Overweight and obesity are major risk factors for many serious chronic diseases and conditions including cardiovascular disease, dyslipidemia, hypertension, type 2 diabetes, cancer and osteoarthritis. Being overweight in a society that stigmatizes this condition is also associated with serious shame, self-blame, low self-esteem and depression. These conditions may also impair social and academic functioning, leading to discrimination, negative stereotyping and social marginalization. With increasing adiposity (body fatness) the risk of each disease increases. Adults whose BMI is under 25 kg/m2, but who have gained 10 or more pounds after 21 years of age, are also at increased risk of many diseases. The benefits of weight reduction for those overweight or obese are substantial, especially if the individual has other health risk factors. Weight loss as modest as 5-10% of total body weight in a person who is overweight or obese can reduce elevated blood pressure, elevated blood glucose levels, and elevated cholesterol levels. In NYS, adults who are overweight or obese are significantly more likely to report fair or poor health (Figure 8).
Figure 8: Prevalence of fair or poor health vs. BMI by race/ethnicity
Source NYS BRFSS 2003
The association between obesity and cardiovascular disease (CVD), including stroke is well documented (Kraus, Winston, Fletcher, 1998). Deaths due to CVD have been linked directly to obesity (Stevens et al., 2002). Adults under the age of 50 years are at an increased risk of developing coronary heart disease if they are obese (Hubert, Feinlab et al., 1983). Part of the increased risk of CVD associated with obesity is due to increased rates of risk factors including hypertension, high serum cholesterol levels and diabetes an association found for nearly all gender, race and socioeconomic groups (Parateukel, Lovejoy et al., 2002). Even after adjusting for these risk factors, obesity remains directly associated with CVD (Hubert, Feinlab et al., 1983). Fat distribution, (i.e., abdominal obesity, waist/hip ratio) independent of total fat has been shown to increase the risk of hypertension (Okason et al., 2001), stroke (Walter et al., 1996) and the risk of CVD for older men and women (Rimm, Stampfer et al., 1995; Gillum, 1987) (Figure 9 and Figure 10).
Figure 9: Prevalence of hypertension vs. BMI by race/ethnicity
Source NYS BRFSS 2003
Figure 10: Prevalence of cardiovascular disease vs. BMI by race/ethnicity
Source NYS BRFSS 2003
In NYS, the prevalence of self-reported hypertension increases with increasing BMI for Whites, Blacks, and Hispanics (Figure 9). Prevalence of self-reported cardiovascular disease increases with increasing BMI for Whites and Hispanics (Figure 10). For Blacks, however, reported CVD rates did not differ by BMI group.
The increased risk for CVD associated with obesity begins early in life. Obese youth, aged 5 to 10 years, are more than twice as likely as non-obese children to have at least one CVD risk factor such as elevated blood cholesterol, triglycerides, insulin, or blood pressure (60% vs. 27%); 25% of obese children have two or more risk factors for CVD. The Pathological Determinants of Atherosclerosis in Youth (PDAY) study among teens and young males aged 15-35 years, showed at autopsy that obesity greatly accelerated the extent of atherosclerosis present in the abdominal aorta and coronary arteries after adjusting for other risk factors including blood lipids, blood pressure, smoking and insulin levels (McGill et al., 2002).
Overweight and obesity are strongly associated with glucose intolerance and insulin resistance (Perry, 2002). More than 80% of persons with type 2 diabetes are overweight or obese (Perry, 2002). Both degree and duration of obesity are significant risk factors for type 2 diabetes. Persons who have been obese for more than 10 years are twice as likely to develop type 2 diabetes than those who have been obese for 5 or fewer years. Among NYS adults, the prevalence of diabetes increases with higher BMI for Blacks, Whites, and Hispanics (Figure 11). Location of body fat is also a strong and independent risk factor for type 2 diabetes, with abdominal or visceral obesity associated with an increased risk of type 2 diabetes. Weight loss and/or increased physical activity are the most effective means of preventing the development of type 2 diabetes among those with pre-diabetes (Klein et al., 2004; Lindstrom et al., 2003).
Figure 11:Prevalence of diabetes vs. BMI by race/ethnicity
Source NYS BRFSS 2003
Children whose mothers had diabetes during pregnancy are at higher risk of childhood obesity, and subsequently of developing type 2 diabetes (Dabelea and Pettitt, 2001). Until recently, type 2 diabetes was commonly referred to as adult onset diabetes. But type 2 diabetes is rapidly becoming a disease of children and adolescents, with a five to tenfold increase in the prevalence of diabetes mellitus among adolescents over the past decade (Rosenbaum et al., 2004). It is estimated that today's youth have a significantly increased lifetime risk of developing type 2 diabetes - 30% for boys and 40% for girls (IOM, 2004). These rates are even higher among ethnic minorities and for those with a family history of type 2 diabetes. In a recent study of children, family history of type 2 diabetes was associated with beta-cell dysfunction, which was unmasked by increasing insulin resistance secondary to obesity (Rosenbaum et al., 2004) (Figure 11).
Obesity and overweight are significant risk factors for certain cancers, including multiple myeloma and cancers of the esophagus, colon and rectum, liver, gallbladder, pancreas, kidney and stomach. Overweight and obese women are at increased risk for breast, uterus, cervix and ovarian cancers. Increased cancer risk is found not only among the most obese; for example, women with a BMI between 25 and 29.9 were found to have a 34% higher risk for breast cancer (Calle, Rodriguez et al., 2003). Overweight and obese men are also at significantly increased risk for prostate cancer. It is estimated that 14% of all cancer deaths in men are related to overweight or obesity, while 20% of women's cancer deaths can be attributed to overweight or obesity (Calle, Rodriguez et al., 2003).
Obesity is a significant risk factor for arthritis. Although arthritis rates are highest among Whites, lowest among Hispanics, and in between for Blacks in NYS, the prevalence of arthritis increases with higher BMI for all three racial/ethnic groups (Figure 12).
Figure 12:Prevalence of arthritis vs. BMI by race/ethnicity
Source NYS BRFSS 2003
Maintaining an appropriate weight or reducing weight to a recommended level reduces a person's risk for developing certain forms of arthritis. Obesity is a major risk factor for both the development and progression of osteoarthritis of the knee and is associated with an increased prevalence of hip osteoarthritis (Anderson, Felson, 1988; Davis, Ettinger, Neuhaus, 1990; CDC, 1999). It is estimated that obesity accounts for 19% of osteoarthritis of the knees (Felson, 1990). An increase in weight is significantly associated with increased pain in weight-bearing joints while weight loss decreases the risk of developing symptomatic knee osteoarthritis in women (Felson, Zhang et al., 1992). In one study, women who lost as little as 11 pounds decreased their risk of developing osteoarthritis of the knee by 50%. Obesity is also a risk factor for gout in men (Wortman, 2002).
In the past two decades there has been a dramatic increase in the prevalence of asthma in the U.S. The number of Americans suffering with asthma has doubled between 1980 and 1994 and it is estimated that 14.9 million Americans have asthma (Luder, 2002). This increase in asthma prevalence affects all age groups, races and both sexes (Redd, 2002). A number of studies have demonstrated a relationship between obesity and asthma among children, adolescents and adults (Shaheen, 1999). Obese adults were 66% more likely to have asthma than their normal weight peers (Medical Letter on the CDC and FD, 2002).
There are several possible theories regarding the association between obesity and asthma, including the possibility that individuals with asthma are less likely to participate in physical activities (von Kries, Hermann, Grunert and von Mutius, 2001), obese people may spend more time indoors exposed to indoor allergens leading to asthma (Bukowski, Lewis, Gamble, Wojcik and Laumbach, 2001), or that obesity leads to decreased lung function due to abdominal fat impeding the diaphragm (Luder, 2002).
Studies have consistently found that a moderate weight loss of 10% of body weight is beneficial for asthma sufferers, leading to increased lung function, decreased asthma symptoms, decreased need for asthma medication and improved health status (Luder, 2002; Stenius et al., 2000).
Traditionally, disability was believed to originate from disease or pathology. However, recent evidence shows that physical inactivity can itself be a primary cause of disability (Chandler and Hadley, 1996; DiPeitro, 1996; Morey et al., 1998; Rikli and Jones, 1997). Physical inactivity contributes to a "vicious cycle" where inactivity contributes to obesity, obesity exacerbates disability and disability impedes exercise (NIH Clinical Guidelines, 1998; Heath and Fenton, 1997). A high BMI may also be a proxy for physical inactivity and disuse (Rissanen et al., 1991), which in turn leads to reduced capacity or reserve in neurological and musculoskeletal systems and functional decline (Buchner and Wagner 1992). Physical inactivity contributes to the higher prevalence of obesity among adults with disabilities (Finch, 2001) since adults with disabling conditions or disabilities are more likely to face barriers to regular exercise. Among NYS adults, disability rates increase with increasing BMI group (Figure 13).
Figure 13:Prevalence of disability vs. BMI by race/ethnicity
Source NYS BRFSS 2003
Costs of Obesity-related Diseases
Obesity is expensive in terms of morbidity, mortality and financial costs. The total lifetime medical care costs for the treatment of obesity, hypertension, diabetes, coronary heart disease and stroke add up to $10,000 for an obese person. Obesity accounts for 40 million workdays of lost productivity, 63 million doctors' office visits, 239 million restricted activity days, and 90 million days confined to bed per year (Wolf M, Colditz GA, 1998).
Obesity and obesity-related illnesses in the U.S. are estimated at more than $117 billion each year. Medical spending for conditions attributable to overweight and obesity accounted for 9.1% of total annual U.S. medical expenditures (Finkelstein, 2003). In New York State, obesity costs exceed $6 billion per year and Medicare and Medicaid finance approximately one-half of these costs. Medical spending for overweight and obesity now rivals that for smoking (U.S. Department of Health and Human Services, 2001; Finkelstein et al., 2003). Obese individuals spend more on both health services and medications than do daily smokers and heavy drinkers (The Surgeon General's Call, 2001; Finkelstein et al., 2003; Pastor et al., 2002; Thompson, Edelsberg et al., 1999; Wellman and Friedberg, 2002; Sturm, 2002).
Nationwide, poor diet and physical inactivity are estimated to cause over 365,000 deaths per year or 1000 deaths every day (Mokdad, 2003). In fact, poor diet and physical inactivity are the second leading underlying, or actual, cause of preventable death in our country (Mokdad, 2005). By 2010, if current trends continue, poor nutrition and physical inactivity are expected to surpass tobacco as the leading underlying cause of preventable deaths in the U.S.
Seventy-five percent of healthcare costs are attributable to chronic diseases, and 70% of deaths (CDC). Obesity is associated with a shortened life expectancy. Chronic obesity (BMI greater than 45 kg/m2) among 20 to 30 year olds reduces the lifespan of men more than women. Black men experience more years of life lost than white men (20 years vs. 13 years respectively) while white women experienced more years of life lost than black women (8 years vs. 5 years respectively) (Fontaine KR, Redden DT, Wang C et al., 2003). In fact, obesity threatens to reverse the improved life expectancy trend achieved with the reduction of infectious diseases over the past century, so that for the first time in history, today's children are predicted to have a shorter life expectancy than their parents (IOM, 2004).
Steps to a Healthier NY
The goal of the Steps to a Healthier NY (Steps) program is to help individuals live longer, better and healthier lives by reducing the burden of diabetes, asthma and obesity by addressing three related risk factors - physical activity, poor nutrition, and tobacco use. New York State's Departments of Education and Health are partnering with four counties to implement effective strategies to maximize community and school resources and address the critical health issues and related risk factors.
In September 2003, New York State received a five year grant from the CDC to address these issues; seventy-five percent of these federal funds are provided directly to the four counties of Broome, Chautauqua, Jefferson and Rockland with a combined population of approximately 800,000 people. These counties were selected based on their need, demographics, and previous experience in developing and implementing effective community-based public health programs.
The goals of Steps are achieved through the building of partnerships (community consortiums) between public and private organizations working in areas of disease prevention and medical, social, educational, business, religious and civic organizations. Evidence-based community and school-based interventions have been tailored to each individual county's needs and resources. A number of Steps interventions related to obesity, nutrition, and physical activity exist in the areas of Policy, School-Based, Community-Based, Workplace, Health Care. The Obesity Prevention Program works with the Steps to a HealthierUS. Program including providing data and information for New York's four Steps counties and providing staff expertise in Steps counties. Together, the Obesity Prevention and Steps Programs sponsored social marketing training for stakeholders involved in both the Obesity intervention and the four Steps counties. The benefits of this included economy of scale in purchasing services and importantly, brought together staff of both programs and intervention sites to share information, network and create new partnerships to prevent diabetes in New York State.