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2011 Diabetes and Obesity Conference 04-18-11 Addressing Health Disparities in Obesity and Type 2 Diabetes / Metabolic Syndrome


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Title: 2011 Diabetes and Obesity Conference 04-18-11 Addressing Health Disparities in Obesity and Type 2 Diabetes / Metabolic Syndrome

2011 Diabetes and Obesity Conference04-18-11
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

  • 1) Review the epidemiological link between
    obesity, metabolic syndrome and diabetes.
  • 2) Review impact of obesity and disparities in
  • 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 gt 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
Obesity Related Conditions are Leading Causes Of
Death In The U.S.
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
  • 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 countrys
major health problem for the beginning of the
21st century.
  • 55 of Women in USA, 63 of Men and 15 of
  • are overweight (BMI 25) and/or obese (BMI
    30) .
  • 300,000 pre-mature deaths/year attributable to
  • 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

Source CDC and NCHS Data 2001
Obesity Trends Among U.S. Adults From 1991-2000
(BMI ? 30, or 30 lbs overweight for 54
Obesity Trends Among U.S. AdultsBRFSS, 1990,
1999, 2009
(BMI ?30, or about 30 lbs. overweight for 54
No Data lt10 1014
1519 2024 2529
Obesity Trends Among U.S. AdultsBRFSS, 2009
(BMI 30, or 30 lbs. overweight for 5 4
No Data lt10 1014
1519 2024 2529
Groups / Factors Associated With Higher Risk of
  • Ethnic Minorities
  • Lower Income
  • Gap narrowing
  • Lower level of education
  • Higher Household Density
  • Ratio of inhabitants to bedrooms gt 1
  • Strong predictor in African American women
  • Ethnicity and Disease (2010) 20366

Obesity Rates 1995 2008(Ethnicity and Disease
(2011) 2158)
Obesity Rates 1995 2008(Ethnicity and Disease
(2011) 2158)
Relationship of Socioeconomic Factors and Obesity
Rates(Ethnicity and Disease (2011) 2158)
  • 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) 2158)
SNAP Supplement Nutrition Assistance Program
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 gt/ 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 lt20 years, by race/ethnicity,
20022003, (CDC)
lt 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

Metabolic Syndrome
Insulin Resistance
Hyperglycemia / Diabetes
Metabolic Syndrome (NCEP-ATP III)Need Any 3 to
Make Diagnosis
  • Abdominal Obesity
  • Waist Circumference gt 102 cm male, 88 cm female,
    BMI gt 30
  • Elevated Triglycerides
  • gt 150 mg/dl (fasting)
  • Low HDL Cholesterol
  • lt 40 mg/dl male
  • lt 50 mg/dl female
  • Hypertension
  • SBP gt 130 mm/Hg
  • DBP gt 85 mm/Hg
  • On Anti-HTN meds
  • Insulin Resistance
  • gt 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) 585618. 2000.
(No Transcript)
Jackson Heart StudyThe African American
  • 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

Clinic Exam Components 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 ComponentsTesting
  • Sitting
  • ABI
  • 24 hr Ambulatory
  • Carotid Arteries
  • FEV1.0
  • FVC
  • Urine Collection 24 Hour
  • Chemistries
  • Hematology
  • Hemostasis
  • Lipids

Jackson Heart Study Physical Activity and
Obesity(Ethnicity and Disease 2010, 20383)
  • 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
Baseline cohort (aged 21-84) Examined 2000 - 2004
Jackson Heart Study Physical Activity and
Obesity(Ethnicity and Disease 2010, 20383)
  • Dose response between physical activity and BMI /
  • 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
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

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 OKeefe, et al. The American Journal of
    Medicine (2010) 1231082.)

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.
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(OKeefe, 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(OKeefe, 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)
  • 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

Robert Wood Johnson Foundation Childhood Obesity
  • We want to help all children and families eat
    well and move moreespecially 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
  • www.rwjf.org/childhoodobesity/

Prevalence of Obesity Among Children 1971

Childhood Obesity
  • Nearly 1/3 of U.S. children are overweight or
  • 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
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
  • Playworks / Sports4Kids
  • Goal is to bring play back into lives of American
  • 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
  • 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 cant
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) 10345
  • 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

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
  • 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
Cassel, et. al. Ann Intern Med 128 890-895,
1971 Crook et. al. Am J Med Sciences 325307-314,
Evans Co. Study of CVD
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 325307-314, 2003
Evans County Study of CVD
Cassel, et. al. Ann Intern Med 128 890-895,
1971 Crook, et. al. Am J Med Sciences
325307-314, 2003
Metabolic Syndrome Associated with Increased
  • 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) 1641066
  • 30 89 yrs, n gt 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
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