Presentation on theme: "University of South Alabama College of Medicine"— Presentation transcript:
1University 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, MDAbraham A. Mitchell Professor and ChairDepartment of Internal MedicineDirector Center for Healthy CommunitiesUniversity of South Alabama College of Medicine
2Objectives1) 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.
4Defining Obesity Other measures Triceps Skin Fold Thickness Waist CircumferenceWaist to Hip RatioAbsolute Pounds Over Ideal Body Weight
5Obesity & 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
6Obesity 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
7Obesity as “Contributor To” vs. “Marker For” Poor Health Healthiest Alabama CountyShelby28 % obesity in adults8 % of children live in povertyLeast Healthy Alabama CountyBullock38% obesity in adults38% of children live in poverty(Univ of WI Population Health Inst and RWJF)
8General 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 childrenare 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 healthcare budget)Contributing substantially to the epidemic of diabetes also occurring in the U.S. and worldwideSource: CDC and NCHS Data 2001
9Obesity 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)
10Obesity Trends* Among U.S. Adults BRFSS, 1990, 1999, 2009 (*BMI 30, or about 30 lbs. overweight for 5’4” person)199019992009No Data <10% %–14% %–19% %–24% %–29% ≥30%
11Obesity 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
12Groups / Factors Associated With Higher Risk of Obesity Ethnic MinoritiesLower IncomeGap narrowingLower level of educationHigher Household DensityRatio of inhabitants to bedrooms > 1Strong predictor in African American womenEthnicity and Disease (2010) 20:366
13Obesity Rates 1995 – 2008 (Ethnicity and Disease (2011) 21:58)
14Obesity Rates 1995 – 2008 (Ethnicity and Disease (2011) 21:58)
15Relationship of Socioeconomic Factors and Obesity Rates (Ethnicity and Disease (2011) 21:58) In Southern States and ColoradoFactors closely related to obesityIncome below poverty levelReceipt of food stampsUnemploymentGeneral income level (indirect relationship)
16Obesity Rates 1995 – 2008 (Ethnicity and Disease (2011) 21:58) SNAP: Supplement Nutrition Assistance Program
17Diabetes and Gestational Diabetes Trends Among Adults in the United States From 1990-2001
18Diabetes Prevalence (CDC 2005) 7% of US population has diabetes (20.8 million)21% of Americans >/= 60 yrs10% aged yrs2% aged yrsAt current trends persons born in 2000 have 1 in 3 chance of developing diabetes.
19Rate 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
20Who Is At Highest Risk for Type 2 Diabetes Older ageEthnic MinorityObeseFamily History of DiabetesPhysically InactiveHistory of Gestational DiabetesHypertension
21Consequences of Diabetes if Not Controlled BlindnessAmputationsKidney FailureHeart AttackStrokeTherefore prevention of Type 2 Diabetes is important!
26Jackson 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, MDLarge involvement of Community PartnersRecruited 5302 participantsBecause 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.
28Clinic Exam Components: Interviews HOME and CLINIC INTERVIEWSPsychosocial/SocioculturalCES-DGlobal Stress*Weekly Stress Inventory*Daily Hassles*ReligionSocio-economic Status*ViolenceAnger (CHOST, Anger In & Out)HostilityCoping Inventory: Approach to Life A, B, and C*Racism & DiscriminationSocial Support*OptimismJohn HenryismJob Strain*Medical/Health behaviorDietary IntakeFamily History of CHD*CHD Events/ProceduresHealth History*Medication SurveyPersonal History* (Smoking, Alcohol, Access)Physical Activity*Reproductive HistoryRespiratory SymptomsTIA/StrokeVitamin SurveyHome/Alternative* RemediesMedical data review.
30Jackson Heart Study: Physical Activity and Obesity (Ethnicity and Disease 2010, 20:383) 3,174 women, 1830 men51% aged yrs32% overweight, 53% obeseWomen less active than men except in home life.Work physical activity was associated with lowest BMI, but also with less favorable SES and health.
31Metabolic Syndrome in African Americans: The Jackson Heart Study MS%High BPAbdObesityLow HDL-CHigh GlucoseHigh TGFemale2845184.108.40.2062.518.411.9Male166727.766.838.437.321.917.7Baseline cohort (aged 21-84); Examined
32Jackson Heart Study: Physical Activity and Obesity (Ethnicity and Disease 2010, 20:383) Dose response between physical activity and BMI / WCLower 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.
33Questions About Fat – Is all fat equal? Where is it?Visceral, subcutaneous, intramuscular, central, peripheral, upper body, lower bodyHow much is there?Fat massIs there enough?lipodystrophyWho has it?Gender, ethnicity
34Fat: 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
35Where is the Fat? Subcutaneous vs. Visceral Fat Liver, kidney, intestines, etc.Abdominal Cross section
36So, Why Are We Fat? (YRUFAT) Thrifty Gene HypothesisHunter-Gathers for 84,000 generationsRequired 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.
37So, Why Are We Fat? (YRUFAT) Thrifty Gene HypothesisWhat about the last 350 GenerationsAgricultural 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.
38So, Why Are We Fat? (YRUFAT) Thrifty Gene HypothesisResults of ProgressThe 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.)
39Solutions to the Obesity / Diabetes Epidemic Increase Physical ActivityImprove Diets / NutritionWeight LossReduce Social and Environmental Stressors
40Determinants of Health Schroeder SA. We can do better – Improving the health of the American People. N Engl J Med. 2007;357:1221-840
41How 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 intensityEven older adults can be trained to exerciseSomething is better than nothing.Mayo Clin Proc (2007) 82: 797; 82: 803.
42Recommendations For Exercise (O’Keefe, Amer J Med (2010) 123: 1082) Return to Hunter-Gatherer FitnessWalk 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.
43Recommendations For Exercise (O’Keefe, Amer J Med (2010) 123: 1082) Return to Hunter-Gatherer FitnessStrength and flexibility trainingMaintain physical activity your entire lifeHigh 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).
44Recommendations For Exercise Practical ConsiderationsGet 30 or minutes of aerobic activity 4 – 5 times per week. Should break a light sweat.Can do in 5 – 10 minute intervalsPark 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).
45Challenges and Questions Prevention is CriticalBehavior Modification Has to Start EarlyChildren have to be a major focus or our attention!!!!!
46Robert 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.”
47Prevalence of Obesity Among Children 1971 – 2006 CDC, NHANES
48Childhood Obesity Nearly 1/3 of U.S. children are overweight or obese. 16.3% of children ages are obeseGreat increase in obesity and overweight over the last 4 decades.An obese teenager has 80% chance of being and obese adult.
50Sugar 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.
51School Based Interventions to Combat Childhood Obesity Playworks / Sports4KidsGoal is to bring play back into lives of American ChildrenOrganizes activities at recess for schoolsOld fashioned games (hopscotch, 4-square, etc)Conflict resolutionParticipation is focus, not winningHires 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
52Disparities in Factors Leading to Childhood Obesity White neighborhoods are 4 times more likely to have supermarkets than Black neighborhoodsCommunities with high poverty rates are significantly less likely to have places for exercise (parks, safe school yards, green spaces, bike trails, etc)
53You 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 surroundingsRealizing that it needs to drink
54Disparity 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: 244Int J Obes Relat Metab Disord (2003) 27: 856Obes Res (2002) 10:345Obesity (2009) 17: 790
55Practical Barriers to Healthy Lifestyles and Healthy Communities Lack of access to healthy food choicesWhere are supermarkets?Development of community food markets provides healthy sources of calories and neighborhood jobsUnsafe, none walk able neighborhoodsNo public parks for recreationLack of effective physical education programs in schools
56Can we legislate healthy behaviors? Soda pop taxesLimit use of food stamps for certain foodsNew York CityTaxes or surcharges for health insurance premiumsObesitySmoking
57Action is Urgently Necessary to Impact the Obesity / Diabetes Epidemic More 3rd Generation ResearchResearch looking for a positive outcome, rather than merely documenting the problemLocally focused, community-based programs are the most effectiveWe need: Healthy communities where physical activity is encouraged and actually an option, healthy foods are available, and health care providers are nearby.
58Thank You Acknowledgements: Donald McClain, MD, PhD; P. Lalit Singh, PhDEddie Greene, MD; John Flack, MDJackson Heart Study InvestigatorsAlethea Hill, RN, PhDMartha Arrieta MD, PhD, MPH; Roma Hanks, PhD, Hattie Myles, EdDSeveral 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
59The 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.
60The 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); andInstitute regulatory policies mandating minimum play space, physical equipment and duration of play in preschool, afterschool and child-care programs.
61A Story on Benefits of Exercise Evans County Study of Cardiovascular DiseaseObjective: To confirm the clinical observation that coronary heart disease was less prevalent in African Americans when compared to whites.
62Evans Co. Study of CVDCassel, et. al. Ann Intern Med 128: , 1971Crook et. al. Am J Med Sciences 325: , 2003
63Evans Co. Study of CVDSocial 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: , 1971Crook, et. al. Am J Med Sciences 325: , 2003
64Evans County Study of CVD Cassel, et. al. Ann Intern Med 128: , 1971Crook, et. al. Am J Med Sciences 325: , 2003
65Metabolic 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) 164:106630 – 89 yrs, n > 11,000 European cohortsPrevalence 15.7% males, 14.2% femalesHazard ratio for death MS vs. non-MSAll-cause: 1.44 male, 1.38 femaleCV: male, 2.78 female