Co-hosts Ryan Piansky, a patient advocate living with eosinophilic esophagitis (EoE) and eosinophilic asthma, and Holly Knotowicz, a speech-language pathologist living with EoE who serves on APFED's Health Sciences Advisory Council, interview Angelica Lackey Mirzoca, MPH, about her research on social vulnerability and EoE.

Disclaimer: The information provided in this podcast is designed to support, not replace, the relationship between listeners and their healthcare providers. Opinions, information, and recommendations shared in this podcast are not a substitute for medical advice. Decisions related to medical care should be made with your healthcare provider. Opinions and views of guests and co-hosts are their own.

Key Takeaways:

[:51] Co-host Ryan Piansky introduces this episode, brought to you thanks to the support of Education Partners GSK, Sanofi, Regeneron, and Takeda. Ryan introduces co-host Holly Knotowicz.

[1:13] Holly introduces today's topic — research on social vulnerability and eosinophilic esophagitis (EoE) — and today's guest, Angelica Lackey Mirzoca, a fourth-year medical student at the University of North Carolina School of Medicine in Chapel Hill.

[1:38] Angelica will start an internal medicine residency this summer and is planning to do a fellowship in GI and liver disease. Before medical school, she studied public health nutrition at UNC and worked in clinical research in eosinophilic diseases.

[1:58] Angelica has been able to use her analytic and public health skills as a member of UNC's EoE Research Group, which is part of the larger Center for Esophageal Diseases and Swallowing, led by Dr. Evan Dellon.

[2:15] Ryan sees Dr. Dellon as his GI. Dr. Dellon has been a guest on the Real Talk: Eosinophilic Diseases podcast. Ryan says Dr. Dellon is wonderful, and many in the community look up to him. It's exciting that Angelica is doing research alongside him.

[2:38] Dr. Craig Reed, part of the EoE Group, who works closely with Dr. Dellon, invited Angelica to a research meeting. She's always had an interest in digestive tract function and diseases.

[2:55] When Angelica was growing up, her father had Barrett's Esophagus. She saw him choking a lot when he was swallowing. It was really scary.

[3:04] Angelica says that being in the EoE space and appreciating the impact that problems swallowing have, not only on the patient's everyday life but on the people around the patient, it was important to her to dedicate her skills and time to EoE.

[3:37] Angelica researched EoE and social vulnerability. Her abstract at the 2025 Digestive Diseases Week was titled "Increasing Social Vulnerability Impacts Presentation and Decreases Treatment Response in Eosinophilic Esophagitis."

[3:58] Angelica explains that social vulnerability is a term to describe the context of people's day-to-day lives and the barriers and obstacles they navigate.

[4:07] In this context, their lived experience has a dramatic impact on people's ability to anticipate and recover from different stressors.

[4:16] Some groups are notably more vulnerable, including kids, older adults, single-parent households, and people who live with physical and mental disabilities.

[4:28] Social vulnerability can be measured qualitatively in terms of socio-economic status and household composition. Other composite scores or variables can serve as quantitative assessments of social vulnerability.

[4:50] Ryan says he does research for graduate school associated with climate vulnerability and infrastructure. He has done some work with the CDC's Social Vulnerability Index and the Climate and Environmental Justice Screening Tool.

[5:20] Angelica says they used the CDC's Social Vulnerability Index in the study. It's a 16-variable composite score with four overarching themes. It's down to the Census Track level. You can associate it with patient zip codes.

[5:37] The SVI can populate into patient charts or a QI database. It was very easy to incorporate into the database.

[5:50] The QI database was developed to help people understand what neighborhoods and communities might need additional support in natural disasters. It includes variables that impact people's health day-to-day.

[6:18] Angelica says health equity is core to everything she does. Participating in the EoE research, it was important to her to consider the social vulnerability, or people's lived reality, and how it impacts their ability to feel empowered to access care.

[6:42] Angelica talks about people not knowing what's wrong with them, choking. Angelica worked in restaurants for 12 years before going to medical school. She listened to a lot of people share their struggles to communicate with the doctors.

[7:09] Holly says when she worked at a major children's hospital in an EoE clinic, they had local patient families and patients that flew in from farther away. The local patients got to see her weekly for feeding therapy. That's when she started doing telehealth.

[8:04] Angelica says the biggest strength of the database is its size. Having 1,400 people and adding every new diagnosis they get at UNC, and every new diagnosis over the past 23 years.

[8:25] There are adult (60%) and child (40%) patients in the database. There is also a good range of social vulnerability among the patients.

[8:42] Ryan notes that one of the findings of this research was that people with higher social vulnerability often experience delays in diagnosis.

[8:52] Angelica says most of the work was postulating on what could be the things that kept people from being diagnosed early, which is important. Angelica hopes that all institutions work to ensure that early endoscopies and biopsies are done.

[9:!2] The new guidelines help. Having that high index of suspicion for everyone, not basing it on demographics or judging by appearance, for whether someone needs biopsies or not.

[9:28] Social vulnerability includes access to care, getting endoscopies and biopsies, having health insurance, and ER care, which is expensive even with insurance. Specialty copays are expensive. Transportation is expensive.

[9:53] Taking time off work can be hard. People take time off to get care for their children, but often not for themselves.

[10:18] Ryan was diagnosed in 2002. Knowledge of EoE was not widespread, but his parents took off work and took him to doctors out of state. They had insurance that covered it. He saw five or six physicians in multiple states before he got a diagnosis.

[10:42] Ryan's situation is not feasible for most people. He says he is fortunate to have gotten to a doctor who had the expertise to diagnose EoE.

[10:51] Ryan says Dr. Emily McGowan was a guest on the Real Talk: Eosinophilic Diseases podcast (Episode 15), speaking on access to specialty care for EoE. She had researched urban and rural populations getting diagnosed with EoE.

[11:05] Her research showed that if you're near a center that can diagnose you, you get diagnosed more frequently, which brings it back to access to care.

[11:19] Angelica's research did not look at the urban/rural divide. That's something that may be a future direction of research. Eighty percent of North Carolina, where the study was located, is rural.

[11:41] The Social Vulnerability Index shows there is the highest vulnerability in more rural areas, especially Eastern North Carolina. Angelica imagines that the urban/rural divide plays a big role.

[11:59] Holly grew up in rural New York. She wasn't diagnosed until her twenties. She had issues, but her parents couldn't take her to be diagnosed. It's reassuring to have someone look into this, because when people do research, things change.

[12:30] Ryan says all of these points make a lot of sense on the diagnostic side. If you are in a more socially vulnerable place, you don't have the resources. You can't go and get that diagnosis.

[12:41] Ryan mentions the study found a difference in symptoms, such as vomiting, nausea, and abdominal pain. Ryan asks what that tells us about how EoE may affect patients differently in these different circumstances.

[12:53] Angelica says the study group was 40% children, and children can present with different symptoms, like belly pain and regurgitation. They're eating different foods and may not be noticing solid foods getting stuck as often.

[13:20] Anglica says there can be a lot of overlap with GERD and EoE. There may be some gut-brain interaction. There's a lot of psycho-social stress among people who have higher social vulnerability. That often manifests with the motility of the GI tract.

[13:56] Angelica says their database doesn't include people who have eosinophilic GI diseases outside of EoE.

[14:13] Holly says the study also showed that patients with higher social vulnerability were less likely to respond to swallowed steroid treatments, even after accounting for factors like age and insurance. Holly asks Angelica to explain this finding.

[14:34] Angelica says this is really important. The way you manage EoE is very patient-specific. The new guidelines give jurisdiction to you, as a patient, and your provider in deciding other things.

[14:51] You can choose dietary therapy first, or topical steroids first. People can take PPIs. They used to be required first, but now they are not. Topical steroids, the ones that you swallow, are common. Cutting out foods from your diet can be challenging.

[15:17] Some people don't love the idea of taking medicine daily in their twenties or thirties.

[15:32] The fact that you would start a patient on something and not see a histologic response opens up the door to follow-up questions of why it is not working.

[15:50] Holly says the pattern wasn't shown in people using diet-based treatments and asks what might explain that difference. She mentions that dietary elimination groceries are expensive, compared to having good insurance covering the medicine.

[16:14] Angelica says Dr. Dellon and part of the group did a study a couple of years ago looking at the cost of dietary elimination for patients. There was a lot of heterogeneity in diet elimination. It wasn't all six food elimination. It was different for everybody.

[16:36] They found that it was cheaper for patients to do elimination diets than to pay for the compounded medicines.

[16:44] Angelica was doing interviews recently for her residency, and a patient told her that when they were first diagnosed, it was hundreds of dollars for their compounded medicine, and they couldn't afford it.

[17:00] Angelica says diet therapy can be different for children versus adults. Adults are sometimes very motivated to try diet therapy. The team wondered if that motivation could influence their outcomes or their ability to adhere to eliminating things.

[17:23] Holly remembers sitting with the social worker at the Children's Hospital of Colorado GDP Clinic, talking about explaining when you're dairy-free, looking at ingredients like whey. There's so much that comes with it. It's confusing.

[17:41] Ryan says he has used swallowed steroids; he's now on a biologic. He's done diet elimination. Groceries are expensive, but there are ways to work around that. Insurance can be frustrating with step therapies, so sometimes diet is the best option.

[18:18] Ryan asks if a delayed diagnosis can impact symptom severity and disease progression, and therefore, the response to treatment options. Is the later diagnosis you see with more socially vulnerable populations playing into the treatment response?

[18:34] Angelica says the delayed diagnosis can lead to a more acute change in the lining of the esophagus, to become more fibrotic and tougher, and the esophagus loses some of its natural flexibility. She says we do wonder if that can be a component of it.

[18:59] Angelica says that's one of the limitations of the study. We need follow-up information to look longitudinally at some of the more recent endoscopies and the outcomes for these patients. She says that's something that we hope to do.

[19:16] Ryan asks about information about disease severity within the data set. Angelica says they have information on the severity scores of patients.

[19:54] The data showed that patients with higher social vulnerability had more of a mixed inflammatory phenotype compared to people with lower social vulnerability.

[20:09] Ryan notes that there are so many different angles to look at. He says in doing research, especially when working with medical charts, you can't get everything for such a large population. What you're able to figure out from all this is so cool.

[20:24] Holly says she was the person who ended up in the ED with a food impaction, and that could have been avoided. She loves that Angelica is researching it.

[20:44] Holly asks what the key takeaways are for clinicians from this research.

[20:54] Angelica says a key takeaway for all clinicians caring for people with EoE is that you have to take into consideration the vulnerabilities that patients are navigating. We operate within a complicated health system that needs to be more efficient.

[21:14] Angelica says you get more messages daily and have a lot of competing needs. It can be easy to assume that this patient in front of me is doing well enough and has access to what they need to be supported.

[21:31] Patients having space to ask a question about something important to them can be validating and affirming. Whether patients want to share at that encounter, or at the next. It normalizes that we humans need help navigating life, because it's hard.

[22:20] Holly talks about providers sitting down with you and asking if you have access to drive to this specialty pharmacy, or if you live in a home where this medicine can be delivered to you safely. It's nice to have someone ask what's going to work best for you.

[22:49] Angelica agrees. She says the Social Vulnerability Index can be incorporated into Epic. You can look at a high score and make sure the patient has a social worker and care management. Make it standard procedure to discuss it with patients.

[23:10] Ryan explains to listeners that Epic is where all patient information and records are stored. Holly mentions that her office doesn't have Epic, and she misses having electronic medical records.

[23:34] Ryan says as a patient, it's impactful that his healthcare team considers his life outside the doctor's office and that he is sticking with his care and can find care that works well for him.

[24:11] Angelica says it's important that patients understand that the spaces they are in outside the clinic do impact their health. Up to 80% of our health is influenced by things outside of the hospital and clinic, like health behaviors, exercise, smoking, and alcohol.

[24:36] Angelica says your physical environment is so important: the quality of your housing, your carpet, the pollution in your air, working in a factory, working with animals, that's important to consider.

[25:00] Angelica says your general stress level is important. That can be worse when you live in an environment that's very noisy or where you don't feel physically safe. Those are very important things to share with your doctors.

[25:25] Ryan speaks of research he does on California wildfires, where the power might be turned off for days at a time to avoid starting fires, which can spoil refrigerated foods or medicines that are difficult to replace. Where you live has major impacts.

[26:31] Angelica says something we want to do is to look at a pooled subset of around 80 patients to see what is going on with their swallowed steroid treatment. You can discern quite a lot from a chart review by the questions patients send to their team.

[26:56] Questions might be things like confusion about how to take the medication, any trouble with insurance claims, or if the medicines are touching the throat the way they're supposed to be. Is the throat not getting adequate exposure to the medicine?

[27:20] A thought the team had was that if there's increased chronic stress, that increases the allostatic load, and that can impact total inflammation. Will that make the mucosa in some people inherently resistant, and do they need bigger doses to treat the disease?

[27:42] Angelica says we're also going to incorporate the jobs they are working and the potential exposures they have there. How far they live from UNC Main, and if they are living in a rural county or not. They are trying to identify specific areas to help patients.

[28:08] Ryan speaks of the benefits and drawbacks of integrating AI into patient records. In chronic cases, the AI summaries are skimming over important details.

[28:45] Angelica says they are using AI at UNC, a lot of times when people are being admitted to the ED. It's also being used in the clinic. Angelica sees that AI edits out important details of a patient's social history.

[29:27] Holly says her office is trialing an AI, and she has learned she can teach it what is necessary to include in the notes. It can be good if you use it appropriately and train it.

[30:03] Ryan says his father recently had a prescription denied because the AI said he didn't have the disorder. He was diagnosed 20 years ago. It took several phone calls to override the AI and see in his chart that he needed this medication.

[30:54] Angelica says she hopes that this study can be the beginning of a conversation.

[31:00] Health equity is important in all of medical care. Angelica hears more about it in a primary care setting. She looks forward to health equity becoming the core of GI and liver diseases and to how we approach that care.

[31:20] Having the conversation can be the beginning of advocacy. It will be the beginning of having medications be more affordable, so you do not have to try and fail so many medications before you get the one that works for you.

[31:40] Angelica says every hour of not having the medication that works for them is hard for people. This research was a relatively simple project that answered some very important questions and left us with many more important questions to answer.

[32:00] Angelica hopes it shows the feasibility of using these tools that we already have in the community, to start making everyone's health better, and not just people who have access.

[32:15] Ryan says we're excited that you're here talking about this with us. We'd also like to congratulate you on receiving an award last year at Digestive Disease Week.

[32:23] It was an honor to recognize you with the American Gastroenterological Association APFED Abstract Award for your outstanding research that we've been discussing today.

[32:31] The abstract, "Increasing Social Vulnerability Impacts Presentation and Decreases Treatment Response in Eosinophilic Esophagitis," was selected in recognition of its significant contributions to the field.

[32:47] Angelica says it was such an honor. It means a lot to her because she conceptualized and executed this project, with so much support from Dr. Dellon and the larger EoE Group. She says she couldn't have done it without them.

[33:05] Angelica says, most importantly, the project was a small win for health equity. She hopes that it starts a lot of important conversations and that we continue to be more attuned to the social drivers that impact our really vulnerable patient population.

[33:30] Angelica's final words: For patients, caregivers, and loved ones, I encourage you to ask questions. There are no stupid or silly questions. If you feel silly asking, how you feel is valid, but it's really important that you get your questions answered.

[33:55] It's OK to say you don't know what questions to ask. You are the expert on what you need and what is important to you. Ask questions, and say when you don't know what to ask.

[34:40] Holly thinks that's great for people with a new diagnosis, or children. Ask, what would you ask, if you were in my shoes?

[34:54] Ryan thinks this is a great start for listeners who are newly diagnosed. If you'd like to learn more about eosinophilic disorders, we encourage you to visit apfed.org and check out the links in the show notes.

[35:09] If you're looking for a specialist who treats eosinophilic disorders, we encourage you to use APFED's Specialist Finder at APFED.org/specialist.

[35:18] If you'd like to connect with others impacted by eosinophilic diseases, please join APFED's online community on the Inspire Network at APFED.org/connections.

[35:28] If you've been personally impacted by eosinophilic disorders and are interested in sharing your experience, please check out APFED.org/shareyourstory.

[35:37] Ryan thanks Angelica for joining us today. This was a super insightful conversation. Angelica thanks Ryan and Holly for having her on. It was a pleasure getting to talk today.

[35:54] Holly thanks Angelica and also thanks APFED's Education Partners GSK, Sanofi, Regeneron, and Takeda for supporting this episode.

Mentioned in This Episode:

APFED on YouTube, Twitter, Facebook, Pinterest, Instagram

Real Talk: Eosinophilic Diseases Podcast

Apfed.org

apfed.org/specialist

apfed.org/connections

apfed.org/research/clinical-trials

Angelica Lackey Mirzoca, MPHpubmed.ncbi.nlm.nih.gov/41551662

apfed.org/blog/may-2025-research-roundup-ddw-edition

gastro.org/news/introducing-the-2025-aga-research-foundation-awardees

Education Partners: This episode of APFED's podcast is brought to you thanks to the support of GSK, Sanofi, Regeneron, and Takeda.

Tweetables:

"When I was growing up, my Dad had Barrett's Esophagus. I saw him choking a lot when he was swallowing. It was really scary. And so, being in the EoE space…was really important and attractive to me." — Angelica Lackey Mirzoca, MPH

"We used the CDC's Social Vulnerability Index in the study. It's a 16-variable composite score with four overarching themes. It's down to the Census Track level. You can associate it with patient zip codes." — Angelica Lackey Mirzoca, MPH

"Health equity is core to everything I do. Having the opportunity to participate in the EoE research, I felt it was important that we considered the social vulnerability, or people's lived reality, and how that impacts their ability to access care." — Angelica Lackey Mirzoca, MPH

"Most of the work was postulating on what could be the things that kept people from being diagnosed early, something that's really important." — Angelica Lackey Mirzoca, MPH

"I encourage you to ask questions…It's OK to say you don't know what questions to ask. You are the expert on what you need and what is important to you. Ask questions, and say when you don't know what to ask." — Angelica Lackey Mirzoca, MPH

Guest Bio:

Angelica Lackey Mirzoca, MPH