Comments of the American
Obesity Association
on Healthy People 2010
Table of Contents
Executive Summary
Part I. Justification for Obesity as a Leading Health Indicator
1. Why Obesity Should be Considered a Leading Health Indicator
A. Criteria for Leading Health Indicators
- Audience Interpretability
- Population Applicability
a. Children
b. Adults
3. Problem Impact
a. Mortality
b. Morbidity
c. Economic Costs
4. Link to Objectives
5. Representative Indicators
6. Measurable Data
7. Multilevel Trackability
8. Sensitivity to Change
9. Profile Balance
10. Relevance to Policy and Individual Action
a. Individual Action
b. Family Action
c. Community Groups
B. Developing Leading Health Indicators: Answering Questions Posed by
the Department of Health and Human Services
Part II. Justification for Obesity as a Healthy People 2010
Focus Area and Chapter
1. Why Obesity Should be Treated as a Distinct Focus Area Under the
Objective "Prevent and Reduce Diseases and Disorders."
A. Impact of Obesity on Years and Quality of Healthy Life
- Years of Healthy Life
- Quality of Healthy Life
a. Quality of Life Indicators
b. Stigma
c. Disability
B. Reduce and Eliminate Racial, Ethnic, Gender and Socioeconomic
Disparities
- Racial and Ethnic Disparities
- Effect of Obesity on Women
- Effect of Obesity on Children and Adolescents
- Obesity and Socioeconomic Status
2. Health Effects of Obesity
Part III. Proposed Model Chapter for Obesity as a Focus Area
Appendices
Executive Summary
The United States is in the midst of an obesity epidemic contributing to
premature death, sickness, and suffering of millions of Americans. The
combined prevalence of overweight and obesity in the United States has
increased from 46% of the adult population in the second National Health
and Nutrition Examination Survey (NHANES II, 1976 to 1980) to 54.9% of the
adult population in NHANES III (1988 to 1994). The prevalence of obesity
in adults increased from 12.8% (NHANES II) to 22.5% (NHANES III), and
overweight in adults increased from 30.5% (NHANES II) to 32% (NHANES III)
(see figure labeled Prevalence of Obesity Among Adults in
Appendices). Thus, obesity clearly deserves the descriptions that have
been given by the World Health Organization, which are: an "escalating
epidemic" and "one of the greatest neglected public health
problems of our time with an impact on health which may prove to be as
great as smoking." (Consultation on Obesity, Geneva Switzerland,
World Health Organization, June 3-5, 1997; National Heart, Lung, and Blood
Institute. Clinical Guidelines on the Identification, Evaluation, and
Treatment of Obesity in Adults: The Evidence Report. NHLBI Obesity
Education Initiative Expert Panel on the Identification, Evaluation, and
Treatment of Obesity in Adults. Washington, DC: U.S. Department of Health
and Human Services, 1998; Flegal KM et al, Overweight and Obesity in the
United States: Prevalence and Trends, 1960-1994. Int J Obesity,
1998;22:39-47)
In the Healthy People 2000 objectives, established in 1990, the
Department of Health and Human Services set the goal for the incidence of
obesity at no more than 20% of the adult US population by the year 2000.
Clearly this goal is not being met. (Rippe JM, Obesity as a Chronic
Disease: Modern Medical and Lifestyle Management. J Am Diet Assoc,
1998;98(suppl 2):S9-S15) Since Healthy People 2000, obesity and overweight
has increased as have many of the adverse health conditions caused by or
related to obesity. Nevertheless, the Draft Report of Healthy People
2010 fails to reflect the scale and impact of this epidemic.
Increases in obesity and overweight have occurred across virtually all
ethnic, racial, and socioeconomic populations and all age groups. The
combined prevalence of overweight and obesity for men is 59.4% and for
women, 50.7% (see figure labeled Prevalence of Overweight and Obesity
Among Adults in Appendices). Certain minority populations,
particularly minority women, have been found to be at the greatest risk
for obesity and hence, its co-morbidities. According to NHANES III, 66% of
non-Hispanic black women and 65.9% of Mexican American women are obese or
overweight. (National Heart, Lung, and Blood Institute. Clinical
Guidelines on the Identification, Evaluation, and Treatment of Obesity in
Adults: The Evidence Report. NHLBI Obesity Education Initiative Expert
Panel on the Identification, Evaluation, and Treatment of Obesity in
Adults. Washington, DC: U.S. Department of Health and Human Services,
1998)
An estimated 97 million adults in the United States are overweight or
obese, a condition that substantially raises the risk of morbidity from
more than 30 conditions including, in part, cancer (breast, colorectal,
and endometrial), coronary heart disease, dyslipidemia, gallbladder
disease, hypertension, osteoarthritis, respiratory problems, sleep apnea,
stroke, and type 2 diabetes. Higher body weights are also associated with
increases in all-cause mortality. Furthermore, obese individuals suffer
from social stigmatization and discrimination, have an impaired quality of
life, and high rates of disability. (National Heart, Lung, and Blood
Institute. Clinical Guidelines on the Identification, Evaluation, and
Treatment of Obesity in Adults: The Evidence Report. NHLBI Obesity
Education Initiative Expert Panel on the Identification, Evaluation, and
Treatment of Obesity in Adults. Washington, DC: U.S. Department of Health
and Human Services, 1998)
Researchers and clinicians in the field of obesity are in near universal
agreement that prevention is the key to controlling the epidemic of
obesity. In part this is due to the fact that various interventions on
people who have already developed obesity have had limited success. This
should not be interpreted to mean that treatments are totally ineffective.
Life long management of obesity with utilization of lifestyle changes in
diet and physical activity as well as pharmacological or surgical
intervention, used appropriately, can help to control obesity. However,
preventive efforts are needed to control the spread of the epidemic.
The World Health Organization Consultation of Obesity has stated:
Without societal changes, a substantial and steadily rising proportion
of adults will succumb to the medical complications of obesity; indeed,
the medical burden of obesity already threatens to overwhelm health
services. The spectrum of problems seen in both developing and developed
countries is having so negative an impact that obesity should be regarded
as today's principal neglected public health problem. (WHO Consultation on
Obesity, Geneva, June 3-5, 1997, Executive Summary, p. xvi)
The approach taken in Healthy People 2000 has not been adequate
to control the rise in overweight and obesity. Many of the sentinel health
objectives for Healthy People 2000 have been met - with notable
exceptions of obesity and major co-morbid conditions such as diabetes. "More
important than corrections in the targets themselves are corrections in
the strategies to achieve them. From the nature of those areas in which
our national failures are most prominent, such as violence, teen
pregnancy, and overweight prevalence, it is evident that many strategies
currently in place are not working." (McGinnis JM, Lee PR, Healthy
People 2000 at Mid Decade. JAMA, 1995;273;14:1123-129) Emphasis added.
For this reason, we propose a major addition to Healthy People 2010
that is appropriate given the goals of this effort. We propose that:
- Obesity or Overweight be included as a Leading Health Indicator as
appropriate, and
- Obesity have a separate chapter in Healthy People 2010 under
the objective, "Prevent and Reduce Diseases and Disorders."
The continuing epidemic, the effects on mortality and morbidity, the
growing incidence of childhood obesity, the significant racial, ethnic,
gender and socioeconomic disparities all indicate a need to make obesity
more clearly understood as a major public health priority requiring
aggressive prevention and intervention measures.
Obesity has extremely limited identification in Healthy People 2000.
No reasons are given for this inattention but two putative reasons may
exist. The first putative reason is that obesity may be seen still as a
voluntarily created condition by weak persons and therefore not worthy of
the devotion of limited public health resources. If this was a rationale
it has two faults.
First, it is inconsistent with scientific understanding of obesity. As
summarized by the National Institutes of Health in 1985:
Formerly, obesity was considered fully explained by the single adverse
behavior of inappropriate eating in the setting of attractive foods. The
study of animal models of obesity, biochemical alterations in man and
experimental animals, and the complex interactions of psychosocial and
cultural factors that create susceptibility to human obesity indicate that
this disease in man is complex and deeply rooted in biologic systems.
Thus, it is almost certain that obesity has multiple causes and that there
are different types of obesity. (Health Implications of Obesity. NIH
Consensus Statement Online 1985 Feb. 11-13; 5(9):1-7)
Second, Healthy People 2000 and Healthy People 2010 give
major attention to other diseases or conditions such as smoking, HIV/AIDS,
teen pregnancy, violence, substance abuse and sexually transmitted
diseases, ostensibly as much caused by individual behavior as obesity.
A second putative reason for not attending to obesity may be an attitude
that it is already Ôcovered' by attention to causal factors -
physical activity and nutrition - on the one hand and the major co-morbid
conditions of obesity - diabetes, heart disease, and cancer - on the
other. In this light, obesity may be viewed as a Ôtransitional'
state between poor diet and inactivity and Ôreal diseases'. If this
is a justification for the low level of recognition of obesity, the
argument has four critical flaws.
First, physical activity and nutrition are only two of many causal
factors of obesity as we currently understand the disease. Other factors
are genetic predisposition, environmental factors (social and cultural),
physiologic and metabolic factors, behavioral, and psychological
conditions. There is no question that physical activity and nutrition are
factors in the development, management and prevention of obesity. However,
research is progressively increasing our understanding of the critical
roles played by genetic factors and psychological factors. "The
belief that obesity is largely the result of a lack of willpower, though
widely held, is unsatisfactory. Studies of twins, analyses of familial
aggregation, adoption studies and animal models of obesity all indicate
that obesity is the result of a high percentage of genetic as well as of
environmental factors." (Friedman JM, Leptin and the Regulation of
Body Weight in Mammals. Nature, 1998; 395:763-770)
Second, the prevailing consensus is that obesity is its own disease
state not merely a transition period from one condition to another. It is
recognized as a disease in its own right by the National Institutes of
Health, the World Health Organization, the International Classification of
Diseases, the Food and Drug Administration and throughout medical and
scientific literature.
Third, focusing on selected co-morbid conditions, especially diabetes
and heart disease, to the exclusion of obesity is inappropriate and
insufficient. There is no dispute that obesity is a major risk factor of
diabetes, heart disease and stroke to name a few of the better known
co-morbid conditions. However, there are more than 30 other major health
conditions related or associated with obesity which have not been factored
in as part of this equation. Treating three of more than 30 co-morbid
conditions is unlikely to have a major effect in alleviating the
significant mortality and suffering associated with obesity. In addition,
the approach of focusing on only a limited number of conditions is only
likely to increase total health care costs without achieving a significant
improvement in the Nation's health.
Fourth, the current, indirect strategies have failed to control the
incidence and prevalence of overweight and obesity and its co-morbidities.
Even as improvements in the treatment of diabetes and heart disease have
been made, the overall incidence rates continue to increase as obesity
increases. In addition, the increases in childhood and adolescent obesity
indicate that the prevalence of diabetes and heart disease, as well as the
other co-morbid conditions, will also increase. Clearly, a new strategy
focused directly on obesity is needed.
The comments we submit for Healthy People 2010 are divided into
three sections. Part I gives evidence for why obesity/overweight meets the
criteria to be considered a leading health indicator. Part II provides
supporting material on why obesity is justified as a distinct focus area
and for having a separate chapter in Healthy People 2010. The
reader should be advised that as the criteria for sections 1 and 2 are
somewhat similar, there is some overlapping material. We have made an
effort to keep such redundancy to a minimum while satisfying the criteria
in each section. Part III is a proposed obesity chapter for inclusion in
the Healthy People 2010 document.
Readers should note that researchers have not always used the same
criteria to identify obesity. In these comments we have tried to use the
definition of obesity, which is generally agreed to, as a BMI of 30 or
greater. We have made an effort to identify studies which have also used
other scientifically accepted criteria to measure obesity such as waist
circumference and waist to hip ratio.
Part I. Justification for Obesity as a Leading Health Indicator
1. Why Obesity Should Be Considered A Leading Health Indicator
Leading health indicators are "intended to engage the
public-at-large. In undertaking the development of the indicators, it will
be essential to identify a small set of measures that will better
communicate with the general public and new partners such as managed care
organizations and businesses." (Healthy People 2010 Objectives: Draft
for Public Comment. DHHS, OPHS 1998 Sept.)
Obesity has become a major health concern in the United States and
abroad. Acknowledging obesity as one of the Nation's leading health
indicators in a well recognized and widely used document such as Healthy
People 2010 could firmly establish the need for furthering the
understanding of obesity by the public at large. By creating clear,
trackable objectives for obesity, the many organizations, agencies,
communities, and businesses that use Healthy People 2010 as a
resource can prioritize ways to implement obesity education, prevention,
and treatment strategies on a national, state and local level.
In the past, several terms have been used to define the nation's weight
problem, including "obesity', "weight", "overweight"
or a combination of weight and other health factors.
- "Weight" has the advantage of being well understood and
easily measurable. However, weight alone does not provide enough
information to constitute a measure of a nation's health.
- "Overweight" is defined as a BMI equal to or greater than
25.* "Overweight" has the advantage of encompassing both the
population at higher risk for developing obesity as well as the
population experiencing obesity. Most recent studies indicate that even
a moderate weight gain or moderate overweight significantly increases
medical risk factors. Overweight could potentially be considered a
pre-obesity state, or a risk factor for obesity. Thus prevention efforts
are appropriate in cases of overweight.
*Note: BMI of 25 or greater has been recognized to designate
overweight in guidelines issued by the National Institutes of Health, and
conforms to the criteria of the World Health Organization. The third
National Health and Examination Survey (NHANES III, 1980-1994) previously
defined overweight as 27.3 for women and 27.8 for men.
3. "Obesity," a BMI equal to or greater than 30, has the
advantage of being rather clearly defined and consistently employed in
scientific studies as an indicator of ill effects on health. The BMI of 30
or above has been used to designate obesity in guidelines issued by Shape
Up! America/American Obesity Association, and the National Institutes of
Health, and conforms to the criteria of the World Health Organization.
Obesity is a chronic disease, and as such must be taken more seriously
by the general public and health care professionals in order for action to
be taken to reduce the damage being caused to the Nation's physical and
financial health.
Therefore, for the purpose of recognition of "Obesity" as a
Leading Health Indicator, we propose that both obesity and overweight be
addressed and defined in the manner in which they are outlined above.
Depending on the ultimate leading health indicator model chosen by the
Department of Health and Human Services, obesity or overweight will be
more or less appropriate.
A. Criteria For Leading Health Indicators
Obesity amply meets all 10 criteria designated for consideration as a
leading health indicator. Criteria are indicated in italics.
Criteria 1. Audience Interpretability
"An indicator chosen as a leading health indicator should be
easily interpretable to, and understandable by, the general public and
opinion leaders, as well as to the health and medical communities. It
should be relevant and salient to the general public."
In general, weight is easily interpretable to and understandable by the
general public and opinion leaders, as well as relevant to the health and
medical communities. Almost all adults and many adolescents are aware of
their weight and height. However, many persons are not aware that they
would be considered obese according to standard measurements nor do they
understand the extensive health risks to which they are exposed as a
result of their excess weight.
Many persons who are in fact obese, i.e. have a BMI of 30 or more,
believe themselves to be merely "overweight" and unaware of the
risk for the ill health effects which are well established at this level.
Members of the public may be even less aware of the Body Mass Index - what
it is, how to use it, and specific health risks linked to varying levels -
as well as principles of weight loss and maintenance, proper nutrition and
physical exercise, and other obesity treatment options. As will be seen
from our model Obesity chapter (Part III), we are proposing a national
campaign of obesity education which includes a greater understanding of
using Body Mass Index to measure obesity.
Criteria 2. Population Applicability
"An indicator chosen as a leading health indicator should
reflect an issue that applies in important ways to the diverse national
population."
Obesity is prevalent in almost every segment of the Nation's population
with few exceptions such as medical conditions that cause weight loss
leading to lower body weight. (National Heart, Lung, and Blood Institute.
Clinical Guidelines on the Identification, Evaluation, and Treatment of
Obesity in Adults: The Evidence Report. NHLBI Obesity Education Initiative
Expert Panel on the Identification, Evaluation, and Treatment of Obesity
in Adults. Washington, DC: U.S. Department of Health and Human Services,
1998) Populations affected by obesity are segmented into age groups below.
Racial groups and gender are represented within these groups as well as in
many other sections of these comments.
a. Children and Adolescents
Evidence of this increasing prevalence can best be seen in overweight
data of children and adolescents since overweight during this growth
period is linked to overweight during adulthood. (Guo SS et al, The
Predictive Value of Childhood Body Mass Index Values for Overweight at Age
35 Years. Am J Clin Nutr, 1994;59:810-19) Approximately one in five
children in the U.S. is overweight. (Troiano RP et al, Overweight
Prevalence and Trends for Children and Adolescents. The NHANES Surveys
1963 to 1991. Arch Pediatr Adolesc Med, 1995;149:1085-1091) The number of
overweight children (age 6-17) has doubled within three decades. (Troiano
RP, Flegal KM, Overweight Children and Adolescents: Description,
Epidemiology, and Demographics. Pediatrics, 1998 (suppl.);101(3):497-504;
National Institute of Diabetes and Digestive and Kidney Diseases.
Statistics Related to Overweight and Obesity. Rockville, MD: National
Institutes of Health; July 1, 1996. NIH Publication 96-4158) Poor white
adolescents were approximately 2.6 times as likely to be overweight
compared to those in middle- or high-income families. (National Center for
Health Statistics. Health, United States 1998 with Socioeconomic Status
and Health Chart Book. Hyattsville, MD. DHHS Publication Number (PHS)
98-1232. 1998) The highest rates of overweight and obesity among children
and adolescents (age 6-11) was found in Mexican American males (17%), and
adolescents (age 12-19) from low-income households (16%). (Public Health
Service. Healthy People 2010: National Health Promotion and Disease
Prevention Objectives. DHHS Publication draft for comment. 1998)
b. Adults
In U.S. adults, the combined prevalence of overweight and obesity (BMI >
25), among persons aged 20 to 80 plus years, can be seen across all ages,
racial/ethnic groups, and genders. (Flegal KM et al, Overweight and
Obesity in the United States: Prevalence and Trends, 1960-1994. Int J
Obes, 1998;22:39-47) According to NHANES III (1980-1994), 59.4% of men and
50.7% of women in the U.S. are overweight or obese, with the prevalence
being even higher in non-Hispanic African American women (66%),
Mexican-American women (65.9%), and Mexican-American men (63.9%).
(National Heart, Lung, and Blood Institute. Clinical Guidelines on the
Identification, Evaluation, and Treatment of Obesity in Adults: The
Evidence Report. NHLBI Obesity Education Initiative Expert Panel on the
Identification, Evaluation, and Treatment of Obesity in Adults.
Washington, DC: U.S. Department of Health and Human Services, 1998)
Criteria 3. Problem Impact
"An indicator chosen as a leading health indicator should
address a problem of substantial impact. Mortality, morbidity and economic
costs are all parameters that reflect the relative impact of a problem and
can be calculated either for a disease or injury that impact directly, or
for the conditions that predispose to disease or injury and contribute
through them to increased mortality, morbidity, or economic loss. In any
case, it is anticipated that an indicator selected for inclusion in this
set will be in the top tier of factors impacting on national health
prospects."
Obesity meets all of these criteria, and its impact can be seen in data
on mortality, morbidity, and economic costs.
a. Mortality
Mortality estimates attributed to obesity are presented in two separate
analyses:
According to J. Michael McGinnis and William Foege, dietary factors and
activity patterns that are too sedentary together accounted for at least
300,000 deaths each year.
The interdependence of dietary factors and activity patterns as risk
factors for certain diseases is illustrated by the case of obesity, which
is associated with increased risk for cardiovascular disease, certain
cancers, and diabetes, and is clearly related to the balance between
calories consumed and calories expended through metabolic and physical
activity.... Other studies have associated dietary factors or sedentary
lifestyles with 22% to 30% of cardiovascular deaths, 20% to 60% of fatal
cancers, and 50% to 80% of diabetes mellitus cases, including 30% of
diabetes deaths. If the boundaries of these various estimates were summed,
they would yield a range of approximately 309,000 to 582,000 deaths in
1990 related to diet and activity patterns. Because of the complexity of
the issues and the difficulty of the analyses relating diet and activity
patterns to disease outcomes, the lower bound is used as the basis for the
300,000 deaths figure. (McGinnis JM, Foege WH, Actual Causes of Death in
the United States. JAMA, 1993;270:2207-2212) Emphasis added.
The figure of 300,000 to 582,000 deaths is compared to 400,000 deaths
from tobacco, 100,000 from misuse of alcohol, 90,000 from microbial
agents, 60,000 from toxic agents, 35,000 related to firearms, 30,000 due
to sexual behavior, 25,000 from motor vehicles, and 20,000 from illegal
use of drugs (see figure labeled, All Causes of Death in the U.S.
in Appendices).
Consistent with the McGinnis and Foege results, George Bray demonstrated
that:
In 1993 there were 1.25 million deaths from natural causes occurring in
American men and women who were 35 to 74 years of age and whose BMI was
greater than 21 kg/m2. Of this 1.25 million, 325,000 deaths could be
attributed to overweight in this population. Van Itallie estimates that
77,315 of 406,923 deaths caused by coronary heart disease and 34,413 of
55,110 caused by diabetes can be attributed to obesity. With a BMI of
greater than 30 kg/m2, more than 50% of all-cause mortality among the 18
million women and 16.7 million men in the United States aged 20 to 74
years can be attributed to overweight. (Bray G, Health Hazards of Obesity,
Endocrinology and Metabolism Clinics of North America. 1996;25(4):907-919)
b. Morbidity
Obesity is related to or associated with more than 30 diseases,
disorders, medical conditions, or complications including:
Arthritis
- Osteoarthritis of knee and hip
- Rheumatoid Arthritis
- Birth Defects
Cancers
4. Breast Cancer in Women
5. Breast Cancer in Men
6. Cancers of the Esophagus and Gastric Cardia
7. Colorectal Cancer
8. Endometrial Cancer
9. Renal Cell Cancer
10. Carpal Tunnel Syndrome
11. Cardiovascular Disease
12. Chronic Venous Insufficiency
13. Daytime Sleepiness
14. Deep Vein Thrombosis
15. End Stage Renal Disease
16. Gallbladder Disease
17. Gout
18. Heat Disorders
19. Hypertension
20. Impaired Immune Response
21. Impaired Respiratory Function
22. Infections Following Wounds
23. Liver Disease
24. Low Back Pain
25. Obstetric and Gynecological Complications
26. Pain
27. Severe Acute Biliary and Alcoholic Pancreatitis
28. Sleep Apnea
29. Stroke
30. Surgical Complications
31. Traumatic Injuries to Teeth
32. Type 2 Diabetes (NIDDM)
33. Urinary Stress Incontinence
34. Other
(For more detailed information, see Section 3D, below)
In addition, obesity has important relationships to mental disorders and
possibly to the initiation of smoking as a method of weight control in
adolescents.
Research on the relationship of obesity to mental disorders such as
depression, binge eating disorders, anorexia nervosa and bulimia is in the
early stages. Eating disorders may share common biological pathways with
obesity. (Ericsson JP et al, Common Biological Pathways in Eating
Disorders and Obesity. Addictive Behav, 1996;21(6):733-743; Rosmond R,
Bjorntorp P, Psychiatric Ill-Health of Women and Its Relationship to
Obesity and Body Fat Distribution. Ob Res, 1998;6(5):338-345, Yanovski SZ
et al, Association of Binge Eating Disorder and Psychiatric Co-morbidity
in Obese Subjects. Am J Psych, 1993;150;(10):1472-1479; Fairburn CG et al,
Risk Factors for Binge Eating Disorder. Arch Gen Psych, 1998;55:425-432)
Responsible education and prevention efforts on the risks of obesity
directed to children and adolescents need to take into account the level
of obesity-phobia in this population. Thus, messages of body acceptance
should consistently be structured with sound life-long patterns of caloric
intake and physical activity, and avoidance of harmful dieting practices.
Weight is also associated with the initiation of smoking among
adolescents, particularly adolescent girls who diet or who are concerned
about their weight. Girls who are concerned about their weight or who are
dieting are likely to use multiple methods for weight control, one of
which may be cigarette smoking. (French SA et al, Weight Concerns, Dieting
Behavior and Smoking Initiation Among Adolescents: A Prospective Study, Am
J Pub H, 1994;84:1818-1820) In addition, weight gain after cessation of
smoking is a concern to some smokers and should be addressed in smoking
cessation programs. (Williamson DF et al, Smoking Cessation and Severity
of Weight Gain in a National Cohort. NEJM, 1991;324:739-745)
c. Economic Costs
The total costs attributable to obesity, according to Wolf and Colditz,
amounted to $99.2 billion dollars in 1995. Approximately $51.64 billion of
those dollars were direct medical costs. The number of physician visits
attributed to obesity increased 88% from 1988 to 1994. It should be noted
that this study was limited to cost data from type 2 diabetes, coronary
heart disease, hypertension, gallbladder disease, breast cancer,
endometrial cancer, colon cancer and osteoarthritis. Costs attributable to
obesity are likely to be much higher, considering the other medical
conditions, of the more than 30 associated with obesity (birth defects,
carpal tunnel syndrome, gout, sleep apnea, etc.) that were not accounted
for in recent estimates.
The cost of lost productivity attributed to obesity was $3.9 billion
reflecting 39.2 million days of lost work, 239 million restricted-activity
days, 89.5 million bed-days, and 62.6 million physician visits
attributable to obesity in 1994. Compared with 1988 data, the number of
restricted-activity days (36), bed-days (28%), and work-lost days (50%)
increased substantially. (Wolf AM, Colditz GA, Current Estimates of the
Economic Cost of Obesity in the United States. Obes Res, 1998;6(2):97-106)
In a study of primary care practices in Michigan, overweight (in this case
27.3 for female and 27.8 for male) and severely overweight (32.3 for
female and 31.3 for male) patients made up 50% of all patients. This
estimate excludes patients diagnosed with diabetes and heart disease, and
thus indicates the impact of other medical conditions associated with
excessive weight. (Noel M et al, The High Prevalence of Obesity In
Michigan Primary Care Practices. J Fam Pract, 1998;47:39-43)
The direct health care costs of obesity is responsible for about 5.7% of
the U.S. National Health Expenditure. However, the direct health care
costs of obesity accounts for only 52% of the sum of the costs of obesity.
The indirect costs of obesity, not included in this 5.7% figure, account
for the other 48% of the sum. (Wolf AM, Colditz GA, Current Estimates of
the Economic Cost of Obesity in the United States. Obes Res,
1998;6(2):97-106)
In a health survey of members of a large health maintenance
organization, a clear association was found between BMI and annual rates
of inpatient days, number and costs of outpatient visits, costs of
outpatient pharmacy and laboratory services, and total costs. The authors
concluded that, "Given the high prevalence of obesity and the clearly
elevated disease risks and increased use of health services, there is
great potential for a reduction in health care expenditures through
efforts in weight reduction and prevention of weight gain."
(Quesenberry CP et al, Obesity, Health Services Use, and Health Care Costs
Among Members of a Health Maintenance Organization. Arch Intern Med,
1998;158:466-472) A similar study in a workplace setting demonstrated that
direct and indirect employer costs increase with increasing BMI. (Burton
WN et al, The Economic Costs Associated with Body Mass Index in a
Workplace. JOEM, 1998;40(9):786-792)
Criteria 4. Link to Objectives
"An indicator chosen as a leading health indicator should be
linked to one or more Healthy People 2010 objectives. The notion that this
set of key indicators may be used to reflect in some fashion both the
nature of the health objectives and the progress toward them requires that
they be linked to them and reflect their content"
Obesity is clearly linked to several objectives from other focus areas
in Healthy People 2010. The focus area objectives listed below
originate from the four larger objectives in the draft document, which are
to: promote healthy behaviors, promote healthy and safe communities,
improve systems for personal and public health, and prevent and reduce
diseases and disorders. The relationship of obesity to these focus areas
and objectives demonstrates the depth and breadth of the issue.
Promote Healthy Behaviors
Physical Activity and Fitness
1 Leisure time physical activity
2 Sustained physical activity
3 Vigorous physical activity
4 Muscular strength and endurance
5 Flexibility
6 Vigorous physical activity, grades 9-12
7 Moderate physical activity, grades 9-12
8 Daily school physical education
9 Physical education requirement in schools
10 School physical education quality
11 Inclusion of physical activity in health education
12 Access to school physical activity facilities
13 Worksite physical activity and fitness
14 Clinician counseling about physical activity
Nutrition
4 Fat intake
5 Saturated fat intake
6 Vegetable and fruit intake
7 Grain product intake
10 Worksite nutrition education
11 Nutrition assessment and planning
12 Nutrition counseling
13 Meals and snacks at school
14 Nutrition education, elementary schools
15 Nutrition education, middle/junior high schools
16 Nutrition education, senior high schools
17 Worksite nutrition education
18 Nutrition assessment and planning
19 Nutrition counseling
Tobacco Use
10 Advice to quit smoking
12 Providers advising smoking cessation
15 Worksite smoking policies
Promote Healthy and Safe Communities
Educational and Community-Based Programs
7 Patient satisfaction with health care provider communication
10 Community health promotion initiatives
11 Culturally appropriate community health promotion programs
12 Elderly participation in community health promotion
Injury/Violence Prevention
Unintentional Injuries
13 Nonfatal motor vehicle injuries
14 Worksite stress reduction programs
Occupational Safety and Health
3 Workplace injury and illness surveillance
4 Overexertion or repetitive motion
Improve Systems for Personal and Public Health
Access to Quality Health Services
1 (A.1) Uninsured children and adults
2 (A.2) Insurance coverage
3 (A.3) Routine screening about lifestyle risk factors
4 (A.4) Reporting on service delivery
5 (A.5) Training to address health disparities
6 (B.1) Source of ongoing primary care
7 (B.2) Failure to obtain all needed health care
9 (B.4) Access to primary care providers in underserved areas
11 (B.6) Preventable hospitalization rates for chronic illness
13 (C.2) Insurance coverage
17 (C.6) Follow-up mental health services
18 (D.1) Functional assessments
19 (D.2) Primary care evaluation
20 (D.3) Access to the continuum of services
Maternal, Infant, and Child Health
10 Prenatal care
26 Neural tube defects
29 Breastfeeding
34 Training in genetic testing
35 Understanding of inherited sensitivities to disease
36 Genetic testing
Medical Product Safety
1 Monitoring of adverse drug reactions
2 Approval of medical products
3 Response from managed care organizations regarding adverse drug
reactions
5 Drug alert systems
7 Complementary and alternative health care
8 Safety related labeling changes
9 Updates to drug alert systems
10 Patient information about prescriptions
Public Health Infrastructure
7 Tracking Healthy People 2010 objectives for select populations
8 Data collection for Healthy People 2010 objectives
9 Use of geocoding in health data systems
Health Communication
1 Public access to health information
4 Satisfaction with health information
Prevent and Reduce Diseases and Disorders
Arthritis, Osteoarthritis, and Chronic Back Conditions
Arthritis
10 Provision of Arthritis Education
Chronic Back Conditions
15 Activity Limitations
Cancer
3 Breast cancer deaths
4 Cervical cancer deaths
5 Colorectal cancer deaths
9 Provider counseling about preventive measures
Diabetes
1 Type 2 diabetes
14 End-stage renal disease
Disability and Secondary Conditions
10 Compliance with Americans with Disabilities Act
11 Environmental barriers
Heart Disease and Stroke
1 Coronary heart disease deaths
6 High blood pressure
7 Controlled high blood pressure
11 Blood cholesterol levels
Mental Health and Mental Disorders
4 Mental disorders among children and adolescents
Respiratory Diseases
Asthma
6 Patient education
Obstructive Sleep Apnea
18 Medical Evaluations
Criteria 5. Representative Indicators
"An indicator chosen to reflect the state of the Nation (or
subregion) on a particular health issue or condition should be
representative and offer an indication of the overall level and direction
or issues and problems embraced by that area or condition. That is, to the
extent possible, it should not reflect the problem from the perspective of
only a relatively narrow aspect or population group."
Obesity is relevant to most populations, children to the elder
population, and men and women of various ethnic backgrounds, as an
indicator of numerous health conditions and risk of premature death. The
scope of obesity is not at all narrow. In fact, health experts agree that
there exists an obesity epidemic. As defined by Stedman's Medical
Dictionary, an epidemic is "a disease attacking many people in a
community simultaneously." (Stedman's Medical Dictionary, 23rd ed.,
The Williams and Watkins Company, Baltimore, 1976) Further indicative of
obesity as a representative indicator is the broad array of health care
professionals that work together to research and treat the complex factors
involved in obesity: physicians, dietitians, exercise physiologists,
psychologists, behavior therapists, physiologists, and epidemiologists.
(Rippe JM, The Obesity Epidemic: Challenges and Opportunities. J Am Diet
Assoc, 1998;98(suppl 2):S5; Frank A, A Multidisciplinary Approach to
Obesity Management: The Physician's Role and Team Care Alternatives. J Am
Diet Assoc 1998;98(suppl 2):S44-S48; National Heart, Lung, and Blood
Institute. Clinical Guidelines on the Identification, Evaluation, and
Treatment of Obesity in Adults: The Evidence Report. NHLBI Obesity
Education Initiative Expert Panel on the Identification, Evaluation, and
Treatment of Obesity in Adults. Washington, DC: U.S. Department of Health
and Human Services, 1998)
Criteria 6. Measurable Data
"An indicator chosen as a leading health indicator should be
one for which data can be anticipated from an established data source on a
regular basis. Although some exceptions may pertain, this suggests that
the data should be collected on at least a biennial basis."
BMI is the preferred measure of excess weight to estimate relative risk
in epidemiological studies. It is inexpensive and efficient to collect,
requiring only the acquisition of body weight and height. Weight and
height are regularly collected in a variety of nationally representative
surveys such as the National Nutrition and Examination Surveys (NHANES)
and the National Health Examination Surveys (NHES). BMI correlates with
total body fat content, and morbidity and mortality, and can be applied
generally to adults. (National Heart, Lung, and Blood Institute. Clinical
Guidelines on the Identification, Evaluation, and Treatment of Obesity in
Adults: The Evidence Report. NHLBI Obesity Education Initiative Expert
Panel on the Identification, Evaluation, and Treatment of Obesity in
Adults. Washington, DC: U.S. Department of Health and Human Services,
1998) While percentages of BMI are preferred when evaluating excess weight
in children, collection of weight, height, age, and gender are only
necessary. (Troiano RP, Flegal KM, Overweight Children and Adolescents:
Description, Epidemiology, and Demographics. Pediatrics,
1998;101(3):497-504)
Criteria 7. Multilevel trackability
"An indicator chosen as a leading health indicator should be
one for which data can be anticipated at multiple levels and for multiple
groups. Specifically, data should be available at the national, State, and
county levels, as well as by age, gender, and ethnicity."
Researchers consistently use BMI in studies of all populations both in
the United States and internationally. NHANES is conducted by the National
Center for Health Statistics (NCHS) of the Centers for Disease Control and
Prevention (CDC). Both NHANES and NHES collect data on nationally
representative samples. The Behavioral Risk Factor Surveillance Survey
(BRFSS) and the Youth Risk Factor Behavior Survey provide data to assess
dietary and activity patterns, which also aid in determining overweight
and obesity prevalence.
For some medical conditions waist measurement, waist to hip ratio and
more sophisticated measures are used and preferred. However, such measures
are more difficult to obtain in large samples and less typically employed
in population studies.
Criteria 8. Sensitivity to change
"An indicator should be sensitive to change over a reasonably
short period of time."
Because BMI level can increase or decrease with a weight change of as
little as five to ten pounds, it is sensitive to change over a short
period of time. In addition, changes in metabolic and cardiovascular risk
factors with weight change have been reported to be linear. (Sjostrom CD,
Lissner L, Sjostrom LV, Relationships Between Changes in Body Composition
and Changes in Cardiovascular Risk Factors: The SOS Intervention Study.
Obes Res, 1997;5(6):519-530)
Criteria 9. Profile balance
"The set of indicators should reflect a balance among targets
that does not overemphasize any one group or condition. The set should
reflect contributing factors in a manner and frequency roughly
proportionate to their impact."
Obesity has been, and continues to be underemphasized. Obesity is a
disease with powerful effects on all-cause mortality, morbidity,
disability, and psychosocial functioning. Nevertheless, it still gets lost
among a few associated co-morbidities and only two of its causal factors:
physical activity and nutrition. The balance among targets can better be
achieved by including obesity.
Criteria 10. Relevance to Policy and Individual Action
"The set of indicators identified as the Nation's leading
health indicators should be useful in directing policy and operational
initiatives. That is, changes reported in the status of a measure from one
period to the next should offer lessons to the policy domain that are
readily interpretable, if not actionable. In addition, the indicators
should motivate action across multiple levels of the general population,
including families, individuals, and community groups."
As indicated in our recommended chapter on obesity (see Part III), we
are advocating numerous action steps at a national, regional, state and
local level for various sub-populations of obese individuals. Changes
reported on the leading health indicators allow for a continuous
monitoring of the effects that result from the action items in the
recommended objectives. Monitoring the state of the Nation's overweight
and obesity is particularly critical now, at the height of the obesity
epidemic, and must continue into the future.
a. Individual Action
Regular reporting on obesity will assist persons with obesity to realize
that the nation is concerned about their health and efforts for weight
reduction and/or weight maintenance. A great deal of current media
attention and commercial advertising overly focuses on the appearance
related aspect of obesity. By including obesity in the leading health
indicators and by implementing the related objectives that we propose, the
health effects of obesity and the importance of weight management would
be regularly emphasized and reinforced.
Intervention to achieve weight loss and sustain the loss over a long
period of time is generally perceived to be of limited success. However,
successful weight losers have not been the subjects of many research
studies. For some people weight loss and maintenance are achievable
through a combination of life long methods including restrictions on food
intake, physical activity, behavioral, surgical, and pharmacological
intervention. Education and support groups are also regarded as key
factors in successful weight loss programs.
One of the major benefits of inclusion of obesity in Healthy People
2010 will be to encourage overweight and obese individuals to continue
weight loss efforts. Many individuals are not aware that even a modest
loss of weight can improve their health as well as reduce health care
costs. In a study of patients in a primary care practice, a reduction of
weight by 15 pounds resulted in less frequent doctor's visits by
overweight persons (from 53% to 38%) and severely overweight persons (from
28% to 18%). (Noel M et al, The High Prevalence of Obesity In Michigan
Primary Care Practices. J Fam Pract, 1998;47:39-43)
b. Family Action
There is a familial aggregation of obesity cases which is thought to be
caused in part by the transmission of a genetic predisposition. This
genetic susceptibility often leads to childhood obesity. Moreover, the
home environment is no doubt important in the development of lifelong
patterns of nutrition and physical activity. Obesity as a leading health
indicator will reinforce the commitment on the part of families to monitor
and/or control the entire family's weight profile. (Written communication
from Claude Bouchard, Professor of Exercise Physiology at Laval
University's Physical Activity Sciences Laboratory in Quebec, Canada)
c. Community Groups
Communities in the United States have a major stake in obesity. As
exemplified in a letter from the Lexington-Fayette County Health
Department in Kentucky (see Appendices), communities are in search of new
initiatives to address the problem of obesity and to reverse the current
trend in increasing prevalence. Community development plays a critical
role in creating an environment that is either obesogenic or not.
Construction and proper maintenance of sidewalks, parks and recreation
areas, and safe streets for children and adults to walk to schools and
stores can promote more physically active communities. Contrarily, closed
environments such as malls and sports arenas offer food choices that are
mostly limited to those with low nutritional value - of high fat, high
caloric density - that contributes to weight gain.
B. Developing Leading Health Indicators: Answering Questions Posed
By The Department Of Health And Human Services
The Draft Report of Healthy People 2010 includes a section to
comment on specific questions regarding the development of leading health
indicators as posed by the Department of Health and Human Services. Those
6 questions follow below.
A. Are the criteria for leading health indicators adequate. If not,
in what way should they be modified.
Yes, the criteria are comprehensive and adequate.
B. Based on these criteria, what topics should be included in the
leading health indicators?
We propose and provide evidence in our comments to warrant the inclusion
of "obesity" as a leading health indicator.
C. Based on these criteria, what measures do you recommend including
in the leading health indicators?
We recommend Body Mass Index (BMI), the measure for obesity commonly
used by researchers, easily calculated requiring only measurements of
height and weight, and easily understandable by the general public. The
BMI has been widely used by advisory council members of the American
Obesity Association and elsewhere for epidemiological and clinical
purposes. Almost all of the current epidemiological reports use this
index, and it is also used as the basis for inclusion in many drug trials.
Specifically, we recommend a BMI equal to or greater than 30 to measure
obesity in the adult population, and a BMI of 25 or greater to measure
overweight.
D. How often should progress on the leading health indicators be
reported?
Progress should be reported annually to monitor trends in data.
E. In what ways has your organization or community used leading
health indicators? Please describe the experience.
"Leading health indicators may prompt enhanced public awareness of
the status and determinants of the health of the Nation." (Leading
Indicators for Healthy People 2010: A Report from the HHS Working Group on
Sentinel Objectives. U.S. Department of Health and Human Services, ODPHP,
March 1998) In 1998, the American Obesity Association (AOA) began its
National Campaign of Obesity Education to enhance public awareness of
obesity and its impact on the health of the Nation. As part of this
campaign, AOA designated the third week in September as Weight Wellness
Week with plans to continue this educational effort annually. Members,
health professional, and the media were encouraged to take this
opportunity to communicate to the public what we know about obesity,
related health risks, weight loss, and weight maintenance. The American
Obesity Association developed the Weight Wellness Profile (see Appendices)
to help individuals assess their risk of adverse health due to excess
weight.
F. In what ways might the leading health indicators be used by your
organization or community?
Education
We would expect to use the leading health indicator as a tool to
mobilize individual, family and community action to respond to the obesity
epidemic. Establishing obesity as a leading health indicator would likely
pave steps for a future in which information about obesity would be a more
integral part of health education campaigns such as AOA's Weight Wellness
Week. In addition to AOA's activities, other organizations and individuals
would be prompted to become involved in similar health promotion efforts.
Research
Expanding research on obesity in both the public and private sector is a
major goal of the AOA. It is expected that treatment of obesity as a
leading health indicator will help draw attention to this currently
neglected area. Furthermore, the education component requires currency of
research to develop greater understanding on the causation and treatment
of obesity.
Access to Quality Health Services
Another priority for AOA is expanding access to individuals with obesity
to receive health insurance, and weight loss and weight maintenance
services provided by health insurance programs. Many individuals with
obesity cannot obtain health insurance due to their weight. When they do
gain access, most insurance programs do not reimburse them for weight loss
or weight maintenance services including surgery and pharmacy benefits
even though they cover the co-morbid conditions. We expect to use obesity
as a leading health indicator to draw attention to the need to rectify
this inequitable situation.
Part II. Justification for Obesity as a Healthy People 2010
Focus Area and Chapter
1. Why Obesity Should be Treated as a Distinct Focus Area Under the
Objective "Prevent and Reduce Diseases and Disorders."
We are proposing that Obesity be treated in a distinct chapter under "Prevent
and Reduce Diseases and Disorders."
We believe that this treatment will strongly support the goals of
Healthy People 2010 to:
A. Increase the Years and Quality of Healthy Life, and
B. Eliminate Racial and Ethnic Disparities.
A. Impact of Obesity on Years and Quality of Healthy Life
1. Years of Healthy Life
Poor diet and inactivity is responsible for between 300,000 and 587,000
deaths a year, making it the second leading cause of preventable death in
the United States. (McGinnis JM, Foege WH, Actual Causes of Death in the
United States. JAMA, 1993;270:2207-2212) Solomon and Manson concluded
that, "Obesity is strongly predictive of mortality from all causes
combined, cardiovascular disease, and some cancers. Although some data
have suggested J- or U-shaped associations between BMI and mortality
risks, any apparent adverse effects of leanness appear to be markedly
attenuated or completely eliminated with appropriate control for
confounding by smoking and underlying disease." (Solomon CG, Manson
JE, Obesity and Mortality: a Review of the Epidemiologic Data. Am J Clin
Nutr, 1997;66(suppl)1044S-1050S)
In a recent review of data from the NHANES I Epidemiologic Follow-up
Study, the relation of BMI to mortality was examined among 14,407
individuals aged 25 to 74 years. This study found "consistent
evidence of a non-monotonic U-shaped relation between BMI and mortality
risk." (Durazo-Arvizu RA et al, Mortality and Optimal Body Mass Index
in a Sample of the US Population. Am J Epidemiol, 1998;147:739-749)
Mortality and morbidity data was presented in a 55 year follow-up of
overweight adolescents who participated in the Harvard Growth Study of
1922 to 1935.
After 55 years of follow-up, mortality from all causes and from coronary
heart disease, stroke, and colorectal cancer was greater among men who
were overweight in adolescence than among those who were lean. Overweight
in adolescence increased the risk of morbidity for several conditions in
men, women, or both, and compromised functional capacity in women. The
increased risk was independent of adult body-mass index for all morbidity
and mortality outcomes except morbidity from diabetes.
For men, the relative risks of death from all causes and death from
coronary heart disease were approximately two times higher among those who
had been overweight in adolescence than among those in a lean group. The
results were similar when a more restrictive definition of mortality from
coronary heart disease that included only myocardial infarction, angina
pectoris, and coronary artery disease was used.... For men, the survival
curves for mortality from all causes and from coronary heart disease
reveal poorer survival in the overweight groups starting at about 45 years
of age. (Must JA et al, Long-Term Morbidity and Mortality of Overweight
Adolescents. NEJM, 1992;327:1350-1355)
"The death rate increases in proportion to the degree of obesity:
Relative weights of 130% are associated with an excess mortality rate of
35% and relative weights of 150% a greater than two-fold excess death
rate. Patients with Ômorbid' obesity (relative weight>200%) have
as much as a ten-fold increase in death rate." (Current Medical
Diagnosis and Treatment 1998, Ed. by Tierney LM, McPhee SJ, Papadakis MA,
Appleton and Lange, Stamford, CT, p.1161)
An increased risk of sudden death has long been associated with severe
obesity (BMI > 40). Hippocrates made this observation initially more
than 2,000 years ago, and confirmation of this has been made by numerous
epidemiological studies including the Framingham and the Wadsworth
Veterans Administration study. In addition to sudden death, severe obesity
is also associated with cardiomyopathy, Pickwickian/sleep apnea syndrome,
pituitary/gonadal dysfunction, acanthosis nigricans, and osteoarthritis.
(Bray GA, Pathophysiology of Obesity. Am J Clin Nutr, 1992;55:488S-494S)
The incidence of sudden death unexplained by autopsy in persons with
severe obesity (BMI > 35) may be up to 40 times higher than the general
population (Sjostrom LV, Mortality of Severely Obese Subjects. Am J Clin
Nutr, 1992;55(2 Suppl):516S-523S)
Complications with most surgical procedures are higher for obese
patients, and there is an increase morbidity postoperatively. Similarly,
obese patients "are at a significant risk for poor outcome if they
sustain anything greater than trivial injuries." In blunt trauma
victims, the severely overweight have been shown to have a marked increase
in mortality due primarily to an increase in pulmonary complications.
Injury severity and BMI were found to be independent determinants of
outcome. (Choban PS et al, Obesity and Increased Mortality in Blunt
Trauma. J Trauma 1991;31;9:1253-1257) In a separate injury related study,
overweight burn victims were also determined to be at increased risk of
morbidity. The incidence of wound infection is higher with obesity as well
as the duration of mechanical ventilatory support. (Gottschlich MM et al,
Significance of Obesity on Nutritional, Immunologic, Hormonal, and
Clinical Outcome Parameters in Burns. J Am Diet Assoc, 1993;93:1261-1268)
2. Quality of Healthy Life
a. Quality of Life Indicators
The impact of obesity on the health related quality of life (HRQL) can
be measured with the widely used Medical Outcomes Study Short Form 36
Health Survey (SF-36), a self-administered 36 item questionnaire that
assesses 8 domains of functioning. Using the HRQL makes it possible to
quantify the magnitude of the effects of a particular medical condition
and to make comparisons with persons experiencing other medical ills or
with those having no medical condition.
Fontaine, Cheskin, and Brofsky reported more impairment on all eight
quality of life domains, especially bodily pain and vitality, in obese
persons (mean BMI of 38.1) when compared with general population norms.
Persons with a mean BMI of 48.7 reported significantly worse physical,
social, and role functioning, worse perceived general health, and greater
bodily pain than did either those with mean BMI's of 29.2 or 34.5.
Compared with patients in the other obesity severity classifications,
obese persons in the mean BMI category of 48.7 scored worse in all domains
except mental health and role limitations due to emotional problems. The
pattern of these results indicates that as weight increases, HRQL related
to the physical domains becomes more adversely affected.
Persons with obesity reported significantly greater disability due to
bodily pain than did patients with other chronic medical conditions with
the exception of migraine. The authors state, "Interestingly, obesity
had the most adverse effect on the bodily pain scale. Although obesity has
been known to be associated with musculoskeletal or joint-related pain,
the impact of this pain on functioning and well-being has not been
well-documented. Because the SF-36 bodily pain scale measures the severity
of pain as well as the extent to which it affects normal day-to-day
activities, it can serve as a marker of disability associated with
excessive body weight."
In summary, this study found that relative to U.S. population norms,
obese persons seeking university-based weight loss treatment reported
substantial decrements in HRQL, the impact of obesity on HRQL varied with
severity of obesity, and functional disability among obese persons due to
bodily pain was particularly common - comparable to that of chronic
migraine sufferers. (Fontaine KR, Cheskin LJ, Barofsky I, Health-Related
Quality of Life in Obese Persons Seeking Treatment. J Fam Pract,
1996;43(3):265-279).
b. Stigma
It is well established that persons with severe obesity suffer from
extraordinary stigma in our society. This is particularly true for obese
women, who appear to have far more prejudice and discrimination directed
against them than against obese men. Discrimination against the obese is
widespread and is found in such areas as: hiring and promotion
opportunities, acceptance to college, and official guidelines which limit
the weight of military personnel and commercial flight attendants. (Rand
CS, MacGregor AMC, Morbidly Obese Patients' Perceptions of Social
Discrimination Before and After Surgery for Obesity. So Med J, 1990;
83(12):13980-1395)
Further evidence of the magnitude and pervasiveness of social stigma
against obesity was compiled by Garner and Wooley:
ÔPublic derision and condemnation of fat people is one of the few
remaining social prejudices...allowed against any group based solely on
appearance...' (Fitzgerald FT, The Problem of Obesity. Ann Rev Med,
1981;32:221-231) It is well documented that obese people are denied
educational opportunities, jobs, promotions, and housing because of their
weight. (Bray GA, The Obese Patient. 1976, Philadelphia: W.B. Saunders;
Canning H, Mayer J, Obesity-Its Possible Effects on College Admissions.
NEJM, 1966;275, 1172-1174; Karris L, Prejudice Against Obesity Renters. J
Soc Psych, 1977;101:159-169) The affront to those who are obese goes
beyond the almost uniform judgment that they are unattractive. (Furnham A,
Radley S, Sex Differences in the Perception of Male and Female Body
Shapes. Pers Ind Diff, 1989;10:653-662) This includes negative stereotypes
that begin early in childhood. The aversion to obesity is evident by
kindergarten. (Lerner RM, The Development of Stereotyped Expectancies of
Body-Build-Behavior Relations. Child Dev, 1969;40:137-141; Lerner RM,
Gelbert E, Body Build Identification, Preference, and Aversion in
Children. Dev Psych, 1969;5:256-262) Grade-school children consistently
associate larger body shapes with adjectives such as Ôstupid,' Ôdirty,'
Ôlazy,' Ôsloppy,' Ômean,' Ôugly,' and Ôsad.'
(Maddox GL, Black K, Liederman V, Overweight as Social Deviance and
Disability. J Hlth Soc Beh, 1968;9:287-298; Stafferi JR, A Study of Social
Stereotype of Body Image in Children. J Per Soc Psych, 1967;7:101-104;
Stafferi JR, Body Build and Behavior Expectancies in Young Females. Dev
Psych, 1972;6:125-127; Wooley et al. Obesity and Women. II. A Neglected
Feminist Topic. Wom St Int Qtly, 1979a;2:81-92) (Garner, DM, Wooley, SC,
Confronting the Failure of Behavioral and Dietary Treatments for Obesity,
Clinical Psychology Review. 1991;11(6):729-780)
Persons with obesity, who are treated surgically and successfully reduce
weight view morbid obesity as an enormous personal liability. "Patients
who lost 100 lb or more and who successfully maintained weight loss for at
least three years following gastric restrictive surgery for morbid obesity
viewed their previous morbidly obese state as having been extremely
distressful. In spite of the strong proclivity for people to evaluate
their own worst handicap as less disabling than other handicaps, patients
said they would prefer to be normal weight with a major handicap (deaf,
dyslexic, diabetic, legally blind, very bad acne, heart disease, one leg
amputated) than to be morbidly obese. All patients said they would rather
be normal weight than a morbidly obese multimillionaire." (Rand CS,
MacGregor AM, Successful Weight Loss Following Obesity Surgery and the
Perceived Liability of Morbid Obesity. Int J Obes, 1991;15:577-579)
As reported by Rand and MacGregor, patients of obesity surgery
experience changes in their perception of social discrimination after
achieving weight reduction.
Preoperatively, patients reported experiencing an overwhelming amount of
prejudice and discrimination; postoperatively, patients reported
experiencing almost no prejudice or discrimination.... Preoperatively, 40%
or more of patients answered Ôalways' or Ôusually' to every
item describing acts of prejudice or discrimination and to the two items
on access to public facilities. More than 80% of the patients answered Ôalways'
or Ôusually' in the following four situations: ÔI feel that my
weight has negatively affected whether or not I have been hired for a job'
(86.9%); ÔAt work people talk behind my back and have a negative
attitude toward me related to my weight' (90.9%); ÔI do not like to
be seen in public because of my weight' (84.0%); and ÔBecause of my
weight I avoid fast food restaurants with booths' (80.6%).... No patient
reported the same degree of prejudice and discrimination experienced
preoperatively. (Rand CS, MacGregor AMC, Morbidly Obese Patients'
Perceptions of Social Discrimination Before and After Surgery for Obesity.
So Med J, 1990; 83(12):13980-1395)
"Harsh attitudes toward the obese depend on the assumption that
they bring their condition on themselves through lack of willpower and
self-control. In the face of the overwhelming social rejection, obese
individuals may seek professional support; however, research has shown
that health professionals share in the culture's pejorative view of
obesity and that this prejudice may influence their clinical judgment."
(Garner, DM, Wooley, SC, Confronting the Failure of Behavioral and Dietary
Treatments for Obesity, Clinical Psychology Review. 1991,11;6:729-780)
Studies indicate that their professional judgment is negatively influenced
by their client's weight. (McArthur LH, Ross JK, Attitudes of Registered
Dietitians toward Personal Overweight and Overweight Clients. J Am Diet
Assoc, 1997;1: 63-66; Agell G, Rothblum ED, Effects of Clients' Obesity
and Gender on the Therapy Judgments of Psychologists. Prof Psych Res Prac,
1991;22:3: 223-229.)
c. Disability
The quality of life of many persons with obesity is compromised by
functional limitations so severe that their ability to engage in
significant gainful occupations is lost or diminished. Mansson et. al.
concluded that "obesity in particular remains a risk factor of
disability and mortality. Severe overweight also affects risk of morbidity
in a wider context, quality of life and for society, increased costs of
health care and loss of productivity." (Mansson NO et al, Body Mass
Index and Disability Pension in Middle-Aged Men - Non-Linear Relations,
Int J Epid, 1996;25(1):80-85)
A recent report of the Cardiovascular Health Study, researchers studied
5,201 men and women, all white, to determine if high body mass or low
fat-free muscle mass was associated with an increased risk of disability.
The study found that a high fat mass at baseline resulted in a 2 to 3 fold
greater risk of being disabled three years later. In addition, fat mass
was positively associated with the severity of the disability. These
associations were similar for men and women and could not be explained by
physical activity, chronic illness, or other potential confounders, thus
establishing body fatness as an independent predictor of disability in old
age. (Visser M et al, High Body Fatness, But Not Low Fat-Free Mass,
Predicts Disability In Older Men and Women: The Cardiovascular Health
Study. Am J Clin Nutr, 1998;68:584-90)
There is a well-documented connection between obesity and employment
discrimination, and employment-related victimization. (Popovich PM,
Criteria Used to Judge Obese Persons in the Workplace. Percep Mtr Skills,
December 1997, Vol. 85, Pages 859-866; Rothblum ED, The Relationship
Between Obesity, Employment Discrimination, and Employment Related
Victimization. J Voc Beh, 1990;37: 251-266) The devastating employment
discrimination directed against persons with severe obesity is evident in
a study that assessed quality of life after obesity surgery. Eighty
percent of all preoperative patients and 84% of the female patients in
this group continued to be unemployed while those figures dropped to 53%
and 64% respectively, in the postoperative group. Overweight as the reason
for unemployment was more frequent in the preoperative group, whereas
full-time housekeeping was the main reason for unemployment in the
postoperative group. (Gemert WG et al, Quality of Life Assessment of
Morbidly Obese Patients: Effect of Weight-Reducing Surgery. Am J Clin Nutr
1998;67:197-201)
The chances of successful employment has been shown to increase after
weight-reducing surgery.
The higher employment rate and possibly job promotion resulted in a
higher yearly income of the overall postoperative group.... Several
studies on economic changes showed increased employment and income after
surgically induced weight loss. Hawke et. al. studied the physical
activity and social status of 240 patients 3 years after gastric
restrictive surgery. They found that full- and part-time employment
increased from 38% before to 60% after surgery. Naslund and Argren
compared the socioeconomic status of 79 patients after gastric restrictive
surgery with a similar group of 54 nonsurgical patients. After surgical
treatment, 81% of the patients were employed compared with 65% of the
nonsurgical patients. (Gemert WG et al, Quality of Life Assessment of
Morbidly Obese Patients: Effect of Weight-Reducing Surgery. Am J Clin Nutr
1998;67:197-201)
Stunkard and Wadden presented further data on employment discrimination.
Canning and Mayer reported lower acceptance rates into prestigious
colleges for obese high school students compared with normal-weight
students, even when controlling for all other relevant variables.
Similarly, Pargaman found obese students seriously underrepresented in a
private college. When they seek employment and on the job, obese persons
face further discrimination. Roe and Eickwort reported that 16% of
employers said that they would not hire obese women under any condition
and an additional 44% would hire them only under special circumstances. A
careful study of executives revealed that discrimination against the obese
is further manifested in their earning potential; it has been estimated
that each pound of fat cost an executive $1000/year. (Stunkard AJ, Wadden
TA, Psychological Aspects of Severe Obesity. Am J Clin Nutr,
1992;55:524S-532S)
B. Reduce and Eliminate Racial, Ethnic, Gender and Socioeconomic
Disparities
1. Racial and Ethnic Disparities
The second National Health and Nutrition Examination Survey, 1976-1980
(NHANES II) indicated that obesity is a greater problem for minority
populations than it is for whites, and a greater problem for women than it
is for men. (Van Itallie T, Health Implications of Overweight and Obesity
in the United States. Ann Int Med, 1985;103: 983-988; Manson JE, A
Prospective Study of Obesity and Risk of Coronary Heart Disease in Women.
NEJM, March 29, 1990;322:13, Pages 882-889, both cited in "
Pi-Sunyer, FX , Health Implications of Obesity, Amer J Clin Nutr,
1991;53(Suppl):1595S) The prevalence of obesity in many minority
populations in some cases exceeds the prevalence among whites threefold.
(Kumanyika SK, The Impact of Obesity on Hypertension Management in African
Americans. J Hlth Care Poor Und, 1997;8(3):352-365)
There is a particularly high prevalence of obesity in African American
women. (Kumanyika SK, The Impact of Obesity on Hypertension Management in
African Americans. J Hlth Care Poor Und, 1997;8(3):352-365) The
age-adjusted prevalence of overweight and obesity has been found to be
higher for non-Hispanic black women and for Mexican-American women than
for non-Hispanic white women. In middle age, non-Hispanic black women,
there appears to be a high prevalence (> 10%) of severe obesity (BMI
equal to or greater than 40), when compared with other groups. (Flegal KM
et al, Overweight and Obesity in the United States: Prevalence and Trends,
1960-1994. Int J Obesity, 1998;22:39-47) Available data for African
Americans indicate a high prevalence of obesity-related diseases including
cardiovascular diseases, cerebrovascular diseases, and osteoarthritis of
the knee. (Kumanyika SK, Special Issues Regarding Obesity in Minority
Populations, Ann Intern Med 1993;119(7 pt2):650-654)
Hispanic Americans, including Puerto Ricans, Mexican Americans and Cuban
Americans all have higher levels of obesity than U.S. non-Hispanic whites.
(Pawson IG et al, Prevalence of Overweight and Obesity in U.S. Hispanic
Populations. Am J Clin Nutr 1991, June, 53;(Supp. No. 6): 1522-1528S; Mein
S, Concerns and Misconceptions about Cardiovascular Disease Risk Factors:
A Focus Group Evaluation with Low-Income Hispanic Women," Hisp J Beh
Sc, 1998, May, 20(2):192) The prevalence of overweight (BMI >25)
was extremely high in Mexican-American men, 80.6% compared to the 55% of
overweight (age > 20 years) in the entire U.S. population. (Flegal KM
et al, Overweight and Obesity in the United States: Prevalence and Trends,
1960-1994. Int J Obesity, 1998;22:39-47)
The prevalence of type 2 diabetes among American Indians and Alaska
Natives is estimated to be more than twice that in the general population.
(Kumanyika SK, Special Issues Regarding Obesity in Minority Populations,
Ann Intern Med 1993;119(7 pt2):650-654) North American native populations
have a very high prevalence of obesity. (Harrison G, Obesity Among North
American Indians in Obesity Per Bjorntorp et al. eds., J.B. Lippincott Co.
1992, P 610; Gladwell M, The Pima Paradox. The New Yorker, February 2,
1998, P 45)
The American Dietetic Association has noted, "Minority women carry
a disproportionate burden of health problems. They suffer shorter life
expectancy, experience higher maternal and infant mortality, and have a
higher incidence of chronic diseases such as diabetes and hypertension.
Women's overall health status is further diminished by higher rates of
poverty, lack of education, and limited or nonexistent access to medical
care," (Position of the American Dietetic Association and the
Canadian Dietetic Association: Women's Health and Nutrition, ADA Reports,
1995, Mar. 95;3:362)
2. Effect of Obesity on Women
From childhood to old age, concerns about and reactions to excess weight
are important health as well as social issues for women. Obesity phobia is
so common among adolescent females that it has been described as a Ônormative
discontent' (Ryan YM et al, The Pursuit of Thinness: A Study of Dublin
School Girls Aged 15 Y. Intl J Obes, 1998;22:485-487) In this young
population, some of the social factors (see above section B2 on Stigma)
may be more important than health concerns, which can lead to
inappropriate dieting and eating disorders.
There are health risks to obese females that begin in young girls and
continue into the elder years. Obese girls have an earlier onset of
puberty than nonobese girls (Smith SR, The Endocrinology of Obesity. End
Met Cl N Am, 1996;25:921-942) Among middle aged women, body weight is
directly related to all-cause mortality. (Manson JE et al, Body Weight and
Mortality Among Women. NEJM, 1995;333(11):677-685) High BMI is a strong
predictor of long-term risk for mobility disability in older women which
persists even into old age. (Launer LJ, Body Mass Index, Weight Change,
and Risk of Mobility Disability in Middle-aged and Older Women. JAMA,
1994;271:1093-1098)
Across a number of co-morbid conditions, women are more affected than
men, minority women more affected than white women. Excess weight and even
modest adult weight gain substantially increases the risk for hypertension
in women. Weight loss reduces the risk. (Huang Z et al, Body Weight,
Weight Change, and Risk for Hypertension in Women. Ann Intern Med,
1998;128:81-88) Obesity and weight gain in women are risk factors for
ischemic but not hemorrhagic stroke (Rexrode KM et al, A Prospective Study
of Body Mass Index, Weight Change, and Risk of Stroke in Women. JAMA,
1997;277:1539-1545)
There are also a number of health issues due to gynecological
complications and health concerns during pregnancy. (see below section D23
on Health Effects, Obstetrical and Gynecological Complications and Birth
Defects) However, obese women are more likely to delay clinical breast
examinations, gynecologic examinations and PAP smears, thus undermining
many important preventive health measures. (Fontaine KR et al, Body Weight
and Health Care Among Women in the General Population. Arch Fam Med,
1998;7:381-384)
3. Effect of Obesity on Children and Adolescents
It has been estimated that the excess weight of the U.S. population is
2.5 billion pounds and increasing rapidly, particularly in American Youth,
an age group that is developing hypertension in adulthood as well as
higher concentrations of total cholesterol and higher lipoprotein rates.
In addition, overweight in adolescence is strongly predictive of increased
long-term morbidity and mortality, particularly regarding hypertensive
cardiovascular disease. (McCarron DA, Reusser ME, Body Weight and Blood
Pressure Regulation. Am J Clin Nutr 1996;63(suppl):423S-425S)
Between 1988 to 1994, approximately 13.7% of children and 11.5% of
adolescents were overweight, defined as having a BMI at or above gender-
and age-specific 95th percentile BMI cutoff points calculated at 6-month
age intervals. (see figure labeled Prevalence of Overweight Among
Children and Adolescents in Appendices). (National Heart, Lung, and
Blood Institute. Clinical Guidelines on the Identification, Evaluation,
and Treatment of Obesity in Adults: The Evidence Report. NHLBI Obesity
Education Initiative Expert Panel on the Identification, Evaluation, and
Treatment of Obesity in Adults. Washington, DC: U.S. Department of Health
and Human Services, 1998) "The prevalence of overweight did not vary
systematically with race-ethnicity, income, or education. Overweight
prevalence has increased over time, with the largest increase between
NHANES II (1976 to 1980) and NHANES III (1988 to 1994)." Examination
of the entire BMI distribution showed that the heaviest children were
markedly heavier in NHANES III than in the National Health Examination
Survey (NHES: cycle II (1963 to 1965) and cycle III (1966 to 1970)).
(Troiano RP, Flegal KM, Overweight Children and Adolescents: Description,
Epidemiology, and Demographics. Pediatrics, 1998;101:487-504)
There are correlations between childhood obesity and several medical
problems. In a study of obese children, 30% were found to have asthma, 25%
had elevated blood pressure, and 28% had hyperlipidemia. "The 30%
rate of asthma was significantly higher than the United States rate for
the general population which was 5% to 12%." (Hernandez B et al,
Prevalence and Correlates of Obesity in Preschool Children, J Ped Nurs,
1998;13(2):68-76) In addition to hypertension and hyperlipidemia, abnormal
glucose tolerance also occurs with greater frequency in children and
adolescents with obesity. "The incidence of NIDDM among adolescents
in Cincinnati appears to have increased 10-fold since 1982." In
addition, the prevalence of acanthosis nigricans, an increased thickness
and pigmentation of skin in intertriginous folds, may be as high as 25% in
obese children. (Dietz WH, Health Consequences of Obesity in Youth:
Childhood Predictors of Adult Disease. Pediatrics, 1998;101:518-525)
Behavioral and psychological problems are also related to childhood.
Some researchers have found that obese children and children with rapid
weight gain were more disorganized, withdrawn, intense, and less adaptable
than children who were of average weight, and were twice as likely to
require special education than their non-obese counterparts. (Hernandez B
et al, Prevalence and Correlates of Obesity in Preschool Children. J Ped
Nurs, 1998;13(2):68-76)
The social functioning of obese children can also be affected by the
stigmatization of obesity.
Children as young as 6 years describe obese children as Ôlazy,
dirty, stupid, ugly, cheats and liars. As they grow older, obese persons
find that they are less likely to be admitted to prestigious school, to
enter desirable professions, to receive equal pay for their work and
respectful treatment by their doctors. Of all conditions for which a
person may be stigmatized in our culture, the stigma of overweight may be
the most debilitating. Since obesity is immediately visible to others, it
can affect most social interactions. Furthermore, the stigma of overweight
has two aspects: stigmatization of the appearance of the body and the
stigmatization of the character of the person for the moral failure on not
controlling one's weight. (Sarlio-Lahteenkorva S et al, Psychosocial
Factors and Quality of Life in Obesity. Intl J Obesity, 1995;(19, Suppl.
6):S1-S5)
"Overweight during adolescence has social, economic and
psychological consequences, including effects on high school performance,
college acceptance and psychological functioning." In a prospective
study of 10,039 adolescents and young adults, evaluating social and
economic characteristics and self-esteem, overweight adolescents and young
adults were found to marry less often and have lower household incomes in
early adult life than their nonoverweight counterparts, regardless of
their socioeconomic origins and aptitude test scores. The authors conclude
that, "Overweight during adolescence and young adulthood has
important social and economic consequences that are more severe for women
than for men and greater than those associated with a variety of other
chronic conditions during adolescence." (Gortmaker SL et al, Social
and Economic Consequences of Overweight in Adolescence and Young
Adulthood. NEJM, 1993;329(14):1008-1012)
4. Obesity and Socioeconomic Status
Severe obesity is overrepresented in lower socio-economic groups and
among women. Obesity is inversely related to socioeconomic status in women
and is associated with both downward social mobility and lower levels of
socioeconomic attainment, further impairing the quality of life for
persons with severe obesity. (Sarlio-Lahteenkorva S et al, Psychosocial
Factors and Quality of Life in Obesity. Intl J Obesity, 1995(19, Suppl.
6); S1-S5)
Low-income women in some minority populations appear most likely to be
overweight.
For example, Mexican-American women ages 20 to 74 years, the
age-adjusted prevalence of overweight is 46% for women living below the
poverty line compared with 40% for those living above the poverty line;
comparable figures for non-Hispanic women are 39% and 25% for women below
and above the poverty line, respectively. (Kumanyika SK, Special Issues
Regarding Obesity in Minority Populations. Am Coll Phys, 1993:119(7
pt2):650-654)
In the young population, white adolescents in low income families were
found to be approximately 2.6 times as likely to be overweight compare
with middle- or high-income families. (National Center for Health
Statistics. Health United States 1998 with Socioeconmic Status and Health
Chart Book. Hyattsville, MD. DHHS Publication Number (PHS) 98-1232. 1998)
2. Health Effects of Obesity
We propose that "Obesity" be treated as a separate chapter in
the Healthy People 2010 section entitled, Prevent and Reduce
Diseases and Disorders for the following reasons:
- Obesity is a major threat to the health of the American people,
equal to or greater than the threat of tobacco.
- The current structure of Healthy People 2010 follows in the
footsteps of Healthy People 2000 wherein obesity is barely
mentioned and subsumed under several related sections (e.g. nutrition,
physical activity, diabetes, heart disease, etc.). This type of
structure has failed to stem the tide of increasing obesity and its
consequences to health. More emphasis is necessary and placing obesity
into a separate chapter is the minimum required.
- Inclusion of Obesity under the "Healthy Behaviors" section
of Healthy People 2010 is not desirable because it diminishes
the disease aspects of obesity and continues the perception that obesity
is solely a voluntarily incurred condition.
- The impact of Obesity on the health of all Americans is as
comparable to the impact of other diseases listed under separate
chapters such as Diabetes, Heart Disease, Cancer, HIV/AIDS, Sexually
Transmitted Diseases, etc.
- Recognition of Obesity as a disease would bring public perceptions
in line with the more recent scientific and medical understanding that
obesity is considered a chronic disease.
An argument might be made that the Draft Report of Healthy People
2010 adequately addresses the obesity epidemic. We would respectfully
disagree. The current format is flawed and is inadequate to deal with the
epidemic of obesity. (McGinnis, JM, Lee, PR, Healthy People 2000 at Mid
Decade. JAMA, 1995;273(14):1123-129)
Major diseases such as type 2 diabetes and heart disease are brought
about in significant part by obesity. However, treatment of these diseases
does not constitute a prevention strategy. With preventive strategies
being the hallmark of the Healthy People 2010 framework, it is
critical to clarify that the way to prevent conditions such as type 2
diabetes and heart disease is to reduce the level of obesity. Furthermore,
there are a host of other conditions associated with obesity that need due
recognition. A focus on obesity, with aggressive objectives designed to
reach selected sub-populations could have broad and far-reaching effects
beyond selected co-morbid conditions.
In 1985, the NIH recognized obesity as a disease at the NIH Consensus
Development Conference, and the following statement was made:
Current knowledge of human obesity has progressed beyond the simple
generalizations of the past. Formerly, obesity was considered fully
explained by the single adverse behavior of inappropriate eating in the
setting of attractive foods. The study of animal models of obesity,
biochemical alterations in man and experimental animals, and the complex
interactions of psychological and cultural factors that create
susceptibility to human obesity indicate that this disease in man is
complex and deeply rooted in biologic systems. Thus, it is almost certain
that obesity has multiple causes and that there are different types of
obesity. (NIH Consensus Conference, Feb. 11-13, 1985)
Obesity is an independent risk factor or an aggravating agent for more
than 30 conditions including:
Arthritis
- Osteoarthritis of knee and hip
- Rheumatoid Arthritis
- Birth Defects
Cancers
4. Breast Cancer in Women
5. Breast Cancer in Men
6. Cancers of the Esophagus and Gastric Cardia
7. Colorectal Cancer
8. Endometrial Cancer
9. Renal Cell Cancer
10. Cardiovascular Disease
11. Carpal Tunnel Syndrome
12. Chronic Venous Insufficiency
13. Daytime Sleepiness
14. Deep Vein Thrombosis
15. End Stage Renal Disease
16. Gallbladder Disease
17. Gout
18. Heat Disorders
19. Hypertension
20. Impaired Immune Response
21. Impaired Respiratory Function
22. Infections Following Wounds
23. Liver Disease
24. Low Back Pain
25. Obstetric and Gynecological Complications
26. Pain
27. Severe Acute Biliary and Alcoholic Pancreatitis
28. Sleep Apnea
29. Stroke
30. Surgical Complications
31. Traumatic Injuries to Teeth
32. Type 2 Diabetes (NIDDM)
33. Urinary Stress Incontinence
34. Other
Arthritis
1. Osteoarthritis
The most common form of arthritis is osteoarthritis (OA). The prevalence
of OA increases with age, and approximately 5% of the U.S. population is
affected with OA of the hip or knee. Of total hip and knee replacements,
more than 70% are for OA.
Overweight persons have consistently been shown, in population-based
studies of OA, to have higher rates of knee OA when compared to
nonoverweight control subjects. Obese women have almost four times the
risk of OA of lean women, and the risk in men was increased 4.8 fold, as
indicated in data from the first National Health and Nutrition Examination
Survey (NHANES I). (Felson DT, Weight and Osteoarthritis. Am J Clin Nutr,
1996; 63(suppl):430S-432S) Overweight is not only a risk factor in the
cause of OA, but is implicated in increasing disability once arthritis is
present. " This modifiable risk is implicated not only in arthritis
etiology but continues to be important in its functional consequences."
(Verbrugge LM, Risk Factors for Disability Among U.S. Adults with
Arthritis. J Clin Epidemiol, 1991;44(2):167-182)
Hip Osteoarthritis
Obesity has been found to be an independent risk factor for hip OA,
which is a major cause of pain and disability. The risk of osteoarthritis
significantly increased with BMI. The relation of obesity and hip
osteoarthritis was found in both men and women. (Cooper C et al,
Individual Risk Factors for Hip Osteoarthritis: Obesity, Hip Injury, and
Physical Activity. Am J Epidemiol, 1998;147:516-522)
Knee Osteoarthritis
Osteoarthritis of the knee probably has greater social costs and more
associated disability than OA of any other joint. The majority of older
Americans are affected by knee OA. Obesity has been shown to precede the
development of knee OA rather than resulting from the inactivity of OA
patients.
Researchers of the Framingham Study, using data collected for more than
35 years, demonstrated an association between obesity and knee OA.
Specifically, the results of the study indicate that OA was stronger in
women than in men in that there was a stepwise increase in OA with each
quintile increase in weight. (Felson DT, Obesity and Knee Osteoarthritis:
The Framingham Study. Ann Int Med, 1988;109:18-24)
This was confirmed by an investigation in 1997 which pointed to studies
showing that obese women had almost four times the risks of osteoarthritis
as lean women. For men, the risk increased to 4.8 fold. Persons with
obesity appear to be at especially high risk of bilateral as opposed to
unilateral knee OA. Persons with obesity have a high risk of experiencing
disease progression. People who are overweight may also be at higher risk
of hand OA than those who are not overweight. (Felson DT, Understanding
the Relationship Between Body Weight and Osteoarthritis. Ball Clin Rheum,
1997;11:671-681)
2. Rheumatoid Arthritis
Rheumatoid arthritis (RA) is a chronic autoimmune disease of which the
causes are unknown. In a population-based case-control study, obesity was
found to be associated with RA in both men and women, although the risk
seemed to be confined to the obese and not the overweight. (Symmons DPM et
al, Blood Transfusion, Smoking, and Obesity as Risk Factors for the
Development of Rheumatoid Arthritis. Arth Rheum, 1997;11:1955-1961) These
findings appear to confirm an earlier in which women in the highest
quartile of BMI had a higher risk of RA compared to women with the lowest
BMI. (Voigt LF et al, Smoking, Obesity, Alcohol Consumption, and the Risk
of Rheumatoid Arthritis. Epidemiology, 1994;5:525-532)
3. Birth Defects
The incidence of obesity during pregnancy is reported to be between 6%
and 10%, and possibly as high as 17%. Maternal obesity has been associated
with an increased incidence of neural tube defects (NTD). An increased
incidence of NTD in the offspring of obese women (BMI greater than 29) who
received folate during pregnancy was reported in one study. In a
comparison of lean and obese mothers in this study, an almost threefold
risk of having a child with NTD was found for the heaviest women. (Morin
KH, Perinatal Outcomes of Obese Women: A Review of the Literature. JOGNN,
1998;27(4):431-440)
Women whose BMI was 31 or greater, compared with a reference group, have
been found to be at an increased risk of having an infant with NTD, spina
bifida, non-neural tube defects of the central nervous system, great
vessel defects, ventral wall defects and other intestinal defects. (Waller
DK et al, Are Obese Women At Higher Risk For Producing Malformed
Offspring? Am J Obstet Gynecol, 1994;170:541-548) Kallen provided further
support for the association between maternal BMI and NTDs, especially
Spina Bifida. (Kallen K, Maternal Smoking, Body Mass Index, and Neural
Tube Defects. Am J Epidemiol 1998;147:1103-1111)
Cancers
4. Breast Cancer in Women
Studies analyzing the relationship of obesity to breast cancer have had
inconsistent results, however, recent research has clarified this issue.
The Nurses' Health Study investigated 95,256 nurses, aged 30 to 55, for 16
years concluding that adult weight gain (after age 18) was associated with
breast cancer incidence after menopause, although unrelated before
menopause. However, a stronger relationship was seen among postmenopausal
women who never used hormone replacement therapy.
"Current BMI and weight gain were even more strongly associated
with fatal postmenopausal breast cancer. In this population, the
percentage of postmenopausal breast cancer accounted for by weight gain
alone was approximately 16% and by hormone replacement therapy alone was
5% but when the interaction between these variables was considered,
together they accounted for about one-third of postmenopausal breast
cancers." (Huang Z et al, Dual Effects of Weight and Weight Gain on
Breast Cancer Risk. JAMA, 1997;278(17):1407-1411)
Women with BMIs of >28-30, had a relative risk estimate for
postmenopausal breast cancer that ranged from 1.2 to 1.5, leading to
postmenopausal breast cancer-attributable risk estimates of 9-21% due to
overweight. These risk estimates are comparable to family history as a
risk factor. (Ballard-Barbash R, Swanson CA, Body Weight: Estimation of
Risk for Breast and Endometrial Cancers. Am J Clin Nutr,
1996;63(suppl):437S-41S)
5. Breast Cancer in Men
The risk of male breast cancer is significantly increased by obesity,
whether evaluated by usual adult weight, BMI, or perceived overweight. An
estimation for 1997 was made that 1,400 new cases and 290 deaths would be
attributed to breast cancer in men. As with female breast cancer, there
are also suggested links to socioeconomic status, dietary factors and
exercise. (Hsing AW et al, Risk Factors From Male Breast Cancer (United
States). Canc Caus Con, 1998;9:269-275)
6. Cancers of the Esophagus and Gastric Cardia
In the past 15 years, there has been a rapid increase in the United
States and Western Europe in the incidence of adenocarcinomas of the
esophagus and gastric cardia, which had previously been rare. Between 1976
and 1990, the rate of esophageal adenocarcinomas among white males
tripled, data which was derived from nine population-based cancer
registries in the U.S. "Although, the incidence among black males and
among females of both racial groups is substantially lower than it is
among white males, it now appears that rates in these groups is increasing
just as rapidly."
As of yet the reason for this increase in incidence is unexplained.
However increased abdominal girth is hypothesized to promote
gastroesophageal reflux. which, in turn, is a known risk factor for
Barrett's metaplasia, a precursor lesion in the development of esophageal
adenocarcinoma. Population-attributable risk estimates for adenocarcinomas
were 34% for smoking, 10% for alcohol consumption of 7 or more
drinks/week, and 18% for BMI above the 50th percentile. All three factors
accounted for 50% of the adenocarcinoma cases observed in the population.
The authors noted that smoking and alcohol consumption cannot account for
the increasing incidence but that the increasing incidence of obesity can
account for the changes. (Vaughan TL et al, Obesity, Alcohol, an Tobacco
as Risk Factors for Cancers of the Esophagus and Gastric Cardia:
Adenocarcinoma Versus Squamous Cell Carcinoma. Can Epid Bio Prev,
1995;92(4):85-92)
7. Colorectal Cancer
Colorectal cancer is a disease that predominantly occurs in Westernized
countries, with approximately two-thirds of the world's cases found in
developed countries. Obesity, caloric intake, and physical activity, all
aspects of a Western society, are independently associated with the risk
of colorectal cancer. The highest risk group was found to be overweight
persons with high caloric intake and little physical activity. (Le
Marchand L et al, Associations of Sedentary Lifestyle, Obesity, Smoking,
Alcohol Use, and Diabetes with the Risk of Colorectal Cancer. Can Res,
1997;57:4787-4794)
Results of a large case-control study, demonstrated an association
between colorectal cancer risk and BMI at various ages in men. In women,
high waist-to-hip ratio, indicative of abdominal obesity, represented a
significant risk factor as opposed to BMI. (Russo A et al, Body Size and
Colorectal-Cancer Risk. Int J Can, 1998;78:161-165)
8. Endometrial Cancer
Numerous epidemiological studies have reported a two-fold to ten-fold
increased risk of endometrial cancer in overweight women, irrespective of
the distribution of body fat. (Folsom AR et al, Association of Incident
Carcinoma on the Endometrium with Body Weight and Fat Distribution in
Older Women: Early Findings of the Iowa Women's Health Study. Can Res
1989;49:6828-6831) Women with BMIs of 28-30 range have relative risk
estimates for endometrial cancer ranging from 2.0 to 3.5, leading to
endometrial cancer-attributable risk estimates of 34-56% due to
overweight. (Ballard-Barbash R, Swanson CA, Body Weight: Estimation of
Risk for Breast and Endometrial Cancers. Am J Clin Nutr,
1996;63(suppl):437S-41S) Obese women with diabetes have approximately a
threefold increase in risk above that attributed to body size alone.
(Shoff, SM, Newcomb PA, Diabetes, Body Size, and Risk of Endometrial
Cancer. Am J Epidemiol, 1998;148:234-240)
9. Renal Cell Cancer
The incidence of renal cell cancer (or kidney cancer) has been
increasing in the United States. The Iowa Women's Health Study, the
largest reported cohort study of renal cell carcinoma among women,
confirmed previous reports that obesity is a risk factor for renal cancer.
(Prineas RJ et al, Nutrition and Other Risk Factors for Renal Cell
Carcinoma in Postmenopausal Women. Epidemiology, 1997;8:31-36; Muscat JE
et al, The Epidemiology of Renal Cell Carcinoma. Cancer,
1995;75:2552-2557; Lindblad P et al, The Role of Obesity and Weight
Fluctuations in the Etiology of Renal Cell Cancer: A Population-based
Case-Control Study. Can Epidem Bio Prev, 1994;3:631-639) Risk of renal
cell carcinoma for women was found to increase with increasing BMI. The
highest risk, 30-50%, for men was found in the upper deciles of weight or
BMI. (Chow WH et al, Obesity and Risk of Renal Cell Cancer. Can Epidem,
1996;5:17-21)
Malignant kidney tumors in the U.S. rank about 10th in cancer incidence
and mortality. An estimation for 1998 was made, and included 29,900 new
diagnosed cases and nearly 12,000 deaths of patients with renal cancer. In
a population-based case-control study in Minnesota, the population
attributable risk for the three main risk factors were 21% of
hypertension, 21% for excess weight and 18% for smoking. These factors
accounted for 49% of cases. The risk of renal cell cancer increased with
BMI, and BMI was found to be the risk factor with the greatest impact on
women. (Benichou J et al, Population Attributable Risk of Renal Cell
Cancer in Minnesota. Am J Epidem, 1998;148:424-430)
10. Cardiovascular Disease
"Obesity is an important determinant of cardiovascular disease
(CVD)." The effects of obesity on cardiovascular health and disease
are many, and can begin in childhood. Obese children have an elevated risk
of developing cardiovascular disease in adulthood.
Risk factors of CVD include elevated total cholesterol and LDL
cholesterol (LDL-C), low levels of HDL cholesterol (HDL-C), and elevated
blood pressure. Obesity has a strong effect on lipoprotein metabolism. "Increased
weight is a determinant of higher levels of triglycerides, elevated LDL-C,
and low HDL-C." Weight loss has a beneficial effect resulting in
healthier lipoprotein profile in both men and women: triglycerides
decrease, HDL-C increases, and LDL-C decreases. (Krauss RM et al, Obesity:
Impact on Cardiovascular Disease. Circulation, 1998;98:1472-1476)
In middle and old age groups, researchers found that heavier weight was
positively associated with CVD and its risk factors, particularly for
women. At age 50, heavier weig
