The AOA, through its National Campaign of Obesity Education, is proud to announce the first Weight Wellness Week, a program that is scheduled for September 13 -19, 1998.

As part of the week, AOA has produced a Weight Wellness Profile, a one-page self-assessment of health risks associated with overweight and obesity. The profile will be distributed in the medical community (physician offices nationwide) and to the general public via newspapers and other media. A longer version of the profile, along with an explanation of its development, appears in this edition of the AOA Report.

In addition, on-line internet discussions on various obesity related topics will be scheduled during Weight Wellness Week. These discussions, in an interactive question/answer format, will be hosted by professionals working in the field of obesity. You can participate or observe the discussion by logging on to www.betterhealth.com or to AOA’s website, www.obesity.org.

For more information about Weight Wellness Week programs or about getting involved, call 1-800-98-OBESE or visit www.obesity.org

Development of the Weight Wellness Profile

Obesity is a disease affecting approximately 58 million Americans. The continuing increase in the prevalence of obesity, coupled with evidence that prevention or management of obesity can improve health status, provides the impetus for the development of the Weight Wellness Profile.

The Weight Wellness Profile has been developed by the American Obesity Association in an effort to provide individuals and health care providers with a tool to make a general overall assessment of risk, and to determine a treatment approach when appropriate. The Weight Wellness Profile provides a format to assess increased health risk due to overweight or obesity, and to determine the impact of lifestyle habits and medical history on that overall risk.

This risk profile is based on the fact that the overall risk of disease or death for an individual usually depends on the number of contributing factors, often called risk factors, present in that person’s life. In general, people with a greater number of risk factors have a greater chance of developing a medical condition or of dying. A recent study examined the likelihood of survival related to the presence of risk factors, including: high blood pressure, diabetes, smoking, high blood cholesterol, and overweight. In this study, a person with one risk factor was 20% more likely to die in the next twenty years than a person with no risk factors, three risk factors increased the risk of death by 70%, and four risk factors presented a 310% greater likelihood of death in twenty years. (1)

The scoring for the Weight Wellness Profile is based on research that has examined the relative risk of total mortality for each item listed. Most of this research data is derived from studies of groups of people rather than an individual. Thus scoring on the profile is designed for use only as a guide to risk rather than an absolute definition.

There are items not included on this profile that could influence an individual’s overall risk. Non-modifiable risk factors (age, gender, heredity) and questions of a more complicated nature (blood insulin levels, triglyceride and HDL levels, sleep apnea, weight gain and weight cycling trends) are not included in this first Weight Wellness Profile (version 1). Future revisions of this profile may contain the items currently not included. Items selected for this profile were chosen because they make significant contributions to risk, and can be interpreted and answered by most people. The significance of each item is described below.

Body Mass Index (BMI)

BMI is used as a measure of obesity and overweight because it provides the best correlation with body fat. (2) BMI is calculated by using the formula, weight in kilograms / height in meters2 or the conversion, weight in pounds / height in inches2 x 704.5. A BMI of less than 25 is considered acceptable, whereas a BMI of 25 to 29.9 is defined as overweight, and a BMI of 30 or more is defined as obesity.

Most studies agree that the risk of dying increases with each additional step in BMI, starting with a BMI of 25. (3,4) For people with a BMI of 30 or more, the risk of dying from any cause is increased by 50 to 100 % above that for people with a BMI of 20-25. (5)

Treatment of obesity is recommended based on evidence that weight loss reduces risk factors for disease. Weight loss may not only help control diseases worsened by obesity, but it may also reduce the chance that these diseases will develop. Strong scientific evidence supports the recommendation of weight loss to help lower blood pressure, to improve levels of cholesterol and other blood fats, and to reduce blood sugar levels. (6)

Waist Measurement

Central obesity, or the "apple" shape, indicates a higher proportion of fat stores in the abdominal cavity and is recognized as a predictor of cardiovascular disease and mortality. Waist measurement, or waist circumference, has been identified as an effective way to estimate abdominal fatness, and has replaced the use of waist to hip ratio in estimating increased risk.

A waist circumference of 40 inches in men or 35 inches in women represents a threshold above which metabolic complications, including diabetes, cholesterol abnormalities, and heart disease, are more likely to develop. (7) Waist circumference is useful to identify obese or overweight people who have abdominal fatness, in addition to people in the acceptable BMI category (below 25) who are also at high risk because of an accumulation of abdominal fat.

The waist circumference measurement should be made midway between the top of the hip bone and the bottom of the rib cage. Waist measurements over time can be used to show changes in abdominal fat stores, and may motivate people who exercise and lose inches but not pounds.

Exercise

Scientific evidence indicates that physical inactivity is detrimental to health and that moderate levels of physical activity have health benefits. Regular exercise of moderate-intensity reduces the chances of developing heart disease, high blood pressure, Type 2 diabetes, osteoporosis, colon cancer, and anxiety and depression. (8) In addition, individuals who participate in moderate physical activity live longer and healthier lives than those who do not.

The US Centers for Disease Control and Prevention and the American College of Sports Medicine have issued guidelines and recommendations on the amount and frequency of moderate levels of physical activity necessary to elicit health benefits in currently inactive adults. They recommend that adults should accumulate 30 minutes or more of moderate-intensity physical activity on most, and preferably, all days of the week. Moderate intensity exercise burns approximately 4 to 7 calories per minute and includes brisk walking, and domestic activities such as house cleaning and lawn/garden care performed at an intensity similar to brisk walking. The most recent exercise research suggests that 30 minutes of exercise will produce benefits when performed in one continuous period or in a few short time periods totaling 30 minutes.

The greatest health benefits from increased activity seem to occur when the most inactive people become moderately active. Regular physical activity is an essential element of any weight management program, and it is the most important predictor of long-term weight maintenance. (8)

Food Choices

Diet has a vital influence on health. Scientific studies have associated diet with 5 of the top 10 causes of death in the United States (coronary heart disease, cancer, stroke, diabetes, and atherosclerosis). Although it is impossible to say exactly what proportion of these diseases could be reduced by improvements in food choices, it is clear that what people eat contributes in a substantial way to the development of these diseases and that modification of food choices can contribute to the prevention of these diseases. (9)

One focus of dietary modification in the United States is a reduction in total fat intake because of the role that fat plays in the development of several chronic diseases. High fat diets contribute to obesity since fat is a concentrated source of energy, and often leads to a high calorie intake. High fat diets can lead directly to an increase in blood cholesterol levels, and have been associated with increased risk for several types of cancers.

Diets including generous amounts of fruits and vegetables are recommended because these foods are high in fiber and relatively low in calories and fat. A diet high in fruits and vegetables usually leads to a reduction in total calories and fat, which enhances weight management. (9) A high fiber intake has beneficial effects on blood cholesterol and blood sugar, and a diet plan including at least 8 servings of fruit or vegetable and 2-3 servings of low fat dairy products has been shown to reduce blood pressure. (10)

Smoking

Cigarette smoking is the leading preventable cause of death in the United States, with 19.5% of all deaths attributable to smoking. The majority of these smoking related deaths are due to cardiovascular disease, with cancer as the second major cause, and respiratory disease third. It is estimated that 25 million persons alive today will die prematurely from smoking-related illness. (11)

Some damage from smoking is irreversible, but there is a significant benefit to be gained by quitting smoking. Overweight or obese smokers may be reluctant to quit smoking because of the possibility of weight gain upon cessation. The average weight gain with smoking cessation is 5-10 pounds, and the additional health risk from this weight gain is much less than the continued risk of smoking. (12) People planning a smoking cessation program should anticipate increased appetite and desire to snack, and thus should implement appropriate strategies of diet and exercise to minimize weight gain once they quit smoking.

Diabetes or High Blood Sugar

Diabetes mellitus is a group of metabolic diseases characterized by high blood sugar, resulting from defects in the amount of insulin produced, the way insulin is used, or a combination of the two. Diabetes and its complications are a significant cause of death and disability in the United States. Long-term high blood sugar is associated with damage to various organs, including the eyes, kidneys, nerves, heart, and blood vessels. (13)

Diabetes has become one of the most common chronic diseases in our country, and Type 2 diabetes is the most common form of diabetes. People with Type 2 diabetes produce insulin, but their bodies are not able to use it effectively due to a condition called insulin resistance. Most people with Type 2 diabetes are obese, and obesity itself causes some of the insulin resistance. Type 2 diabetes may go unrecognized for years because high blood sugar develops slowly and does not produce any obvious symptoms. Nevertheless, patients with undiagnosed diabetes are at risk of developing the complications that often accompany diagnosed diabetes. It is important that obese persons be tested for high blood sugar levels.

Heart Disease

The number of people dying from heart disease has decreased in the last 10 years, but heart disease is still the number one cause of death in the United States. Approximately one and one-half million Americans have heart attacks each year, and about 1/3 of these people die. (14)

Heart disease includes a variety of disorders, but the most common form is atherosclerosis or coronary artery disease. In this disease, deposits of fatty substances, cholesterol, calcium, and blood clotting materials develop in the lining of an artery. The resulting buildup is called plaque. The plaque can partially block the blood flowing through the artery, and if a hemorrhage or blood clot affects the plaque, blood flow in the artery can be completely cut off, causing a heart attack.

High blood cholesterol, high blood pressure, smoking, lack of physical activity, and obesity are risk factors for the development of atherosclerosis that can be modified to reduce risk. Bypass surgery or angioplasty (balloon treatment) can be used to open a blocked artery, but there is a high risk that the plaque will redevelop unless risk factors are controlled.

High Blood Pressure

High blood pressure, also called hypertension, increases the heart’s workload, causing the heart to enlarge and weaken over time. High blood pressure can also increase the risk of stroke, heart attack, kidney failure, and congestive heart failure. The higher a person’s blood pressure, the higher the risk of developing heart disease and other complications.

Excess body weight, especially abdominal fat, is correlated closely with increased blood pressure. If high blood pressure is present, treatment to lower levels is useful to prevent stroke, preserve renal function, and slow heart failure progression. Control of high blood pressure may be accomplished with lifestyle in some cases but in other cases may require medication. Weight loss, a low-fat diet plan high in fruits, vegetables and low-fat dairy products, reduction of sodium intake (for some), regular exercise, and avoidance of alcohol have been proven to reduce blood pressure. As little as a 10 pound weight loss has been demonstrated to reduce blood pressure in a large proportion of overweight persons with hypertension. (15)

High Blood Cholesterol

The risk of heart disease rises as blood cholesterol levels increase. Cholesterol levels below 200 mg/dl indicate a relatively low risk of heart disease, but the risk doubles for people with cholesterol levels over 240 mg/dl. Blood cholesterol levels depend on age, gender, heredity, diet, and weight. Overweight or obese people are more likely to have cholesterol elevations or abnormal values for other blood fats. (16)

In addition to cholesterol, abnormal triglyceride and HDL-cholesterol levels can increase the risk of heart disease. These levels are often affected by excess body weight, and should be tested in people who are overweight or obese. It is possible to have a normal cholesterol level, but abnormal triglyceride and HDL levels. Triglyceride levels should be below 150 mg/dl, while HDL (often called the good cholesterol) should be 35 mg/dl or higher.

Weight loss is an important part of the treatment of elevated blood cholesterol, in addition to a diet low in saturated fat (animal fats) and cholesterol. High fiber foods like vegetables, fruits, and whole grains are also an important part of a cholesterol lowering diet.

Conclusion

Health problems and medical conditions are usually the result of multiple factors in a person’s life or lifestyle. Although some factors that affect the risk of disease cannot be modified (age, gender, heredity), many factors are controllable (dietary habits, exercise, smoking) and can reduce the chances of developing or worsening a medical condition which can shorten lifespan.

An assessment of risk related to overweight and obesity can be an important first step in the process of living a healthier life. The Weight Wellness Profile was developed to create awareness regarding weight, and the impact of lifestyle habits and medical conditions associated with overweight and obesity. A plan to manage weight and reduce related health risks should be developed on an individual basis with a health care provider. Investing effort in lifestyle changes and better management of medical conditions is not easy, but this effort offers great rewards.

Scientific Basis for the Weight Wellness Profile

A panel including doctors, nutritionists, physiologists and epidemiologists were involved in the development of the Weight Wellness Profile. AOA would like to express gratitude and thanks to the many contributors.

Principal development of the profile was under the direction of:

Gail Underbakke, RD, MS Richard Atkinson, MD

Expert Panel of Collaborators:

George Bray, MD, Joann Manson, MD, DrPH, Judith Stern, ScD

Expert Panel of Reviewers:

George Blackburn, MD, Roy Blank, MD, Claude Bouchard, PhD, Patricia Choban, MD, Robert Eckel, MD, Katherine Flegal, PhD, John Foreyt, PhD, Arthur Frank, MD, Barbara Hansen, PhD, Ahmed Kissebah, MD, Barbara Moore, PhD, Xavier Pi-Sunyer, MD, Barbara Rolls, PhD, Sachiko St. Jeor, PhD, G.Michael Steelman, MD, Theodore VanItallie, MD, David Williamson, PhD, MS.

Guidelines from the following leading health organizations were used in developing the profile:

National Institutes of Health, National Heart, Lung and Blood Institute, Centers for Disease Control and Prevention, American College of Sports Medicine, AOA and Shape Up America!, U.S. Surgeon General’s Report on Nutrition and Health, Department of Health and Human Services, Expert Committee on the Diagnosis and Classification of Diabetes Mellitus, American Heart Association, National High Blood Pressure Education Program, National Cholesterol Education Program, USDA Dietary Guidelines for Americans

References:

1. Yusuf HR, Giles WH, Croft JB, Anda RF, Casper ML. Impact of Multiple Risk Factor Profiles on Determining Cardiovascular Risk. Prev Med 1998; 27:1-9.

2. Guidance for Treatment of Adult Obesity. Shape Up America! and American Obesity Association, 1996 (Revised 1998).

3. Manson JE, Willett WC, Stampfer MJ, Colditz GA, Hunter DJ, Hankinson SE, Hennekens CH, Speizer FE. Body Weight and Mortality Among Women. NEJM 1995; 333:677-85.

4. Lee IM, Manson JE, Hennekens CH, Paffenbarger RS. Body Weight and Mortality. A 27 Year Follow-up of Middle-aged Men. JAMA 1993; 270:2823-2828.

5. Manson JF, Stampfer MJ, Hennekens CH, Willett WC. Body Weight and Longevity. A Reassessment. JAMA 1987; 257:353-358.

6. NHLBI Obesity Education Initiative Expert Panel on the Identification, Evaluation, and Treatment of Obesity in Adults at High Risk for Cardiovascular Disease: Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. National Heart Lung and Blood Institute, National Institutes of Health, 1998.

7. Stevens J, Keil JE, Rust PF, Tyroler HA, Davis CE, Gazes PC. Body Mass Index and Body Girths as Predictors of Mortali ty in Black and White Women. Arch Intern Med 1992; 152:1257-1262.

8. Pate RR, Pratt M, Blair SN, Haskell WL, Macera CA, Bouchard C, Buchner D, Ettinger W, Heath GW, King AC, et.al. Physical Activity and Public Health. A Recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA 1995; 273:402-407.

9. Surgeon General’s Report on Nutrition and Health. Public Health Service, Department of Health and Human Services, 1988.

10. Appel LJ, Moore TJ, Obarzanek E, Vollmer WM, Svetkey LP, Sacks FM, Bray GA, Vogt TM, Cutler JA, Windhauser MM, Lin PH, Karanja N. A Clinical Trial of the Effects of Dietary Patterns on Blood Pressure. NEJM 1997; 336:1117-1124.

11. Centers for Disease Control: Smoking Attributable Mortality and Years of Potential Life Lost - United States 1984. MMWR 1997; 46:444-451.

12. Williamson DF, Madans J, Anda RF, Kleinman JC, Giovino GA, Byers T. Smoking Cessation and Severity of Weight Gain in a National Cohort. NEJM 1991; 324:739-745.

13. Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 1998; 21:S5-S19.

14. American Heart Association. Heart and Stroke Facts. American Heart Association 1992; Publication Number 55-0501.

15. Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure and the National High Blood Pressure Education Program Coordinating Committee. The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Arch Intern Med 1997; 157:2413-2444.

16. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Summary of the Second Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II). JAMA 1993; 269:3015-3023.