November 25, 1998  

Donna Nagle
U.S. Department of Education
600 Maryland Ave. S.W.
Room 3418
Switzer Bldg.
Washington, D.C. 20202-2645

RE:  Long Range Plan, National Institute on Disability and Rehabilitation Research

Dear Ms. Nagle:

The American Obesity Association (AOA) is pleased to comment on the proposed Long Range Plan of the National Institute on Disability and Rehabilitation Research (Fed. Reg. October 26, 1998).

Obesity has a profound effect on disability. Obesity, especially at a severe level, is itself disabling. More frequently, obesity at lower levels is an independent risk factor for over 30 conditions many of which are disabling, e.g. cancers, stroke, diabetes, etc. Finally, many persons with an existing disability may become obese (often due to activity limitations) and thus compound the existing health and disability issues.

Furthermore, as the prevalence of obesity continues to skyrocket in this country, we will see more and more cases of obesity-related disabilities. This is especially urgent in regard to children and adolescents. Rates of obesity in these populations are increasing at an alarming rate. This means that the adverse consequences of obesity will occur earlier and continue for a longer period of time with far greater costs and levels of disability.

Yet, for these profound effects, obesity as a disabling condition or causal factor is largely ignored by the disability community. It is not the purpose here to explore the reasons for this neglect. Rather, the American Obesity Association would like to take this opportunity to inform the NIDRR of the extent and seriousness of obesity-related disability to better inform the Long Range Plans proposed.

The announcement of the Long Range Plan provides AOA an opportunity to raise several important concerns:

            1. Obesity is increasing overall in the United States population, includin children.          Its serious health consequences have a disproportionate effect on minorities, women, children, the aging population and those in lower socioeconomic status.

2. Obesity, in terms of disability research and policy, is marked by (A) extreme social stigma, (B) employment discrimination (C) education (D) impaired quality of life and (E) impaired mobility.

            3. Traditional disability research and advocacy has largely ignored the role of    obesity.

            4. Specific Comments on NIDRR Long Range Plan

Our statement is organized to elaborate on these assertions.

Throughout these comments we will refer to the disability effects of excess body fat as measured by the Body Mass Index. The Body Mass Index or BMI expresses the relationship between weight and height and is used to asses morbidity and mortality associated with excess body fat. BMI is frequently used by researchers and clinicians. However, it should be noted that other measures are useful in determining risks of excess body weight, such as waist-hip ratios, waist circumference and percentages of body fat. The disadvantage of the percent-of-ideal weight tables is that they were developed primarily using a Caucasian, higher socioeconomic status population.  In addition, they are based on mortality outcomes and are not necessarily a predictor of morbidity.

1. Obesity is increasing overall in the United States population, including children. Its serious health consequences have a disproportionate effect on minorities, women, children, the aging and those in lower socioeconomic status.

A. Prevalence

Obesity has been described by the World Health Organization as 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)

The prevalence of obesity in the United States has increased from 25% of the adult population in the second National Health and Nutrition Examination Survey (NHANES II, 1976 to 1980) to approximately 35% of the adult population in the NHANES III survey (1988 to 1991).  This represents an absolute increase in prevalence of 10% and a relative increase of 40%.

Increases in obesity have occurred across virtually all ethnic, racial, and socioeconomic populations and all age groups.  Certain minority populations, particularly minority women, have been found to be at the greatest risk for obesity and hence, its co-morbidities.  In NHANES III, nearly 50% of all African-American and Mexican women surveyed were obese.  Within the 45- to 55-year-old age group, the prevalence of obesity was between 60% and 70%.  The Healthy People 2000 objective for obesity established in 1990 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)

An estimated 97 million adults in the United States are overweight or obese, a condition that substantially raises the risk of morbidity from approximately 32 conditions including, in part, hypertension, dyslipidemia, type 2 diabetes, coronary heart disease, stroke, gallbladder disease, osteoarthritis, sleep apnea, respiratory problems, and endometrial, breast and colon cancer. Higher body weights are also associated with increases in all-cause mortality.  Obese individuals also 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)

The World Health Organization Consultation of Obesity has stated:     

The Consultation concluded that global epidemic projections of obesity for the next decade are so serious that public health action is urgently required. Analyses show that merely concentrating on children and adults who have a high BMI and associated health problems will not stem the escalating numbers of people entering the medically defined categories of ill health. It is thus essential to develop new preventive public health strategies which affect the entire society. 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)

B. Women

Weight and women have strong correlations. From childhood to old age, concerns about and reactions to excess weight are important health as well as social issues. Obesity phobia is so common among adolescent females that it has been described as a ‘normative discontent’ (Ryan YM, The pursuit of thinness: a study of Dublin school girls aged 15 y, 1998, Intl J Obesity 22:485-487.) Obese girls have an earlier onset of puberty than nonobese girls (Smith SR, The Endocrinology of Obesity, Endocrinology and Metabolism Clinics of North America, 1996, 25:921-942)

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) Excess weight and even modest adult weight gain substantially increases the risk for hypertension in women. Weight loss reduces the risk. (Huang, 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, A Prospective Study of Body Mass Index, Weight Change, and Risk of Stroke in Women, JAMA, 1997;277:1539-1545) Body weight and mortality from all causes is directly related among middle aged women (N Engl J Med, 1995, 333:677-685) Across a number of co-morbid conditions, women are more effected than men, minority women more effected than white women.

Obese women are more likely to delay clinical breast examinations, gynecological examinations and PAP smears, thus undermining many important preventive health measures. (Fontaine, KR, body Weight and Health Care Among Women in the General Population, Arch Fam Med, 1998;7:381-384)

In addition to the relationship between maternal obesity and neural tube defects (see Birth Defects, below in Health Effects Section), maternal obesity has been associated with “an increased risk of pregnancy complications and fetal and neonatal mortality. Maternal obesity coexists with a number of medical and behavioral risk factors and is more prevalent in women of low socioeconomic status, itself a risk factor for poor pregnancy outcome. In a recent review, Abrams and Parker reported that obese women were seven times more likely to have diabetes, four times more likely to manifest essential hypertension, and twice as likely to develop pregnancy-induced hypertension than were lean women. In addition, during pregnancy, obesity has been shown to be a risk factor of urinary tract infection, preeclampsia, and cesarean delivery. Using data from the Collaborative Perinatal Study, which involved nearly 60,000 women from 1959 to 1966, Naeye reported that perinatal mortality rates progressively increased from 37 per 1000 deliveries among lean women to 121 per 1000 deliveries among obese women. (Editorial, Pregnancy Weight and Pregnancy Outcome, Goldenberg RL, JAMA, April 10, 1996, 275:1127-1128)

Obesity in pregnancy brings a number of health issues, (see below Section on Health Effects, Obstetrical and Gynecological Complications and Birth Defects)

C. Minorities

The National Health and Nutrition Examination Survey, 1976-1980 (NHANES II) found 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 Medicine, 1985;103: 983-988 and 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, June 1991; 53, (Supplement): 1595S.) Hispanic Americans, including Puerto Ricans, Mexican Americans and Cuban Americans all have higher levels of obesity than U.S. non-Hispanic whites.  (Pawson IG, Prevalence of Overweight and Obesity in U.S. Hispanic Populations, Am J. Clin Nutr 1991, June, Vol. 53, (Supplement, No. 6) Page 1525S.) ( Mein S, Concerns and Misconceptions about Cardiovascular Disease Risk Factors:  A Focus Group Evaluation with Low-Income Hispanic Women," Hispanic Journal of Behavioral Sciences, 1998, May, Vol. 20;  2:192.)

Prevalence data for non-Hispanic whites indicates that obesity affects approximately one in four adults. The prevalence of obesity in many minority populations in some cases exceeds the prevalence among whites threefold.

Low income women in some minority groups, such as among Mexican-American women, show the greatest disparity.

As a result, minority populations have a relatively higher prevalence of obesity-related diseases than do white populations, particularly diabetes mellitus.

The prevalence of diabetes among American Indians and Alaska Natives is estimated to be more than twice that in the general population. Available data for black Americans indicate a high prevalence of obesity-related diseases including cardiovascular diseases, cerebrovascular diseases, and osteoarthritis of the knee. (Kumanyika, Shiriki, 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.  ("Obesity Among North American Indians," Gail G. Harrison, in Obesity (Per Bjorntorp et al. eds., J.B. Lippincott Co. 1992) Page 610.) ("The Pima Paradox," Malcolm Gladwell, The New Yorker, February 2, 1998, Page 45.)

There is also a particularly high prevalence of obesity in African American women.  (Kumanyika, SK, "The Impact of Obesity on Hypertension Management in African Americans," Journal of Health Care for the Poor and Underserved, 1997, Vol. 8;3:353.)

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)           

D. Children

Approximately 11% of children and adolescents were overweight in 1988 to 1994, and an additional 14% had a BMI between the 85th and 95th percentiles. The prevalence of overweight did not vary systematically with race-ethnicity, income, or education. Overweight prevalence increases over time, with the largest increase between NHANES II and NHANES III. Examination of the entire BMI distribution showed that the heaviest children were markedly heavier in NHANES III than in NHES, but the rest of the distribution of BMI showed little change. (Troiano, RP, Overweight Children and Adolescents: Description, Epidemiology, and Demographics, Pediatrics, 1998;101:487-504)

It has been estimated that the excess weight of the US 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 with 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, Body Weight and blood pressure regulation, Am J Clin Nutr 1996;63(suppl):423S-425S)

Health problems may be correlates of childhood obesity. White children with elevated blood pressure had a greater percentage of body fat than did African American children. In one study of obese children 30% had 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%. Behavioral and psychological problems have been related to childhood obesity by a number of researchers. Some researchers have found that obese children as well as children with rapid weight gain were more disorganized, withdrawn, intense, and less adaptable than children who were of average weight. Obese children were twice as likely to be in special education than their non-obese counterparts. (Hernandez, B, Prevalence and Correlates of Obesity in Preschool children, J Ped Nurs, 1998;13(2):68-76)

 “In affluent societies, obese people are subject to intense prejudice and discrimination. Numerous studies have documented the stigmatization of obese persons in most areas of social functioning. Children as young as 6 years describe obese children as ‘lazy, 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, Psychosocial Factors and Quality of Life in Obesity,  Intl. Journal of 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 performance. One study found a greater prevalence of overweight among women who were downwardly mobile socially than among those who were upwardly mobile. In a prospective study of 10,039 adolescents and young adults, their social and economic characteristics and self-esteem were evaluated over seven years. The results indicated that overweight adolescents and young adults 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, “Evidence from several studies indicates that obese persons, particularly women, are highly stigmatized in the United States. There is evidence of discrimination against obese person, including “employer prejudice, and lower-than-expected levels of occupational attainment among overweight workers.” (Gortmaker, SL, Social and Economic Consequences of Overweight in Adolescence and Young Adulthood, , NEJM, 1993, Sept. 329;14:1008-1012)

The effect of obesity on educational attainment is greatly understudied. In one such effort, researchers examined the effects of obesity on school performance of black urban elementary school children. Their findings suggested behavioral differences between obese and non-obese black children, including sex problems, being more disorganized, withdrawn and intense and less adaptable. A “notable” finding in this study was that obese children were twice as likely to be in a special education or remedial education setting than non-obese children. (Obesity, school performance and behavior of black, urban elementary school children, Tershakovec, AM, Intl. J Obes, 1994, 18:323-327)

E. 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, Psychosocial Factors and Quality of Life in Obesity, Int. J. Obesity Related Metabolic Disorders, 1995; Nov. 19 Supp. 6:S1-S5)

F. Aging Population

In an investigation of the relationship between body mass index, weight change and the onset of disability in older women in which the BMI range for the two cohorts in this study was 22.9 to 28, the author notes:

Several avenues of study point to the contribution of body weight to the development of disability in older persons.  High body mass index (BMI) , a measure of weight standardized for height, has been shown to be positively associated with prevalent disability, with new disability pensions issued to young and middle-aged adults, and with short-term risk for developing problems in physical functioning among the oldest-old.  Other studies have shown an increased risk for disability in association with diseases related to weight status, including cardiovascular disease, arthritis, diabetes, and pulmonary disease.  These studies suggest an important long-term contribution of body weight to the onset of disability in older women, although none have addressed this issue....In both cohorts, the crude rate of incident disability increase with level of past BMI.  After adjustment for age, education, cigarette smoking, and study time, high past BMI was associated with a twofold increase in the risk of disability while mid past BMI was positively but nonsignificantly associated with disability....High BMI may influence the risk for disability in several ways, including increasing wear and tear on various joints or reducing the flexibility of movement.  High BMI may also be a proxy for inactivity and disuse, which lead to a reduced capacity or reserve in neurological and musculoskeletal systems and functional decline.  High BMI may also increase the risk for diseases that may have a more direct impact on the development of disability... This study suggests that a high BMI is an important contributor to disability and should be of major concern in the attempt to compress morbidity in later years. (Launer, LJ, Body Mass Index, Weight Change, and Risk of Mobility Disability In Middle-aged and Older Women,  The Epidemiologic Follow-up Study of NHANES I, JAMA, 1994, 27;114: 1093-1098)

Similarly, in the Swedish Obesity Study (in which obesity was defined as a BMI of 30 or greater):

BMI proved to be associated with risk of disability pension and also with mortality.  These findings support the results gained by other investigators, who found that overweight increased the risk for early retirement.  The high pension rate among the obese men was, as expected, mainly a result of an increased morbidity in illnesses that are related to obesity, e.g., diseases of the circulatory and musculoskeletal systems.  The risk of disability from mental disorders was increased as well, a finding contradictory to previous results....Thus, according to the findings in this study, obesity in particular remains a risk factor for disability and mortality. Severe overweight also affects risk of morbidity in a wider context, quality of life and for society, increased costs for health care and loss of productivity.  (Mansson N, Body Mass Index and Disability Pension in Middle-Aged Men - Non-Linear Relations, International Journal of Epidemiology, 1996,25;1:80-85)

G. Health Effects

The adverse health effects of obesity are not well understood in general and in the disability community in particular. Obesity can create disability in several ways. A major aspect of this is the relationship of obesity to birth defects, cancers, heart disease, stroke, arthritis (rheumatoid, knee and hip), trauma etc.

Finally, an individual who is not obese at the outset of an event or disease causing a state of disability may subsequently become obese due to inactivity and poor diet, thus compounding the aspects of the first disability.

Obesity is an independent risk factor or an aggravating agent for some 32 conditions. They are:

1.     Birth Defects

            2.     Breast Cancer in Women

            3.     Breast Cancer in Men

            4.     Cancers of the Esophagus and Gastric Cardia

            5.     Carpal Tunnel Syndrome

6.     Cardiovascular Disease

7.     Chronic Venous Insufficiency

            8.     Colon Cancer

9.     Daytime Sleepiness

10.   Deep Vein Thrombosis

11.   Diabetes Mellitus

            12.   Endometrial Cancer

            13.   End Stage Renal Disease

14.   Gallbladder Disease

15.   Gout

16.   Heat Disorders

17.   Hypertension

18.   Impaired Immune Response

19.   Impaired Respiratory Function

20.   Infections Following Burns

            21.   Liver Disease

            22.   Osteoarthritis of knee and hip

23.   Obstetric and Gynecological Complications,

24.   Pain

25.   Renal Cancer

26.   Rheumatoid Arthritis

27.   Severe Acute Biliary and Alcoholic Pancreatitis

28.   Sleep Apnea

29.   Stroke

30.   Surgical Complications

31.   Traumatic Injuries to Teeth

32.   Urinary Tract Infection

1. Birth Defects

The incidence of obesity during pregnancy is reported to be between 6% and 10% and possibly 17%.  Maternal obesity has been associated with an increased incidence of neural tube defects - irrespective of the use of folic acid.

 One study reported an increased incidence of neural tube defects in the offspring of obese women (BMI greater than 29) who received folate during pregnancy. Lean and obese mothers comprised the sample. The heaviest women in the sample had an almost threefold risk of having a child with neural tube defect. More women who are obese than women are of normal weight start their pregnancy with chronic hypertension as well as at increased risk for sever preclampsia. Diabetes is more common in obese pregnant women. Obese women experience more operative interventions, primary cesarean births and repeat cesarean  births, increased blood loss during surgery, are 13 more times more likely to have a blood loss, an increased incidence of overdue births, longer labors, prolonged second-stage labor, increased incidences of labor induction. Postpartum complications associated with obesity include an increased risk of  wound and endometrial infection, a greatly increased risk of endometritis and a greater rate of both noninfected open wounds and infected open wounds. (Morin, Perinatal Outcomes of Obese Women: A Review of the Literature, JOGNN 1998;July:431-440)

Another study found that, after adjusting for maternal age, education, smoking status, alcohol use, chronic illness, and vitamin use, obese women, when compared to average weight women had almost twice the risk of having an infant with spina bifida or anencephaly. (Is Maternal Obesity a Risk Factor for Anencephaly and Spina Bifida? Watkins, ML, Epidemiology 1996;7:507-512)

Regarding the use of folic acid, another study found, “Lack of folic acid among women with a BMI greater than 29 was not the explanation of the increased NTD (neural tube defect) risk. In fact, the opposite was observed...”(Risk of Neural Tube Defect-Affected Pregnancies Among Obese Women, Shaw, GM, JAMA, April 10, 1996, 275;14:1093-1096. A similar finding was reported in Prepregnant Weight in Relation to Risk of Neural Tube Defects, Werler, MW, JAMA, April 10, 1996; 275:1089-1092)

Women whose BMI was 31 or greater had an increased risk of having an infant with neural tube defect compared with women in the reference group. Women with a body mass index had an increased risk of having an infant with spina bifida and an increased risk of having an infant with non-neural tube defects of the central nervous system, great vessel defects, ventral wall defects and other intestinal defects. (Waller, DK, Are obese women at higher risk for producing malformed offspring? Am J. Obstet Gynecol 1994 Feb;541-548) (See also, Kallen K, Maternal Smoking, Body Mass Index, and Neural Tube Defects, Am J. Epidemiol 1998;147:1103-1111)

2. Breast Cancer in Women

Studies analyzing the relationship of obesity to breast cancer have had inconsistent results. However, recent research has clarified this issue. A study encompassing 12,203,498 person years found higher current BMI was associated with lower breast cancer risk before menopause. However, a stronger positive 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 variable was considered, together they accounted for about one-third of postmenopausal breast cancers. (Huang, Z, Dual Effects of Weight and Weight Gain on Breast Cancer Risk, JAMA, 1997, 278;17:1407-1411)

3. Breast Cancer in Men

Male breast cancer is a rare tumor, accounting for 0.8% of all breast cancer in the United States and 0.2% of all male cancer. It is estimated that 1,400 new cases and 290 deaths in 1997 will be attributed to breast cancer in men. Obesity is a significant risk factor for male breast cancer, whether evaluated by usual adult weight, BMI, or perceived overweight. As with female breast cancer, there are also suggested likes to socioeconomic status, dietary factors and exercise. (Hsing, AW, Risk Factors From Male Breast Cancer (United States) Cancer Causes and Control 1998;9:269-275)

4. Cancers of the Esophagus and Gastric Cardia

Adenocarcinomas of the esophagus and gastric cardia were once rare, but during the part 15 years there has been a rapid increase in their incidence in the United States and Western Europe. Recent data from nine population-based cancer registries in the United States indicate that the rate of esophageal adenocarcinomas among white males tripled between 1976 and 1990 and is now equal to the rate of squamous cell carcinomas. 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. While the reason for this rise in incidence is unknown, it is hypothesized that increased abdominal girth promotes gastroesophageal reflux. Reflux, in turn, is a know 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 body mass index above the 5th percentile. All three factors accounted for 50% of the adenocarcinoma cases observed in the population The researchers estimated that if this is a causal relationship, obesity alone may account for 18% of the cases observed in the Seattle area. 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, Obesity, Alcohol, an Tobacco as Risk Factors for Cancers of the Esophagus and Gastric Cardia: Adenocarcinoma versus Squamous Cell Carcinoma, Cancer Epidemiology, Biomarkers & Prevention, 1995, 4;92:85-92)

5. Carpal Tunnel Syndrome

Studies in the last two decades concluded that repetitive or forceful hand use causes a variety of upper extremity workplace ailments, including tendinitis, tenosynovitis, and carpal tunnel syndrome (CTS). Repetitive motion disorders (stress and strains resulting from free bodily motion with no impact involved) were surveyed by the Bureau of Labor Statistics in 1992. Nearly 90,000 cases resulting in lost work time were found. Carpal tunnel syndrome was the most common disabling condition at 36% of the total, and resulted in the more lost work (median 32 days per case) than any other illness or injury reported in 2.3 million cases. The 1994 Bureau of Labor Statistics survey  of injuries and illnesses showed that repetitive motion disorders had increased by just 3% over the 1992 figures, but cases of CTS resulting in lost work time had increased by 16% and by then represented more than 41% of all repetitive motion disorders.

Contrary to popular understanding, studies have concluded that non-workplace variables constitute greater risk factors for developing CTS than do occupational factors. One recent study found that medical diseases and obesity were significantly correlated with CTS diagnoses, confirming some earlier studies. (Atcheson, SG, Concurrent Medical Disease in Work-Related Carpal Tunnel Syndrome, Arch Intern Med, 1998;158;1506-1512. Werner, RA, The Relationship Between Body Mass Index and the Diagnosis of Carpal Tunnel Syndrome, Muscle & Nerve 1994;17:632-636)

A study published a year earlier also established obesity as a risk factor for CTS, concluding “The 3.92 crude OR indicated that the odds of an obese patient having CTS (positive findings on nerve-conduction studies) were almost four times greater than the odds of a nonobese patient having CTS. (Stallings, SP, A Case-Control Study of Obesity as a Risk Factor for Carpal Tunnel Syndrome in a Population of 600 Patients Presenting for Independent Medical Examination, J. Hand Surg. 1997;22A;2:211-215)

6  Cardiovascular Disease

Obesity is an important determinant of cardiovascular disease. Obese children have an elevated risk of developing cardiovascular disease in adulthood.  The effects of obesity on cardiovascular health and disease are many, one of the most profound of which is hypertension. Risk estimates from population studies suggest that over 75% of hypertension can be directly attributed to obesity. Obesity has a strong effect on lipoprotein metabolism regardless of ethnic group. Increased weight is a determinant of higher levels of triglycerides, elevated LDL-C, and low HDL-C. Conversely, weight loss is associated with a healthier lipoprotein profile in both men and women: triglycerides decrease, HDL-C increases, and LDL-C decreases. “The public health approach (to obesity) requires a systematic education of the public about the dangers of obesity. Various health agencies could work together to promulgate such a message that would reach all population groups.” (Krauss, RM, Obesity, Impact on Cardiovascular Disease, Circulation, 1998;98:1472-1476)

The Framingham Study reported that if everyone were at ideal body weight, the incidence of coronary heart disease would be 25% less and the incidence of atherothrombotic brain infarction and of congestive heart failure would be approximately 35% lower. (Wittels, Obstructive Sleep Apnea and Obesity, Otolaryngologic Clinics of North America, 1990, 23;4:751-760) 

Patients who are more that 50% overweight have been found to have a 50% prevalence of left ventricular hypertrophy (LVH), an abnormal enlargement of the heart.  Obesity produces predominately LVH and left ventricular chamber dilation or eccentric hypertrophy.  Body weight and body surface area have been shown to be powerful determinants of left ventricle chamber size, wall thickness, and muscle mass.  When compared with lean counterparts obese patients with eccentric LVH had a markedly increased prevalence and complexity of ventricular ectopy.  These findings demonstrate a greater risk for sudden death and other cardiovascular morbidity and mortality.  (Lavie, CJ, Messerli, FH, Cardiovascular Adoption to Obesity and Hypertension, Chest, 1986, Aug; 90 (2): 275-279).

Coronary Heart disease (CHD) is still the leading cause of morbidity and mortality in the United States despite the decline in CHD incidence and CHD death rate observed over the past decades. Approximately 700,000 patients are hospitalized each year with a diagnosis of acute myocardial infarction. About 400,000 people die annually die from CHD in the United States, which accounts for about one third of all deaths. The annual financial cost of CHD in the United States is close to $80 billion and constitutes 15% of the annual US health care budget.  Most of this decline appears to come from improvements in the treatment of patients with CHD rather than from reductions in risk factors. (Hunink, MGM, The Recent Decline in Mortality From Coronary Heart Disease, 1980-1990, JAMA, 1997, 27;7:535-542 and Rosamond, WD, Trends in the Incidence of Myocardial Infarction and in Mortality Due to Coronary Heart Disease, 1987 to 1994,, N. Engl J Med 1998;339:861-867)

Heavier weight in middle and old age was positively associated with CVD and its risk factors, particularly for women. Heavier weight at age 50 was associated with prevalent CVD, particularly for women. Heavier past and current weight were associated with electrocardiogram left ventricular hypertrophy even after those with prevalent CVD were excluded, and heavier weight was associated with a poorer cardiovascular risk-factor profile. Last, heavier weight was associated with poorer health status and with many of the some behavioral characteristics associated with overweight in younger persons, such as reduced energy expenditure. (Harris, TB, Carrying the Burden of Cardiovascular Risk in Old Age: Associations of Weight and Weight Change With Prevalent Cardiovascular Disease, Risk Factors, and Health Status in the Cardiovascular Health Study, Am J Clin Nutr, 1997;66:837-844)

7. Chronic Venous Insufficiency

Venous ulcers have a considerable impact on society. Most estimates of the point prevalence of chronic venous insufficiency (CVI) place 0.1% to 0.2% of the population in developed countries at risk. Chronic leg ulcers are a drain on both time and economic resources as a result of their recurrent nature and the long-term therapy required. In a dual case controlled epidemiologic study, obesity was one of the most frequently reported risk factors and, after adjusting for age, probably a risk factor in  its own right. (Scott, TE, Risk Factors for Chronic Venous insufficiency: A Dual Case-control Study, 1995, J Vasc Surg 22:622-628)

8 Colon Cancer

Colon cancer is one of the most commonly diagnosed malignancies in the United States. It claims about 47,000 lives annually in the Unites States, second only to lung cancer as a cause of cancer death. Among men, there is positive association between body mass index as well as diabetes, parental history of colon cancer and alcohol consumption.(Singh PN, Dietary Risk Factors for Colon Cancer in a Low Risk Population, Am J. Epidemiol 1998;148:761-774)  confirming earlier studies (Larchand, Associations of Sedentary Lifestyle, Obesity, Smoking, Alcohol Use, and Diabetes with the Risk of Colorectal Cancer Research 1997 57:4787-4794)

In women,  high waist-to-hip ratio, as opposed to BMI,  represented a significant risk factor. (Russo A, Body Size and Colorectal-Cancer Risk,  Int J. Cancer, 1998 78;161-165)

9. Daytime Sleepiness

Daytime sleepiness is a significant problem for 5% of the adult population and its prevalence appears to be increasing. In addition to its effect on  occupational and social life, daytime sleepiness appears to be a major concern of public safety. More than 20% of all drivers report having fallen asleep behind the wheel at least once. The most frequently cited probable cause of mass transportation crashes is fatigue. Daytime sleepiness and fatigue is a frequent complaint of obese patient even among those without sleep apnea. This appears to be a result of circadian abnormality rather than just being secondary to nighttime (Vontzas, AN Obesity Without Sleep Apnea Is Associated With Daytime Sleepiness, Arch Intern Med. 158:1333-1337)

10. Deep Vein Thrombosis

Deep venous thrombosis is an important clinical condition accounting for 600,000 hospitalized patients in North America per year. Pulmonary embolism is often a coexisting condition. Obesity is a considered a risk factor for deep vein thrombosis (Collins, LM, Deep Venous Thrombosis, Nurse Pract Forum, 1998  9:163-169. Persson, AV, Deep Venous thrombosis and Pulmonary Embolism, 1991 Surg Clinics North Am, 71:1195-1209)

11. Diabetes Mellitus

Type 2 diabetes or non-insulin dependent diabetes mellitus (NIDDM) accounts for 90-95% of the 16 million cases of diabetes in the Unites States today. As many as 90% of individuals with Type 2 diabetes are overweight or obese. However, not all individuals with type 2 diabetes are obese and not all persons with obesity develop type 2 diabetes. Cross-sectional studies have shown that the largest environmental influence on the prevalence of diabetes in a population was its degree of obesity. Data from the second National Health and Nutrition Examination Survey indicated that the prevalence of diabetes is 3.8 times higher in overweight (defined as the 85th percentile value of BMI for men and women aged 20 -29 years). An increased risk of diabetes with increasing weight has been shown by prospective studies in Norway, the United States, Sweden and Israel.  “Obesity not only increases the risk of developing type 2 diabetes,  but also complicates its management. The presence of obesity exacerbates metabolic abnormalities of type 2 diabetes including hyperglycemia, hyperinsulinemia, and dyslipidemia. Obesity also increases insulin resistance and glucose intolerance. Obesity may contribute to excessive morbidity in type 2 diabetes. While obesity is an independent risk factor for hypertension and cardiovascular disease, the coexistence of obesity and type 2 diabetes makes the risk of developing these associated disorders even greater and significantly increase morbidity and mortality. In general, the mortality ratio for individuals with diabetes whose body weights are 20-30% above ideal is 2.5 to 3.3 times higher than for those of normal weight. For individuals with diabetes whose body weights are more than 40% above ideal, the mortality ratio becomes 5.2-7.9 times higher. (Maggio, CA and Pi-Sunyer, FX, The Prevention and Treatment of Obesity, Application to Type 2 Diabetes, 1997 Diabetes Care, 20:1744-1766)

12. End Stage Renal Disease

End stage renal disease (ESRD) is diagnosed in more than 50,000 persons in the United States each year.

ESRD patients must undergo either kidney dialysis or transplantation of a healthy kidney. Most ESRD patients are eligible for federally funded care which costs the Untied States government about $9.3 billion a year. African-American and American Indians are reported to have at least a four-fold increase of ESRD than white Americans. Five risk factors have been identified: hypertension, glucose intolerance, insulin resistance, hyperlipidemia and salt sensitivity. There are some preliminary data suggesting a role for obesity either as a direct or indirect factor in the initiation or progression of renal disease. (Powers, DR, End-Stage Renal Disease in Specific Ethnic and Racial Groups, Arch Intern Med. 1988;158:793-800)

13. Endometrial Cancer

Numerous epidemiological studies have reported that overweight women have a two-fold to 10-fold increased risk of endometrial cancer irrespective of the distribution of body fat. (Folsom, AR, 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,  Cancer Research 1989;49:6828-6831) Women with diabetes who are not obese have no increased risk of endometrial cancer compared with nonoverweight women without diabetes. For obese women, having diabetes is associated with an approximately threefold increase in risk above that attributed to body size alone.( Shoff, SM, Diabetes, body Size, and Risk of Endometrial Cancer, Am J. Epidemiol 1998;148:234-240)

Women with Body Mass Index in the 28-30 range have relative risk estimates for endometrial cancer from 2.0 to 3.5 leading to endometrial cancer-attributable risk estimates of 34-56% due to overweight. The relative risk estimates for postmenopausal breast cancer reported for women with BMIs of 28-30 range from 1.2 to 1.5 leading to postmenopausal breast cancer-attributable risk estimates of 9-21% due to overweight, a figure comparable to family history as a risk factor.

(Ballard-Barbash, Body Weight: Estimation of Risk for Breast and Endometrial Cancers, Am J. Clin Nutr. 1996 (63 suppl) 437S-41S)

14. Gallbladder Disease

Gallstones are a common occurrence. In the United States the prevalence of gallstones among person over 40 is estimated to be at least 20% in women and 8 percent in men. Obesity is the best established predictor of gallbladder disease. A recent study of Harvard Alumni found that obesity, weight gain since early adulthood, and cigarette smoking are independently associated with increased risk of developing gallbladder disease in men. (Sahi, T, Body Mass Index, Cigarette Smoking, and Other Characteristics as Predictors of Self-reported, Physician-Diagnosed Gallbladder Disease in Male College Alumni, Am J Epidemiol 147;7:644-651) (See also, Everhart, Contribution of Obesity and Weight Loss to Gallstone Disease, Ann Int Med 119;10:1029-1035)

15. Gout

Obesity is risk factor for gout. (Emmerson, BT, The Management of Gout, Drug Therapy, N Engl J Med, 1996 334;7:445-451)

16. Heat Disorders 

Poor heat tolerance is common for many persons with obesity. In a study of soldiers, obesity defined as a BMI of more than 27 produced a higher risk of heat disorders by a magnitude of 3.5 times compared to normal weight individuals. (Chung, Obesity and the Occurrence of Heat Disorders, Mil Med. 161;12:739-742)

17. Hypertension

High blood pressure is the most common chronic disease in the United States, afflicting over 50 million Americans and is the primary contributor to the development of cardiovascular disease, stroke, and renal failure. Weight or body mass index in association with age is the strongest indicator of blood pressure in humans. The correlation between obesity and blood pressure has been observed in virtually all societies, age, and ethnic groups, and in both sexes. BMI, after adjustment for age, has been estimated to account for 25%-39% of the variation in blood pressure in populations. Among obese adult Americans who are 20-45 year of age, the relative risk of developing hypertension is five to six times that in lean individuals. (McCarron, DA, Body Weight and Blood Pressure Regulation, Am J Clin Nutr 1996;63(suppl):423S-425S)

Risk estimates from population studies suggest that over 75% of hypertension can be directly attributed to obesity. (Krauss, RM, Obesity, Impact on Cardiovascular Disease, Circulation, 1998;98:1472-1476)

Increases in weight are associated with increases in blood pressure.  Persons who were only 20% overweight had an eightfold greater incidence of hypertension.  The increased risk for hypertension also leads to an increased risk for stroke.  In the Framingham study, every 10% increase in relative weight was associated with an increase in plasma cholesterol of 12 mg/dL.  Triglycerides have generally been found to be higher in obese compared with lean persons.  A higher BMI has been positively associated with the occurrence of each category of coronary heart disease. Even mild to moderate overweight increased the risk for coronary heart disease. 

18. Impaired Immune Response

Growing evidence in human beings and laboratory  animals indicates that obesity impairs immune responses and that graft disruption may be greater in obese patients because of stress created by massive body weight.(Gottschlich, MM, Significance Of Obesity On Nutritional, Immunologic, Hormonal, And Clinical Outcome Parameters In Burns, J. Am Diet Assoc. 1993;93:1261-1268)

19. Impaired Respiratory Function

Obesity is known to induce respiratory mechanical impairment that may be combined with gas exchange abnormalities. The mass loading of the ventilatory system induced by obesity, particularly on the abdominal component of the chest wall, modifies the static balance within the respiratory system. Lung volumes and expiratory flows were also determined and significant negative correlations with BMI were found. (Zerah, F Effects of Obesity on Respiratory Resistance, Chest 1993;103:1470-1476)

20. Infections Following Burns

Obese burn victims had a significant increase in  the incidence of bacteremia and clinical sepsis than the nonobese-obese group. Pneumonia and wound infection occurred twice as frequently in the obese group and had an increased likelihood of developing some form of infection after acute thermal injury. The obese group required a mean of 8.5 days of antibiotic therapy compared with 3.4 days for the nonobese group. The duration of mechanical ventilatory support was greater than twice as long for the obese group as for the nonobese group. Obese persons had a length of stay nearly 1.5 weeks longer than the non-obese group. “Our study demonstrates that obesity is an important and previously unrecognized effector of metabolism that should be considered a significant factor in determining clinical outcome in burns.” (Gottschlich, MM, Significance Of Obesity On Nutritional, Immunologic, Hormonal, And Clinical Outcome Parameters In Burns, J. Am Diet Assoc. 1993;93:1261-1268)

21. Liver Disease

The hepatotoxicity of ethanol has been established. However only 8% to 20% or chronic alcoholics develop cirrhosis. Excess weight for at least 10 years is an independent risk factor for the development of alcoholic cirrhosis, acute alcoholic hepatitis and steatosis. (Naveau, S, Excess Weight Risk Factor for Alcoholic Liver Disease, Hepatology, 1997,  25;1:108-111)

Common gastrointestinal sequelae of obesity include gastroesophageal reflux disease, gallstones, hepatic steatosis and non alcoholic steatohepatitis (NASH). In recent years, steatohepatitis has been recognized as a major cause of progressive liver disease. The number of patients diagnosed with NASH is rising rapidly, and cirrhosis resulting from this disorder is an increasingly common indication for liver transplantation. “Although the increasing diagnosis of NASH partly reflects increased physician awareness and screening, the expanding epidemic of obesity is almost certainly causing a dramatic increase in the true prevalence of NASH as well.” (Kaplan, Leptin, Obesity, and Liver Disease, Gastroenterology, 1998;115:997-1001)

22. Osteoarthritis.

Osteoarthritis is the most common form of arthritis. Its prevalence increases with age. About 5% of the US population is affected with hip or knee osteoarthritis. More than 70% of total hip and knee replacements are for osteoarthritis.  Population-based studies of osteoarthritis have consistently shown that overweight persons have higher rates of knee osteoarthritis than do nonoverweight control subjects. In data from the first National Health and Nutrition Examination Survey, obese women have almost four times the risk of osteoarthritis of lean women. For men, the risk was increased to 4.8. (Nelson, DT, Weight and Osteoarthritis, Am J. Clin Nutr 1996; 63(suppl):430s-432s)

Overweight is strongly implicated in arthritis, especially osteoarthritis. It is also implicated in 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)

Knee Osteoarthritis

Osteoarthritis (OA) of the knee probably has greater social costs and more associated disability than osteoarthritis of any other joint. The majority of older Americans are affected by knee OA. Obesity has been shown to preceed the development of knee OA rather than resulting from the inactivity of OA patients.

The Framingham Study demonstrated that obesity was associated with knee osteoarthritis. That study found that the link between obesity and the disease was stronger in women than in men in that there was a stepwise increase in osteoarthritis 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 is a study 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 that those who are not overweight. (Felson, DT, Understanding the relationship between body weight and osteoarthritis, Balliere’s Clinical Rheumatology 1997 11:671-681)

Hip Osteoarthritis

Hip osteoarthritis is a major cause of pain and disability In a study of risk factors, obesity, previous hip injury and the presence of Heberden’s nodes were independent risk factors for hip osteoarthritis among men and women. The study found that obesity and hip injury are important independent risk factors for hip osteoarthritis which might be amenable to primary prevention. (Cooper C, Individual Risk Factors for Hip Osteoarthritis: Obesity, Hip Injury, and Physical Activity Am J. Epidemiol 198;147:516-522)

23. Obstetric and Gynecologic Complications,

Massively obese women are at a higher risk of respiratory complications and hypoxemia and mortality with cesarean section and had a much higher incidence of postoperative infections and wound complications (Isaacs, JD, Obstetric Challenges of Massive Obesity Complicating Pregnancy Journal of Perinatology  1994 14;1:10-14) See also Ogunyemi, D. Prepregnancy Body Mass Index, Weight Gain During Pregnancy, and Perinatal Outcome in a Rural Black Population, Journal of Maternal-Fetal Medicine 1998; 7:190-193)

In obese girls, the onset of  menarche occurs earlier than in normal weight girls. Obese women tend to have heavier infants and larger placentas. Both placental weight and maternal weight are predictors of childhood weight at entry to school. Obesity, hirsutism, anovulation, multiple cysts in the ovaries and insulin resistance characterize a syndrome known as the polycystic ovarian syndrome (PCOS). PCOS may enhance the risk for myocardial infarction.  (Bray, Obesity and Reproduction, Human Repro 1997;12:26-32)

Excess fat can lead to menstrual abnormality, infertility, miscarriage and difficulties in performing assisted reproduction. Observational and theoretical considerations indicate that body weight has an inverted U effect on reproduction, whereby low or high body mass contributes to infertility, menstrual disorders and poor reproductive outcome. “Grossly obese” women have a rate of menstrual disturbance 3.1 times more frequent than women in the normal range. Teenage obesity was positively correlated correlated with menstrual irregularity later in life and obesity was correlated with abnormal and long cycles, heavy flow and hirsutism. Increased body mass is associated with higher incidence of infertility and miscarriage. In massively obese women, there are much higher health risks and increased costs to the health system. Studies from Europe indicate that high pre-pregnancy weight is associated with an increased risk in pregnancy of hypertension, toxemia, gestational diabetes, urinary infection, macrosomia, and Cesarean section. Regarding infertility treatment, studies show that increasing BMI is associated with an increased requirement for clomiphene citrate which has some association with ovarian cancer. (Norman RJ, Obesity And Reproductive Disorders: A Review, Reprod. Fertil. Dev. 1998;10:55-63)

24. Pain

“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.” (Fontaine KR, Health-Related Quality of Life in Obese Persons Seeking Treatment. J. Fam Pract, 1996, Sept;43(3):265-279).

25. Renal Cancer

Kidney cancer has been increasing in incidence n the United States.  The Iowa Women’s Health Study cohort was surveyed and compared to the rate of kidney plus renal pelvis cancer for the whole of Iowa. Weight was the greatest relative risk. This confirmed other studies. which found increased risk of renal cell carcinoma for men and women in the upper quintile of body mass index for women only. (Prineas RJ, Nutrition and Other Risk Factors for Renal Cell Carcinoma in Postmenopausal Women, Epidemiology 1997;8:31-36) (See also, Chow, WH, Obesity and Risk of Renal Cell Cancer, Cancer Epidemiology, 1996;5:17-21, Muscat JE, The Epidemiology of Renal Cell Carcinoma, Cancer 1995;75:2552-2557, Lindblad, P, The Role of Obesity and Weight Fluctuations in the Etiology of Renal Cell Cancer: A Population-based Case-Control Study, Cancer Epidemiology, Biomarkers & Prevention, 1994;3:631-639))

Malignant tumors of the kidney in the United States  rank about 10th in cancer incidence and mortality. It is estimated that in 1998, 29,900 new cases will be diagnosed and nearly 12,000 patients will die of renal cancer, most of which will be renal cell carcinoma. 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. BMI was the risk factor with the greatest impact on women. (Benichou, Population Attributable Risk of Renal Cell Cancer in Minnesota, Am J Epidemiol, 1998;148:424-430)

26. Rheumatoid Arthritis

Rheumatoid arthritis is a chronic autoimmune disease of unknown etiology. In the first case-control study of rheumatoid arthritis used incident cases of both sexes derived from primary care. It found an association between obesity and rheumatoid arthritis in both men and women. The risk seemed to be confined to the obese and not the overweight. It was hypothesized that the mechanism would be metabolic, similar to that for osteoarthritis and obesity, i.e. altered estrogen metabolism in obese subjects. (Symmons DPM, Blood Transfusion, Smoking, and Obesity as Risk Factors for the Development of Rheumatoid Arthritis, Itis & Rheumatism, 1997, 11:1955-1961) This would appear to confirm an earlier study, Voigt, LF, Smoking, Obesity, Alcohol Consumption, and the Risk of Rheumatoid Arthritis, Epidemiology 1994, 5:525-532)

27. Severe Acute Biliary and Alcoholic Pancreatitis

Over 24% of cases involving acute pancreatitis are severe with a mortality as high as 10%. Obese patients developed significantly more complications than nonobese patients. Obesity by itself is associated with a greater morbidity and mortality. Obese patients developed respiratory failure more frequently than did nonobese patients. (Suazo-Barahona, Obesity: A Risk Factor for Severe Acute Biliary and Alcoholic Pancreatitis, Am J Gastroenterol 1998;93:1324-1328)

28. Sleep Apnea

Sleep apnea, defined as repetitive prolonged cessation of air flow associated with anoxia and hypoxemia during sleep, is now recognized as a major health problem affecting the American adult population. The cardiopulmonary complications of sleep apnea include congestive heart failure, co pulmonale, pulmonary hypertension, cardiac arrhythmias and possible sudden death. The constellation of obesity, obstructive sleep apnea, hypoventilation, chronic hypoxemia and cor pulmonale which has been termed the obesity hypoventilation or Pickwickian syndrome affects 5% of morbidly obese patients. (Ahmed, Cardiopulmonary Pathology in Patients with Sleep Apnea/Obesity Hypoventilation Syndrome, Hum Pathol  1997 28:264-269)

There is a significant association between obstructive sleep apnea and obesity. The majority of patients with obstructive sleep apnea are males. The dominant factor for this syndrome independent of age or hormonal status is massive obesity. The obesity hypoventilation syndrome is associated with morbid obesity in an awake resting patient breathing room air who has hypoxemia and hypercapnia. Essentially all patients with obesity hypoventilaton syndrome have obstructive sleep apnea.

(Wittels, Obstructive Sleep Apnea and Obesity, Otolaryngologic Clinics of North America, 1990, 23;4:751-760)

Obstructive sleep apnea occurs in approximately 4% to 9% of middle-aged men and in 1% to 2% of middle-aged women. The most significant risk factor of obstructive sleep apnea is obesity, especially upper body obesity. The incidence of obstructive sleep apnea among morbidly obese patients is 12 to 30-fold higher than the general population.(Kyzer S, Obstructive Sleep Apnea in the Obese, World J. Surg. 1998, 22;998-1001)

29. Stroke

Stroke ranks as the third leading cause of death after cardiovascular disease and cancer. Stroke is the primary cause of long term neurologic disability among adults.

Ischemic strokes account for approximately 80 to 85% of all strokes.

A strong association exists between abdominal obesity and stroke. The waist-to-hip ration may be a better predictor of risk of stroke than BMI (Walker SP, Body Size and Fat Distribution as Predictors of Stroke among US men, Am J Epidemiol 1996;144:1143-1150)

Modifiable risk factors for stroke include diabetes, smoking and obesity. “Independent of age, systolic blood pressure, and serum glucose, elevated body mass was associated with increased risk of ischemic stroke in nonsmoking men aged 55 to 68 years at the inception of the Honolulu Heart Program study.” Risk detection and reduction methods for persons at high risk of ischemic stroke involve screening and identification of risk factors in primary care practice or referral for further management of the symptomatic patient. Population-based health surveys affirm a persistent dilemma in the inability to reduce the frequency of ischemic stroke risk factors such as hypertension, cigarette smoking, obesity, and physical inactivity levels. These alarming trends indicate that “mass approach” policies and programs need to be implemented or rethought to attain maximum levels of benefit in ischemic stroke risk reduction for the entire community. Optimal gains for stroke prevention can be achieved only with primary preventive strategies.” (Orencia, AJ, Prevention of Primary Event, Ischemic Stroke Risk Detection and Reduction, Neurosurgery Clinics of North America, 1997 8:165-178)

Hyperinsulinemia was associated with the risk of stroke but not independently of other risk factors such as obesity, particularly upper body obesity with subscapular skinfold thickness used as an index. (Pyorala, M, hyperinsulinemia and the Risk of Stroke in Health Middle-Aged Men, Stroke, 1998:1860-1866)

Mortality from stroke has been declining but at a slower rate for African-Americans than for whites. The rising prevalence of diabetes and obesity in this population seem likely candidates for the reason for the slower trend. (Gillum RF, Secular Trends in Stroke Mortality in African Americans: The Role of Urbanizaton, Diabetes and Obesity, Neuroepidemiology 1997;16:180-184)

30. Surgical Complications

Obese patients are often at risk for the development of disorders that may require surgical intervention including gallstones, gastroreflux esophagitis, osteoarthritis and malignancies such as breast, endometrial, colon and prostate. In a study to determine the risk of hospital acquired infectious complications and deaths with increasing degrees of obesity, the investigators found that there was  a significant increase in the total number of nosocomial infections in the severely overweight patients compared to the normal weight patients as well as a significant increase in the incidence of these infections in both the overweight and severely overweight, suggesting that the immune dysfunction associated with obesity may have real clinical consequences. (Choban PS, Increased Incidence of Nosocomial Infections in Obese Surgical Patients,  Amer Surg 1995;61:1001-1005)

Obesity has been established as a risk factor for infection following spinal surgery (Wimmer, C, Predisposing Factors for Infection in Spine Surgery: A Survey of 850 Spinal Procedures)

31.  Traumatic Injuries to Teeth

A recent investigation of traumatic dental injuries in children found the injury prevalence of obese and non-obese children was 31.8% and 20%, a highly significant difference. The most common cause of traumas reported by obese subjects was indoor play . The study found that obesity significantly increased the risk of traumatic injury. One of the reasons explaining this result was that obese children were less active that the other children and that an active life-style was trauma-protective. In other words, subjects frequently playing sports and lively games would be not only less obese but also more skillful and for this reason less prone to trauma when they fall or sustain impacts. (Petti S, Childhood Obesity: a risk factor  for traumatic injuries to anterior teeth, Endod Dent Trauamatol 1997; 13:285-288)

32. Urinary Tract Infection

Involuntary loss of urine is a common symptom in women with a prevalence of at least 6-25%. Incontinence is also seen among younger women, and pregnancy and delivery by itself have been proposed as risk factors. Obesity is a well documented risk factor for not only stress incontinence, but also urge incontinence and urgency. Nearly one-third of obese women experienced their incontinence as a social or hygienic problem. Obesity significantly increases the risk of transient and persistent stress incontinence as well as having a social or hygienic problem with leakage. (Rasmussen KL, Obesity as a predictor of postpartum urinary symptoms, Acta Obstet et Gynecol Scand,1997;96:359-362)

2. Obesity, in terms of disability research and policy, has is marked by (A) extreme social stigma, (B) employment discrimination (C) impaired quality of life and (D) impaired mobility.

Obesity is a devasting disability. In addition to the risk of premature death and the large number of adverse health conditions described above, obesity, especially for the severely (sometimes called morbidly obese) has major implications on (A) Social Stigma (B) Employment (C) Education, (D) Impaired Quality of Life, and (E) Impaired Mobility. 

A. Social Stigma

Persons with severe obesity have a greater avoidance of this disability than other disabled persons have of their own disability. Patients who lost 100 lb or more and who successfully maintained weight loss for at least three years following gastric restrictive surgery for severe obesity viewed their previous severe obese status 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, Sept;15:577-579)

According to George S. M. Cowan, Jr, MD , President of the International Federation for the Surgery of Obesity:

The morbidly obese appear to their fellows as billboards of their own nonconformity.  The larger they grow, the more people view them as flaunting society, flaunting convention, deviating from society’s accepted wisdom of ‘not letting yourself go’.  As such, they tend to be visualized as deviants placed on a level together with transvestites, alcoholics, drug addicts and homosexuals.  All of these categories but the obese are, to some extent, currently protected by ‘political correctness. As a consequence, the morbidly obese person has assumed the role of a modern day moral equivalent of a leper.” (Cowan, GSM, What do Patients, Families and Society Expect From the Bariatric Surgeon? OB Surg. 1998;8:77-85)

Obesity is a particularly unpopular and unsympathetic impairment.  It is immediately visible to others and impossible to conceal.  Many Americans inversely link a person's weight and size to their moral measure.  The degree of obesity is often directly related to the level of prejudice and discrimination confronted in social and employment settings.  (Cassell, JA, Social Anthropology and Nutrition:  A Different Look at Obesity in America,  Journal of the American Dietetic Association, 1995, April, 95;4:424.) 

It is well established that persons with severe obesity suffer from extraordinary stigma in our society:

Discrimination against the obese occurs in hiring and promotion opportunities and in acceptance to college.  Official guidelines limit the weight of military personnel and commercial flight attendants.  Obese individuals also pay higher life insurance premiums.  It is probable that morbidly obese adults arouse more prejudice and experience more discrimination than adults who are less obese...  Far more prejudice and discrimination appear to be directed against obese women than against obese men...  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 “always” or  “usually” 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 “always” or “usually” in the following four situations:  “I feel that my weight has negatively affected whether or not I have been hired for a job” (86.9%); “At work people talk behind my back and have a negative attitude toward me related to my weight” (90.9%); “I do not like to be seen in public because of my weight” (84.0%); and “Because of my weight I avoid fast food restaurants with booths” (80.6%). .. No patient reported the same degree of prejudice and discrimination experienced postoperatively.  (Rand, CS, Morbidly Obese Patients’ Perceptions of Social Discrimination Before and After Surgery for Obesity, So. Med. J. 1990, Dec, 83:12:13980-1395)

Another paper noted,

            The social stigma against obesity is extraordinary in its magnitude and pervasiveness. As Fitzgerald (1981) notes: “Public derision and condemnation of fat people is one of the few remaining social prejudices...allowed against any group based solely on appearance...It is well documented that obese people are denied educational opportunities, jobs, promotions, and housing because of their weight..The affront to those who are obese goes beyond the almost uniform judgment that they are unattractive and includes negative stereotypes that begin early in childhood. The aversion to obesity is evident by kindergarten and grade-school children consistently associate larger body shapes with adjectives such as “stupid.” “dirty,” lazy,” “sloppy,” “mean,” ugly,” and “sad”...Harsh attitudes toward the obese depend on the assumption that they bring their condition on themselves through lack of willpower and self-control.  (Garner, DM, Wooley, SC, Confronting the Failure of Behavioral and Dietary Treatments for Obesity, Clinical Psychology Review, 1991,11;6:729-780)

B. Education

There is little research on the effect of obesity on educational attainment in elementary, secondary or university education.

            In one paper, Stunkard and Wadden wrote:

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 16% of employers said that they would not hire the 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. Employment

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.

A recent report of the Cardiovascular Health Study studied 5,201 Caucausian 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 had a 2 to 3 fold greater risk of being disabled 3 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, 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)

A Finnish study published in 1996 found “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, body Mass Index and Disability Pension in Middle-Aged Men - Non-Linear Relations, Int. J. of Epidemiology, 1996;25:1(80-85)

The devastating employment discrimination directed against persons with severe obesity is evident in a study in which 80% of all patients preoperative for surgery for obesity, and 84% of the female patients in this group continued to be unemployed while those figures dropped to 53% and 64% in the postoperative group, respectively. 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. This study reported that the chances of successful employment 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, Quality of Life Assessment of Morbidly Obese Patients: Effect of Weight-Reducing Surgery, Am J. Clin. Nutr 1998;67:197-201)

Further evidence of the relationship of obesity to the likelihood of engaging in significant gainful employment can come from looking at the lost work days due to obesity and the use of medical resources. A report published in March of 1998  by Anne M.Wolf and Graham A. Colditz, estimated costs of obesity in the United States.  Their research demonstrated a 88% increase in physician office visits associated with obesity from 42.9 million in 1988 to 81.2 in 1994, using a BMI cutoff of 25 for overweight and 30 for obesity.  In addition, they report a total of 52,591,480 work days were lost because of obesity which amounted to approximately $4.9 billion in 1995. In 1994, there was a total of 58,456,780 work-lost days, amounting to approximately $5.7 billion in 1995. Seventy percent of the work-lost days were from obese women.  (Wolf, AM, Colditz, GA, Current Estimates of the Economic Cost of Obesity in the United States, Obesity Research, 1998, Mar. 6:2:97-106)

C. Impaired Quality of Life

            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. Compared with general population norms, participants with a mean BMI of 38.1 reported  more impairment on all eight quality of life domains, especially bodily pain and vitality. Those 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 to 34.5.  Persons with  obesity reported significantly greater disability due to bodily pain than did patients with other chronic medical conditions with the exception of migraine. 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. This study found that, relative to U.S. population norms, obese persons seeking university-based weight loss treatment reported substantial decrements in HRQL, that the impact of obesity on HRQL varied with severity of obesity, and that functional disability among obese persons due to bodily pain was particularly common - comparable to that of chronic migraine sufferers.  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. 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.” (Fontaine KR, Health-Related Quality of Life in Obese Persons Seeking Treatment. J. Fam Pract, 1996, Sept;43(3):265-279).

D. Impaired Mobility

Mobility difficulty is a primary risk factor for the onset of disability. Studies have presented considerable evidence that mobility problems have a strong negative impact on the ability to perform basic and household activities of daily living, as well as on perceived health and the incidence of depression. In a study to determine predictors of onset of mobility difficulty, the strongest predictors were female sex, less education, low net worth, lack of private health insurance, obesity, and frequent pain. (Predictors of Onset of and Recovery from Mobility Difficulty among Adults Aged 51-61 Years, Clark, DO, Am J Epidemiol, 1998; 148:63-71)

When compared to a non-arthritis group, those with severe overweight (> 30 BMI) had significantly greater difficulty with activities of daily living (personal care and household tasks), gross mobility (walking) and functional limitations. (Verbugge, LM, Risk Factors For Disability Among U.S. Adults with Arthritis, J. Clin Epidemiol, 1991, 44;2:167-182)

3. Traditional disability research and advocacy has largely ignored the role of obesity.

Before becoming Executive Director of the American Obesity Association, I was employed as the Director of Governmental and Legal Affairs for the American Speech-Language-Hearing Association from 1977 to 1989. Through this work, as the representative of speech-language pathologists and audiologists, I was involved in virtually all of the legislative and regulatory initiatives involving persons with disabilities during this period. Subsequently in private law practice I continued to participate in or follow, the same issues.

During this period of some 21 years, I cannot recall any proposals or discussions relating to obesity as a causal or compounding factor in disability research. The reasons for this are not clear but may include the lack of an advocacy organization for persons with obesity as well as a general societal-wide avoidance of dealing with this issue and persons with obesity.

For whatever reason, the data cited above are compelling as to the causal role of obesity in creating or compounding disabilities.

Furthermore, since obesity is preventable and manageable, it is one of the few risk factors which can be modified to the betterment of individuals and the community.

4. Specific Comments on NIDRR Long Range Plan

In general, the American Obesity Association commends the NIDRR on the presentation of an excellent long range plan including both theoretical and practical information on the agency’s approach to disability research.

As far as it concerns obesity-related disability research needs, the document is not adequate. In part this may be because of a lack of understanding the research presented above and the prior lack of advocates in this area. But there may be more profound reasons. Individuals with obesity are too often so full of shame and guilt and too burned by encounters with the ‘intolerant lean’, that are not as strong advocates for their needs as other groups drawn together by a common disabling condition. Perhaps more importantly the public attitudes toward obese persons today can only be likened to public attitudes in some quarters in the 1920s or 1930s regarding African-Americans, Jewish persons and the mentally ill. Fat people are the last politically acceptable target of gratuitous insults. In our culture, such expressions are uniform and universal.

Therefore, whether it is the new or old paradigm, by any criteria,

obesity should be considered as a major contributor to the state of disability in the United States.

In some particular cases, the Long Range Plan refers to some specific groups or specific disabling conditions. AOA urges the NIDRR to look behind these categories. For example, disabilities among the elderly experienced today (e.g. blindness or amputations) were brought on by diseases occurring earlier in life (e.g. diabetes) which were caused in part or in whole by obesity.

So too, specific disabling conditions such as birth defects and arthritis have a clear connection to obesity. Likewise, the largest category of repetitive motion impairments comes from carpal tunnel syndrome which is due to obesity and medical illness.

In addition, more consideration should be given to the role of obesity incurred after the disability has arisen and the extent to which this complicates either rehabilitation, employment and community reintegration. Most frequently, this obesity will result from lack of physical activity as opposed to increased food intake.

For example, spinal cord injured individuals have a shocking rate of prevalence of diseases associated with obesity such as cardiovascular disease and diabetes mellitus. Specifically, the mortality rate for cardiovascular disease is 228% higher in the spinal cord injured population. (Body Composition of Spinal Cord Injured Adults, Kocina, P, Sports Medicine 1997 23(1):48-60)

Obesity, pain, spasticity, urinary tract infections, and pressure sores are common secondary complications in spinal cord injuries (Incidence of secondary complications in spinal cord injury, Anson, CA, Intl J Rehab Res 1996, 19:55-60) 

Another example is Down Syndrome. Adults with Down syndrome have significantly higher tendencies to be overweight. (Overweight Prevalence in Persons with Down Syndrome, Rubin SS, Mental Retard 1998 June 36(3) 175-181)

Regarding specific areas of the Long Range Plan:

1. Measurement Issues.

There is a great lack of basic information on the relationship of obesity to states of disability.

2. Attitudinal Research

As indicated above, the severe social stigma directed against persons with obesity is recognized by many researchers and individuals with obesity as a major hindrance to the goal of treating persons with obesity like all other citizens.

Research on the attitudes of health professionals and the experiences of persons with obesity would help to shed light on possible instances of stereotyping by health professionals.

3. Prevailing Definitions

            Whether obesity is classified as a disease, impairment, handicap or functional limitation or obesity-phobia recognized as a societal limitation, it is important that obesity be recognized in disability research studies as a potential causal or exacerbating factor. Uniform use of Body Mass Index would be helpful in making relationships with specific studies and population surveys. However, it should be noted that BMI is not the only measurement of obesity and that other measurements can be more predictive in particular situations.

4. Research on Children

            The Long Range Plan indicates (p. 57196) that NIDRR is directing its research on children to areas outside of the school because other components of the Department of Education have responsibility for school issues. We would recommend that NIDRR reconsider this position at least in so far as obesity is concerned. While childhood obesity prevalence is increasing and while the stigma and resultant behaviors of children are expressed in the schools, and while no state requires physical education for students in grades K-12, and while there is a little evidence of the overrepresentation of obese children in special and remedial education, there is no research or attention to these school concerns at all within the Department of Education as far as we are aware. If NIDRR does not look at this issue, who will?

5. Prevention

            We encourage NIDRR to consider a more prominent role for research on the causes of disabilities and strategies for their prevention. This can include situations, for example, where obesity leads to a condition causing a disability or where obesity arising after a disabling event would exacerbate the individual’s health and independent living needs.

6. Employment

            Much research needs to be undertaken to evaluate the role of obesity in employment decisions including whether its effects are primarily on educational attainment, employment discrimination, avoidance of positions involving social interaction on the part of the individual with obesity or the avoidance on the part of the employer for potentially greater costs in the provision of health, life and disability insurance, lost productivity, etc.

7. Health Care

            A major issue for persons with obesity is access to adequate health care. In many plans, individuals are excluded on the basis of their weight. In other plans, coverage for weight loss or weight maintenance benefits (e.g. surgery, pharmacotherapy, medical care, behavioral modification) is unavailable or subject to extreme limits. Research on the exact relationship of weight to health insurance and cost/benefits is urgently needed.

8. Public Accommodations

In spite of much progress in elimination of architectural barriers, many such barriers remain for persons with obesity.

Seats on airplanes are a frequent source of complaints. Some public access areas in governmental agencies, such as libraries, IRS offices and places of public accommodation do not have seating or tables or even toilets accessible to persons with severe obesity.  

9.  Independent Living and Community Integration

Clearly, the disability rights movement has had great success in recent years in forging greater degree of independent living and community integration for persons who previously would be living in segregated communities such as nursing homes, institutions for the mentally ill and the like. The issues relating to obesity in this regard may be much different and much in need of research. Individuals with severe obesity have not been institutionalized in the past. They do live in communities. However,  anecdotal evidence indicates that persons with obesity do live independently but alone and isolated from their communities. Many appear so adverse to exposing themselves to the gratitutous hurtful comments of others, that they live in increasing isolation. Research is desperately needed to shed light on the relationship of obesity to community integration.

10. Self-Advocacy Skills

We strongly support research on the development of self-advocacy skills of persons with obesity.

11. Research on Social Roles

We strongly support public policy research on various aspects of obesity. For example, earlier this year the Social Security Administration proposed eliminating obesity from its Listing of Disability Impairments supposedly on the basis of studies showing lack of a relationship between obesity, its major comorbid conditions and inability to engage in significant gainful activity. The AOA was able to submit comments on this topic including many of the studies referenced above. However, it was clear that many such studies can from Europe rather than the United States. The lack of a solid foundation of research in the United States hinders effective and sound policy making at the federal and state level.

12. Disability Statistics

Our research for the Social Security Administration and for these comments indicates a significant disconnect. A wealth of scientific studies tracks obesity (usually employing BMI) to the 30+ comorbid conditions described above. Then, the information

regarding the disability/employment aspects runs out. The lack of disability statistics which account for body weight is a grave deficit in understanding both the disabling effects of obesity and results in poor information for policy planning purposes. Statistical gathering efforts of NIDRR should include gathering of BMI information over time, at the very least.

There are numerous opportunities in the development of NIDRR’s Long Range Plan to not only reverse the past patterns of neglect of obesity by the disability and rehabilitation communities but also to enhance and perfect the complete understanding of disability in our society. NIDRR’s mission cannot be carried out if such a significant contributor to the nation’s disabled population as obesity is excluded.

Our final recommendation is that NIDRR establish a Task Force on Obesity-Related Disability to provide a more in-depth and

continuous input from other governmental agencies, and the obesity community, including researchers, clinicians and individuals with obesity, to this and other activities of the NIDRR. The American Obesity Association would be pleased to work with NIDRR to facilitate such an effort.

                                                Sincerely,

                                                Morgan Downey
                                                Executive Director