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Aman Chopra: Folks, welcome back to another episode of the IAMGPH podcast. Our guest today has worked in the world of nutrition, obesity, racism, psychology, and data. You name it, it's everything. Dr. Adolfo Cuevas is an assistant professor in the Department of Social and Behavioral Sciences here at NYU GPH. Dr. Cuevas is a distinguished scholar in the Center of Anti-Racism, Social Justice, and Public Health, renowned for his interdisciplinary approach to understanding the complex interplay between discrimination, social determinants, and health outcomes. We cannot wait to hear all about his story. He has, in fact, recently secured a $1.6 million, four-year NIH grant, which is commendable, and we can't wait to hear how your multifaceted approach is actually going to go forward in your research. Dr. Adolfo Cuevas, welcome to the IMGPH podcast.
Dr. Adolfo Cuevas: Thank you very much. My pleasure.
Aman Chopra: So excited to hear. You have done so many things and I think the biggest one is you've recently received this NIH grant, and I'm pretty sure everyone knows about the NIH, this is a big deal. I want to know, first, how would you describe the NIH, also, to people who don't know the level of integrity it holds, and what is this grant for? What did you get this grant for?
Dr. Adolfo Cuevas: Sure. So the NIH stands for the National Institute of Health. It's really the hub, the institution that really guides and directs research on health and addresses issues of health inequities from different domains, so there are aspects of cancer, diabetes, cardiovascular disease, and these are prominent institutions that really set the agenda for researchers to really engage in the kind of questions that could actually advance the science in those domains. For the kind of work that I'm doing, it's really trying to advance our understanding of what does it mean to have allostatic load. And what Allostatic load really is, is the dysregulation of multiple physiological systems that you actually may have in your body. And we noticed that certain racial groups that have higher levels of these multi-system dysregulation compared to other groups and, to advance our understanding here, I want to see whether discrimination specifically contributes to these disparities, and whether we could further advance that understanding by identifying protective factors that may buffer the impact of discrimination on allostatic load.
Aman Chopra: Okay, this makes sense. So, I'm curious, what does the process look like to even gather data like this? So it's a very large grant, and I'm assuming this grant is so large because the work is also very heavy and requires a lot of intensive labor, data, to figure these things out. What does the process look like to discover these answers?
Dr. Adolfo Cuevas: Well, I think a lot of students would appreciate what I'm about to say, that the data that I'm working on has already been collected. So we're using secondary data from three large representative sample: Ad Health, Midlife United States, and Health and Retirement Study. So, in fact, the NIH funded the collection of all three of these cohorts, but the thing about this is that a lot of the data has not been analyzed, and so this is an immense opportunity for researchers like myself to see if there are variables of interest, excuse me, that could be analyzed and advance our understanding of X, Y, and Z. And so what's important here for everyone to know is that most of the labor that is going to be actualized is really about merging these three data sets that capture different stages of the life course. So Ad Health focuses on young adults; Midlife United States focuses on middle-aged adults; and the Health and Retirement Study focuses on middle-aged and older adults. And we want to see whether discrimination has a different impact on health for these three cohorts, that then gives us a better understanding is, are the cohort that you're in make you more vulnerable to the experiences of discrimination compared to other cohorts?
Aman Chopra: Wow. How do you find out experiences of discrimination? So I'm intrigued by this, what is a variable to assess that?
Dr. Adolfo Cuevas: There are two ways to measure discrimination, and one would say there are actually multiple ways but I'll dwindle it down to two major ways, which is everyday discrimination, and there's the major lifetime discrimination. And major lifetime discrimination is analogous to experiencing acute forms of stress in your life, such as the death of a loved one or being involved in a car accident. These are just acute forms of unfair treatment that people may experience. And just to give you an example of what I mean by this is being denied a bank loan, being mistreated by a police officer, so these are acute instances in people's life. Then there's everyday discrimination, and this is analogous to more subtle, consistent forms of stress. And so these tend to be things like being treated with less courtesy, being treated with less respect. And, in fact, in the literature, everyday discrimination seems to be much more toxic to your health than these major forms of discrimination, and I think it's because even though they're much more subtle, in nature they tend to be much more chronic. So, if you're being treated with less respect, with less courtesy in your day-to-day life, and it's as if water keeps dropping on wood. The first drop is not going to have an impact on that piece of wood, but the constant exposure to that drop will create wear and tear on your body, and especially if you're not addressing it, it is associated with an increased risk of disease and early mortality.
Aman Chopra: Oh my God. One could also say, I mean, the first thing that came to my mind is how something acute is more well-documented or well-researched, so it feels like there's more compassion around it. And the ones that are frequent, there's no data around it, as well. How do you even find that out?
Dr. Adolfo Cuevas: Yeah, and this is actually one of the biggest critiques in the literature, that especially for these everyday forms of discrimination. People tend to dock it as, "Well, that's just your perception." And all you have to do is change your perception and, therefore, you're not going to feel the stress activations." And that is quite a negative way to respond to that kind of experience. But fortunately, for these three cohorts that we're focusing on, participants were asked that question: "Did you experience day-to-day unfair treatment?" And just to give you a quick glimpse, because now we're finally engaging with these data, that everyday discrimination, specifically, it's associated with biological aging. Even after adjusting for your chronological age, it is an indicator of accelerated biological aging.
Aman Chopra: Man. Okay, this is very, very interesting. This is very, very interesting, it's the hidden problems that we don't see that are have such a big impact. I'm very interested to know how you got to this point in your career, but before that I'm sure there's a student or someone watching that is incredibly blown away by how someone gets an NIH grant. What was that process like? How does one even get a grant from the National Institute of Health?
Dr. Adolfo Cuevas: Well, you know, there are many ways to get it but I should add a really quick preface to this all, which is that perseverance is key to obtaining a grant like this because I've submitted many NIH grants before I struck success with this one. And so there is a lot of failure and rejection along the way to finally reach this particular goal. So for young investigators there are F31, these are NIH training grants where you can work with established researchers, learn from them for three or four years, and this goes to those who are already in graduate school, who are trying to obtain their doctorate. This is an amazing opportunity because it not only supports one's tuition but also provides a stipend to really engage in the kind of work you're doing. If you want to become a leader in whatever area it might be, F31 is something to consider. For those who already obtained their PhD, there are K awards, these are training grants that further help a researcher, young to scholar establish their research agenda. By that point you have a clearer understanding of the kind of work you want to do, but these K awards allow you to work with mentors from different fields to further refine the question you're looking to address. And then finally, there are the R grants, which is the one that typically assistant professors, associate, full professors try to obtain and by that point you really want to, as a scholar, identify gaps in the literature, or gaps in the literature, and find ways to address them. And these R mechanisms allow you to get the support you need to really further advance the field. And so one thing they tell you when you begin to write a grant proposal, from an F, K, or R, is that you have to persevere because you will for sure get many red-line edits from mentors and from your colleagues, but, really, the true perseverance is the potential rejections you may encounter. And those rejections, you can view it two ways, you could say, "This research question wasn't good and I don't want to do this anymore," and you could go on your life doing other things but the way people have told me to accept these rejections is as a form of learning, that you really sit down and read the comments from reviewers, and really appreciate, I mean, these are scientists looking to provide helpful feedback. And I really sat down, I appreciated every single comment that was given, and it further enhanced, and so one got rejected, that was never discussed, and then the second time around was not discussed again but I kept refining over and over and by the third I got the third submission it was scored but not funded. And so you get the story from here, that it's just a matter of perseverance.
Aman Chopra: I mean, whoever's watching this and rewind, rewind, rewind, take notes. That was a masterclass, a short, you did it in like a few minutes and explained an entire process. It really is about doing the reps, failing, in fact it sounds like you got a gift by getting rejected multiple times 'cause you understood how to do this in this way and know how to create something better, in that sense.
Dr. Adolfo Cuevas: Yes, exactly.
Aman Chopra: I love this. I'm curious to know how, what you're doing is very interesting, you've gone to the specifics like that wood analogy you just gave, the drop of water on wood does this to someone's aging, someone's livelihood, and because of these certain things that are happening, how did you get to this point? I'd love to hear your public health journey, where did you start from? How did you even come to this area?
Dr. Adolfo Cuevas: I guess there is two ways to answer this question. I grew up in New York City, born and raised in Washington Heights, which is a predominantly Dominican neighborhood and the experience of living in that neighborhood exposed me to a wide range of adversities that my neighbors were experiencing; financial stress, discrimination, a lot of different forms of discrimination, discrimination based on immigrant status, discrimination based on race, discrimination based on ethnicity as well, and that stuck with me. It was not until I was in college that my questions began to form. I was originally a jazz performance major at City College and my goal was really just to become not just a jazz musician but also I was really heavily involved in the punk and metal scene in New York City, and I wanted to just be a jazz musician by day and a punk metal musician by night.
Aman Chopra: So different.
Dr. Adolfo Cuevas: Very different. And thankfully I had a guitar teacher who told me, "You may want to consider other fields." And I think he probably just knew that the lifestyle of a musician is really rough and he just didn't want to see me going down that road, and I thank him very much for suggesting these alternatives. And I remember going back to City College the next day and I wanted to finish, and so I chose the degree with the least amount of credits, which was psychology. And I wanted to just finish just to do it for my mom, and so I remember the next semester taking this class called Enculturation, Acculturation, Immigration, and it was about how immigrants choose different strategies to survive their host country. So some immigrants choose to isolate themselves, whereas other immigrants choose to integrate themselves into the host country. And depending on what strategy immigrants use, determines their health outcome in the future. And that resonated with me because I've seen how my father decided to isolate himself from the host country, and my mom decided to integrate herself to the host country. So not only did we, we're celebrating Dominican Independence Day but we're also celebrating the fourth of July. And it also kind of contributed to their health trajectory as well. And so those two experiences of witnessing Dominicans being exposed to financial stress and discrimination but then also the immigrant experience, it forced me to ask this question about, how do these social experiences shape the health of groups? And that has basically been my question since then. I went to Portland State University where I obtained a degree in applied psychology, and there I worked with Dr. Kurt O'Brien and Dr. Sam Saha. And they were looking at these experiences, these social experiences, but within the context of the healthcare system. And they asked a really intriguing question, I remember when we were both interviewing each other, myself and Dr. Kurt O'Brien, and she was saying, "A lot of what's happening in the literature," this was around 2010, was that people are coming up with this construct called cultural competency. And the idea there is that doctors should be culturally competent, and we're asking doctors what are the different ways that they could become more competent in the healthcare system? But we're missing a key player here, we're missing the patient's perspective. And so what constitutes cultural competency and what constitutes a good or bad relationship with their clinician and their patients, from the patient's perspective? And I love that question, and so for the next five years I worked with them on understanding both Hispanic and black American patients' perspective on what constitutes a good or bad relationship. And one of the most pervasive experiences that both groups shared with us, this was qualitative interviews, by the way, was that they were experiencing discrimination as soon as they walked into the doctor's office; from the staff and from not only just the staff but also patients who were around them as well. And I was driven to better understand, how do these forms of social experiences, discrimination, get under the skin? And I was diving into articles, and one author that I loved his writing because it was so clear was Dr. David Williams, who's currently at the Harvard School of Public Health. And he showed compelling evidence that discrimination is a determinant of health above and beyond socioeconomic status. And I'll take a quick detour here, why this is important, because in the early 1990s, even say like even the 1980s, people knew that black Americans specifically had shorter life expectancy compared to white Americans. And they implicated socioeconomic status, both education, income, occupation, as fully explaining racial differences. And that makes sense, if you look into those three indicators, black and even Hispanic Americans are overrepresented at the lower end of the socioeconomic stratum. When it comes to education, black and Hispanic have fewer bachelor's degrees compared to whites. Well, what they showed starting in the mid-1990s was that even after adjusting for income, education, and occupation, Black Americans still live shorter lives compared to White Americans, and so what else can explain these differences? And he showed in his work that discrimination is a unique determinant that contributes to poor health beyond income, education, occupation. And so I feel like that was my calling, I wanted to better understand how discrimination affect health and, really, how does discrimination get under the skin? So that analogy I provided earlier about the water drop falling on the wood, what's happening at the molecular level as well, does discrimination activate physiological systems and how and why? And this has been the driving force for my research since grad school.
Aman Chopra: Wow. How did obesity come into this picture? You had a lot of work around that. First off, what does this word obesity even mean? Let's get your definition of it, and then how did this come out 'cause you are in the world of discrimination and understanding how different people are treated differently for x, y, z reasons. And how did this whole thing play out, because it's a big part of your career?
Dr. Adolfo Cuevas: Yeah, I view obesity as a indicator of aging and physiological dysregulation, and it's just one of a constellation of other indicators of aging. So in other words, there's blood pressure as well. And typically, the people that suffer from high levels of obesity also have hypertension, also have diabetes, so it is just one marker that I fixated on, and I'll explain why. Back in the early 2000s the Surgeon General came out with a report. This was around 2000 or 2001. David Satcher was the Surgeon General, and he was ringing an alarm bell at that time and it scared everyone. He said, "There's a crisis going on, 30% of the population, of the adult population, have obesity." And the ways it's measured is a body mass index of 25 or more. And he said, "This is a crisis and we need to do something about it immediately." And there was a lot of money since then that has been poured into different risk factors to address. So the ones that we often think about is physical activity and diet. Reasonable, right? And one who doesn't necessarily work out vigorously may have more pounds compared to someone who does. Someone who has a poor diet would have more pounds compared to someone who has a better diet, just to keep it simple. But one thing that we noticed is that, for sure, when interventions were implemented since 2000, the obesity rate continued to creep up. And currently we're at about 45% of adults have obesity.
Aman Chopra: Oh my gosh.
Dr. Adolfo Cuevas: And this is after pumping billions of dollars into these industries of physical activity and nutrition. And it had me thinking, "What other determinants of health we're not paying attention to." And stress was one, and mainly because my background is in psychology, I think I naturally gravitated toward the concept of stress and I went into the literature and I found compelling evidence from both my studies, and even human studies, that chronic exposure to stress leads to greater fat deposits and, in turn, increased risk of obesity. But one thing that we didn't know or it was still basically understudied, was the type of stressors that may contribute to obesity. And so that's how I went kind of down into the world of obesity for a while, is to see whether discrimination and other psychological and social stressors, like financial stress, relationship problems, and even workplace mistreatment, do they contribute to more weight gain in the future? And we have found evidence, two papers that came out in the last five years. One was showing that discrimination and financial stress is associated with higher weight gain for middle-aged and older adults, and just last year we published a paper showing that racial discrimination, being mistreated based on your race, ethnicity, skin color, is associated with higher weight gain for children, adolescents, as young as nine years old. And there are children, unfortunately, who report experiencing discrimination from their teachers, their peers, other adults, and that seems to be quite toxic to their body. That leads to physiological disregulation.
Aman Chopra: I'm silent for a while for a reason, it's not that the video is stuck, everyone. It's interesting to see how these things are so hidden and never spoken of. I'd love to hear your whole life has been put, I wouldn't say your whole life but a lot of your life has been put into this work. What are solutions that we have found so far? It seems like the core issue is discrimination that's causing these things, obviously there's a multitude of reasons for many other things, but what is the solution to this?
Dr. Adolfo Cuevas: If you mean like the solution to address discrimination and its impact on health, specifically?
Aman Chopra: Yeah, so I mean the first thing that came to my mind, how can we prevent children from having these issues, and then it goes back to discrimination, I'm assuming? So then, what are ways to start solving these issues and preventing any of this from happening for people?
Dr. Adolfo Cuevas: Yeah, I've had this a really great conversation with a colleague of mine, Dr. Steve Cole, he's at UCLA. And there are three schools of thought here. And if I may, I'll probably explain each one-
Aman Chopra: Please, please.
Dr. Adolfo Cuevas: Very briefly here. The first one is there's been emerging work showing how mindfulness meditation seems to buffer or mitigate the impact of discrimination on health. And there's promise there of this intra-psychic form of intervention that could help alleviate someone who is constantly bombarded by different forms of indignities. I buy it, there's like compelling evidence that it really reduces the activation of certain parts of the brain that process fear and threat. There's something compelling about this. Our problem with that particular school is that it places a burden on the victims, it really absolves a lot of the perpetrators of discrimination from the responsibility in changing their behavior. The other school of thought is a lot of people, especially in the last five years, saying, "Let's ignore what's happening currently at the individual level," or at the very least just give them some grace, let's put it in abeyance for a while and focus on structural forms of discrimination and racism, because that has been an ongoing issue and that tends to drive a culture of racism, sexism, heterosexism. So having someone that lives in a racially segregated community tends to be exposed to poor quality education, and because we tend to live in ahistorical society that forgets that policies that were put in place created the structures that we have today, they then tend to blame the victim and mistreat these victims. And a lot of the people in this particular school are suggesting that we should focus on policies or the absence of policies, to restructure society, to eventually ameliorate the culture of all of these -isms, and then in turn this will address discrimination and blah, blah, blah, blah, blah. That's the second school. The problem we have with that one, as well, is that it'll take... We believe, yeah, this is actually a really core place to put most of our efforts in, it's just gonna take a long time to galvanize political will to develop effective policies to address many of these issues, one of which is like wealth inequities. It's gonna take a while. I think where we could probably place a lot of our effort, and unfortunately I think we have forgotten a lot of this, is the third school which is implementing interventions that creates racial harmony. This was core in the 1960s and '70s by a lot of social psychologists that created interventions like the jigsaw, for example, where you give a really difficult task to these children but one, for example, black child will have the knowledge for part of that particular task, and a white child will have knowledge of the other particular task. And so they need to work together to address the issue at hand, and they found compelling evidence that this actually reduces racial bias exposure. And both the perpetrator reduces the belief of these like negative stereotypes, and the potential victim is not exposed to racial biases. And there have been a lot of more sophisticated interventions since then to further enhance racial harmony. We have not put as much attention to this particular school within the context of health, I believe, and I think this holds a lot more promise because, again, it doesn't place the burden on the victim, and it could actually be implemented in an immediate sense to improve the health of the potential victim, and also place a bit of the burden on the potential perpetrator. And so I think the kind of work that we are wanting to do in the near future is focus on this third school, both from a population-level perspective, are there variables that could give us an inkling of whether this actually has any effect? But then eventually begin developing an intervention to see whether there's something promising there.
Aman Chopra: What do you mean by population level perspective? What does that term mean? I hear it a lot whenever I read about data, and someone who's in the world of data and collecting all this data, what does this population level mean?
Dr. Adolfo Cuevas: Yeah, I think we could oftentimes talk from an individual-level perspective, like really what's happening to me as an individual is contingent upon all of the different characteristics that I bring to the table, whether an intervention may work or not. But at the population level we wanna see whether an intervention or particular protective factor has any impact at really a much larger level of analyses. And this is not just one individual but, really, 1000s, 100s of 1,000s of people. And because at that point, then we know that we could definitely shift disparities drastically and dramatically.
Aman Chopra: For the student or anyone, the young student or someone that's in their GPH- Global Public Health career as well, how do they get involved in your work? They must be relating to it or fascinated by it, how does someone get involved in your kind of work?
Dr. Adolfo Cuevas: Well, I have an open-door policy, and so students could always email me, and I'm always happy to both talk about just career development but also talk about interesting research questions and see whether we could actually address them. Especially if there are things in the literature that there's a big void there, and there's a particular population-level data that could address it. I'm all for it, and I'm always willing to collaborate with students. I don't necessarily see them as like trainees, I see them as potential colleagues with like their own expert knowledge, and so I'm always learning and I yearn for new knowledge from people.
Aman Chopra: No discrimination there either.
Dr. Adolfo Cuevas: No, not at all.
Aman Chopra: I'm gonna ask you this last few things, where this seems like an area of research where even the three options you presented to me as a solution sound so taxing. Sound like you have to climb El Cap without the rope again and again and again, it kind of feels like that. What do you do when you hit a roadblock in these areas for yourself?
Dr. Adolfo Cuevas: Well, I take a step back and just speak with members of the community. I think that's usually the most refreshing way to engage with a lot of this kind of work, because it's easy to remain in the ivory tower, publish papers, and then if you hit a roadblock just kind of like step away and hopefully you get them muse the next day and continue writing. But really, what I find to be one of the most effective way is talking to people in the community about your research, because a lot of them are aware that they are victims of inequities. And I remember talking to my aunts about discrimination, and I said, "Hey, did you know discrimination is really bad for your health?" And they were like, "You needed a PhD to get you to understand- I knew this." And that's a common response that academics get, especially in this field, when they talk to members of their family and members in the community. But the good thing about speaking with members of your community, or any community, is that they could also give you some really innovative ideas for how to move forward in your work. And so to give you an example of this is now that I'm back in New York City, I'm very interested in looking at the determinants, the social determinants that contributes to racial health inequities within the Hispanic population. There is emerging research showing that the life expectancy of black Hispanic, particularly black Hispanic men, is much shorter compared to white Hispanic men specifically. And speaking with people in the Dominican, Puerto Rican, Cuban community, they gave me some really good ideas about what might be contributing to a lot of these potential health inequities, which is there is colorism within the community where people of lighter skin tend to be better treated, even within their own family, better treated compared to those with darker skin; but there's very little work looking at how colorism at the population level contributes to shorter life expectancy for black Hispanic men. And so those are just simply based on my engagement with the community, just taking a step back, talking, now I'm back in the office with refreshing research questions.
Aman Chopra: These are things that I assume but it's crazy to see that the data supports it, that you're saying such things within the family, as well, colorism exists and being treated differently. And now you're targeting it at a population level, it makes a lot of sense. Let's leave us... I find it really funny that you were trying to get out of a jazz degree a long time ago, and then you completed a degree 'cause you wanted to please your mom, and then you ended up getting a PhD. So your heart is clearly in this topic a lot deeper. As we're recording this interview right now, where does your heart lie right now? Where do you think your public health intention is gonna go?
Dr. Adolfo Cuevas: There's a saying by a philosopher, Jiddu Krishnamurti, and he said that there is no measure of health to be well-adjusted in a sick society. And I think my heart, based on that particular quote, my heart is in two areas, really. One is to find ways to relieve the immediate suffering of people, but then also think about the society, the sick society that people are in and what are ways that we could actually change the social structures, so people in the future could actually live a healthy life that they deserve.
Aman Chopra: That's beautiful. Can't wait to see where this research goes and what awesome discoveries you make.
Dr. Adolfo Cuevas: Oh, thank you.
Aman Chopra: Dr. Cuevas, thanks for being on this podcast.
Dr. Adolfo Cuevas: My pleasure.
Aman Chopra: Dr. Cuevas mentioned a few before the interview that I tend to talk and give a lot of detail, and I wish we had another hour, and we hope to have you back soon. Thanks for being on the podcast-
Dr. Adolfo Cuevas: My pleasure, thank you so much.
Aman Chopra: Take care, everyone. All the links are in the description, if you have any questions, shoot a comment and like and subscribe. We'll see you in the next one.