University of South Alabama College of Medicine 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 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

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

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% 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% 11

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)

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

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) SNAP: Supplement Nutrition Assistance Program

Diabetes and Gestational Diabetes Trends Among 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 CVD Insulin Resistance Dyslipidemia Hypertension CKD Insulin Resistance Dyslipidemia Hypertension Hyperglycemia / Diabetes Obesity

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 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.

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

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

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

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

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 325:307-314, 2003

Evans County Study of CVD 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