2011 Diabetes and Obesity Conference
04-18-11
“Addressing Health Disparities in
Obesity and Type 2 Diabetes /
Metabolic Syndrome"
Errol D. Crook, MD
Abraham A. Mitchell Professor and Chair
Department of Internal Medicine
Director Center for Healthy Communities
University of South Alabama College of
Medicine
Objectives
• 1) Review the epidemiological link between
obesity, metabolic syndrome and diabetes.
• 2) Review impact of obesity and disparities in
obesity.
• 3) Review interventions that may curtail the
impact of obesity and diabetes with specific
focus on eliminating disparities.
Defining Obesity
• BMI
–
–
–
–
Normal
Overweight
Obese
Extremely Obese
18 – 24.9 kg/ m2
25 – 29.9 kg/m2
30 – 40 kg/m2
> 40 kg/m2
Defining Obesity
• Other measures
–
–
–
–
Triceps Skin Fold Thickness
Waist Circumference
Waist to Hip Ratio
Absolute Pounds Over Ideal Body Weight
Obesity & Tobacco Cause Over 735,000 Deaths Yearly In The U.S.
Actual Causes Of Death In The United States In 1990 And 2000
Actual Cause Of Death
Number (%)
Of Deaths,
1990
Number (%)
Of Deaths,
2000
Tobacco
400,000 (19%)
435,000 (18.1%)
Poor Diet And Physical Inactivity
300,000 (14%)
400,000 (16.1%)
Alcohol Consumption
100,000 (5%)
85,000 (3.5%)
Microbial Agents
90,000 (4%)
75,000 (3.1%)
Toxic Agents
60,000 (3%)
55,000 (2.3%)
Motor Vehicles
25,000 (1%)
43,000 (1.8%)
Firearms
35,000 (2%)
29,000 (1.2%)
Sexual Behavior
30,000 (1%)
20,000 (0.8%)
Illicit Drug Use
30,000 (< 1%)
17,000 (0.7%)
Total
1,060, 000 (50%) 1,159000 (48.2%)
*****The percentages in parentheses represent a percentage of all deaths.*****
After Mokdad, AH. Actual Causes Of Death In The U.S. In 2000. JAMA. 291(10): 1238-1245; 2004
Obesity Related Conditions are Leading Causes Of Death In The U.S.
Leading Causes Of Death In The United States In 2000
Cause Of Death
Number Of
Deaths
Death Rate Per
100,000
Population
Heart Disease
710,760
258.2
Malignant Neoplasm
553,091
200.9
Cerebrovascular Disease
167,661
60.9
Chronic Lower Respiratory Tract Disease
122,009
44.3
Unintentional Injuries
97,900
35.6
Diabetes Mellitus
69,301
25.2
Influenza And Pneumonia
65,313
23.7
Alzheimer Disease
49,558
18
Nephritis, Nephrotic Syndrome, & Nephrosis
47,251
13.5
Septicemia
31,224
11.3
Other
499,283
181.4
Total
2,403,351
873.1
After Mokdad, AH. Actual Causes Of Death In The U.S. In 2000. JAMA. 291(10): 1238-1245; 2004
Obesity as “Contributor To” vs.
“Marker For” Poor Health
• Healthiest Alabama County
– Shelby
28 % obesity in adults
8 % of children live in poverty
• Least Healthy Alabama County
– Bullock
• 38% obesity in adults
• 38% of children live in poverty
– (Univ of WI Population Health Inst and RWJF)
General Facts About Obesity In The U.S. 2004
The Surgeon General (David Satcher) labeled obesity an
epidemic (2000) and the country’s major health problem
for the beginning of the 21st century.
• 55% of Women in USA, 63% of Men and 15% of children
are overweight (BMI ≥ 25) and/or obese (BMI ≥ 30) .
• 300,000 pre-mature deaths/year attributable to obesity
• ≥ $100 billion in health care costs/year (5-7% of the total health
care budget)
• Contributing substantially to the epidemic of diabetes also
occurring in the U.S. and worldwide
Source: CDC and NCHS Data 2001
Obesity Trends Among U.S. Adults From 1991-2000
(*BMI  30, or ~ 30 lbs overweight for 5’4” Person)
(*BMI ³ 30, or ~ 30 lbs overweight for 5Õ4Ówoman)
1991
No Data
1995
2002
< 10%
10-14%
15-19%
20-24%
> 25%
Source: Mokdad et al.,JAMA.;282:(16); 1999 and 286(10); 2001, and 289:(1); 2003
Obesity Trends* Among U.S. Adults
BRFSS, 1990, 1999, 2009
(*BMI 30, or about 30 lbs. overweight for 5’4” person)
1999
1990
2009
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
Obesity Trends* Among U.S. Adults
BRFSS, 2009
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
Groups / Factors Associated With
Higher Risk of Obesity
• Ethnic Minorities
• Lower Income
– Gap narrowing
• Lower level of education
• Higher Household Density
– Ratio of inhabitants to bedrooms > 1
– Strong predictor in African American women
• Ethnicity and Disease (2010) 20:366
Obesity Rates 1995 – 2008
(Ethnicity and Disease (2011) 21:58)
30
26.5
Obesity Rates
25
20
25.2
24.6
23.8
25
21.3
15.4
15
10
5
0
USA
MS
AL
LA
TN
South CO
Avg
Obesity Rates 1995 – 2008
Obesity Rates
(Ethnicity and Disease (2011) 21:58)
40
35
30
25
20
15
10
5
0
USA
Total
MS
AL
LA
TN South CO
Avg
African American
Whites
Relationship of Socioeconomic Factors
and Obesity Rates
(Ethnicity and Disease (2011) 21:58)
• In Southern States and Colorado
• Factors closely related to obesity
–
–
–
–
Income below poverty level
Receipt of food stamps
Unemployment
General income level (indirect relationship)
Obesity Rates 1995 – 2008
(Ethnicity and Disease (2011) 21:58)
30
Obesity Rates
25
20
15
10
5
0
USA
MS
Obesity
AL
LA
SNAP Rates
TN
South
Avg
Poverty
SNAP: Supplement Nutrition Assistance Program
CO
Diabetes and Gestational Diabetes Trends
Among Adults in the United States From 1990-2001
1990
1995
2001
No Data
< 4%
4-6%
6-8%
8-10%
> 10%
Source: Mokdad et al.,Diabetes Care; 23:1278-83; 2000, JAMA; 286:(10); 2001.
Diabetes Prevalence (CDC 2005)
• 7% of US population has diabetes (20.8
million)
–
–
–
–
21% of Americans >/= 60 yrs
10% aged 40-59 yrs
2% aged 20-39 yrs
At current trends persons born in 2000 have 1
in 3 chance of developing diabetes.
Rate of new cases of type 1 and type 2 diabetes among
youth aged <20 years, by race/ethnicity, 2002–2003,
(CDC)
< 10 yrs
10 – 19 yrs
Who Is At Highest Risk for Type
2 Diabetes
•
•
•
•
•
•
•
Older age
Ethnic Minority
Obese
Family History of Diabetes
Physically Inactive
History of Gestational Diabetes
Hypertension
Consequences of Diabetes if Not
Controlled
•
•
•
•
•
Blindness
Amputations
Kidney Failure
Heart Attack
Stroke
– Therefore prevention of Type 2
Diabetes is important!
Metabolic Syndrome
CKD
Insulin Resistance
Dyslipidemia
Hypertension
Hyperglycemia
/ Diabetes
Obesity
CVD
Metabolic Syndrome (NCEP-ATP III)
Need Any 3 to Make Diagnosis
• Abdominal Obesity
– Waist Circumference >
102 cm male, 88 cm
female, BMI > 30
• Elevated Triglycerides
– > 150 mg/dl (fasting)
• Low HDL Cholesterol
– < 40 mg/dl male
– < 50 mg/dl female
• Hypertension
– SBP > 130 mm/Hg
– DBP > 85 mm/Hg
– On Anti-HTN meds
• Insulin Resistance
– > 110 mg/dl fasting
– Use of anti-DM
meds/Rx
From Matthaei, S, et al. Pathophysiology and Pharmacological Rx
of Insulin Resistance. Endocrine Reviews 21(6): 585–618. 2000.
Jackson Heart Study
The African American Framingham
• Observational, prospective study of African
Americans in Central Mississippi.
• Goal: Determine why African Americans
have higher rates of CVD.
• PI: Herman Taylor, MD
• Large involvement of Community Partners
• Recruited 5302 participants
De Soto
Marshall
Benton
Alcorn
Tishomingo
Tippah
Prentiss
Tate
Tunica
Union
Panola
Lafayette
Lee
Coahoma
Quitman
Bolivar
Itawamba
Pontotoc
Yalobusha
Calhoun
Tallahatchie
Monroe
Chickasaw
Grenada
Clay
Leflore
Washington
Webster
Carroll Montgomery
Oktibbeha
Sunflower
Choctaw
Humphreys
Holmes
Winston
Attala
Lowndes
Noxubee
Sharkey
Yazoo
Leake
Neshoba
Kemper
Scott
Newton
Lauderdale
Smith
Jasper
Madison
Issaquena
Hinds
Warren
Clarke
Rankin
Claiborne
Copiah
Simpson
Jefferson
Covington
Lincoln
Adams
Wilkinson
Franklin
Amite
Jones
Wayne
Lawrence
Jefferson
Davis
Pike
Marion
Forrest
Perry
Greene
Lamar
George
Pearl River
24 Miles
Stone
Jackson
Harrison
Clinic Exam Components: Interviews
•
HOME and CLINIC INTERVIEWS
– Psychosocial/Sociocultural
• CES-D
• Global Stress*
• Weekly Stress Inventory*
• Daily Hassles*
• Religion
• Socio-economic Status*
• Violence
• Anger (CHOST, Anger In & Out)
• Hostility
• Coping Inventory: Approach to
Life A, B, and C*
• Racism & Discrimination
• Social Support*
• Optimism
• John Henryism
• Job Strain*
– Medical/Health behavior
• Dietary Intake
• Family History of CHD*
• CHD Events/Procedures
• Health History*
• Medication Survey
• Personal History*
(Smoking, Alcohol,
Access)
• Physical Activity*
• Reproductive History
• Respiratory Symptoms
• TIA/Stroke
• Vitamin Survey
• Home/Alternative*
Remedies
• Medical data review
Clinic Exam Components:
Testing
•
ANTHROPOMETRY
•
•
BLOOD PRESSURE
•
– Sitting
– ABI
– 24 hr Ambulatory
PHYSICAL ACTIVITY
MONITOR
PULMONARY FUNCTION
–
–
FEV1.0
FVC
•
ECHOCARDIOGRAPHY
•
Urine Collection 24 Hour
•
ELECTROCARDIOGRAPHY
•
VENIPUNCTURE
•
ULTRASOUND, B-MODE
– Carotid Arteries
–
–
–
–
Chemistries
Hematology
Hemostasis
Lipids
Jackson Heart Study: Physical
Activity and Obesity
(Ethnicity and Disease 2010, 20:383)
•
•
•
•
3,174 women, 1830 men
51% aged 45-64 yrs
32% overweight, 53% obese
Women less active than men except in home
life.
• Work physical activity was associated with
lowest BMI, but also with less favorable
SES and health.
Metabolic Syndrome in African
Americans: The Jackson Heart Study
Abd
Obesity
Low
HDL-C
High
Glucose
High TG
36.1 66.1
72.7
42.5
18.4
11.9
27.7 66.8
38.4
37.3
21.9
17.7
N
MS
%
Female
2845
Male
1667
High BP
Baseline cohort (aged 21-84); Examined 2000 - 2004
Jackson Heart Study: Physical
Activity and Obesity
(Ethnicity and Disease 2010, 20:383)
• Dose response between physical activity and BMI
/ WC
• Lower physical activity generally associated with
being female, increasing age, lower education, and
lower income.
• Overweight group most active.
• Relatively high participation in active living and
sport physical activity, but the intensity was low.
Questions About Fat – Is all fat
equal?
• Where is it?
– Visceral, subcutaneous, intramuscular, central,
peripheral, upper body, lower body
• How much is there?
– Fat mass
• Is there enough?
– lipodystrophy
• Who has it?
– Gender, ethnicity
Fat: Who has it and where it is
may impact its effects
Worse. More likely in AA women,
but may not have as severe
Apple vs. Pear Shapes
consequences in that group.
Where is the Fat? Subcutaneous
vs. Visceral Fat
Liver, kidney, intestines, etc.
Abdominal
Cross section
So, Why Are We Fat? (YRUFAT)
• Thrifty Gene Hypothesis
– Hunter-Gathers for 84,000 generations
– Required large amount of daily energy just to
survive (chase down the wild animal, gather the
nuts, berries, roots, etc.)
– Those with genetics / metabolism that allowed
for storage of calories to survive long durations
without food had a survival advantage.
So, Why Are We Fat? (YRUFAT)
• Thrifty Gene Hypothesis
• What about the last 350 Generations
– Agricultural Revolution (350 generations ago)
– Industrial Revolution (7 generations ago)
– Digital Age (2 generations ago)
– Result: Ease in getting calories and
maintaining necessities for survival and
less need to expend energy.
So, Why Are We Fat? (YRUFAT)
• Thrifty Gene Hypothesis
• Results of Progress
– The survival advantage of storing calories
for long periods of fasting is now a survival
disadvantage as it leads to obesity and its
severe health consequences.
• (See O’Keefe, et al. The American Journal of
Medicine (2010) 123:1082.)
Solutions to the Obesity /
Diabetes Epidemic
•
•
•
•
Increase Physical Activity
Improve Diets / Nutrition
Weight Loss
Reduce Social and Environmental Stressors
Determinants of Health
Schroeder SA. We can do better – Improving the health of the American People. N Engl J Med.
2007;357:1221-8
How Much Exercise Do We
Prescribe?
• Exercise, in the absence of weight loss,
prevented diabetes among those with
impaired fasting glucose. (Diabetes
Prevention Project)
• Walking: Moderate vs. High intensity
– Even older adults can be trained to exercise
– Something is better than nothing.
– Mayo Clin Proc (2007) 82: 797; 82: 803.
Recommendations For Exercise
(O’Keefe, Amer J Med (2010) 123: 1082)
• Return to Hunter-Gatherer Fitness
– Walk 6 – 16 km, expend 800 – 1200 kcal (3 – 5
X more than average American Adult).
– Follow hard days with lighter days (ample rest,
sleep, relaxation)
– Interval training: intermittent bursts of
moderate- to high-level intensity activity mixed
with periods of recovery.
Recommendations For Exercise
(O’Keefe, Amer J Med (2010) 123: 1082)
• Return to Hunter-Gatherer Fitness
– Strength and flexibility training
– Maintain physical activity your entire life
• High and medium physical activity after age 50
associated with lower mortality than those with low
physical activity (Byberg BMJ (2009) 338:b688).
– Do physical activity in social settings (take
advantage of natural world).
Recommendations For Exercise
• Practical Considerations
– Get 30 or minutes of aerobic activity 4 – 5 times per
week. Should break a light sweat.
• Can do in 5 – 10 minute intervals
• Park at outskirts of parking lot rather than circling for several
minutes to get a spot close to the door.
• Gardening, walking, biking, swimming (all activities count)
• Find ways to increase physical activity at work (take stairs,
deliver a memo yourself, take a walk around building).
Challenges and Questions
• Prevention is Critical
• Behavior Modification Has to Start
Early
• Children have to be a major
focus or our attention!!!!!
Robert Wood Johnson Foundation Childhood
Obesity Initative
• “We want to help all children and families eat
well and move more—especially those in
communities at highest risk for obesity. Our
goal is to reverse the childhood obesity
epidemic by 2015 by improving access to
affordable healthy foods and increasing
opportunities for physical activity in schools
and communities across the nation.”
– www.rwjf.org/childhoodobesity/
Prevalence of Obesity Among
Children 1971 – 2006
CDC, NHANES
18
16
14
12
10
Prevalence
8
6
4
2
0
2 - 5 yrs
6 - 11 yrs
12 - 19 yrs
71-74
76-80
88-94
Years
'03 - '06
Childhood Obesity
• Nearly 1/3 of U.S. children are overweight
or obese.
• 16.3% of children ages 2- 19 are obese
• Great increase in obesity and overweight
over the last 4 decades.
• An obese teenager has 80% chance of being
and obese adult.
Disparities in Childhood Obesity
40
35
Prevalence
30
25
20
15
10
5
0
Mex - Amer
Black
White
www.rwjf.org/childhoodobesity (NHANES, CDC)
Sugar Sweetened Beverages –
Disparities in Intake
• African American Collaborative Obesity Research
Network (AACORN) - trends in sugar-sweetened
beverage (SSB)
– Black Americans (both genders, wide age range)
consume more calories from SSBs daily compared
with White Americans.
– Since the 1990s, SSB consumption among Black
adolescents has increased significantly compared to
White adolescents.
– Studies suggest that SSB marketing
disproportionately targets Black Americans relative
to Whites.
• www.rwjf.org/childhoodobesity/
School Based Interventions to
Combat Childhood Obesity
• Playworks / Sports4Kids
– Goal is to bring play back into lives of American
Children
– Organizes activities at recess for schools
• Old fashioned games (hopscotch, 4-square, etc)
• Conflict resolution
• Participation is focus, not winning
– Hires and trains coaches who work at school full time
and run recess programs.
• The Robert Wood Johnson Anthology, To Improve Health and
Health Care, vol 14, chapter 3, 2011
Disparities in Factors Leading to
Childhood Obesity
• White neighborhoods are 4 times more
likely to have supermarkets than Black
neighborhoods
• Communities with high poverty rates are
significantly less likely to have places for
exercise (parks, safe school yards, green
spaces, bike trails, etc)
You can lead the horse to water
but you can’t make him drink.
• What improves the chance that the horse
may take a drink?
– Comfort in surroundings
– Realizing that it needs to drink
Disparity in Weight Perception and
Weight Management Behavior
• Hispanic and Black Women who are
overweight or obese are more likely to
“under-assess their weight and incorrectly
perceive themselves to be at recommended
weight.”
–
–
–
–
Ethnicity and Disease (2010) 20: 244
Int J Obes Relat Metab Disord (2003) 27: 856
Obes Res (2002) 10:345
Obesity (2009) 17: 790
Practical Barriers to Healthy Lifestyles and
Healthy Communities
• Lack of access to healthy food choices
– Where are supermarkets?
– Development of community food markets provides
healthy sources of calories and neighborhood jobs
• Unsafe, none walk able neighborhoods
• No public parks for recreation
• Lack of effective physical education programs in
schools
Can we legislate healthy
behaviors?
• Soda pop taxes
• Limit use of food stamps for certain foods
– New York City
• Taxes or surcharges for health insurance
premiums
– Obesity
– Smoking
Action is Urgently Necessary to Impact
the Obesity / Diabetes Epidemic
• More 3rd Generation Research
– Research looking for a positive outcome, rather than
merely documenting the problem
– Locally focused, community-based programs are the
most effective
• We need: Healthy communities where physical
activity is encouraged and actually an option,
healthy foods are available, and health care
providers are nearby.
Thank You
• Acknowledgements:
–
–
–
–
–
Donald McClain, MD, PhD; P. Lalit Singh, PhD
Eddie Greene, MD; John Flack, MD
Jackson Heart Study Investigators
Alethea Hill, RN, PhD
Martha Arrieta MD, PhD, MPH; Roma Hanks, PhD,
Hattie Myles, EdD
– Several fellows, residents, and medical/ graduate students at the
University of Mississippi Medical Center, Jackson State
University, Wayne State University School of Medicine, and the
University of South Alabama College of Medicine
The Institute of Medicine (IOM) produced Local
Government Action to Prevent Childhood Obesity
• Healthy Eating:
•
•
•
•
•
•
Create incentive programs to attract supermarkets and grocery stores to
underserved neighborhoods;
Require menu labeling in chain restaurants to provide consumers with calorie
information on in-store menus and menu boards;
Mandate and implement strong nutrition standards for foods and beverages
available in government-run or regulated after-school programs, recreation
centers, parks, and child-care facilities, including limiting access to unhealthy foods
and beverages;
Adopt building codes to require access to, and maintenance of, fresh drinking
water fountains (e.g. public restrooms).
Implement a tax strategy to discourage consumption of foods and beverages that
have minimal nutritional value, such as sugar sweetened beverages.
Develop media campaigns, utilizing multiple channels (print, radio, internet,
television, social networking, and other promotional materials) to promote healthy
eating (and active living) using consistent messages.
– www.rwjf.org/childhoodobesity/
The Institute of Medicine (IOM) produced Local
Government Action to Prevent Childhood Obesity
•
•
•
•
•
•
•
Physical Activity Promising Strategies:
Plan, build and maintain a network of sidewalks and street crossings that connects
to schools, parks and other destinations and create a safe and comfortable walking
environment;
Adopt community policing strategies that improve safety and security of streets
and park use, especially in higher-crime neighborhoods;
Collaborate with schools to implement a Safe Routes to Schools program;
Build and maintain parks and playgrounds that are safe and attractive for playing,
and in close proximity to residential areas;
Collaborate with school districts and other organizations to establish agreements
that would allow playing fields, playgrounds, and recreation centers to be used by
community residents when schools are closed (joint-use agreements); and
Institute regulatory policies mandating minimum play space, physical equipment
and duration of play in preschool, afterschool and child-care programs.
– www.rwjf.org/childhoodobesity/
A Story on Benefits of Exercise
• Evans County Study of Cardiovascular
Disease
• Objective: To confirm the clinical
observation that coronary heart disease was
less prevalent in African Americans when
compared to whites.
Evans Co. Study of CVD
Age-adjusted Prevalence Rates for
CHD (per 1000 pop)
70
60
50
40
Prevalence
30
Rate
20
10
0
Wh male Blk male
Wh
women
Cassel, et. al. Ann Intern Med 128: 890-895, 1971
Crook et. al. Am J Med Sciences 325:307-314, 2003
Blk
Women
Evans Co. Study of CVD
Age-adjusted Prevalence Rates for
CHD by Social Class (per 1000 pop)
100
80
Prevalence
Rate
60
40
20
0
High (WM) Low (WM)
Blk male
Social Class
Social Class: Determined by social class score based on occupation,
education, and source of income of head of household.
Cassel, et. al. Ann Intern Med 128: 890-895, 1971
Crook, et. al. Am J Med Sciences 325:307-314, 2003
Evans County Study of CVD
Relationship of CHD Prevalence to Surrogate
Measure of Physical Activity
Black male
No supervision, all physical work
Part Supervision, part physical work
All Supervision, no physical work
No supervision, no physical work
0
50
100
150
Prevalence Rate (per 1000 pop)
Cassel, et. al. Ann Intern Med 128: 890-895, 1971
Crook, et. al. Am J Med Sciences 325:307-314, 2003
Metabolic Syndrome Associated
with Increased Mortality
• Hu G, et. al. Prevalence of the metabolic
syndrome and its relation to all-cause and
cardiovascular mortality in nondiabetic European
men and women. Arch Intern Med (2004)
164:1066
– 30 – 89 yrs, n > 11,000 European cohorts
– Prevalence 15.7% males, 14.2% females
– Hazard ratio for death MS vs. non-MS
• All-cause: 1.44 male, 1.38 female
• CV:
2.26 male, 2.78 female