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‘Obesity Has To Be Treated As a Disease—Not a Lifestyle Issue’

Despite high obesity rates, Kansas City heart surgeon says steps are underway “to reduce heart mortality 20 percent by 2020.”

Dr. Willie E. Lawrence Jr. is a Kansas City-based cardiologist working with the American Heart Association to reduce the behaviors and risk factors that create heart disease.
National Journal
Willie E. Lawrence Jr.
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Willie E. Lawrence Jr.
March 7, 2014, 4:39 a.m.

As a Kan­sas City, Mo., car­di­olo­gist, Wil­lie E. Lawrence Jr., 56, sees a con­nec­tion in many of his pa­tients between obesity and hy­per­ten­sion, con­di­tions that can lead to heart dis­ease.

Dr. Lawrence, an ac­com­plished in­ter­ven­tion­al car­di­olo­gist, now ad­voc­ates for pro­grams and ap­proaches that may be more ef­fect­ive.

Ac­cord­ing to 2011 data re­leased by the Health and Hu­man Ser­vices’ Of­fice of Minor­ity Health, Afric­an-Amer­ic­an wo­men are 80 per­cent more likely to be obese than non-His­pan­ic white wo­men. Forty-four per­cent of Afric­an-Amer­ic­ans have high-blood pres­sure. Afric­an-Amer­ic­an wo­men are nearly twice as likely to suf­fer dia­betes as whites, yet only one in five Afric­an-Amer­ic­an wo­men be­lieves she is per­son­ally at risk for car­di­ovas­cu­lar dis­ease, ac­cord­ing to the Amer­ic­an Heart As­so­ci­ation/Amer­ic­an Stroke As­so­ci­ation.

To ad­dress these dis­par­it­ies, Lawrence has long been in­ter­ested in fig­ur­ing out tools that clin­ic­al pro­viders can use.

This in­ter­view, con­duc­ted by Jody Bran­non, has been ed­ited for length and clar­ity.

Obesity is an im­port­ant prob­lem in our Afric­an-Amer­ic­an com­munit­ies, and it’s get­ting worse. My spe­cif­ic in­terest in obesity ex­tends to hy­per­ten­sion. Obesity is one of the risk factors for hy­per­ten­sion, and both, along with dia­betes, in­ter­mingle to in­crease one’s risk for de­vel­op­ing heart dis­ease and stroke.

It’s hard in a 20-minute of­fice vis­it, for a doc­tor or a car­di­olo­gist to really im­pact obesity. First you need to make the per­son real­ize it’s a prob­lem. Obesity may be more ac­cep­ted in some com­munit­ies than in oth­ers. This may make it more dif­fi­cult to mo­tiv­ate pa­tients to diet, ex­er­cise, and re­cog­nize the health risks as­so­ci­ated with obesity. That’s one po­ten­tial obstacle to cre­at­ing an Afric­an-Amer­ic­an cul­ture of health.

Heart dis­ease de­vel­ops over time, and there’s no lin­ear re­la­tion­ship between weight and heart dis­ease. Non­ethe­less, as you lose weight you can po­ten­tially elim­in­ate some of the risk factors for heart dis­ease and stroke. That in­cludes dia­betes, hy­per­lip­idemia (high levels of fat in the blood), and hy­per­ten­sion (high blood pres­sure). As people lose weight, their risk of de­vel­op­ing dia­betes will go down. Rates of high blood pres­sure de­crease. Weight loss may make it easi­er to treat these dis­eases.

The re­search of Don­ald Lloyd-Jones has demon­strated that if you reach the age of 55 with no more than one risk factor for heart dis­ease, it is un­likely that you will die of heart dis­ease be­fore the age of 80. The goal is to not de­vel­op risk factors. 

We’re deal­ing with odds. That’s what makes it so chal­len­ging. If you’re part of a pop­u­la­tion that leads a healthy life­style or if you’re obese and yet you’re among the group that loses 10, 20, or 30 pounds, you’re go­ing to do bet­ter than the group that doesn’t lose weight.

Obesity is a dis­ease that is typ­ic­ally asymp­tot­ic — same thing with hy­per­ten­sion. You don’t really feel bad when you’re over­weight, but it puts people at in­creased risk of oth­er­wise avoid­able heart dis­ease and stroke in their life­time. While there may be no guar­an­tees, put your­self in the co­hort of people who are more likely to live longer, health­i­er lives than people who don’t con­trol cho­les­ter­ol, don’t ex­er­cise or con­tin­ue to smoke

As a car­di­olo­gist, there are frus­tra­tions. Of­ten I get up in the middle of the night and treat pa­tients who are hav­ing a heart at­tack. I open up blocked ar­ter­ies with bal­loons and stents. I may pre­vent a heart at­tack in a pa­tient with a blocked ves­sel. They thank me, but they don’t al­ways do what they need to do to pre­vent fu­ture events.

That’s one of the reas­ons I be­came a vo­lun­teer for the AHA and its hy­per­ten­sion pro­grams. In­stead of deal­ing with end-stage heart prob­lems, we are cre­at­ing policies and sys­tems of care that can im­pact lar­ger num­bers of people. We want to im­prove the car­di­ovas­cu­lar health of all Amer­ic­ans by 20 per­cent, and re­duce death from heart dis­ease and stroke by 20 per­cent by the year 2020.

We need to treat risk factors and change the mi­lieu in which heart dis­ease evolves. We have to de­crease rates of hy­per­ten­sion and obesity. It’s not just enough to take a pill to lose weight, to stop smoking or even treat hy­per­ten­sion. We need to pro­mote true life­style changes to achieve op­tim­al health. Med­ic­a­tions can only get you so far. We’re try­ing to change the psyche of pop­u­la­tions, of pa­tients so that the ex­pect­a­tion is a healthy life­style. That wasn’t al­ways the case.

It wasn’t long ago when it was ac­cept­able to get on a plane and smoke. People were in­dig­nant in a res­taur­ant when they were told not to smoke. For years it was the right of a ci­gar­ette smoker to smoke. Now it’s not ac­cept­able. We’ve changed the en­vir­on­ment. We’ve changed the ex­pect­a­tion for a healthy en­vir­on­ment. Sim­il­arly, obesity has to be treated as a dis­ease — not a life­style is­sue. Hav­ing a healthy life­style has to be the ex­pect­a­tion. And that’s what we’re try­ing to ef­fect at the Heart As­so­ci­ation, wheth­er through obesity aware­ness or ex­er­cise.

There’s that re­cent Biggest Loser win­ner and the dis­cus­sion that the lady lost weight too fast. You don’t want to go over­board and con­trib­ute to in­creased rates of eat­ing dis­orders. But you clearly need to re­cog­nize that obesity is a dis­ease and an im­port­ant health be­ha­vi­or. We have to change the mind-set and draw a re­la­tion­ship between obesity, dia­betes, and high blood pres­sure; and heart dis­ease and stroke.

That’s one of the battles we’re los­ing. We haven’t for­mu­lated a sys­tem­at­ic ap­proach to obesity. We’re see­ing res­ults in young kids, through the work of the AHA. We’ve been able to fo­cus on sug­ary drinks in school. The Heart As­so­ci­ation has worked to­ward le­gis­la­tion to deal with ban­ning them. That is lead­ing to de­creas­ing rates of obesity. En­cour­aging phys­ic­al activ­ity will help. In some mu­ni­cip­al­it­ies, we’ve en­cour­aged city plan­ning — like build­ing side­walks to en­cour­age walk­ing. We are win­ning many of these battles. But we’re los­ing that battle in oth­er places, re­lated to fin­ances. Schools are drop­ping phys­ic­al-edu­ca­tion re­quire­ments.

In terms of le­gis­la­tion around adult obesity spe­cific­ally, I’m not a big fan of lim­it­ing in­di­vidu­al choice. I lean more to­ward cre­at­ing in­cent­ives. The gov­ern­ment’s job is to pro­tect the in­di­vidu­al, so that may be easi­er with smoking ces­sa­tion. But to man­date policies that pre­vent obesity, that’s trick­i­er. What you don’t want is over­re­li­ance on re­strict­ive policies and man­dates that may not fun­da­ment­ally im­pact be­ha­vi­or. In con­trast, we must pro­tect our kids. More sup­port­ive ac­tion re­quires money. For in­stance, in pro­grams that are fin­anced by the fed­er­al gov­ern­ment that provide food for un­der­priv­ileged kids, the re­quire­ment should be that schools of­fer and pro­mote healthy food choices. That’s something we can do.

Our main goal has to be to pro­mote what the Amer­ic­an Heart As­so­ci­ation has termed a “cul­ture of health.” We are do­ing that. I re­main op­tim­ist­ic that in the next dec­ade, through our ef­forts, we will con­tin­ue to see im­prove­ment in the car­di­ovas­cu­lar health of all Amer­ic­ans.

Jody Brannon contributed to this article.
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