Leslie Sue Lieberman, Ph.D.
Professor of Anthropology, Courtesy Professor of Medical
Education , Director Women’s Research Center
University of Central Florida, [email protected]
Understanding and Managing Diabetes:
Perspectives from Behavioral and Biomedical Disciplines
University of Pennsylvania November 15, 2010
Presentation Outline
 The discipline of anthropology- concepts, theories and
methods
 The focus on diabesity insights from evolutionary
medicine on etiology, prevention and management
Medical Anthropology
Comparing Disciplines
Psychology
Anthropology
Biology
++
0
SCALE OF LIKENESS
ANTHROPOLOGY
Hallmarks of Anthropology





Holism
Comparative – Cross Cultural through
space and time
Participant-Observation Techniques
Scientific Method and other modes
of inquiry
Increases awareness of anthropocentricity and
ethnocentricity
TIME
SPACE
COMPARATIVE
FOCUS
Hallmarks of Anthropology





Holism
Comparative – Cross Cultural through
space and time
Participant-Observation Techniques
Scientific Method and other modes
of inquiry
Increases awareness of anthropocentricity and
ethnocentricity
Sub-Disciplines of Anthropology
 Sociocultural Anthropology
 Linguistic Anthropology
 Archaeology
 Physical Anthropology
Shaman healing young
girl Ecuador
Sub-disciplines of Anthropology
Medical Anthropology
Is a subfield of anthropology that draws upon
social, cultural, biological, and linguistic
anthropology to better understand those
factors which influence health and well being
(broadly defined), the experience and
distribution of illness, the prevention and
treatment of sickness, healing processes, the
social relations of therapy management, and
the cultural importance and utilization of
pluralistic medical systems. The discipline of
medical anthropology draws upon many
different theoretical approaches.
Subfields and Specialties of Medical
Anthropology
Biomedical Studies of
Adaptation
Ethnomedical Studies of
Health and Healing
Social Problems and
Interventions
genetics and disease
culture-bound syndromes
mental health
medical ecology
folk therapies
clinical anthropology
evolution of disease
healing roles
addictions
social epidemiology
medical pluralism
family violence
nutrition
enthnopharmacology
birthing studies
demography
ethnoscience
disabilities
paleopathology
midwifery
public health
stress and disease
shamanism
international health
Theoretical Approaches in Medical
Anthropology
 Critical Medical Anthropology =
Political Economy of Health (focus on
class, access)
 Ecological /Evolutionary
Anthropology (adaptation)
 Biocultural Anthropology
 Interpretive = Post-Modern
Anthropology (phenomenological)
Etic and Emic Definitions
 Etic - a description of a behavior or belief by an observer,
in terms that can be applied to other cultures; that is, an
etic account attempts to be 'culturally neutral‘
 Emic -a description of behavior or a belief in terms
meaningful (consciously or unconsciously) to the actor;
that is, an emic account comes from a person within the
culture.
Explanatory Models of Health
and Illness
 Disease- biomedically defined (etic perspective)
 Illness- the lived experience of a disease or condition;




not feeling well (emic prespective)
Etiology: body balance, emotions, weather,
supernatural, food, sexual relations, heredity,
old age
Kleinman’s model- cultural construction of illness,
holistic & meaning centered
Health Belief Model- internal & external motivation
Healers: indigenous, pluralistic, western, others
Internal
States
Internal
States
External
States
Behavior Reported Observed
Artifacts
I
External
States
Behavior
Reported
Observed
Artifacts
Environment
II
IIIa
IIIb
IV
V
VI
VIIa
VIIb
VIII
IX
Xa
Xb
Xc
XIa
Xib
XIIa
XIIb
XIII
XIV
Environment
Bernard, H.R. Research Methods in Cultural Anthropology p. 123, 1988
XV
Qualitative research:
Explores the subjective world. It aims to provide an indepth understanding of people’s experiences,
behaviours, perspectives and histories (and the
meanings they ascribe) in the context of their personal
circumstances or settings.
Ethnographic methods
 Field work is:
“the study of people and of their culture in their natural
habitat. Anthropological fieldwork has been characterized
by the prolonged residence of the investigator, his
participation in and observation of the society, and his
attempt to understand the inside view of the native
peoples” ( H. Powdermaker "Field Work" in International
Encyclopedia of the Social Science, David L. Sills, ed. New York:
Macmillan and Free Press, 1968)
 participating and observing
Prevalence and Socioeconomics
 Over 70% of the world’s population with diabetes
live in low- and middle-income countries; the
prevalence of diabetes in some of the world’s poorest
cities is as high, or higher, than in high-income
countries------- today type 2 diabetes can no longer
characterize as a ‘disease of affluence’
Equity, Social Determinants and Public Health
Programmes. Eds. E Blas and A S Kurup. 2010 WHO
Developing Countries
Developed Countries
Diabetes Prevalence
High
Low
Socio-Economic Status (SES)
High
Equity, Social Determinants and Public Health
Programmes. Eds. E Blas and A S Kurup. 2010 WHO
Equity, Social Determinants and Public Health
Programmes. Eds. E Blas and A S Kurup. 2010 WHO
Obesity among Poor Americans: Is
Public Assistant the Problem?
P.K. Smith, Vanderbilt U. Press, 2009
 Public Assistance
 Obesity
Obesity (more food)
Public Assistance (poor health, job
 Poverty
Obesity and Public Assistance (low income,
 Factor X
Obesity and Public Assistance (domestic
discrimination)
poor nutrition, low education & skills)
abuse, disabilities)
 All are probable or possible causes especially
for women
Poverty and Obesity
Paradox or Orthodoxy
 Maximize ratio of caloric intake to cost
 Choose energy dense foods
 Maximize quantity and reduce quality
 Overeat when food is available (ex. Food Stamps)
 Reduce energy expenditure (ex. Sedentary jobs,
TV, computers, remote controls, mobile phones,
transportation)
fats and sweets
■ = fats and sweets □ = meat, fish, eggs ○ = fruits and vegetables
New Approaches (beyond medical models)
 Identification of underlying and proximate causes of
physical, mental , social and environmental health and
well-being- The Social Determinants of Health
 Ethical commitment to address issues of health
disparities and health inequity
 Multisectoral (intra- and inter-sectoral) collaboration =
communication, cooperation and planning ,
implementation and evaluation of different stakeholders
engaged in the intervention process: community,
government, business sector, civil society, other
professional bodies
Interventions- Community based
 The most direct attempt to reduce inequities that
 include inequities in diabetes is seen in the Racial and Ethnic










Approaches to Community Health (REACH)
2010 project in the United States, a large, multifactorial
community-based attempt to reduce racial and ethnic
inequities in six key health areas, one of which is
diabetes (110). There are many interventions involved,
including developing partnerships, supporting faithbased
groups, nutrition and physical activity classes,
and classes specifically designed to change social and
cultural norms. This project is being evaluated using
quantitative and qualitative methods, including risk
factor surveys, and its results are awaited with interest.
Comparison of Definitions
Health Disparities
Health Inequities
Health Equity
SDOH
Differences in the
incidence and
prevalence of health
conditions and
health status
between groups
based on:
Systematic and
unjust distribution of
social, economic,
and environmental
conditions needed
for health.
The opportunity for
everyone to attain
his or her full health
potential.
Life-enhancing
resources whose
distribution across
populations
effectively
determines length
and quality of life.
•Race/ethnicity
•Socioeconomic status
•Sexual orientation
•Gender
•Disability status
•Geographic location
•Combination of these
•Unequal access to
quality education,
healthcare, housing,
transportation, other
resources (e.g., grocery
stores, car seats)
•Unequal employment
opportunities and
pay/income
•Discrimination based
upon social status/other
factors
No one is
disadvantaged from
achieving this potential
because of his or her
social position or other
socially determined
circumstance.
•Equal access to
quality education,
healthcare, housing,
transportation, other
resources
•Equitable pay/income
•Equal opportunity for
employment
•Absence of
discrimination based
upon social status/other
factors
CDC
•Food supply
•Housing
•Economic
relationships
•Social relationships
•Transportation
•Education
•Health Care
Expert Panel on SDOH
Why are we having a diabesity
‘pandemic’ now?
Is there a mismatch of human biology
sculpted by millennia of natural
selection and the modern environment?
- orHas the modern environment optimized
human biological functions? In modern
environments are we naturally selected
to be fat?
The Eternal Triangle
Human Adaptability Model
Culture
Biology
Environment
The Real and the
Ideal- Then
The Real and the Ideal- Now
IDF Regions and global projections for the number of
people with diabetes (20-79 years), 2010-2030
IDF Diabetes Atlas, 4th edition, 2009
Regional Changes in Obesity Prevalence
2000- 2030
International; Obesity Task Force, WHO, 2007
Prevalence of Diabetes Among
US Minority Populations (age ≥ 20 yrs)
 Native American/Alaskan Native 16.5%
 African American/Black 14.7%
 Hispanics/Latinos 10.4% of all Hispanics/Latinos
Cubans 8.2%, Mexican Americans 11.9%, Puerto
Ricans 12.6 %
NIDDK, National Diabetes Statistics 2007.
www/.diabetes.niddk.nih.gov/dm/pubs/statistics
Obesity Genes
 Following inconsistent replication of candidate
gene associations and family-based linkage
analyses, genome-wide association studies have
replicated in > 65,000 individuals ~17 genetic
loci containing variants associated with BMI
(e.g., FTO, MC4R, TMEM18)
 FTO genotype AA is associated with higher fat mass,
lower activity level, greater enjoyment of food and
higher satiety threshold than other genotypes
 Relatively little variation (~1%), but in aggregate
may explain ~ 6 kg difference in adult body wt.
 Many expressed in hypothalamus, may regulate
appetite
Prenatal Epigenetic Effects
The mother of the mouse on the right received a normal diet, while the
mother of the mouse on the left received a diet supplemented with
methyl donors such as choline, betaine, folic acid, and vitamin B12. The
mice are genetically identical. (Jurtle, R., Genetic, Engineering &
Biotechnology News, 2009)
Fetal Origins of Thrifty Phenotypes
Deleterious intrauterine
environment →
dysregulation of growth →
low infant birth weight and
altered energy regulation
I
Infancy
 Critical period of rapid growth and cognitive and physical
maturation- evolutionary advantage to slower growth
rates in unstable food environment
 High rates and prolonged illnesses with decrease food
intake and use of energy reserves-evolutionary
advantage to have reserves
 Weight recovery faster with a quick insulin trigger-
evolutionary advantage to efficient energy storage
 Catch-up growth in fat tissues for low birth weight babies-
evolutionary advantage for energy reserves
Catch-Up and Catch-Down Growth in Weight-for-Age
Starting Point <25th Percentile
Mei et al. Pediatrics, 2004 CA Child Health and Development Study
Appetite-Regulatory Hormones, Enzymes
and Neuropeptides (Examples)





Some have multiple sources and interact
Adipocytes- (Adipokinins) Enhance: Resistin
Suppress: Leptin, Adiponectin,TNF-ą
Stomach/Intestines- Enhance: Orexin,
Ghrelin; Suppress: PYY, PPY, CCK, Proglucagon
Pancreas- Enhance and Suppress: Insulin
Hypothalmus- Enhance: NPY, Dopamine
Suppress: POMC, CART, Endocanabinoids
Neuroendocrine Control of Energy
Regions of the Brain Containing Von Economo
Neurons (VENs)
(a) A lateral view with fronto-insular cortex (FI) in red.
(b) A medial view with anterior cingulate cortex (ACC) in red.
Von Economo and Koskinas (1925) Die Cytoarchitectonik der Hirnrinde
des erwachsenen Menschen, Springer
Other Biological Obesogenic Factors
 Taste- preference for sweet (and fat);
processing produces ‘super-delicious’ foods
 Sleep - short sleep duration reduces leptin &
increases ghrelin and increases BMI
 Gut microorganisms- Firmicute bacteria
extract sugar from plant carbs and in mice
increase obesity & insulin resistance
 Adenovirus-36- 50% of infected stems cells
became fat cells (Pasarica, 2007)
 Restrained eating (dieting) induces
psychological stress and stress hormones
 Pharmaceuticles – psychoactive drugs,
antidepressnts
Environmental Obesogens
 Definition: Obesogens are xenobiotic chemicals
that can disrupt adipogensis and homeostatic
control over energy metabolism (Grün and Blumberg
,Endocrinology, 2, Vol. 147, 2006)
 The model is similar to environmental endocrine
disruptors that affect reproduction and health (e.g.,
prenatal exposure to nicotine alters postnatal weight gain, exposure to
pesticides and herbicides have been linked to gestational diabetes
mellitus)
 Some examples are: fungicides (organotins- tributyltinTBT), herbicides (atrazine ATZ) and pesticides (diazinon)
Physical Activity and Overweight
 Increased Media Access and Viewing
 Increased Daycare placement and
duration (activity limitation, liability)
 Increased Organized Sports (time and money costs,
facilities, peer interactions)
 Perceived and actual Neighborhood Safety
 Cultural Roles and appropriate behaviors
Vision is the Dominant Sense
Decreased sense of smell
and size of snout
Orbital frontality
Orbits protected by bone
Stereoscopic vision/depth
perception
Color vision
Complex, large brain
Vision and Food-Related Behaviors
 Must see food- hunting, foraging, scavenging
 Color has appeal and signals taste, texture and
nutrients, toxins (e.g., ripened fruits; leaves)
 Poor judge of ingested portion sizes based on
sensory information
 ‘Size’ based on experience, expectations
(norms), variety, form, packaging
 We are visually distractible- people, TV, reading,
driving, etc.
Cephalic Phase of Digestion
 Seeing, smelling and anticipating food is perceived by
the brain that informs the stomach to prepare for a
food
 Parasympathetic stimuli acting through the vagus
nerve
enteric nervous system to release
acetylcholine to stimulate G cells to secrete gastrin and
parietal cells to secrete stomach acid

Increase in gastric motility
Abundant Food Choices – The more You See, the
More You Eat- The Omnivore's Dilemma
Food Qualities and Serving
Characteristics Variety (color, taste, shape)
 Attractiveness (shape, color, arrangement)
 Amount (large serving sizes, stockpiles)
 Eating effort (low effort-fingers, forks, bit
sizes, shelled nuts, easy-open packaging)
Wansink, B. Mindless Eating: Why We Eat More Than We Think
2006
Misjudging Calories in
Restaurant Foods
Zinczenko, D. Eat This , Not That, 2008
What 200 kcals Look Like?
http://www.wisegeek.com
We Can’t Judge Portions Sizes
and Calories
 Popcorn- 50% more from large vs. small popcorn,
14-day-old stale popcorn- still ate 31% more
 M & M’s- 120 eaten from 1 lb. bag vs. 63 eaten from
½ lb. bag
 Ice Cream- 31% more in large bowls vs. small
bowls
 Soup- continually filled, ate 76% more
 Lunch- college students could not tell low vs. high
calorie foods (B. Rolls, Penn State U.)
Where We Get Food
 Food is available 24 hrs/day every day in the
US
 On any one day, 40% of US adults are eating in
a restaurant or food outlet (e.g., Starbucks) 45
million/day - fast food
Little or no energy expended on food
acquisition, preparation, service or clean up.
 Restaurants, shopping malls, supermarkets, out door
markets, kiosks, street vendors, vending machines,
work and school cafeterias, theaters, sports events,
gas stations, convenience stores, bookstores, coffee
shops, airports, hospitals- - -
Number of Selected Fast Food Restaurant
Chains and Number of Countries (2008-09)
Foraging Behavioral Ecology and Optimal
Environments
Modern environments have:
1. High density of high quality food patches
2. Patches are accessible and well advertised
(visual cues) to reduce search/ travel time
3. The rate of diminishing returns is modulated
by abundance energy-dense food and human
capacity (satiety)
4. Marginal Value Theorem-get as much energy
per time (and money) spent (Chernov)
What Can be Done Now?
 Intervene prenatally and infancy- phenotypic
programming, enhance intrauterine environment,
normal birth weight; Breastfeeding protective?
 Develop efficacious drugs- treat obesity as a
chronic disease not a failure of hypervigilence
 Choice Architecture- Making good choices easy,
rewarding, normative (Nudge: Improving Health, Wealth and
Happiness, R. Thaler & C. Sunstein, Yale U. Press, 2008)
 Legislate/regulate the food supply- food labels,
calories on menus, outlaw transfats, reduce use of
corn syrup, provide healthy choices in vending
machines
Choice Architecture
 School Cafeteria Line- item placement ld
accounted for 25% difference in consumption of
specific foods (Thaler, RH & Sunstein, CR Nudge:
Improving Decisions about Health, Wealth &
Happiness, Yale U. Press, 2008)
 Reduce cognitive effort for a ‘good choice’
(e.g.,carrots at eye level) and increase effort or cost
for a ‘bad’ choice” (e.g., candy)
Children’s Exposure to
TV Food Ads
 2006 Children’s Food and Beverage Advertising
Initiative, 50% of all advertising to healthier foods or
messages on fitness or nutrition
 Average annual number of food ads and nutrition
PSA’s
2-7 yr olds 4,427 and 164
8-12 yr olds 7,609 and 158
13- 17 yr olds 6,098 and 47
Television Food Advertising to Children in the United States
A Kaiser Family Foundation Report Gantz W. , et al 2007
Distribution of Advertising Exposure by Food
Products Among Adolescents Ages 12 to 17
S. Weiss, RWJF Research Highlight, Adolescent Exposure to Food
Advertising on Television, Number 34, Sept 2007.
Mirroring Consumption Behaviors
 People consume more food when they are with
other people in a positive linear relationship 35%
more with one person, 75% more with 4 people
and 96% more with 7 or more people (Winsink B,
Mindless Eating: Why We Eat More than WE Think, 2006)
 People more closely mimic the weight gain of
friends than family or neighbors . An obese close
friend increases one’s risk of obesity by 171% based
on the longitudinal Framingham study. (Christakis, N. et
al, New England J of Medicine, 2006)
Fat-Proofing Your Home
 Use smaller plates ,cups, bowls, and
and spoons & forks
 Use glasses that are tall and narrow
 Serve plates of food- If you eat while watching
TV, reading not family style
 Leave the food in the kitchen not on the table
 If it is on the table, cover the food-out-ofsight
Fat-Proofing Your Home
 If you eat while watching TV or reading, take small
portions
 If you buy bulk food, divide it into smaller portions
and make it difficult to get at it (ex. back of the pantry,
freeze it)
 Keep food out-of-sight
 Remember, people will follow your lead, you set the
eating norms
Fat-Proofing Meals Out
 Do not frequent buffet-style restaurants
 Do not order fatty appetizers (ex., fried onion
rings, cheese dips, loaded nacho chips) order
veggies or protein (ex., veggies & dip, chicken
wings, fish) and share with others
 Share an entrée and/or dessert
 Order low calorie or no calorie drinks and watch
out for refills
 Take home a doggie bag
North American Woodrat Neotoma cinerea
A peculiar characteristic of packrats (and anthropologists) is that
if they find something they want, they will drop what they are
currently carrying and "trade" it for the new item. They are
particularly fond of shiny objects. They can also be quite vocal
and boisterous.
http://en.wikipedia.org/wiki/Pack_rat
The Sun Never Sets on McDonalds
Thank you