Dr. Amelie Ramirez, director of Salud America!, a Robert Wood Johnson Foundation national research program and network to prevent obesity among Latino youth.

Mark Masselli: This is Conversations on Health Care. I am Mark Masselli.

Margaret Flinter: And I am Margaret Flinter.

Mark Masselli: Margaret, I can't believe how fast these past months have
flown by. A major of Health Care Reform is about to kick in. Remember
that temporary high-risk pool we spoke about so much back in April, that
will help people get health insurance who have been denied coverage due
to a preexisting medical condition. Well, the launch is here. Enrollment
st st
will begin on July 1 and coverage starting on August 1 . And for those
states that did not give the Department of Health and Human Service an
answer on how they intend to run the health insurance pools, the federal
o ! cials are giving them one more chance. They have until the end of
th
this week, June 25 , I think that’s just right around the corner, to
produce that answer as well as how much the high-risk pool would cross
since many state o ! cials have expressed concern over funding. If
undeclared, the task will be past on to the Federal Government to operate
the pools.

Margaret Flinter: Mark, it's exciting to see implementation beginning to
come out of the Reform. And at the same time, we also see HHS’s new
insurance web portal www.healthcare.gov to help individuals in small
businesses identify a " ordable coverage options in their states. And then,
another very exciting announcement I think, the Centers for Medicare and
Medicaid Service or CMS has launched the o ! cial website for the
Medicare and Medicaid Electronic Health Record incentive programs. The
Medicare and Medicaid EHR incentive program will provide payments to
eligible professionals and hospitals as they adopt, implement, upgrade,
or demonstrate meaningful use of EHR technology. Now, Mark, this is the
first guidance in how physicians, nurse practitioners, dentists and
physician assistants can begin the process of registering for
reimbursement of the cost of implementing electronic health records and
this is something we discussed on our show with Dr. David Blumenthal
from the O ! ce of National Coordinator a few months ago, really a major
initiative of the Federal Government to speed up the adoption of
electronic health records across the country. And I have a feeling we will
be talking more about this in the future show.

Mark Masselli: I think you are right and it's very exciting to see that
progress. As we turn to today’s topic Obesity within the Latino
Community, I also want to mention an e " ort by the Department of Health
and Human Services to further along First Lady Michelle Obama’s

Childhood Obesity campaign. Secretary Sebelius was out on the road
with her new launch of Let’s Move Cities and Towns component to the
Let’s Move Campaign. This is meant to encourage local o ! cials to adopt
a long-term sustainable approach to fighting the obesity problem within
every community. We can't stress enough how important it is to get the
communities involved, helping parents make healthy choices, creating
healthy schools, providing access to healthy and a " ordable food, and
promoting physical activity.

Margaret Flinter: And our guest today, Mark, is Dr. Amelie Ramirez who
is going to add insights into this ongoing discussion since obesity has a
dramatic impact on everybody, but just proportionally so on the Latino
Population. Dr. Ramirez directs Salud America! of Robert Wood Johnson
Foundation National Research Program and Network to build evidence on
what is e " ective in treating obesity and reversing the obesity epidemic
among Latino youth. We are delighted that she is going to join us today.

Mark Masselli: No matter what the story, you can hear all of our shows
on our website Chcradio.com. You can subscribe to iTunes to get our
show regularly downloaded or if you would like to hang on to our every
word and read a transcript of one of our shows, come visit us at
Chcradio.com.

Mark Masselli: And as always, if you have feedback, email us at
Chcradio.com, we would love to hear from you. Now, before we speak
with Dr. Ramirez, let’s check in with our producer Loren Bonner with the
Headline News.

Loren Bonner: I am Loren Bonner with this week’s Headline News. Health
Reform passed 90 days ago and President Obama marks the anniversary
on Tuesday unveiling the patient’s bill of rights, as well as how the law
will make the insurance market more competitive until the health
insurance exchanges are up and running in 2014. The President says,
“This health care plan means stability and accountability for patients.”

Barack Obama: These rights guarantee just that, basic rules of the world
that will America’s health care system more consumer driven and more
cost e " ective, and give Americans the piece of mind that their insurance
will be there when they need it.

Loren Bonner: Last week, President Obama spoke to a gathering of
health care experts, including the representatives of many national
nursing organizations and the premier university schools of nursing. He

highlighted the investment his administration is making and supporting
the preparation of advanced practice nurses and nurse practitioners, all
part of the strategy to ensure that when more people are covered by
health insurance, they will be able to find a primary care provider to take
care of them. The investment includes funding to allow students training
part time to become nurse practitioners to start training full time. In
addition, the President announced Federal funding for Nurse-Managed
Health Centers, primary care clinics led in sta " by advanced practice
nurses and nurse practitioners. The funds will significantly expand the
number of Nurse-Managed Health Centers, currently at around 250 in the
United States. The Reform Legislation already authorized a
demonstration project to create Nurse Practitioner Residency Training
Programs and Federally Qualified Health Centers and Nurse-Managed
Health Centers. HHS’s Health Resources and Services Administration
Administrator Dr. Mary Wakefield spoke to the importance of this
initiative for workforce training.

Mary Wakefield: Also, within those Nurse-Managed Health Clinics, we see
other types of health care providers educated and trained, social workers,
medical students, and others, because typically that clinic is tied to an
academic institution.

Loren Bonner: The administration’s focus on increasing the supply of
primary care providers is not just about access but also outcomes.
According to a new study published in the Journal of Health Care for the
Poor and Underserved, patients who report having an established
relationship with the primary care provider, either at a Community Health
Center or in a private o ! ce, report receiving better quality health care
and have a better health care experience than patients who have a regular
place of care but lack an established relationship with a primary care
th
provider. The President’s announcement on June 16 highlighted a total
investment of $250 million in programs to increase the number of
doctors, nurses, and other health care providers. The money includes
$168 million to train 500 new primary care physicians over the next five
years, $30 million to encourage 600 nursing students to attend full time
and complete their education, and $32 million to create 600 new
physician assistants.

This week on Conversations on Health Care, we are exploring how obesity
has disproportionately a " ected the Latino community and what needs to
be done to reverse the epidemic so that both current and future
generations can live healthier lives. Salud America! is a Robert Wood
Johnson Foundation program to reverse childhood obesity for Latino

children. Salud awarded research grants to recipients from around the
country to address an entire range of factors thought to be associated
with increased rates of obesity in Latino children. Dr. Harris Huberman,
Director of Behavioral and Developmental Pediatrics and Child Psychology
at SUNY Downstate Medical Center in New York, was awarded one of the
grants. He calls his project a “low intensity, low cost public health
intervention” but his findings have the potential to impact Latino children
in a profound way. Dr. Huberman’s research project is an extension of
an existing intervention called Primeros Pasos/Building Blocks which is
basically a monthly mailed newsletter containing specific relational and
dietary messages for low-income parents of Latino infants and toddlers.
Dr. Huberman says that the alarming rates of obesity that they were
seeing early on during the original project by two years of age, fully half
of all the Latino children were overweight led them to focus on
integrating obesity intervention messages tied in with parenting
messages.

Harris Huberman: The 10-month newsletter is a typical one, but as we
said, we fold into that a message that’s entitled “Feeding Without
Pressure.” And on the one hand, we are saying this is the time to give
finger foods. Finger foods are perfect. That’s all about the child being in
control. What we are encouraging is healthy finger foods and working in
some fruits and vegetables as well as, for example, piece of soft tortilla.
O " er healthy foods at a given time. But then, if the child doesn’t want it,
don’t pressure the child, don’t let the child run around, carry around a
bottle. But simply, wait till the next scheduled feeding time. Well, that
brought up the question “what is the next scheduled feeding time” and so
with this, we would send a supplementary piece that goes with it, that
talks about what is the sample daily menu.

Loren Bonner: And this simple approach had an impact. In the
randomized controlled trial with 225 children from the initial building
blocks program, they saw that compared to the 50% rate of overweight
children in the control group, they were seeing roughly half of that in
those who received the buildings blocks interventions. Dr. Huberman
says that’s been encouraging and it also led him to dig a little deeper.

Harris Huberman: Something about what we are doing is having an
impact. The question we are studying with the support of Salud America!
is going back and administering questionnaires to the families to see
what aspect, what part of the message seemed to be working whether it’s
the specific parenting, parent-child relational messages or whether there
are some specific things of “don’t drink juice” or “more than 6 ounces,

don’t put cereal in the bottle,” “stop the bottle by 18 months of age,”
things like that, which of those make a di " erence.

Loren Bonner: the research that will stem from this program as well as
several other Salud America! pilot research programs will lay the
foundation for the development of cost-e " ective public health initiatives.
Dr. Huberman envisions his program as a part of an entire network to
prevent childhood obesity. A partnership that may be, for example,
based in a Community Health Center, or a network of health centers, or a
district public health o ! ce that’s systematically reaching at-risk
populations. Let’s turn now to our interview with Dr. Amelie Ramirez who
directs Salud America! to tell us more about the program how obesity is
a " ecting Latino children and what this new foundation of research aims
to do.

Mark Masselli: This is Conversations on Health Care. Today, we are
speaking with Dr. Amelie Ramirez Director of Salud America! of Robert
Wood Johnson Foundation National Research Program and Network to
prevent obesity among Latino youth. Welcome, Dr. Ramirez.

Amelie Ramirez: Thank you very much.

Mark Masselli: Salud America! is dedicated to reversing the obesity
epidemic among Latino youth and is one of the country’s first culturally
sensitive obesity prevention research programs. Who and what were the
driving forces behind its creation?

Amelie Ramirez: Well, actually, it originated here in San Antonio with
myself and my research team here at the UT Health Science Center. We
have been doing for the last 10 years a research program on cancer
prevention research and we have a national research network of which we
have been providing education and information to the Latino community
about risk factor reduction, the need to access health care, and get
appropriate screening early to reduce their risk of developing cancer.
And a lot of the issues that we dealt with have been on diet and exercise
as well, as this becomes now a growing risk factor for cancer. And so,
that kind of set up the initial research network that we established. And
then, coincidently, the Robert Wood Johnson Foundation at the same time
was interested in looking at childhood obesity and reversing childhood
obesity nationwide, and their first initiatives were not culturally specific.
And so the next wave of opportunities that came about, they really
wanted to focus on the disparities that they were seeing with regards to
childhood obesity and they reached out to us.

Margaret Flinter: And Dr. Ramirez, I understand Salud recently awarded
research grants to 20 recipients around the country and those research
proposals really run the gamut addressing everything from
understanding body image perceptions among Latinos to have solutions
like changes and federal subsidies for school lunches to address the
epidemic. Based on the work that’s going on right now, what are the
strategies that you think show significant promise?

Amelie Ramirez: There is very little research currently that we know of
that has the evidence to show what works in Latino population. So our
20-pilot projects are trying to build the evidence to find out what is most
e " ective in reaching the Latino community, and that’s why you see the
wide range of projects that we have. They just got started. They are
two-year pilot projects. They are just now completing their first year and
we will be getting some feedback from them in September. So I wish I
could share more with you in terms of what is working, but we are
waiting to hear that ourselves that we felt that we did need a broad range
of strategies. One of the things that we did stress in each is that they
had to have a policy component whether it was at the local, regional, or
national level. Then we thought this is important because policy helps a
wider change for a larger number of people.

Mark Masselli: We look forward to the results on that. Dr. Bills Dietz, the
Director of the Center for Disease Controls Division of Nutrition, Physical
Activity and Obesity, recently said that the childhood obesity epidemic
seems to be plateauing at about 17% after several years of rapid increase.
Our Community Health Center’s data on our patient population of
100,000 patients, about 50% who are Latino, doesn’t suggest the
plateauing and certainly the rate of overweight obese is far in excess of
17%. This obesity is fundamentally a health disparities issue and how are
you addressing it from that perspective?

Amelie Ramirez: Well, I think right now, it’s still a nationwide issue for a
lot of our children. If you have noticed, I go and give lectures and
presentations now and I have asked “who walks to school?” and almost no
one’s hand will go up. And so you are beginning to see some generation
gap here where we have just become such a mobile society and not
needing exercise. But you see it a little bit more in our minority
populations and in our underserved communities because they don’t
have access to specific places that are safe to walk. Sometimes we have
some cultural issues, the a " ordability, we have food deserts. So, this is
what we are trying to find through our pilot projects if we are able to

implement some of these small changes, what can we find that works and
eventually disseminates them to a larger degree.

Margaret Flinter: Today, we are speaking with Dr. Amelie Ramirez,
Director of Salud America!, a national research program to prevent
obesity among Latino youth. Dr. Ramirez, we frequently say in our
Community Health Center that this is one health problem that’s not going
to be solved in the clinical exam room and we have a number of obesity
initiatives that bridge policy and practice. One of them, I am pleased to
say, funded by Salud America’s initiative and focused on Latino
adolescents who are of course tomorrow’s adults and mothers. That
really underscores for us the long-term nature of the commitment that’s
required. Are you concerned about sustaining the country’s focus on this
problem over the long term? We certainly have the focus from the White
House and the Foundation, but how are you building institutionalized
support for those interventions that your research ultimately proves to be
e " ective?

Amelie Ramirez: Well, we feel that finally getting some national support
from Mrs. Obama and focusing on childhood obesity is really critical in
making this a national issue that the public is now more aware of. I think
if we continue to get that particular interest up at national level, it’s
critical. For Salud, we will continue to support our primary researchers
and try to instill in them the skills that they need to help them seek
additional funding to sustain their programs over time. As you all know
things that are funded through the Federal Government or nonprofits,
sometimes we don’t have that ability to keep them in perpetuity. But
what we are looking for is helping build the knowledge and the evidence
of what works in our community so that once we have that evidence, we
can then disseminate it and work on the sustainability component.

Mark Masselli: Dr. Ramirez, Latino youth born to U.S. immigrant parents
are twice as likely to be overweight than foreign-born youths who move
to America, and the second and third generation children are even more
likely to be obese. The conclusion has been that the healthier diet and
more active lifestyle of the home country are lost in the transition to the
United States culture. I am sure this is a complex set of factors, but do
you have any insights on how the more healthy and helpful lifestyle can
be maintained in the United States?

Amelie Ramirez: Yeah. You bring up a very important point, Mark, and
we know that Latinos have an extremely strong sense of family value. So
it's important for us to establish positive family patterns, getting parents

to make sure that their kids, their young children are getting enough
sleep but they plan family meals together that we limit television viewing
in order to maintain healthier activities and eating. We need to help
parents develop kind of rules in their house to limit TV viewing and to get
their kids away from junk food. And that’s how when parents are on a
limited income and you go to a fast food restaurant and feed your family
for $5 each, $1 each or something like that, know those are the types of
challenges we have. But we need to expose them to what our healthier
choices that they can make. And another study conducted by Dr.
Guadalupe Ayala, and she is also a member of her national advisory
committee, she is from San Diego State University, they found that
Hispanic children who eat at homes or friends’ or relatives’ were more
likely to gain weight. As you know, when you go to parties, you always
eat a little bit more than we should. And so these large family
gatherings, it’s an expression, it’s a cultural expression and in most
cultures, you show your love to food. And so we just need to again help
them what’s the right quantity, can you eat more fruits and vegetables
versus going through the heavy fat-laden foods and those kinds of
things.

Margaret Flinter: Dr. Ramirez, we have seen some very good progress in
areas like managing diabetes and improving pregnancy outcomes in
many communities through the use of community health workers or
patient navigators or promotores, a role that specifically refers to
community health workers among the Latino population. We are curious
as to whether you are seeing any initiatives or research that specifically
looks at using the promotore model to help address the obesity
epidemic.

Amelie Ramirez: Well, very specifically, we have been using the
promotore or the patient navigator model to help folks better access to
health care system, particularly for cancer screening. But just recently, as
well, we are developing educational outreach presentations that our
promotores can take into the community and share tips with individuals.

Mark Masselli: Dr. Ramirez, on your Salud blog, you referenced a
Newsweek article that looked at another disparity, that of the
representation by Latinos in America’s medical schools relative to their
representation in the general population. It seems to be a problem in all
health professions. Minority groups are simply not represented in the
number that would reflect the general population. The Newsweek article
stated that by currently available census figures, 14.2% of the U.S.
population is Latino, but they only make up 6.4% of the students coming

out of our country’s medical schools. What do you think the impact of
this discrepancy is on the health care of the Latinos and what specific
strategies do you have underway to try to overcome this?

Amelie Ramirez: Mark, education is a huge problem for Latinos. We are
losing 40% of our kids even before they get to high school and then even
a fewer number going to college and then to a higher degree. So this is a
critical problem for us. We also know that when we interview patients,
they prefer to see a health professional that is of similar background
because they feel that they will be better understood and that individual
understands their cultural sensitivities. So this is a must. But some of
the things that we are doing that are kind of unique, we have just been
awarded a research training program from the National Cancer Institute
to help bridge individuals who are at the Masters level to consider going
into a doctoral program, and we will be bringing them together to
training seminars over the summer, providing some paid internships to
have exposure. One of things that I have noticed is there is kind of a lack
of confidence that I can do it, and those opportunities are there for them.
And so I think we need to kind of help provide the safety net in helping
them understand the application process.

Margaret Flinter: Dr. Ramirez, in a short video that you have about
obesity among Latinos, you said that half of all Latinos live in urban
homes that often lack access to safe and adequate parks and recreation
areas. In our Salud project, we have combined the benefits of technology
and activity and exercise. As one example, our teens use Facebook to
support and encourage each other to show up that why we have arranged
for memberships at no cost for the teens and your many funded projects.
What interesting uses of apps, mobiles apps, other applications, and
technology are you saying that perhaps children and teens in particular
might respond to?

Amelie Ramirez: You are right, Margaret, I mean this is the steps that
they have taken in Facebook and those kinds of things are by Latino
adolescents and teens. And one of the other Salud America! projects Dr.
Zan Gao from the University of Utah is actually taking that video program
Dance Dance Revolution and bringing that video game and encouraging
our middle school kids to come after school and participate in that and
dance on the mat and getting them involved in a fun way for physical
activities. And again, one of our own researchers Dr. Parra-Medina is
working with girl scouts and taking new technology to them and using
our smart phones for texting and having them send positive health
messages.

Mark Masselli: And Dr. Ramirez, let me follow up on that. When you look
around the country and the world, what do you see in terms of innovation
and who should our listeners at Conversations be keeping an eye on?

Amelie Ramirez: You hear a lot of negative on the news. So we need to
really share with them who is making the right changes, and how are they
doing, and how do they overcome some of the consequences and barriers
to leading the healthier life. And I think Michelle Obama’s e " orts also,
we look to some positive things, I mean that’s the first time you have
seen a garden at the White House and exemplifying that. And I have seen
enough take, small but more people say, ”Oh yeah, I want to grow a
garden” and just exposing our children to some of these more natural
opportunities.

Margaret Flinter: Today, we have been speaking with Dr. Amelie Ramirez,
Director of Salud America!, a national research program to prevent
obesity among Latino youth. Dr. Ramirez, thank you so much for joining
us today on Conversations.

Mark Masselli: Each week, Conversations highlights a bright idea about
how to make wellness a part of our communities into everyday lives.

Margaret Flinter: This week’s bright idea comes from an organization
called CYCLE Kids that’s been using bicycles to help kids stay active and
healthy for over six years. The CYCLE Kids program centers on a unique
curriculum whose lessons in bicycle skills and safety engage children in
the broader discussions about exercise and healthy eating. The
curriculum’s specific goals include teaching children not just how to ride
a bike but bike safety skills, basic bike mechanics, the importance of an
active lifestyle and a healthy diet, and the environmental science behind
pollution-free transportation. CYCLE Kids founder Julianne Idlet says, she
was inspired to create what she calls a “kids’ fitness oriented
organization” after hearing too many stories about the public health
epidemic of childhood obesity. They participate in schools and
community centers, receive bikes and helmets, in-person training for
teachers and workbooks to support classroom activities. In the past six
years, CYCLE Kids has helped the intercity neighborhoods of Boston and
New York begin to address the staggering problem of obesity. So far,
CYCLE Kids has reached 2,300 students who leave their class energized
to talk with family and friends about what they have learned and
experienced. And the program continues to grow. CYCLE Kids not only
makes kids’ bodies healthier, it strengthens their minds. The curriculum

now meets New York and Massachusetts State Learning Standards for
physical education, reading comprehension, and math. By promoting
good nutritional habits, practical and recreational exercise, and pollution
free transportation, CYCLE Kids is helping both individuals and
communities live more sustainable and healthy lives. Now, that’s a bright
idea.

Margaret Flinter: This is Conversations on Health Care. I am Margaret
Flinter.

Mark Masselli: And I am Mark Masselli, peace and health.

Conversations on Health Care, broadcasted from the campus of Wesleyan
University at WESU, streaming live at Wesufm.org and brought to you by
the Community Health Center.