Social Determinants of Health Impacting Obesity, Diabetes Mellitus and Death Due to Injury in West Virginia and Virginia Coal Counties by Meacham S, D Meisha, S Woolley, L Balmert, E Talbott, J Buchanich, A Snyder, Kennedy, K

1. SOCIAL DETERMINANTS OF HEALTH
IMPACTING OBESITY, DIABETES MELLITUS
AND DEATH DUE TO INJURY IN WEST VIRGINIA
AND VIRGINIACOAL COUNTIES
Meacham S, D Meisha, S Woolley, L Balmert, E Talbott, J
Buchanich, A Snyder, Kennedy, K
Via College of Osteopathic Medicine, Blacksburg, VA
University of Pittsburgh
2015 ENVIRONMENTAL CONSIDERATIONS IN ENERGY
PRODUCTION
September 22, 2015

2. Introduction
• Recent publications have associated the environmental
impacts of mountain top coal mining in Appalachia with
increased prevalence of chronic conditions such as obesity and
comorbidities such as diabetes mellitus, heart diseases,
cancers, and kidney diseases
• Our previous review and subsequent study findings on chronic
health conditions in coal communities in Central Appalachia
indicated regional differences in lifestyle behaviors and socio-
demographic factors
• We anticipate that our work will lead to programs targeting
specific geographic areas can benefit using evidence based
knowledge to implement interventions with measureable goals
to reduce localized and persistent rates of chronic diseases

3. Introduction (cont.)
• Investigators have identified a number of factors beyond
coal important to health in coal mining communities
• a need for improved access to care, education, cultural
sensitivity, understanding
• managing multiple comorbidities
• family inclusion in healthy lifestyle changes

4. Objective
The objective of this cross-sectional study
was to identify distinguishing social
determinants of health affecting obesity and
diabetes in coal producing counties
compared to non-coal producing counties in
West Virginia and Virginia.

5. VA health districts and prevalence rates
of adults with diabetes mellitus in 2005-
2009 (VDH, BRFSS).
Rate of diabetes in the USA and VA from 1996-2009.
Percentage (%)
Virginia health districts and prevalence
rates of obese adults. (BMI > 30) from
2007-2009 (VDH)

6. Map of Region
Figure 1: West Virginia and Virginia counties representing coal production
and comparison counties identified for our previous study (Woolley et al.,
2015). In the current study only West Virginia coal production counties (n=31,
blue) and Virginia coal production counties (n=7, red) were included for
analysis.

7. Methods
• Percent of obese and those with diabetes and
sociodemographic data on various factors were obtained
from County Health Rankings (RWJF 2015) for the year
2012 for coal producing counties in West Virginia (n = 31)
and Virginia (n = 7).
• Obesity was defined as BMI greater than or equal to
30kg/m2
• Diabetes was designated by all who answered, “yes,” to
Has your doctor every told you that you have diabetes?”
• Death due to injury was a ‘control’, a non-chronic disease
• Includes accidents, drowning, homicides, suicides, etc.

8. Methods
• VDH –VCOM IRB approvals,
• Data management, age adjusted data
• Statistical methods: Paired t-test and
Pearson correlation coefficients were
employed for analyses
• Statistical significance was set, a priori, at p
<0.05.

9. Methods
2012 data was
obtained from:
Health outcomes are determined by
- health behaviors (30%),
- clinical care (20%),
- social and economic factors (40%),
- physical environment (10%)
And, in turn, by the policies and
programs.

10. Result Summary for WV - VA
• Comparison of coal production and select health factors
in West Virginia and Virginia coal producing counties:
• Coal production No
• Diabetes mellitus No
• Obesity Yes
• Injury deaths No
• Income No
• Unemployment No
• Poverty No
• High School diploma Yes
• Adult smoking No
• Uninsured Yes
• Over 65years old No

11. Results WV -VA
Variable
WV Coal Countiesa VA Coal Countiesb
Mean SD Mean SD
P-
valuec
Coal production,
2012, thousand
short tons, n=28
4297 4882 2709 2826 0.28
Diabetes, 2012,
percent
13.29 1.79 12.29 0.76 0.16
Obesity, 2012,
percentage
33.94 2.98 30.86 2.27 0.02d
Injury death, 2012,
per 100,000
94.6 29.7 112.7 23.4 0.17
aWV mean and standard deviations (SD), counties n=31, bVA counties n= 7;
cP-values were for t-tests and equal variances were assumed except for coal production.
dp < 0.05, significant differences between WV and VA coal counties.

12. Results WV - VA
Variable
WV Coal
Countiesa
VA Coal Countiesb
Mean SD Mean SD P-valuec
Population, 2012, n=28 39803 36291 28731 12104 0.44
Per capita income, 2012,
$
32364 5096 31523 2592 0.68
Unemployment, 2012,
percentage
8.35 2.09 7.94 0.87 0.62
Poverty average, percent,
2008-2012
19.45 3.87 20.8 3.87 0.47
High school diploma
average, percent, 2008 –
2012
79.90 6.93 73.0 4.69 0.02d

13. Results WV - VA
Variable
WV Coal Countiesa VA Coal Countiesb
Mean SD Mean SD P-valuec
Age, >65 years, 2012,
percent
17.47 2.07 17.51 1.39 0.96
Rural, 2012, percent 67.46 24.36 80.39 21.49 0.20
Annual health care
cost/person, 2012,
dollars
9958 1121 10864 972 0.06
Uninsured, 2012,
percent
18.9 1.8 16.29 0.49 0.001d
Adult smoking, 2012,
percent (n=6)
26.8 5.46 27.7 4.7 0.71

14. Results WV -VA
• Differences noted in WV and VA coal counties:
• higher obesity rate (%) WV 33.94 ± 3.0 vs
VA 30.86 ± 2.27 (p=0.02)
• lower education (%) VA 73.0 ± 4.7 vs
WV 79.9 ± 6.9 (p=0.02)
• higher uninsured (%) WV 18.9 ± 1.8 vs
VA 16.29 ± 0.49 (p=0.001)

15. Results: Obesity correlated with
Adult obesity (%) and (Variable)
Correlation
coefficient
P-value <
Per capita, income, 2012 -0.43 0.01
Unemployment, percent, 2012 0.43 0.01
Uninsured, 2012, percent 0.40 0.01
Adult smoking, 2012, percent 0.46 0.00
Diabetes, 20120, percent 0.53 0.01
Injury death, 2012, per 100,000 0.38 0.02

16. Results: Diabetes correlated with
variable
Correlation
coefficient
P-value <
High school diploma average,
percent, 2008 – 2012
-0.37 0.02
Unemployment, percent, 2012 0.53 0.00
Adult smoking, 2012, percent 0.33 0.05
Injury death, 2012, per 100,000 0.50 0.01

17. Results: Injury Deaths correlated with
Injury deaths,2012, per
100,000 and (Variable)
Correlation
coefficient
P-value <
Per capita, income, 2012 -0.32 0.05
High school diploma average,
percent, 2008 – 2012
-.0.75 0.00
Unemployment, percent, 2012 0.47 0.00
Poverty average, percent,
2008-2012
0.54 0.00
Annual health care
cost/person, 2012, dollars
0.45 0.01
Rural, 2012, percent 0.45 0.01
Adult smoking, 2012, percent
(n=6)
0.69 0.00

18. Conclusion
• Health disparities present in coal production counties in
Virginia and West Virginia have persisted since data
collection was initiated over half a century ago.
• Causative factors need to be further investigated, yet
correlations are strongest and the most numerous when
relating deaths due to injuries compared to chronic
disease precursor conditions, obesity and diabetes.

19. Conclusion
• While both coal mining areas of WV and VA continue to
have higher mortality rates relative to comparison
counties, a striking finding was the poorer mortality
outcomes in coal mining counties of VA.

20. Conclusion
• Our findings add additional support to the recent focus on
mental health.
• Attempts to improve chronic diseases in recent years may
be losing 'ground' to the troubling increases in mental
health diagnoses.
• An interdisciplinary team of health care professionals may
benefit from these findings when structuring interventions
to improve health, mental and physical, in coal counties of
WV and VA.

21. Ongoing Research: Healthy People 2020 and
Cancer mortality
• Using “County Health
Rankings” and the guidelines
for Healthy People 2020 this
study examines counties
meeting the HP2020 goal for
cancer mortality rates and
compares those meeting the
goal with those not meeting
the goal
• Findings reveal that those
meeting the HP2020 goal for
cancer mortality rates have
higher rates of smoking,
physical inactivity, and obesity.

22. Ongoing Research: Cancer Mortality Rates in
Medically UnderservedAreas
• There is great overlap between the
Medically Underserved regions of
Virginia and those designated as Coal
Mining counties
• In the Medically underserved regions,
Lung cancer mortality rates are
dropping at a slower rate than Non-
Medically Underserved
• Data obtained from
CDC and Virginia
Department of
Health

23. Thank you!
Funding source: This study is sponsored by Initiative for
Environmental Science (ARIES). ARIES is an industrial
affiliates program at Virginia Tech, supported by members
that include companies in the energy sector. The research
under ARIES is conducted by independent researchers in
accordance with the policies on scientific integrity of their
institutions. The views, opinions and recommendations
expressed herein are solely those of the authors and do not
imply any endorsement by ARIES employees, other
ARIES-affiliated researchers or industrial members.
Information about ARIES can be found at
http://www.energy.vt.edu/ARIES.”