'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)

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