The Journal of Clinical Endocrinology & Metabolism Vol. 89, No. 6 2590-2594
Copyright © 2004 by The Endocrine Society
Race/Ethnic Issues in Obesity and Obesity-Related Comorbidities
Nicole Cossrow and
Bonita Falkner
Department of Medicine/Nephrology, Thomas Jefferson University (B.F.), Philadelphia, Pennsylvania 19107; and IMS Health (N.C.), Blue Bell, Pennsylvania 19422
Address all correspondence and requests for reprints to: Bonita Falkner, M.D., Division of Nephrology, Thomas Jefferson University, 833 Chestnut Street, Suite 700, Philadelphia, Pennsylvania 19107. E-mail: bonita.falkner{at}jefferson.edu.
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Abstract
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The prevalence of obesity is increasing among all age and racial groups in the United States. There is, however, a disproportionate rise in the prevalence of obesity among African-Americans and Hispanic/Mexican Americans. Obesity is a major contributor to the insulin resistant syndrome (IRS), a condition of multiple metabolic abnormalities that is a precursor to type 2 diabetes, and confers a high risk for cardiovascular events. The estimated prevalence of IRS is also greater in Mexican Americans and African-Americans than in Caucasians. The IRS is identifiable in children, and as with adults, there are racial differences in its expression even at a young age. The obesity-associated diseases, including diabetes and hypertension, are found at higher rates within the minority races compared with Caucasians. However, there are differences, in that obesity-related hypertension occurs at higher rates among African-Americans, and obesity-related diabetes occurs at higher rates among Mexican Americans. Race/ethnic differences in lifestyle behaviors and economic disadvantage may account for some of the race disparity in obesity-related diseases and disease outcomes. Environmental factors, however, do not explain all of the race disparity in disease expression, indicating that there are genetic/molecular factors that are operational as well.
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Introduction
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DESPITE INTERVENTION EFFORTS, the incidence of obesity continues to increase. The adverse outcomes related to obesity are well established and include a number of serious health complications, problems in psychological well-being, and limitations in socio-economic success. The health complications include, but are not necessarily limited to, type 2 diabetes, hypertension, atherosclerosis, sleep disorders, nonalcoholic steato-hepatitis, arthritis, depression, and cancer. There are racial differences in the prevalence of obesity as well as racial differences in the prevalence of health complications associated with obesity. The purpose of this review was to examine the variability in expression of obesity-related comorbidities among race and ethnic groups. The focus of this review will be those metabolic and cardiovascular disorders that are strongly linked with obesity.
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Prevalence of obesity by race
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The increase in the prevalence of obesity over the last few decades is well documented, with the increase in obesity prevalence occurring in all age and racial groups. Obesity in adults is defined as a body mass index (BMI) greater than 30 kg/m2. To designate obesity in the young, the Center for Disease Control prefers to use the term overweight, defined as a BMI greater than the 95th percentile according to 2000 Center for Disease Control growth charts for the United States (www.cdc.growthcharts.gov). Health statistics in the United States show that between 1963 and 2000 the prevalence of overweight rose from 4% to 15.3% in children between 6 and 11 yr of age; among adolescents (12–19 yr) the prevalence of overweight increased from 5% to 15.5% (1). Data from the National Health and Nutrition Examination Survey (NHANES) demonstrate that the prevalence of overweight increased in each adolescent racial group between the 1988–1994 survey and the 1999–2000 survey. However, the increases were markedly greater in non-Hispanic blacks (13.4% to 23.6%) and Mexican Americans (13.8% to 23.4%) (2). During the same time period, a similar trend in the increase of prevalence of overweight in children between the ages of 6 and 11 yr was observed for the same racial groups (1).
Among adults, the prevalence of obesity has increased in both men and women and in each racial group between the NHANES III in 1988–1994 and NHANES 1999–2000. Although the increases have been statistically significant in all racial and sex groups (3), the longitudinal data on the development of obesity indicates that the rise in obesity rates in women has been greatest in African-American women, followed by Hispanic women, then white women. By age 39 yr, the mean BMI of African-American women was greater than 30 kg/m2, which is at the cut-off point for obesity. Similar trends were observed in men; however, for African-American men the acceleration in weight gain did not occur until after age 30 yr (4).
Table 1
summarizes the most recent data on the prevalence of obesity by race, sex, and age. Compared with white women, the prevalence of obesity is much higher in both African-American and Mexican American women. More than one fourth of adult men are obese, with little difference by race. Among both children and adolescents the prevalence of obesity is greater in African-Americans and Mexican Americans compared with Caucasians in both males and females. The most notable aspect to this population data are the extremely high rates of overweight in the young, which would predict even higher rates of obesity for adults in the future.
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Tracking of obesity into adulthood
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The adverse health effects, in later life of childhood obesity have been established. The Harvard Growth Study showed that overweight in adolescence predicted a broad range of adverse health effects that were independent of adult weight (5). From longitudinal studies that begin in childhood, it has been shown that tracking of the individual cardiovascular risk factors, including blood pressure, plasma lipids, insulin, and BMI, does occur, and that tracking of clusters of risk factors increases progressively with age and adiposity (6). It would then be expected that the higher rates of overweight/obesity in the young among African-American and Hispanic Americans would result in greater expression of cardiovascular risk factors and higher rates of cardiovascular disease among these racial groups. There is some indication that excess adiposity may even have a greater adverse effect in African-Americans. Data from the Bogalusa Heart Study have shown that the effect of a high BMI on later expression of multiple risk factors is greater in African-Americans compared with Caucasians (7).
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Prevalence of the insulin resistant syndrome (IRS), also known as the metabolic syndrome, dysmetabolic syndrome, or syndrome X
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Adipose tissue is very resistant to insulin action compared with muscle tissue. Therefore, obesity is a major cause of insulin resistance, with both obesity and insulin resistance considered to be major contributors to cardiovascular disease. The IRS, or dysmetabolic syndrome, has been defined in the Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) (8) as the presence of three or more of the following criteria: 1) abdominal obesity: waist circumference more than 102 cm in men and more than 88 cm in women; 2) hypertriglyceridemia [
150 mg/dl (1.69 mmol/liter)]; 3) low level of high density lipoprotein (HDL) cholesterol [<40 mg/dl (1.04 mmol/liter) in men and <50 mg/dl (1.29 mmol/liter) in women]; 4) high blood pressure (130/85 mm Hg); or 5) high fasting glucose [110 mg/dl (6.1 mmol/liter)]. The population prevalence of the IRS was estimated, according to race, from the NHANES III data (1988–1994) by Ford et al. (9). This analysis showed that the prevalence of the IRS does not necessarily mirror the patterns observed in the prevalence of obesity. Although African-American women have the highest prevalence of obesity, the prevalence of the IRS is highest in Mexican American women, followed by Mexican American men, then by African-American women. The lowest prevalence of the IRS was in African-American men. These data are presented in Table 2.
Insulin resistance could be the biological basis for the racial difference in the expression and prevalence of diabetes. In a recent study, Dickinson et al. (10) examined possible variations in the evolution of the IRS according to race by comparing Asians and Caucasians. Healthy lean young Asian and Caucasian adults were fed white bread in an amount that provided 75 g of available carbohydrate. Baseline plasma glucose and insulin as well as changes in glucose and insulin concentration were measured for a period of 2 h. Mean fasting glucose concentrations were very similar among the groups. However, postprandial glucose was markedly higher in Asian subjects compared with Caucasians, with a 2.0-fold higher mean incremental area under the curve. For insulin, the mean area under the curve was also over 2.0-fold higher in the Asian group compared with the Caucasians. When insulin sensitivity was estimated by the homeostasis model assessment, the Asians were less sensitive than Caucasians. The differences were not confounded by effects of sex, age, or BMI and were present in the absence of obesity. These data indicate that there are racial differences in apparent predisposition to the development of the IRS. Similar differences in glucose tolerance between African-Americans and Caucasians were found in data from the Coronary Artery Risk Development in Young Adults Study of healthy young adults, which further suggest that the predisposition to abnormalities in glucose tolerance may be more common in African-Americans than in Caucasians (11).
The presence of obesity confers a marked augmentation in the risk for expression of the IRS. The extent to which childhood obesity is predictive of later development of the IRS was examined in the Bogalusa Heart Study (12). Data from this biracial cohort determined that childhood BMI was the most significant predictor of IRS in young adulthood. In another analysis of data from the Bogalusa cohort, the investigators found that having a parent with type 2 diabetes also contributed to the expression, beginning in childhood, of the components of IRS. Offspring of diabetic parents, regardless of race, displayed excess body fat and accelerated progression of adverse risk profile characteristics of the IRS from childhood to young adulthood.
The cluster of metabolic and anthropometric components of IRS are already present in adolescents (13). Cook et al. (14) analyzed the childhood data from NHANES III, 1988–1994, to estimate the prevalence and distribution of IRS among adolescents in the United States. Using the age-modified definition of IRS that is based on the Adult Treatment Panel III (8), the overall prevalence of IRS in adolescents between 12 and 19 yr was 4.2%. However, when the sample was stratified by BMI, nearly 30% of overweight adolescents (BMI >95th percentile) met the criteria for IRS. Among boys, the prevalence of the IRS was comparable in Caucasian and Mexican Americans, but was lower in African-Americans; among girls, the prevalence of IRS was highest among Mexican Americans. Similarly high rates of IRS were reported in obese Asian children. Sung et al. (15) found that nearly 50% of overweight/obese Hong Kong Chinese children, aged 9–12 yr, had at least two of three cardiovascular risk factors of dyslipidemia, high blood pressure, and hyperinsulinemia. A study that focused on obese African-American children, aged 5–10 yr, detected the cluster of IRS components even in very young children (16). Since NHANES III, the rates of child and adolescent obesity have increased, particularly in the racial minority groups, indicating that the prevalence of IRS in the young may presently be higher than described by Cook et al. (14).
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Differences in distribution of adiposity
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In adults, the distribution of excess adipose mass may be more important than total fat in conferring metabolic and cardiovascular risk. Excess fat in the upper body region, particularly abdominal or visceral adipose tissue (VAT), is linked with a more atherogenic plasma lipid profile and greater insulin resistance (17, 18). Thus, upper body or visceral obesity, ascertained by waist circumference, is one of the Adult Treatment Panel III criteria for the IRS. There are, however, racial/ethnic effects on the relationship of VAT with metabolic risk factors that have been reported in both adults (19) and children/adolescents (20, 21). Greater VAT has been demonstrated in Caucasians compared with African-Americans despite greater total fat in African-American women (18, 22). Similar racial differences in the amounts of VAT in young adults were detected in the Coronary Artery Risk Development in Young Adults Study (23). VAT, ascertained by computed tomography, was significantly greater in young Caucasian men compared with young African-American men despite no difference between the two groups in BMI. The ratio of VAT to sc adipose tissue was higher in Caucasian men than in African-American men, but the difference was not statistically significant. Among women, BMI, waist circumference, and VAT were greater in African-Americans than in Caucasians, indicating that both VAT and total fat were greater in young adult AfricanAmerican women. However, the ratio of VAT to sc adipose tissue was similar in the two racial groups of young women. The effect of race on the associations of VAT with cardiovascular risk factors was examined by Perry et al. (24) on a sample that was limited to obese Caucasian and obese African-American women. The two racial groups of obese women had similar age, BMI, and percent body fat. VAT, measured by magnetic resonance imaging, was significantly greater in Caucasian women. Significant relationships between VAT and other cardiovascular risk factors were present in Caucasian women; these relationships were not present in African-American women. In another study to determine whether estimates of VAT are similar among Caucasians, African-Americans, and Hispanic Americans at the established BMI cut-off point for obesity (BMI, >30 kg/m2), Okosun et al. (25) examined data from NHANES III. The results of that analysis demonstrated that waist circumference values that corresponded to both overweight and obesity were substantially lower in African-Americans and Hispanic Americans compared with those in Caucasians.
These racial differences in fat distribution are also present in childhood. Compared with African-American children, Caucasian children have significantly greater visceral fat even after adjusting for total fat. However, African-American children were more insulin resistant, independent of visceral fat accumulation (21, 26). Therefore, both obesity and VAT confer adverse metabolic effects, but these effects may differ according to race/ethnicity.
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Prevalence and race in diseases with cardiovascular morbidity
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Type 2 diabetes.
Native Americans have the highest relative rates of type 2 diabetes. The relative rates of type 2 diabetes are also greater in Mexican Americans and African-Americans compared with Caucasians (27). Brancati et al. (28) reported that African-American women were more than twice as likely, and African-American men were 1.5 times as likely to develop type 2 diabetes than their Caucasian counterparts. This association remained statistically significant even after adjustment for age, BMI, waist to hip ratio and other risk factors, indicating that obesity alone could not account for the entire race disparity in prevalence of type 2 diabetes. The researchers further report that "racial differences in potentially modifiable risk factors, particularly adiposity, accounted for 47.8% of the excess risk in African-American women but accounted for little of the excess risk in African-American men" (28).
Hypertension.
Hypertension is strongly associated with obesity. The prevalence of obesity among patients with hypertension is much higher than the population prevalence of obesity. Moreover, the benefits in blood pressure reduction from weight loss in hypertensive patients is well established. Despite these relationships, there appears to be an added effect of race on the obesity-hypertension relationship. Table 3 summarizes the prevalence of hypertension by race from NHANES data. African-Americans (non-Hispanic blacks) have the highest prevalence of hypertension, with the prevalence of hypertension in Mexican Americans somewhat less than Caucasians (non-Hispanic whites). Thus, Mexican Americans have the highest prevalence of obesity but the lowest prevalence of hypertension compared with Caucasians and African-Americans. The prevalence of hypertension increases with age in all three racial groups, and in all three racial groups there is a gender difference in hypertension rates. In the younger age strata, the rates of hypertension are greater in men compared with women. With increasing age the gender difference in prevalence disappears after 60 yr of age for Mexican Americans and Caucasians. For African-Americans, however, the prevalence of hypertension is equivalent in men and women by age 50–59 yr and thereafter becomes higher in African-American women compared with African-American men (29). The extent to which a greater prevalence and degree of obesity explains the higher prevalence of hypertension in older African-American women has not been determined.
Dyslipidemia.
Obesity, in particular visceral obesity, is associated with an atherogenic plasma lipid pattern. Despite relatively higher rates of cardiovascular disease in AfricanAmericans compared with Caucasians, there are interesting racial differences in plasma lipid concentration. A plasma triglyceride concentration over 150 mg/dl is a risk factor for coronary heart disease (30). However, triglyceride levels in African-American men and women are lower than those in Caucasian men and women independent of the presence of heart disease. In both men and women, the mean plasma triglyceride concentration is reported to be approximately 20 mg/dl lower in African-Americans compared with their Caucasian counterparts (31). Low plasma HDL cholesterol (<40 mg/dl in men and <50 mg/dl in women) is also an independent risk factor for heart disease, with the higher HDL cholesterol levels providing protection from cardiovascular disease. Compared with Caucasians, HDL cholesterol levels are higher in African-Americans (32). The higher HDL cholesterol levels among African-Americans cannot be explained by racial differences in BMI or other factors that have an effect on plasma HDL cholesterol concentration, such as alcohol intake, physical activity, or smoking (33). Hepatic lipase activity is lower in African-American men compared with Caucasian men (34), which could explain the higher HDL cholesterol in African-Americans. Although African-Americans appear to have a more favorable plasma lipid pattern compared with Caucasians and Mexican Americans, it is not clear whether these racial differences are protective in African-Americans or whether the lipid threshold at which risk increases is at a lower level of triglyceride and higher level of HDL cholesterol in African-Americans.
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Racial differences in the association of obesity with mortality
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Despite the fact that obesity is more common in AfricanAmericans than in Caucasian Americans, the effect of obesity with respect to longevity is more lethal for whites than for blacks. Calle et al. (35) reported that nonsmoking Caucasian men and women with no history of disease at the highest level of BMI were at significantly greater risk of mortality than their average weight counterparts, with relative risks of 2.58 and 2.00, respectively. A similar association was not detected in African-Americans. These observations were corroborated in a study by Fontaine et al. (36), who reported that the optimal BMI for adults between the ages of 18 and 85 yr ranges from 23–30 for African-Americans and 23 to 25 for Caucasians. Nevertheless, regardless of the national reduction of mortality rates of coronary heart disease and stroke, the mortality of these diseases remains highest in AfricanAmericans (Table 4).
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TABLE 4. Coronary heart disease (CHD) and stroke mortality rates by race and ethnicity in the United States in 1997
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The obesity epidemic is having a greater impact on minority race/ethnic groups. The prevalence of obesity and the obesity-related cardiovascular diseases are greater in African-Americans and Hispanic/Mexican Americans than in Caucasians. However, the toxic relationship of obesity with disease is not the same in each race. African-Americans have a less arthrogenic plasma lipid pattern compared with Caucasians, but have higher rates of coronary heart disease and stroke. The prevalence of obesity-related diabetes is greater in Mexican Americans, whereas the prevalence of hypertension is greater in African-Americans. Environmental factors, including health-related behaviors or lifestyles and economic disadvantage, contribute to some of the race/ethnic disparities in the prevalence of the diseases associated with obesity. However, because these factors cannot explain all of the racial differences in expression and disease pattern, it is likely that there are genetic or molecular factors that also contribute to the racial differences in obesity-related comorbidities.
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Footnotes
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Abbreviations: BMI, Body mass index; HDL, high density lipoprotein; IRS, insulin resistant syndrome; NHANES, National Health and Nutrition Examination Survey; VAT, visceral adipose tissue.
Received February 20, 2004.
Accepted March 19, 2004.
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734 - 740.
[Abstract]
[Full Text]
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T. Lang and G. Rayner
Obesity: a growing issue for European policy?
Journal of European Social Policy,
November 1, 2005;
15(4):
301 - 327.
[Abstract]
[PDF]
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K. C. Barnes
Genetic Determinants and Ethnic Disparities in Sepsis-associated Acute Lung Injury
Proceedings of the ATS,
October 1, 2005;
2(3):
195 - 201.
[Abstract]
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S. Ehtisham, N. Crabtree, P. Clark, N. Shaw, and T. Barrett
Ethnic Differences in Insulin Resistance and Body Composition in United Kingdom Adolescents
J. Clin. Endocrinol. Metab.,
July 1, 2005;
90(7):
3963 - 3969.
[Abstract]
[Full Text]
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Top
Abstract
Introduction
