Over the past 30 years, the U.S. population living in poverty has become increasingly obese while wealthier income brackets have maintained lower body mass indexes (BMIs). This trend is a reversal of the global correlation of BMI and income. Why are the poor seemingly overfed in America and starving elsewhere? An excess of food may be preferable to a shortage, but the social issues behind this and other health disparities provide some of the most challenging obstacles in medicine today. Physicians, researchers, and politicians are working together on innovative interventions to overcome these barriers to health.
No drug can cure a lack of health care access and nutritious foods. It is easy to point out the basic causes of increasing rates of type 2 diabetes and obesity—poor diet and little to no exercise—but recommending a higher dosage of physical activity and vegetables is often inadequate. The actions required to reverse these trends should target social systems rather than focusing solely on the individual.
Abhimanyu Garg, M.D., professor of internal medicine and chief of the Division of Nutrition and Metabolic Diseases, University of Texas Southwestern Medical Center, Dallas, who recently led a symposium on “Reasons for Increased Diabetes Risk in Southeast Asians” at ENDO 2012, suggested a multi-level approach that begins with education: “We have to reduce risk by lifestyle intervention, and we have to introduce the intervention early in life.” He emphasized the importance of healthy meals and beverages in schools, in addition to including physical activity in the curriculum. Changes must also occur in the household, such as limiting television time, Garg said. “Part of it is the school’s responsibility, but part is the parents’ responsibility too.”
Good Policy vs. Bad Policy
Responsibility also falls on the shoulders of policy makers. Good policy, such as bicycle lanes, can drive positive changes in health disparities, whereas bad policy, like the subsidization of high fructose corn syrup, may exacerbate the issue. Garg described the planning of new communities as one potential way to reduce the disparity of obesity and type 2 diabetes among varying populations. By designing cities and residential areas that are conducive to walking, people may naturally increase their daily activity. “Not jogging or running for exercise,” he said, “but walking, like to the grocery store.” Some European cities are providing free bicycles, Garg said, as a way increase citizen health, decrease trafﬁc congestion, and reduce greenhouse gas emissions from vehicles.
Sherita Hill Golden, M.D., M.H.S., associate professor in the Division of Endocrinology and Metabolism, core faculty in the Johns Hopkins Center to Eliminate Cardiovascular Health Disparities, and Chairperson of the Writing Group for The Endocrine Society’s Scientiﬁc Statement on Health Disparities in Endocrine Disorders, agreed that infrastructure inﬂuences health disparities. Many urban environments promote obesity because they lack access to bike paths, walking and play areas, and stores that sell healthy foods.
Urban design is an important factor in closing the gap, and like Garg, she said change can be achieved on several levels. “Health care can implement disparity interventions at one or more levels of inﬂuence: patients, providers, microsystems, health care organization, community, and policy.” She recommended a review conducted by the Robert Wood Johnson Foundation Diabetes Initiative as a resource to learn more about the different techniques for reducing health disparities. Successful strategies include sensitivity to cultural differences and involving family and community.
Poverty a Marker of Diabetes
Although much discussion of diabetes and obesity incidence has revolved around ethnicity, evidence indicates that these issues are more than skin deep.
“Socioeconomic status is an indicator of diabetes independent of race,” Golden said.
Though cultural factors like language barriers can lead to health dis-
parities, race correlations within type 2 diabetes and obesity appear to be more incidental than causal. Studies show that although some groups may be predisposed to metabolic diseases such as diabetes, poverty is likely to be a stronger driver than genetics, Garg noted. “What we have learned so far from the genome-wide association studies is that the genetic variants that cause susceptibility to diabetes among white Europeans are the same in Asian Indians.”
So how can providers diminish these disparities? The complex social issues at play can make treatment difﬁcult, but there are instruments available that may help. Telemedicine can be a useful option. Studies have shown that patients respond well to remote care through the Internet and other mobile technologies. Such software can remind patients to take medication, get daily exercise, track glucose levels, and answer questions about food choices. Cheap, effective tools like the American Diabetes Association’s MyFoodAdvisor and the Hormone Health Network’s Patient Resources are one route to help level the health care playing ﬁeld. By encouraging patients to take advantage of such resources and becoming involved in policy decisions, providers can help close these prevalent health gaps.