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2011 Diabetes and Obesity Conference

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

             Actual Cause Of Death                             Number (%)             Number (%)
                                                                Of Deaths,             Of Deaths,
                                                                   1990                   2000

Tobacco                                                       400,000 (19%)          435,000 (18.1%)
Poor Diet And Physical Inactivity                             300,000 (14%)          400,000 (16.1%)
Alcohol Consumption                                           100,000 (5%)           85,000 (3.5%)
Microbial Agents                                              90,000 (4%)            75,000 (3.1%)
Toxic Agents                                                  60,000 (3%)            55,000 (2.3%)
Motor Vehicles                                                25,000 (1%)            43,000 (1.8%)
Firearms                                                      35,000 (2%)            29,000 (1.2%)
Sexual Behavior                                               30,000 (1%)            20,000 (0.8%)
Illicit Drug Use                                              30,000 (< 1%)          17,000 (0.7%)
Total                                                         1,060, 000 (50%)       1,159000 (48.2%)
             *****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.
                Leading Causes Of Death In The United States In 2000

                  Cause Of Death                        Number Of         Death Rate Per
                                                         Deaths              100,000
                                                                           Population

Heart Disease                                          710,760                258.2
Malignant Neoplasm                                     553,091                200.9
Cerebrovascular Disease                                167,661                60.9
Chronic Lower Respiratory Tract Disease                122,009                44.3
Unintentional Injuries                                 97,900                 35.6
Diabetes Mellitus                                      69,301                 25.2
Influenza And Pneumonia                                65,313                 23.7
Alzheimer Disease                                      49,558                 18
Nephritis, Nephrotic Syndrome, & Nephrosis             47,251                 13.5
Septicemia                                             31,224                 11.3
Other                                                  499,283                181.4
Total                                                  2,403,351              873.1
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
    (*BMI  30, or ~ 30 lbs overweight for 5’4‖ Person)
           (*BMI ³ 30, or ~ 30 lbs overweight for 5 Õ woman)
                                                     4Ó
           1991                                                    1995




No Data       2002
< 10%
10-14%
15-19%
20-24%
> 25%
           Source: Mokdad et al., JAMA.;282:(16); 1999 and 286(10); 2001, and 289:(1); 2003
          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%
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)

                30
                              26.5
                25                   25.2   24.6           25
                                                   23.8
                       21.3
Obesity Rates




                20

                15                                              15.4

                10

                5

                0
                      USA     MS     AL     LA     TN     South CO
                                                           Avg
Obesity Rates 1995 – 2008
                  (Ethnicity and Disease (2011) 21:58)

                 40
                 35
                 30
 Obesity Rates




                 25
                 20
                 15
                 10
                  5
                  0
                      USA      MS   AL   LA    TN South CO
                                                   Avg

                       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)

                       30
                       25
       Obesity Rates



                       20
                       15
                       10
                       5
                       0
                            USA   MS    AL   LA      TN   South   CO
                                                           Avg

                              Obesity   SNAP Rates    Poverty


SNAP: Supplement Nutrition Assistance Program
             Diabetes and Gestational Diabetes Trends
          Among Adults in the United States From 1990-2001
                        1990                                               1995




                                             2001


No Data
 < 4%
 4-6%
 6-8%
 8-10%
 > 10%
              Source: Mokdad et al., Diabetes Care; 23:1278-83; 2000, JAMA; 286:(10); 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
CKD
      Insulin Resistance        Dyslipidemia

           Hypertension
                                   Hyperglycemia
                                   / Diabetes



                      Obesity
    Metabolic Syndrome (NCEP-ATP III)
      Need Any 3 to Make Diagnosis
• Abdominal Obesity          • Hypertension
   – Waist Circumference >      – SBP > 130 mm/Hg
     102 cm male, 88 cm         – DBP > 85 mm/Hg
     female, BMI > 30           – On Anti-HTN meds
• Elevated Triglycerides     • Insulin Resistance
   – > 150 mg/dl (fasting)      – > 110 mg/dl fasting
• Low HDL Cholesterol           – Use of anti-DM
   – < 40 mg/dl male              meds/Rx
   – < 50 mg/dl female
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
                                             De Soto         Marshall      Benton              Alcorn
                                                                                                                  Tisho-
                                                                                     Tippah                       mingo

                                                  Tate                                               Prentiss
                             Tunica
                                                                                  Union
                                            Panola           Lafayette
                                                                                                   Lee
                                                                                                          Itawamba
                        Coahoma
                                                                                Pontotoc


                                  Quitman            Yalobusha
               Bolivar
                                   Tallahatchie                       Calhoun      Chickasaw             Monroe


                                                    Grenada
                                                                                            Clay
                                  Leflore                                Webster
                                              Carroll Mont-
                                                      gomery
                        Sun-                                                        Oktibbeha
        Washington                                                                                    Lowndes
                        flower                                          Choctaw


                         Hum-            Holmes              Attala                Winston         Noxubee
                         phreys

                Shark-
                ey

                            Yazoo                               Leake       Neshoba            Kemper


                                              Madison


             Issaquena
               Warren
                                 Hinds
                                                                Scott       Newton             Lauderdale




                                                                Smith        Jasper            Clarke
                                          Rankin
            Claiborne
                           Copiah
                                             Simpson

      Jefferson                                                                                Wayne
                                                          Covington         Jones
                           Lincoln        Law-
                                          rence
Adams       Franklin                                Jefferson
                                                    Davis
                                                                        Forrest     Perry           Greene
                                                    Marion      Lamar
                Amite            Pike
Wilkinson




                                                                                                   George
                                                                           Stone
                                                          Pearl River

                                                                                               Jackson
            24 Miles                                                          Harrison
Clinic Exam Components: Interviews
•   HOME and CLINIC INTERVIEWS
     – Psychosocial/Sociocultural          – Medical/Health behavior
         • CES-D                              • Dietary Intake
         • Global Stress*                     • Family History of CHD*
         • Weekly Stress Inventory*           • CHD Events/Procedures
         • Daily Hassles*                     • Health History*
         • Religion                           • Medication Survey
         • Socio-economic Status*             • Personal History*
         • Violence                             (Smoking, Alcohol,
         • Anger (CHOST, Anger In & Out)        Access)
         • Hostility                          • Physical Activity*
         • Coping Inventory: Approach to      • Reproductive History
           Life A, B, and C*                  • Respiratory Symptoms
         • Racism & Discrimination            • TIA/Stroke
         • Social Support*                    • Vitamin Survey
         • Optimism                           • Home/Alternative*
         • John Henryism                        Remedies
         • Job Strain*                        • Medical data review
           Clinic Exam Components:
                    Testing
•   ANTHROPOMETRY         •   PHYSICAL ACTIVITY
                              MONITOR
•   BLOOD PRESSURE        •   PULMONARY FUNCTION
    – Sitting                  –   FEV1.0
    – ABI                      –   FVC
    – 24 hr Ambulatory
•   ECHOCARDIOGRAPHY      •   Urine Collection 24 Hour

•   ELECTROCARDIOGRAPHY   •   VENIPUNCTURE
                               –   Chemistries
                               –   Hematology
                               –   Hemostasis
                               –   Lipids
•   ULTRASOUND, B-MODE
    – Carotid Arteries
    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
                      High BP   Abd       Low     High      High TG
         N      MS              Obesity   HDL-C   Glucose

                %
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
                                Apple vs. Pear Shapes
consequences in that group.
Where is the Fat? Subcutaneous
       vs. Visceral Fat


                                         Abdominal
       Liver, kidney, intestines, etc.   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
   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

           18
           16
           14
           12
           10
Prevalence                                          2 - 5 yrs
            8
            6                                       6 - 11 yrs
            4                                       12 - 19 yrs
            2
            0
                71-74   76-80   88-94   '03 - '06
                            Years
         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
                40
                35
                30
   Prevalence




                25
                20
                15
                10
                5
                0
                     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
          Age-adjusted Prevalence Rates for
                CHD (per 1000 pop)
             70
             60
             50
             40
  Prevalence
             30
     Rate    20
             10
              0
                    Wh male Blk male        Wh       Blk
                                           women    Women



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
         Age-adjusted Prevalence Rates for
         CHD by Social Class (per 1000 pop)
                  100
                   80
                   60
   Prevalence
                   40
      Rate
                   20
                    0
                        High (WM) Low (WM)            Blk male
                                     Social Class
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
        Relationship of CHD Prevalence to Surrogate
                Measure of Physical Activity

                        Black male

   No supervision, all physical work

Part Supervision, part physical work

   All Supervision, no physical work

   No supervision, no physical work


                                       0        50       100      150
                                       Prevalence Rate (per 1000 pop)

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