2011 Diabetes and Obesity Conference04-18-11

“Addressing Health Disparities in Obesity and Type 2 Diabetes /

Metabolic Syndrome"

Errol D. Crook, MDAbraham 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 18 – 24.9 kg/ m2

– Overweight 25 – 29.9 kg/m2

– Obese 30 – 40 kg/m2

– Extremely Obese > 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.

*****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

1,159000 (48.2%)1,060, 000 (50%)Total

17,000 (0.7%)30,000 (< 1%)Illicit Drug Use

20,000 (0.8%)30,000 (1%)Sexual Behavior

29,000 (1.2%)35,000 (2%)Firearms

43,000 (1.8%)25,000 (1%)Motor Vehicles

55,000 (2.3%)60,000 (3%)Toxic Agents

75,000 (3.1%)90,000 (4%)Microbial Agents

85,000 (3.5%)100,000 (5%)Alcohol Consumption

400,000 (16.1%)300,000 (14%)Poor Diet And Physical Inactivity

435,000 (18.1%)400,000 (19%)Tobacco

Number (%)Of Deaths,

2000

Number (%)Of Deaths,

1990

Actual Cause Of Death

Actual Causes Of Death In The United States In 1990 And 2000

Obesity Related Conditions are Leading Causes Of Death In The U.S.

873.12,403,351Total

181.4499,283Other

11.331,224Septicemia

13.547,251Nephritis, Nephrotic Syndrome, & Nephrosis

1849,558Alzheimer Disease

23.765,313Influenza And Pneumonia

25.269,301Diabetes Mellitus

35.697,900Unintentional Injuries

44.3122,009Chronic Lower Respiratory Tract Disease

60.9167,661Cerebrovascular Disease

200.9553,091Malignant Neoplasm

258.2710,760Heart Disease

Death Rate Per100,000

Population

Number OfDeaths

Cause Of Death

Leading Causes Of Death In The United States In 2000

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 adults8 % 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 5Õ 4Ó woman)

No Data

< 10%

10-14%

15-19%

> 25%

20-24%

1991 1995

2002

Source: Mokdad et al., JAMA.;282:(16); 1999 and 286(10); 2001, and 289:(1); 2003

1999

Obesity Trends* Among U.S. AdultsBRFSS, 1990, 1999, 2009

(*BMI 30, or about 30 lbs. overweight for 5’4” person)

2009

1990

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Obesity Trends* Among U.S. AdultsBRFSS, 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)

21.3

26.525.2 24.6 23.8 25

15.4

0

5

10

15

20

25

30

Obe

sity

Rat

es

USA MS AL LA TN SouthAvg

CO

Obesity Rates 1995 – 2008(Ethnicity and Disease (2011) 21:58)

05

1015

2025

303540

Obe

sity

Rat

es

USA MS AL LA TN SouthAvg

CO

Total 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)

0

5

10

15

20

25

30O

bes

ity R

ate

s

USA MS AL LA TN SouthAvg

CO

Obesity SNAP Rates Poverty

SNAP: Supplement Nutrition Assistance Program

No Data

< 4%

4-6%

6-8%

Source: Mokdad et al., Diabetes Care; 23:1278-83; 2000, JAMA; 286:(10); 2001.

1990

8-10%

> 10%

1995

2001

Diabetes and Gestational Diabetes TrendsAmong Adults in the United States From 1990-2001

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

Insulin Resistance

HypertensionHyperglycemia / Diabetes

Obesity

Dyslipidemia

CVDCKD

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 StudyThe 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

Adams

Alcorn

Amite

Attala

Benton

BolivarCalhoun

Carroll

Chickasaw

Choctaw

Claiborne

Clarke

Clay

Coahoma

Copiah

Covington

De Soto

Forrest

Franklin

George

Greene

Grenada

Harrison

HolmesHum-phreys

Itawamba

Jackson

Jasper

JeffersonDavis

Jones

Kemper

Lafayette

Lamar

Lauderdale

Law-rence

Leake

Lee

Leflore

Lincoln

Lowndes

Marion

Marshall

Monroe

Mont-gomery

Neshoba

Newton

Noxubee

Oktibbeha

Panola

Pearl River

Perry

Pike

Pontotoc

Prentiss

Quitman

Scott

Shark-ey

Simpson

Smith

Stone

Sun-flower

Tallahatchie

Tate

TippahTisho-mingo

TunicaUnion

Warren

Washington

Wayne

Webster

Wilkinson

Winston

Yalobusha

Yazoo

Jefferson

Hinds

Madison

Rankin

24 Miles

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

• ECHOCARDIOGRAPHY

• ELECTROCARDIOGRAPHY

• ULTRASOUND, B-MODE– Carotid Arteries

• PHYSICAL ACTIVITY MONITOR

• PULMONARY FUNCTION – FEV1.0– FVC

• Urine Collection 24 Hour

• VENIPUNCTURE– 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

N MS

%

High BP Abd

Obesity

Low HDL-C

High Glucose

High TG

Female 2845 36.1 66.1 72.7 42.5 18.4 11.9

Male 1667 27.7 66.8 38.4 37.3 21.9 17.7

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 consequences in that group.

Apple vs. Pear Shapes

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 HealthDeterminants 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

02468

1012141618

Prevalence

71-74 76-80 88-94 '03 - '06

Years

2 - 5 yrs6 - 11 yrs12 - 19 yrs

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

0

5

10

15

20

25

30

35

40

Prev

ale

nce

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

010203040506070

Prevalence

Rate

Wh male Blk male Whwomen

BlkWomen

Age-adjusted Prevalence Rates for CHD (per 1000 pop)

Cassel, et. al. Ann Intern Med 128: 890-895, 1971Crook et. al. Am J Med Sciences 325:307-314, 2003

Evans Co. Study of CVD

0

20

40

60

80

100

Prevalence

Rate

High (WM) Low (WM) Blk male

Social Class

Age-adjusted Prevalence Rates for CHD by Social Class (per 1000 pop)

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, 1971Crook, et. al. Am J Med Sciences 325:307-314, 2003

Evans County Study of CVDRelationship of CHD Prevalence to Surrogate

Measure of Physical Activity

0 50 100 150

No supervision, no physical work

All Supervision, no physical work

Part Supervision, part physical work

No supervision, all physical work

Black male

Prevalence Rate (per 1000 pop)

Cassel, et. al. Ann Intern Med 128: 890-895, 1971Crook, 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