Obesity is a Chronic Disease

The American Obesity Association (AOA) believes that obesity is a disease. We want obesity understood by the health care community and patients as a serious disease of epidemic portions.

Why do we think obesity is a disease?

First, let's define our terms. Dictionaries agree: obesity is excess body fat. It is not defined as a behavior. However, many people use the term obesity as short-hand for overeating or lack of exercise. But that is not its definition.

Consider this: most people can distinguish between smoking and lung cancer. One is a behavior and one is a disease. Or problem drinking of alcohol and liver disease. One is a behavior and one is a disease. Sunbathing without protection is a behavior; skin cancer is a disease.

Second, obesity - the excess accumulation of body fat - fits all the definitions of "disease." How is "disease" defined? Most dictionaries, general as well as medical, define a disease as an interruption, cessation or disorder of a bodily function, organ or system. Obesity certainly fits this definition.

Some dictionaries have a more precise definition. Stedman's Medical Dictionary says that to be a disease it should have at least two of the following three features:

• recognized etiologic agents


• identifiable signs and symptoms, and,


• consistent anatomical alterations.

The "recognized etiologic agents" for obesity include social, behavioral, cultural, physiological, metabolic and genetic factors.

The "identifiable signs and symptoms" of obesity include an excess accumulation of fat or adipose tissue, an increase in the size or number of fat cells, insulin resistance, increased glucose levels, increased blood pressure, elevated cholesterol and triglyceride levels, decreased levels of high-density lipoprotein and norepinephrine and alterations in the activity of the sympathetic and parasympathetic nervous system. One is also likely to find shortness of breath and back pain.

The "consistent anatomic alteration" of obesity is the increase in body mass. Therefore, obesity meets all three of the dictionary criteria for disease.

• For a medical description of obesity, see the Merck Manual.

Who Considers Obesity a Disease?

Obesity is recognized as a disease in the U.S. and internationally by government, health organizations, researchers and medical professionals.

AOA and Shape Up America!

• The AOA and Shape Up America! collaborated to publish Guidance for Treatment of Adult Obesity, which states:
  

  "Obesity is a disease afflicting millions of Americans and causing a great deal of pain and suffering. Despite evidence to the contrary, many people view obesity as a lack of willpower on the part of the individual. As a result, obese persons are frequently the object of prejudice and discrimination."

National Institutes of Health (NIH)

• In a 1985 consensus statement on the Health Implications of Obesity, NIH declares:
  
  "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."
  
  


• The NIH's National Heart, Lung and Blood Institute's Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults, state:
  
  "Obesity is a complex, multifactorial chronic disease that develops from an interaction of genotype and the environment. Our understanding of how and why obesity develops is incomplete, but involves the integration of social, behavioral, cultural, physiological, metabolic and genetic factors."

National Academy of Sciences' Institute of Medicine

• The National Academy of Sciences' Institute of Medicine formed a committee to evaluate the treatment and prevention of obesity. In their report, Weighing the Options, the committee states:
  
  "These figures (regarding the prevalence of obesity) point to the fact that obesity is one of the most pervasive public health problems in this country, a complex, multifactorial disease of appetite regulation and energy metabolism involving genetics, physiology, biochemistry, and the neurosciences, as well as environmental, psychological, and cultural factors. Unfortunately, the lay public and health-care providers, as well as insurance companies, often view it simply as a problems of willful misconduct - eating too much and exercising too little. Obesity is a a remarkable disease in terms of the effort required by an individual for its management and the extent of discrimination its victims suffer."

Federal Trade Commission (FTC )

• The Partnership for Healthy Weight Management, a coalition of organizations led by the FTC developed Voluntary Guidelines for Providers of Weight Loss Products or Services. The Partnership states:
  
  "Obesity is a serious, chronic disease that is known to reduce life span, increase disability and lead to many serious illnesses including diabetes, heart disease, and stroke." The guidelines were established to "promote sound guidance to the general public on strategies for achieving and maintaining a healthy weight."

Maternal and Child Health Bureau

• An expert committee was formed by the Maternal and Child Health Bureau, a branch of the U.S. Department of Health and Human Services, at a March, 1997 conference on obesity in children and adolescents. Committee members were chosen for their clinical and research experience in the field of pediatric obesity to develop guidance on assessment and treatment for physicians, nurse practitioners, dietitians/nutritionists, and others who care for overweight children. The committee stated,
  
  "obesity represents a chronic disease," and "obesity in children and adolescents represents one of the most frustrating and difficult diseases to treat. "

World Health Organization (WHO)

• A WHO Consultation on Obesity reported:
  
  "Obesity is a chronic disease, prevalent in both developed and developing countries, and affecting children as well as adults. Indeed it is so common that it is replacing the more traditional public health concerns, including undernutrition and infectious diseases, as one of the most significant contributors to ill health."
  
  The WHO publishes the International Classification of Diseases (ICD-9-CM), which lists Obesity and Other Hyperalimentation as an Endocrine, Nutritional, Metabolic and Immunity Disease. The ICD-9-CM is recommended for use in all clinical settings, and is required for reporting diagnoses and diseases to all U.S. Public Health Service and Health Care Financing Administration programs. The World Health Organization recently included the Metabolic Syndrome in ICD-10 (#277). Obesity is a component of the Metabolic Syndrome.

American Heart Association (AHA)

• In June 1998, the AHA added obesity to the association's list of major risk factors that people can control to prevent death and disability from coronary heart disease, the cause of heart attacks. Other major risk factors include smoking, high blood cholesterol, high blood pressure, sedentary lifestyle. According to Robert H. Eckel, M.D., vice chairman of the AHA's Nutrition Committee:



"Obesity itself has become a life-long disease, not a cosmetic issue, nor a moral judgement — and it is becoming a dangerous epidemic."

American Academy of Family Physicians (AAFP)

• The AAFP Congress, the Academy's policy-making body, adopted a policy on obesity stating:



"The AAFP recognizes obesity as a disease and a national health risk for premature death; will support CME programs on childhood obesity; and promotes nutritionally balanced meals, decreased TV viewing and increased physical activities for obese children."

American Society for Bariatric Surgery (ASBS)

• The ASBS states in their Rationale For The Surgical Treatment Of Morbid Obesity:
  
  "The physiologic, biochemical and genetic evidence is overwhelming that clinically morbid obesity is a complex disorder."

The American Society of Bariatric Physicians (ASBP)

• ASBP states in their Frequently Asked Questions:
  
  "Recognized since 1985 as a chronic disease, obesity is the second leading cause of preventable death, exceeded only by cigarette smoking. Obesity has been established as a major risk factor for hypertension, cardiovascular disease, diabetes mellitus and some cancers in both men and women."

The Self-Cleaning Heart

You were born with immaculate arteries. Boost your HDL cholesterol and they can look like new once again

Pop a milk pill, +7 percent

Strong bones, stronger heart. In a yearlong study published in the American Journal of Medicine, those people who took a daily 1,000-mg calcium supplement saw their HDL-cholesterol levels rise by 7 percent. "Calcium interferes with the absorption of fat from the diet and decreases fat mass in the body, both of which may help raise HDL," says Ian Reid, M.D., the lead researcher. Dairy products are an excellent source of calcium . . . except in this case. "Calcium is probably best ingested as a supplement, at least until there's more research on the HDL-increasing effects of calcium-rich foods," says Dr. Reid. Choose a brand that contains calcium citrate (not coral calcium) and 400 international units of vitamin D for maximum absorption.

Build killer quads, +19 percent

Scientists have always believed that you have to run, cycle, or do other aerobic acrobatics in order for exercise to boost HDL. But when Ohio University researchers studied the impact of weight training on older men, they discovered a surprising side effect: The men who did lower-body work--squats, leg extensions, leg presses--twice a week for 16 weeks raised their HDL levels by 19 percent. "If you add weight training to your exercise routine, you are going to increase your HDL," says Robert Staron, Ph.D., one of the study authors. For legs and HDL levels that are something to look at, follow the lead of the men in the study: Do three sets of six to eight repetitions of the half squat, leg extension, and leg press, resting no more than 2 minutes between sets. Use a weight that's about 85 percent of the amount you can lift just once. The Fountain of Youth may be fiction, but there really is a magic gene pool in northern Italy. Thirty years ago, researchers discovered that, despite unhealthy cholesterol levels, 40 inhabitants of the village of Limone sul Garda were seemingly immune to heart disease. Turns out it wasn't the famed Mediterranean diet at work, but rather a variation of a protein in HDL cholesterol (the good kind) called ApoA-1 Milano. In less scientific terms, the villagers were born with self-cleaning arteries.

In about 3 years, you won't need to be a son of Limone sul Garda to enjoy the plaque-busting perks of ApoA-1 Milano. You'll probably be able to ask your doctor for a few shots of ETC-216, a synthetic form of HDL modeled after the Italian wonder protein. In a landmark study published in the Journal of the American Medical Association, Cleveland Clinic researchers found that emergency-room patients who received ETC-216 had an average reduction in arterial plaque of 4.2 percent. This may not sound like much, but according to Steven Nissen, M.D., the lead study author, "that level of reduction of arterial plaque--several weeks of treatment reversing several years' worth of accumulation--is extraordinary and unprecedented."

Think you can wait 3 years? You can't. A man with a low HDL-cholesterol level--40 milligrams per deciliter (mg/dl) or lower--can have as much as a three times greater risk of death from heart disease. So unless you're blessed with blood that consistently scores in the mid-40s or higher, you need to do something now. Make that several somethings. "The key to raising HDL levels with lifestyle changes is to do more than one thing," says Daniel J. Rader, M.D., director of the preventive cardiology and lipid clinic at the University of Pennsylvania school of medicine.

Our thinking exactly, which is why we've come up with these six strategies for making your HDL its level best.

Make a date with Mrs. Paul, +26 percent

Compared with omega-3-rich salmon, whitefish looks like the iceberg lettuce of seafood. However, when Canadian researchers recently compared a steady diet of the stuff with regular consumption of lean beef and chicken, they found that the fish-eating folks experienced a 26 percent increase in HDL2, a particularly protective form of HDL (see "Sizing Up Your HDL," in related articles on right). "Fish protein may increase insulin sensitivity, which in turn can elevate HDL2 cholesterol," says Helene Jacques, Ph.D., one of the study authors. Still, fish sticks aren't health food--unless they're baked, like Healthy Selects Sticks from Mrs. Paul's. Same goes for any other frozen fish: Always choose baked over battered.

Learn how to pronounce this word, +15 percent

"Policosanol" (poly-CO-sanol). This mixture of alcohols derived from sugarcane wax is the rare natural supplement that may actually live up to its hype. "At doses of 10 to 20 mg a day, it can increase HDL by up to 15 percent, which is incredible," says David Maron, M.D., a cardiologist at Vanderbilt University medical center. "I'm amazed it hasn't made more of a splash." One reason may be that most of that research has been done on a brand of policosanol not available in the United States. "A lot of the [U.S.] products don't use sugarcane," says Stephen Sinatra, M.D., an assistant professor of medicine at the University of Connecticut school of medicine. Instead, they use vegetable or bee waxes. Two domestic exceptions: Source Naturals and Nature's Life, both of which are sold at health-food stores.

Make your six-pack disappear, +12 percent

Not your abs, your Amstel lager. Researchers in the Netherlands found that men who drank 2 pints of beer a day increased their HDL levels by 7 percent after only 10 days, and by 12 percent after 3 weeks. "The exact way in which it affects HDL has never really been figured out, but the effect has been observed over and over again," says Norman Kaplan, M.D., a clinical professor of internal medicine at the University of Texas. What's more, says Dr. Kaplan, "beer contains components that reduce homocysteine levels in the blood [a risk factor for heart disease]." Of course, beer does have its limits, as should you--stop at two glasses a day, unless you're celebrating something special, like a triple-digit HDL score.

Munch on macadamias, +8 percent

This Hawaiian native will do even more to keep your heart pumping than getting lei'd by a babe in a grass skirt. In a study of 17 men with high cholesterol, Australian scientists found that when the men replaced 15 percent of their daily calorie intake with macadamia nuts--12 to 16 nuts a day--their HDL levels went up by 8 percent. "Since macadamia nuts contain the highest amount of monounsaturated fat of all nuts, this degree of HDL-raising effect may be unique to them," says Manohar Garg, Ph.D., the study author. And don't worry about your sodium intake; a dozen dry-roasted macadamias contains just 75 mg sodium, a third of what's coating an equivalent pile of peanuts.

Young at Heart

5 secrets to turning back the clock on your ticker

Over the past few years, cardiologists across the country have begun aggressively trying to prevent heart disease in at-risk men, rather than treating them only after their blood pumps have broken down. "My patients who follow a preventive treatment program almost always live free of heart attacks," says Arthur Agatston, M.D., author of The South Beach Heart Program. To help you spot subtle risk factors and correct them before they bury you, we canvassed cardiologists at leading research institutes to compile this list of things they wish you knew.

Your Heart's Mortal Enemy is Often Invisible to Doctors

"I was taught in medical school that when a heart attack happens, vessels have closed gradually, like pipes filling up with sludge," says Dr. Agatston. "We now know that blockages occur suddenly, from soft-plaque ruptures, which often go undetected by standard cholesterol tests and exercise stress tests." The soft plaques resemble pimples in the arterial walls, except instead of pus, they're filled with cholesterol.

Why it's so dangerous: When those pimples pop, a small blood clot forms to heal the injury, followed by scar tissue and tiny calcifications along the arterial wall. By then, you're already incubating an attack, which strikes when a violent explosion of one of the pustules creates a clot big enough to block an artery.

How to ID the problem: If you have a family history of heart disease, schedule a 64-slice CT scan. It's the only test that snaps pictures of the heart quickly enough to reveal minute calcifications in the coronary arteries. Just make sure the scanner has ECG dose modulation, the latest radiation-limiting technology. If trouble's spotted, you may need statins.

How to defend yourself: Toss pecans onto your salad or into your oatmeal. Loma Linda University researchers had 24 people replace 20 percent of their daily calories with pecans for a month, and found the nuts lowered levels of lipid oxidation (the process that turns cholesterol into plaque) by 7 percent, enough to help ward off arterial damage. "Pecans are rich in gamma-tocopherol, a form of vitamin E that isn't in supplements," says lead author Ella Haddad, Dr.P.H., R.D. Even a handful a day can help, she says.

An Untrained Heart Won't Reach the Finish Line

Not every heart test needs to take place in a cath lab. In a 23-year study of 6,000 men in the New England Journal of Medicine, researchers revealed that the greatest predictor of death from heart attack was the ability of a man's heart rate to adapt during and after a workout. "The faster your heart rate goes down after exercise, the healthier you are," says Steven Nissen, M.D., chairman of cardiovascular medicine at the Cleveland Clinic.

Why it's so dangerous: Those men whose heart rates didn't drop by at least 25 beats per minute (bpm) within 1 minute of finishing an intense workout were more likely to suffer a fatal heart attack than those whose heart rates dropped efficiently. The reason? How your heart adapts to exercise is a good indication of how well it will respond to the extreme stress produced before and during an actual infarction.

How to ID the problem: Complete 10 minutes of sprints, check your heart rate, and then check it again 1 minute later.

How to defend yourself: Improve your heart-rate variability by applying the principles of interval training to your lifting regimen. Wear a heart-rate monitor and don't end your first set until the monitor reads 160 bpm, says Alan Stein, C.S.C.S. "Then wait till it drops below 130 bpm to begin your next set."

You've Never Even Heard of the Cholesterol that Wants You Dead

Researchers now realize that the size of cholesterol particles is even more important than their number. Small particles of LDL, called Lp (a), are a particularly damaging form of cholesterol, according to Michael Ozner, M.D., medical director of the Cardiovascular Prevention Institute of South Florida. These particles aren't only smaller, they have a tail, says Dr. Ozner, making it easier for them to sneak into the arterial wall. On the flipside, the larger your HDL particles, the more easily they can usher LDL cholesterol out of your arteries.

Why it's so dangerous: A recent study in the Journal of the American College of Cardiology reveals that people with high Lp (a) were 10 times more likely to suffer a heart attack than those with lower levels.

How to ID the problem: Ask your doctor to schedule a Vertical Auto Profile (VAP) test. (Check it out at www.the vaptest.com. It's covered by most insurance plans.) This detailed blood profile includes a measure of Lp (a)--an ideal level is below 10 milligrams per deciliter--as well as big and small HDL particles.

How to defend yourself: Diet, exercise, and even statins have proven ineffective against Lp (a). But in a review of 8 years of studies on prescription niacin, Dutch researchers determined that swallowing 2 grams of this potent B vitamin lowered Lp (a) by 17 percent and raised the number of large HDL particles by 18 percent. Ask your doctor for a slow-release version of niacin. Research has shown that these formulations produce fewer side effects.

Carbohydrates, Not Fat, are the Real Heartbreakers

The more carbohydrates you consume, the higher your blood sugar and, in turn, your levels of insulin, a hormone that lets us use sugar as energy. But excess insulin may also increase your risk of heart disease, according to a review in Preventive Medicine. "The inflammatory process leading to hardening of the arteries is mediated through insulin," says Wolfgang Kopp, M.D., the study's lead author. Translation: High levels of insulin boost your body's production of stress hormones, which send blood pressure skyrocketing. That increased pressure damages the arterial wall, making it easier for cholesterol to slip inside.

Why it's so dangerous: Insulin may not act alone. It's theorized that the excess carbohydrates that cause insulin to increase to an unhealthy level are turned into triglycerides in your liver. And the more triglycerides you have circulating in your bloodstream, the more Lp (a)--the lethally small cholesterol--you're likely to have.

How to ID the problem: Johns Hopkins University researchers showed that for every 1 percent increase in hemoglobin A1c (HbA1c), an indicator of long-term blood-sugar levels, patients experienced a 14 percent increase in heart-disease risk. If diabetes appears anywhere on your family tree, schedule an HbA1c test. A level higher than 4.6 percent of total hemoglobin often warrants dietary changes and sometimes blood-sugar-lowering drugs.

How to defend yourself: Pour yourself a cabernet. According to a recent study in the Annals of Epidemiology, small amounts of alcohol may help control your blood sugar, and, by extension, your insulin. Researchers studied the drinking habits of people with type-2 diabetes and found that compared with teetotalers, those who indulged in just one alcoholic beverage per night had levels of HbA1c that were 1.3 percentage points lower on average.

Your Heart Might Be Misfiring

One in four men will develop an irregular heartbeat, or arrhythmia, by the time they reach 40. Yet they often don't experience obvious symptoms until they're clutching their chests during cardiac arrest or they suffer a stroke. Your heartbeat originates in the sinoatrial (SA) node, a collection of specialized heart cells that acts as your heart's control center, says Jennifer Cummings, M.D., director of electrophysiology research at the Cleveland Clinic. "It reacts to information from your body and brain about how much blood needs to be pumped, then sends an electrical impulse telling your heart when to beat."

Why it's so dangerous: "When an arrhythmia occurs, the heart stops listening to the SA node, turning its attention to other electrical signals," says Dr. Cummings. One form of arrhythmia, called atrial fibrillation, or AFib, can occur even in young athletic men. "It's like there are 300 voices inside the heart telling it what to do," says Dr. Cummings. Chaotic heartbeats cause the blood to swirl and eddy instead of flowing smoothly through the ventricles, and clots form as a result.

How to ID the problem: One telltale sign of an arrhythmia is a dramatic decline in endurance. If your regular cardio workout is suddenly a lot more exhausting, ask your doctor for an EKG. If that comes up clear, request a Holter monitor. It records your heart rhythm for 24 hours to detect more infrequent missed beats. Passing out may also be a sign of serious heart-rhythm trouble.

How to defend yourself: One of the most common causes of arrhythmia is high blood pressure, so keep yours under 120/80 millimeters of mercury. A massage may provide pleasurable stress relief. In a recent University of South Florida study, people who underwent three 10-minute massages a week experienced an 18-point drop in their systolic blood pressure and a 5-point drop in their diastolic blood pressure after just 10 sessions.

Relax--You're Not Dying

Four alarming chest sensations that can impersonate an infarction

A Fluttering or Pounding Heartbeat

"Some perfectly healthy and normal individuals may feel extra or skipped heartbeats on occasion, and those can be benign," says P.K. Shah, M.D., a Men's Health cardiology advisor. If the sensation is brief and the onset gradual, they are probably the harmless result of too much caffeine or stress. However, frequent flutterings, or those accompanied by lightheadedness or dizziness, could be serious.

Chest Pressure When You Swallow

If you feel a squeezing pain beneath your breastbone and it hurts to swallow, especially in the evening, you may just have heartburn or, at worst, an esophageal spasm. But if it persists most nights of the week, see your doctor to rule out gastroesophageal reflux disease or other more serious conditions.

Shooting Pain on One Side

"Sharp, fleeting pain on the left side of the chest is typically not life-threatening," says John Elefteriades, M.D., a Men's Health cardiology advisor. It can signal pleurisy (an inflammation of the lung lining), a muscle pull, or even a broken bone.

Mild Pressure, Shortness of Breath, and Numbness

Hyperventilation is commonly mistaken for a heart attack. If the pressure in your chest isn't severe, and you lose feeling in your lips or hands, you may simply be hyperventilating. Lie down, try to relax, and breathe into a paper bag for 5 minutes. Still have symptoms? Call 911.

Diabetics More Prone to Depression

Being diagnosed with either type 1 or type 2 diabetes dramatically increases a person's risk of suffering from severe depression, a new study finds. Published in the journal Diabetes Care, the study was conducted by Ohio University researchers. Based on findings from the medical histories of several hundred diabetic patients, researchers concluded that depression may afflict a whopping 25% of all diabetics nationwide. Depression rates appeared to be similar across all ethnic groups, while women and middle-aged diabetics were slightly more prone than men and younger diabetics. Among those diabetics who were diagnosed with depression, more than half reported taking antidepressant medications, while nearly one-fifth sought help in the form of alternative supplement and behavioral therapies.