1. University of South Alabama College of Medicine
2011 Diabetes and Obesity Conference “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

2. 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.

3. Defining Obesity BMI Normal 18 – 24.9 kg/ m2
Overweight 25 – 29.9 kg/m2
Obese – 40 kg/m2
Extremely Obese > 40 kg/m2

4. Defining Obesity Other measures Triceps Skin Fold Thickness
Waist Circumference
Waist to Hip Ratio
Absolute Pounds Over Ideal Body Weight

5. 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 JAMA. 291(10): ; 2004

6. Obesity Related Conditions are Leading Causes Of Death In The U.S.
After Mokdad, AH. Actual Causes Of Death In The U.S. In JAMA. 291(10): ; 2004

7. 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)

8. 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

9. Obesity Trends Among U. S. Adults From 1991-2000 (
Obesity Trends Among U.S. Adults From (*BMI  30, or ~ 30 lbs overweight for 5’4” Person)

10. Obesity Trends* Among U.S. Adults BRFSS, 1990, 1999, 2009
(*BMI 30, or about 30 lbs. overweight for 5’4” person)
1990
1999
2009
No Data <10% %–14% %–19% %–24% %–29% ≥30%

11. Obesity Trends* Among U.S. Adults BRFSS, 2009
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% %–14% %–19% %–24% %–29% ≥30% 11

12. 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

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

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

15. 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)

16. Obesity Rates 1995 – 2008 (Ethnicity and Disease (2011) 21:58)
SNAP: Supplement Nutrition Assistance Program

17. Diabetes and Gestational Diabetes Trends Among Adults in the United States From 1990-2001

18. Diabetes Prevalence (CDC 2005)
7% of US population has diabetes (20.8 million)
21% of Americans >/= 60 yrs
10% aged yrs
2% aged yrs
At current trends persons born in 2000 have 1 in 3 chance of developing diabetes.

19. Rate of new cases of type 1 and type 2 diabetes among youth aged <20 years, by race/ethnicity, 2002–2003, (CDC)
< 10 yrs – 19 yrs

20. 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

21. Consequences of Diabetes if Not Controlled
Blindness
Amputations
Kidney Failure
Heart Attack
Stroke
Therefore prevention of Type 2 Diabetes is important!

22. Metabolic Syndrome CVD Insulin Resistance Dyslipidemia Hypertension
CKD
Insulin Resistance
Dyslipidemia
Hypertension
Hyperglycemia / Diabetes
Obesity

23. 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

24. From Matthaei, S, et al. Pathophysiology and Pharmacological Rx of Insulin Resistance. Endocrine Reviews 21(6): 585–

26. 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
Because of these racial discrepancies in CVD the Jackson Heart Study has been designed. This observational, prospective study of CVD in African Americans is based in Central Mississippi. The goal of this study, of which my mentor is an investigator, is to determine the reasons why African Americans shoulder a disproportionate share of the CVD burden.

27. Issaquena 24 Miles Adams Alcorn Amite Attala Benton Bolivar Calhoun
Carroll
Chickasaw
Choctaw
Claiborne
Clarke
Clay
Coahoma
Copiah
Covington
De Soto
Forrest
Franklin
George
Greene
Grenada
Harrison
Holmes
Hum-
phreys
Itawamba
Jackson
Jasper
Jefferson
Davis
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
Tippah
Tisho-
mingo
Tunica
Union
Warren
Washington
Wayne
Webster
Wilkinson
Winston
Yalobusha
Yazoo
Hinds
Madison
Rankin
24 Miles
Issaquena

28. 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 .

29. 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

30. Jackson Heart Study: Physical Activity and Obesity (Ethnicity and Disease 2010, 20:383)
3,174 women, 1830 men
51% aged 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.

31. Metabolic Syndrome in African Americans: The Jackson Heart StudyMS %
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

32. 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.

33. 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

34. 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

35. Where is the Fat? Subcutaneous vs. Visceral Fat
Liver, kidney, intestines, etc.
Abdominal Cross section

36. 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.

37. 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.

38. 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.)

39. Solutions to the Obesity / Diabetes Epidemic
Increase Physical Activity
Improve Diets / Nutrition
Weight Loss
Reduce Social and Environmental Stressors

40. Determinants of Health
Schroeder SA. We can do better – Improving the health of the American People. N Engl J Med. 2007;357:1221-8 40

41. 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.

42. 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.

43. 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).

44. 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).

45. Challenges and Questions
Prevention is Critical
Behavior Modification Has to Start Early
Children have to be a major focus or our attention!!!!!

46. 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.”

47. Prevalence of Obesity Among Children 1971 – 2006 CDC, NHANES

48. Childhood Obesity Nearly 1/3 of U.S. children are overweight or obese.
16.3% of children ages are obese
Great increase in obesity and overweight over the last 4 decades.
An obese teenager has 80% chance of being and obese adult.

49. Disparities in Childhood Obesity
(NHANES, CDC)

50. 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.

51. 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

52. 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)

53. 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

54. 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

55. 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

56. 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

57. 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.

58. 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

59. 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.

60. 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.

61. 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.

62. Evans Co. Study of CVD
Cassel, et. al. Ann Intern Med 128: , 1971
Crook et. al. Am J Med Sciences 325: , 2003

63. 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: , 1971
Crook, et. al. Am J Med Sciences 325: , 2003

64. Evans County Study of CVD
Cassel, et. al. Ann Intern Med 128: , 1971
Crook, et. al. Am J Med Sciences 325: , 2003

65. 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: male, 2.78 female