard Forman: And just to remind our viewers, we’re talking about stevia and truvia. We’re talking about common substances that people add to their drinks, their coffee. I notice that one of the protein bars that I eat includes direct erythritol, as mentioned. So it’s something we should be thinking about. I do think it’s always good to be a little cautious when you have a study like this come out not to overreact to it, but it does make me think that we need to be doing a lot more actual studies, hopefully randomized controlled trials, on these additives that are in all of our foods at this point.
Harlan Krumholz: Yeah. I mean, I think just for people listening, I mean, sugar-free chewing gum, sugar-free candies and mints, lots of baked goods that are trying to cut down the amount of sugar, cakes, cookies, pastries, diet soda, energy drinks, jams, jellies, preserves, almost everything you look at can be used in combination. And then I think stevia and monk fruit are a little different, but really, we don’t know very much about what might be their impact on long-term health. And let me just say, for me, it was just a decision to say... I mean, I used to drink Diet Cokes all the time. I would—
Howard Forman: I remember. Yeah.
Harlan Krumholz: ... leverage the caffeine and it was just like I thought, “I’m going to start just drinking tea.” And all of it’s just based on a hunch. It was like, I can’t tell anyone for sure what they should do, but I can tell you that there’s evidence emerging that it could be an issue. And this just seemed like a safer choice to me.
Howard Forman: Yeah. No, that’s great. Thank you.
Harlan Krumholz: Yep. Hey. Let’s get onto the interview with Brita.
Howard Forman: Dr. Brita Roy is clinical associate professor at the Department of Population Health and Medicine at NYU Grossman School of Medicine, as well as director of community health and clinical outcomes at Beyond Bridges at NYU Langone Hospital. Dr. Roy’s scholarly work focuses on assessing the relative contribution of positive psychosocial factors to population health outcomes and health equity at the individual and community levels. Dr. Roy is also interested in the implementation of multidisciplinary, assets-based, effective community healthcare collaborations, interventions to improve population health and wellbeing. She co-leads the Yale Gallup wellbeing research team and the Institute for Healthcare Improvement’s 100 Million Healthier Lives measurement team, and is faculty for IHI Pathways to Population Health Action Community. She received her bachelor’s and master’s degree in biomedical engineering at Vanderbilt and Wayne State University, respectively. She then went on to the University of Michigan to pursue a combined MD-MPH in health behavior and health education.
Dr. Roy subsequently completed residency training and internal medicine serving as chief medical resident at the University of Alabama at Birmingham prior to completing the Robert Wood Johnson Clinical Scholars Program at Yale University, where we first had the great fortune to meet her. So first of all, I want to just welcome you to the podcast on behalf of both of us. And I want to start off by asking you because I mean, quite frankly, a lot of these words I can read, but I don’t know what they mean. Can you tell me a little about what “assets-based” means?
Brita Roy: Sure. And thank you for the warm welcome and inviting me to be on this podcast. So an assets-based framework really means identifying and leveraging existing resources to improve an outcome. Now I work in health and public health, so for me what that means is working with a community to identify existing community resources that actually work well, but they either need to be expanded or need additional resources or need to be perhaps paired with a complementary program to achieve broader and greater success and have greater impact in the community. So that is taking an assets-based approach.
Howard Forman: And let me just follow up with one quick question to that. Can you give our audience a little background to what the Beyond Bridges program is? NYU Langone Hospital, which is a community in Brooklyn, basically, where my family is from and where you are now living, as I understand it.
Brita Roy: Yes. So Beyond Bridges is a 10-year initiative based in Brooklyn, primarily the Sunset Park neighborhood of Brooklyn, which is mostly an immigrant community. It’s very, very diverse. And the initiative is philanthropy-funded primarily by the Bezos Family Foundation, with the goal of really transforming how we think about creating health in the community by developing clinical and community partnerships, recognizing that achieving optimal health and wellbeing outcomes doesn’t reside solely within the healthcare sphere but requires partnerships and strategies with community-based organizations and community members themselves as well.
We’re currently about one year into this 10-year initiative, and the primary health outcomes we’re trying to move are, one, increased engagement in primary care, two, better cancer outcomes both in preventive screening but also morbidity mortality. The third is cardiovascular disease prevention. The fourth is improvements in maternal health. And then finally, last two are child health and wellbeing, and behavioral health.
Harlan Krumholz: I was so happy that Brita decided to join us today. And one of the early projects that you and Carley Riley embarked on while you were at Yale was, one, to reduce harm from violence in our community. And I thought that was such an important one. You taught me a lot in the course of pursuing it. We can think about all of our traditional medical interventions, but when you think of years of potential life lost, violence, injury, these kind of things that are endemic in certain communities end up really taking such an enormous toll. And I think most of us feel inadequate to address it. But you guys didn’t. You stood up and you worked with the community. Can you just say a little bit about what was your strategy? How did you try to make a difference there?
Brita Roy: Yeah. That’s a great question. And the issue of gun violence was very salient for the New Haven community when I first arrived there as a Robert Wood Johnson Clinical Scholar over a decade ago. I am still actually working with the New Haven community to this day, and we recently launched a community-based intervention, notably an assets-based intervention, to try to curb rates of community gun violence. Our strategies have been, one, to work really collaboratively with the community, with community-based organizations that work to deter gun violence, also with things like youth mentoring programs, but other community institutions, organizations, and policymakers that influence some of the underlying causes of people engaging in gun violence.
So we took an assets-based approach to identifying resources in the community at multiple levels, at the individual and organizational and neighborhood level, that may reduce rates of gun violence or reduce the likelihood of people who are at high risk of being involved from getting involved in gun violence. Through that process, we developed an intervention that really focuses on two major things in the community. One is housing stability and the other is mental wellbeing.
So for housing stability, we are recruiting people affected by incarceration, defined as either released from prison, the individual was released from prison in the past year, or that they’re a family member of someone who’s currently incarcerated. And engaging them in a program that includes very rigorous, comprehensive, and tailored financial education paired with some financial support through down payment assistance, rental assistance, or low interest home loans so that if we can stabilize the family’s housing or the person who’s recently incarcerated housing situation, they’re less likely to engage in violent activities. It also means that we can start building intergenerational wealth among Black and Brown communities in New Haven.
The second component of mental wellbeing is where we’re training a network of trusted community members within these neighborhoods that are really traumatized by gun violence in trauma-informed counseling so that barbers, educators, faith leaders, the woman on her front stoop that knows everyone on her block, if all of them have a basic understanding of trauma-informed counseling, they can identify people who are affected by trauma. They can provide some level of support themselves, and they can destigmatize and facilitate referral into higher levels of mental health services as well. So we just launched that initiative. We’re actually recruiting in our first neighborhood of six right now, and we hope that this intervention will show a decrease in neighborhood rates of gun violence over time.
Howard Forman: One of the ways that I came to know you was through the work that you did for population health for our medical school and our health system, and I learned a lot from you and from that work on the use of quality measures in our physician practice. And I’m curious. Through your continuous involvement in that, what’s the takeaway? And maybe you could explain a little bit for our audience, number one, why are we even measuring these quality measures? And then number two, are we having the effect we should be having in improving healthcare at the physician level?
Brita Roy: So I think of quality measures in maybe two ways. One is to make sure that we are providing high quality of care to achieve optimal health outcomes from the clinical perspective for our patient populations. There are also some quality measures that are process measures of the adequacy and quality, I guess, of the healthcare system. I do think that they’re important to measure and track and utilize to really adapt and improve the system as we move forward. Nobody, no clinician, no clinical system is perfect. And so by looking at these outcomes, I think that we can figure out where our gaps are, where our biggest room for improvement is, and also identify disparities in these outcomes and work to close them. So with the vaccine initiative, it wasn’t just how many people did we vaccinate, but we also looked at equity in vaccination and tried to develop interventions and programs to reduce disparities that we saw in rates of vaccination among race-ethnic subgroups among our populations.
Harlan Krumholz: One thing I wanted to ask you, Brita, was again, you’re one of the best people I know in the sense that you really just want to do good, and you’ve actually applied your skills and are trying to make differences in communities. We look at the arc over time. It’s hard to make change. It’s just hard to make change. And then we have these political structures that also provide impediments. What is it that gives you continued hope? I mean, how do you maintain optimism that these can actually make a difference when there are so many structural challenges to the progress?
Brita Roy: I honestly think it’s hard to be in this field without being honestly, inherently, naturally optimistic, because it is a struggle. It is a day-to-day slog because exactly what you’re saying, that there are so many structural and political impediments to progress, and our existing systems thrive in their current structures and environments. So in order to make any changes, yes, I’m absolutely going to have to butt heads with a lot of people for which the status quo benefits. And so what I attempt to do is find win-win situations where maybe right now, they don’t care about a certain subpopulation because it doesn’t make them money, but it would improve their quality rankings if this subpopulation actually had better health outcomes in that—
Harlan Krumholz: So let me ask you this just as you reflect on what you’ve done so far. Can you just give us an example of what was your best day and give us an example of what was your worst day in trying to make all of this happen?
Brita Roy: Let’s see. There are probably a number I could choose from. I’ll say one of my best days was during the vaccine campaigns in Connecticut. That was honestly, with the vaccine initiative, that was the first time the health system honestly paid attention and really supported me in engaging the community because they recognized the true importance of closing those racial gaps. And so I was provided support by the communications teams at both the hospital and the university. They, together with me, met with community partners all across the Connecticut seaboard where we had vaccine sites to create tailored materials for the community. And because of that, my actual best day was the day that I learned that we did actually mitigate the racial vaccine gap among those over age 65 in New Haven.
Howard Forman: Yeah. It really speaks to the fact that a concerted effort with coordination of different groups can make a huge difference. You also, by the way, not just on the grounds, you also advocated for time off, for giving essential workers access to vaccines and the time off that they might need to get the vaccine in the early period. This is a multi-pronged approach. And you are a chief resident in Alabama, of all places. Can you give us a little bit about—
Harlan Krumholz: Oh, my God. Can you believe he just said “of all places”?
Howard Forman: Well, no, because—
Harlan Krumholz: Oh, my God. This is a New Yorker’s view of the world. Alabama...
Howard Forman: Well, no. But I mean, she’s been in Michigan. She’s been in Nashville. She’s been in New Haven, now Brooklyn, and she’s been in Alabama. And I’m curious to know... and that was at a very critical juncture. That’s when you trained in internal medicine, became a chief resident, did your first administrative responsibilities. Tell us how that informed you, a former engineer, in how to improve healthcare and deal with disparate populations.
Brita Roy: Yeah. Honestly, I chose to go to the University of Alabama at Birmingham for my training specifically because I knew I was interested in health disparities. And at the time, when I was training there, we did a third of our training at the university hospital, a third at the VA, and a third at the county hospital. The county hospital in Birmingham serves a very, very under-resourced population. So of course, Medicaid uninsured the incarcerated population. And because healthcare is so difficult to access in Alabama, I would see people coming into that hospital with clinical conditions that you otherwise typically don’t see unless you’re in a third-world country.
And it was actually shocking to me coming from Michigan to see some of those things. And from a training perspective, it was clinically very valuable, but from a personal perspective, just shocking that this happens in the United States, one of, you know, the richest country in the world. And so for me, actually witnessing that and caring for that very wide spectrum of people made a huge difference in my understanding of why place matters and how where you live and the local culture and context plays such a big role in long-term health outcomes. And that’s why I do what I do today.
Harlan Krumholz: I know we’re getting to the end of the hour, and really appreciate all the time you spent with us. So it’s a great pleasure to talk to you, Brita. Always good to see you, and thanks for spending the time with us.
Brita Roy: Likewise. Thank you.
Harlan Krumholz: So Howie, that was a terrific interview. I’m just so glad Brita could spend some time with us. So let’s pivot to your side. What’s been on your mind this week?
Howard Forman: Yeah. So a big issue on social media and probably a big enough issue in our lay press because it made the front pages of major newspapers was this issue that came up around the origin of SARS-CoV-2, the virus that causes COVID. And the question remains, where does this come from? And it had long been a mainstream but not uniform view that the virus had jumped from bats or another animal in the wet markets of Wuhan to humans, which is how epidemiologists had identified and virologists had identified prior novel coronaviruses entering the human system. On the other extreme from that—and it was an extreme view for a time—there was this concern that the Wuhan Institute for Virology was working on creating a bioweapon, or even if you didn’t want to go to that extreme, they were at least doing certain types of research that could figure out how certain viruses could be more dangerous. And then of course, part of that was also whether the United States was funding part of that research, and then it leaked out from the lab.
And in the middle of this was a more benign possibility that maybe there was research going on and it leaked out, or even that it leaked out of the lab, made it to the wet markets and came over. There’s lots of different possibilities for all of this. So why does it get back in the news right now? Well, I think it’s a good thing that our intelligence agencies and our own government continues to investigate the origin of the virus, because we should learn as much as we can about how it came to be and figure out how do we prevent both another similar situation and how to mitigate spread if it were to happen. So I think it’s a good thing that we’re doing that.
The Department of Energy, which oversees our national labs, some people were surprised by that, but I think if you think about our official national labs, they’re under the Department of Energy. They were charged with one of these reports and they revised their reporting to say with “low confidence” that they now believe it resulted from a lab leak. To me, the real story, and the reason why I bring this up for the podcast, is not that we have any real more information, because the Department of Energy has not told us why they have changed their prior ideas about this. The real reason, from my point of view, why this was so important, was that there was definitely a sense in the scientific community that if you spent too much time talking about the lab leak as opposed to the wet markets, you were buying into conspiracy theories that included this idea about bioweapons, that included this possibility of gain of function research, that included the possibility that the U.S. was behind that funding.
And I will say that I think that if you look over social media during that time, there were a lot of people that were very angry if somebody espoused that view at any time. I think it’s useless to point fingers and tell people what they should or should not believe. I think it was wrong. I think it was wrong for people to be speculating so much when we didn’t even have the outbreak on our own shores. But now is the time where we really must do the full investigation that we’re allowed to do. And to the extent that we have answers, we should be willing to accept them and modify our understanding of the origin of this.
Harlan Krumholz: Yeah. I think it’s important for people to know that the Department of Energy came out, but they said they have low confidence, which means just that they’re as uncertain as anybody else about what really went on, but they are just saying this is plausible. It’s possible. But by tagging it with low confidence, I think they’re far from coming out and saying that this is actually what happened. You may know... Go ahead, Howie.
Howard Forman: No. I was just going to say the FBI director did an interview. And again, people get excited because the FBI director says it’s probably from the leak. But the FBI has always believed it’s from the leak. Over a year ago, they expressed their opinion, also with relatively low confidence, that it’s from a leak. We have all these agencies. They don’t all agree on this right now. And whatever it is, we should just want the truth to come out as much as possible.
Harlan Krumholz: And I think the degree we can move away from blame and say that it would be useful to understand if this was a breach from a lab, that it might help us understand how we can protect against us going forward. I mean, it’s not that people are going to stop trying to manipulate viruses to understand them better. And sometimes, I mean, I don’t know what the circumstance of this are, but I do think that it would be useful for us to understand the origins. But I have low confidence. My confidence is low that we’re ever going to really learn—
Howard Forman: That’s unfortunate.
Harlan Krumholz: ... what this is about. I think people of goodwill should stand up and say it’s worth understanding. As you know, our own Keiko Osaki was a signatory on a letter that raised some of the questions early on in May of 2020 and said that we should be looking into this.
So I mean, I think we shouldn’t be afraid. Just as I’ve said, we shouldn’t be afraid to look into vaccine injury. It’s like we can walk and chew gum. We can advocate for the use of vaccines. At the same time, we can investigate these things. We can try to avoid getting into a blame game but still try to understand what went on with the origins of this virus and what can we do in the future to try to do better. But I think it’s great that you raised, I know it’s been on a lot of people’s minds this week. I do think it’s just, it will remain kind of idle fascination and speculation until such time that the Chinese want to be more transparent and share more information. Yeah. I saw that this was a really hot topic. I’m glad that you brought up this week. So you’ve been listening to Health & Veritas with Harlan Krumholz and Howie Forman.
Howard Forman: So how did we do? To give us your feedback or to keep the conversation going, you can find us on Twitter.
Harlan Krumholz: @hmkyale. That’s H-M-K Yale.
Howard Forman: And I’m @theHowie. That’s at T-H-E-H-O-W-I-E. You can also email us at firstname.lastname@example.org. Aside from Twitter and our podcast, I’m fortunate to be the faculty director of the healthcare track and founder of the MBA for Executives program at the Yale School of Management. Feel free to reach out via email for more information on our innovative programs, or you can check out our website at som.yale.edu/emba.
Harlan Krumholz: Health & Veritas is produced with the Yale School of Management. Thanks to our researcher, Jenny Tan, and to our producer, Miranda Shafer. They are amazing. Talk to you soon, Howie.
Howard Forman: Thanks very much, Harlan. Talk to you soon.