Background
Methods
AMA National Summit on Obesity
Community Interventions
School Interventions
Worksite Interventions
Medical Practice Interventions
Obesity as a Disease
Argument for Obesity as a Disease
Argument Against Obesity as a Disease
Body Mass Index and Routine Measurement of Waist Circumference
as the Sixth JACHO Vital Sign
Childhood Obesity and School-based Interventions
Conclusion and Recommendations (Adopted AMA Directives)
References

Note: This report, written in response to Resolution 421 (A-04) and presented as CSA Report 4 at the 2005 AMA Annual Meeting, reflects information on this subject as of June 2005. AMA policy and directives, as discussed in this report, are those in effect as of June 2005.

Previously, the Council on Scientific Affairs (CSA) reviewed the epidemiology of obesity and its importance as a public health problem, and urged physicians, managed care organizations, and third-party payers to recognize the complexity of this disorder (AMA Policy H-150.953). Additionally, the CSA encouraged the AMA to work with other public and private stakeholders, including those involved with continuing medical education programs, to enhance physician training and education to more effectively manage overweight and obesity in children and adults. The need for improved physician monitoring, intervention, and referral was also noted, as well as the need to develop coding and payment mechanisms for the evaluation and management of obesity.

Subsequently (CSA Report 8, A-04), the Council reviewed steps the AMA had taken to address these directives, including the development of a primer for physicians on the assessment and evaluation of obesity (Roadmaps for Clinical Practice: Assessment and Management of Adult Obesity); establishment of a working group on childhood obesity; and development of other educational material, including a monograph on adolescent obesity, nutrition, and physical activity. Recognizing the magnitude of obesity and its impact on health and health care, the Council recommended several potential activities, including use of community-based communication strategies, further development of physician training materials, the pursuit of legislative and regulatory strategies, development of a Web-based inventory of relevant Federation activities, and the pursuit of collaborative efforts to update clinical pathways for the identification and management of children with obesity. The Council also called for assessing the value of convening a National Summit to further the dialogue on classifying obesity as a disease. This National Summit was subsequently convened by the AMA on October 19-20, 2004.

This report briefly reviews the findings and recommendations of the AMA National Summit on Obesity in order to identify additional interventions to confront the obesity epidemic. In this context, this report also evaluates the merits of the second resolve of Resolution 421 (A-04) on the concept of obesity as a disease. The report also briefly considers the issue of designating the measurement of BMI and waist circumference as a Joint Commission on Accreditation of Healthcare Organizations (JCAHO)-sixth vital sign. Special attention is also directed to childhood obesity and potential anti-obesity efforts in schools. Finally, the report offers recommendations for specific AMA actions targeting the obesity epidemic. This report does not evaluate specific treatment plans or options for obese patients, nor address the first resolve of Resolution 421.

Background

The size and scope of the obesity epidemic and its effect on health and medical care requires that organized medicine vigorously identify strategies for prevention and intervention. Currently, an estimated 65% of U.S. adults are either overweight or obese, a prevalence that is 16% higher than the age-adjusted overweight estimates obtained from the National Health and Nutrition Examination Survey (NHANES) III (1988-94).¹ Compared with data obtained 25 years ago from NHANES II, notable increases have occurred in the prevalence of persons aged 20 to 74 years who were either overweight or obese. Most of this increase has occurred in the obese category (BMI greater than or equal to 30.0).

The prevalence of obesity and overweight in children and adolescents is rising in parallel with that of adults. It is estimated that 15.8% of individuals aged 6 to 19 years are overweight or obese, up from 4.2% in 1963.² As a result, obesity-associated illnesses such as non-insulin-dependent diabetes and osteoarthritis are being observed among U.S. youth at concerning rates.

The public health burden of the obesity epidemic is well established. Obesity is an independent risk factor for several major diseases, including coronary heart disease, diabetes, gallbladder disease, endometrial cancer, hypertension, and osteoarthritis of the knee. The economic impact of obesity, including direct and indirect costs to employers, has also received increasing attention.^3-7

Current AMA policy on obesity also recognizes the need for continued collaboration to: (1) better recognize and treat obesity as a chronic disease; (2) develop evidence-based recommendations regarding education, prevention, and treatment of obesity; and (3) highlight the relevance of racial and ethnic disparities, and the need for culturally responsive care in the management of obesity and associated diseases (Directive D-440.980; Policy H-440.902).
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Methods

An informational review of current literature was conducted using PubMed to identify articles on the concept of obesity as a disease. English-language articles, published between January 1, 1998, and January 30, 2005, were retrieved. Use of the search term obesity yielded 5955 articles. The journal filter was used to narrow the search. The term obesity yielded 6 journals that were searched for the term obesity as disease. When restricted to title and abstract, 542 articles were recovered and examined for relevance. Of these, 8 articles were relevant. Additional references were culled from the bibliographies of the cited articles. The Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) Web sites were also searched for pertinent information. Proceedings of the AMA National Summit on Obesity were consulted for potential interventions established in breakout sessions.

For the discussion of body mass index (BMI), the CDC Web site was searched using the terms BMI and waist circumference. Links were followed to the National Heart, Lung and Blood Institutes' Web site, which was searched using the terms body mass index, and waist circumference.

For the discussion of obesity and schools, published studies from the years 1998 through 2005 were identified through a PubMed search of English-language articles, using the key words coordinated school health, obesity and school, overweight and school, vending and school, soda and school, nutrition and school, competitive food and school, physical education and school, and physical activity and school. This search yielded 114 articles from the medical/scientific literature. Additional publications were identified by review of references in the above noted articles. In addition, current state legislative initiatives related to physical education and nutrition in schools were reviewed.
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The AMA National Summit on Obesity

During the Summit held in Chicago in October 2004, more than 150 participants convened to discuss and identify different strategies to address the obesity epidemic. These included national experts and representatives in clinical practice, nutrition, public health, worksite health, and school health. Keynote presentations provided an overview of the obesity epidemic; the toll of obesity in medical, social, and economic terms; and legislative and policy actions being developed and implemented. Attention was focused on the community, schools, the workplace, and medical practice. From these discussions, a series of potential interventions were identified for each site. Those receiving highest priority are noted below:

Community interventions

• Work with state medical societies, specialty chapters, government, other health professional organizations, and other key stakeholders to create state-wide task forces on obesity that identify strategic actions for addressing the obesity epidemic in communities.
• Advocate for improved access to healthy foods, especially in communities of low socioeconomic status, and work with existing community resources.
• Encourage physicians to take an active role in their communities by educating community residents, offering leadership, functioning as speakers and educators, and working in various venues.
• Ask physicians to serve as role models for their patients, including empathizing with the challenges of behavioral change and sharing strategies.

School interventions

• Develop a school health advocacy agenda that includes funding for school health programs, at least a minimum amount of physical education and exercise with stricter limits on declining participation, policies for vending machines, school breakfast and lunch programs that promote healthier diets, and standards for a la carte meal offerings. Work with a broad partnership to implement this agenda.
• Convene representatives from government, parent, teacher, and education organizations, and national experts to review existing frameworks for school health.
• Identify basic tenets for promoting school nutrition and exercise using a coordinated school health model, and create recommendations for a certificate program to recognize schools that meet a minimum of the tenets.

Worksite interventions

• Convene a working group representing national and state medical societies, corporate wellness programs, worksite health experts, and health plans to define quality health standards for businesses that comply with Department of Health and Human Services (HHS) regulations; and include obesity as part of a package of wellness strategies that include linking productivity and health. Develop an employer manual that is a composite of successful programs and strategies, and outlines the benefits (fiscal and physical) of employee wellness programs.
• Use reductions in health insurance rates as an incentive for promoting healthy lifestyles.
• Urge state medical societies to partner with local health care coalitions and corporations to promote wellness interventions for worksites.
• Advocate the following policies for worksites:
  • Tax benefits for wellness programs
  • Flex time for physical activity
  • Contract with vendors who provide healthy food choices in cafeterias and vending machines

Medical practice interventions

• Work with appropriate organizations to promote training on overweight and obesity that teaches medical students and physicians how to use behavior change strategies with the 5-A model (ask, advise, assess, assist, and arrange).
• Develop and offer patient education materials and tools for the assessment, prevention, and management of obesity that:
  • are relevant and clinically accurate
  • provide simple, understandable messages
  • account for low health literacy
  • recognize culture/gender/age differences
  • abide by the Culturally and Linguistically Appropriate Services (CLAS) standards established by the HHS Office of Minority Health
• Recognizing ethnic sensitivities, promote BMI and the routine measurement of waist circumference as a sixth JCAHO vital sign.
• Develop an initiative to work with employers and health insurers to recognize obesity as a disease, and secure appropriate reimbursement for health and wellness promotion.

In commenting on this report, the American Academy of Pediatrics noted that as part of medical practice, obesity prevention should be considered before pregnancy, in the prenatal period, postpartum, and during the early infancy, toddler, and childhood time frames. Pre-pregnancy efforts should be directed at normalizing pre-pregnancy BMI. Gestational monitoring should be focused on maintaining normal glucose control throughout gestation, and cessation of tobacco use. Breastfeeding should be promoted throughout the life cycle and supported in the postpartum period. See CSA Report 2, A-05, Factors that Influence Differences in Breastfeeding Rates, for further discussion on the breastfeeding issue.
A monograph of the proceedings of the Summit is expected to be available later this year. Back to top

Obesity as a Disease

Over the last 10 years, the scientific concept of obesity has evolved such that obesity is no longer viewed as simply the result of energy imbalance, with energy consumed exceeding energy expended. While the influence of behavior and environment cannot be ignored, the genetic and molecular basis of obesity have received increasing scrutiny.^8,9 Nevertheless, the question remains whether obesity can be considered a disease or is more appropriately addressed as an evolving public health crisis.

The CMS has become central to this debate because of questions that revolve around obesity and its impact on health and reimbursement for related treatment. In July of 2004, the CMS changed the wording of its Coverage Issues Manual to read:

Obesity may be caused by medical conditions such as hypothyroidism, Cushing's disease, and hypothalamic lesions or can aggravate a number of cardiac and respiratory diseases as well as diabetes and hypertension. Services in connection with the treatment of obesity are covered services when such services are an integral and necessary part of a course of treatment for one of these medical conditions.

This statement reflects the role that obesity plays in certain illnesses; however, the agency is explicit in also saying that the manual is "intended to address the coverage of particular care and services, rather than the definition of illness [and] furthermore, [CMS's] review of current literature indicates that there is no general agreement on the classification of obesity as an illness."¹⁰

To understand the relationship of obesity to disease models in this report, a simple approach was used. Multiple English definitions of "disease" were examined (see the Appendix) and some common precepts were identified. These are (1) an impairment of the normal functioning of some aspect of the body; (2) characteristic signs or symptoms; and (3) resultant harm or morbidity to the entity affected.

Argument for obesity as a disease. According to Greenway and Smith, obesity was first recognized as a disease in 1985.¹¹ Those who agree with that premise have cited many reasons why obesity should be classified as a disease. It is argued that although obesity may be facilitated by certain behaviors, such as overeating or not expending enough energy, it does lead to an altered physiological state, much the same as smoking and risky sexual behavior can lead to lung cancer and AIDS.⁸ Proponents of the disease model argue that obesity is a physiological dysfunction of the human organism with environmental, genetic, and endocrinological etiologies.¹² The role of endocrine dysfunction is supported by studies showing that adipose tissue produces leptin, a molecule that regulates food intake and energy expenditure.¹³ Excess adipose tissue can cause an overproduction of leptin and other mediators, which leads to abnormal regulation of food intake and energy expenditure.^8,9 Excess adipose tissue also alters immune and endocrine functions, which contributes to morbidity.⁸ Obesity also modifies vital bodily functions, places excess stress on the heart, alters pulmonary functions, and increases stress on weight-bearing joints. This last argument also points to the "resultant harm" aspect of the definition of disease.

The second common precept (characteristic signs or symptoms) is straightforward. The only sign of obesity is excess fat. Excess fat can be determined in multiple ways, including measurement of BMI, the finding of increased triceps skin fold thickness, or increased waist circumference measures.

The argument that establishes harm as a result of obesity, the third precept, is exemplified by a well-designed study by Peeters et al, which followed 30- to 49-year-old adults and found that overweight and obesity were associated with large decreases in life expectancy, averaging more than 7 years in the 40-year-old female nonsmoker.¹⁴

Argument against obesity as a disease. Those who argue against classifying obesity as a disease might begin by looking more closely at the definition of "obesity" as well as the definition of "disease" (see the Appendix). The definition of obesity states that obesity is an overproduction of adipocytes; however, overproduction is not necessarily impairment. Instead it is much the same as the overproduction of earwax in some human beings, the presence of additional digits in others, or even the continued development of the appendix. It has been argued that the tendency of the body to increase fat stores is a useful biological adaptation that has only been identified as dysfunctional because of drastic changes in the current economic environment, including the ready availability of food. In support, studies are cited that show deregulation of certain necessary physiological processes once the obese person attempts weight loss and that adipose tissue-related factors can protect some of the body's homeostatic mechanisms.^12,15

Arguments relying on the second precept (related signs and symptoms) to define obesity as a disease may prove to be the weakest. The presence of excess fat is the only sign of obesity and that is also inherent in the definition of obesity. There are no symptoms. This is akin to saying the only sign or symptom of diabetes is elevated blood sugar. It is true that obesity has been linked to the development of other disorders; however, a direct causal relationship has yet to be established and these conditions are not inevitably present.¹⁵ There is also the argument that cites data indicating that obesity accounts for approximately 300,000 deaths each year. However, these deaths result largely from co-morbidities of obesity, diseases for which obesity has been established as a major risk factor.¹⁶ None of these studies have proven the complications associated with obesity to be either caused by obesity or signs or symptoms of that physiological state.

The third precept of disease, showing that harm is caused by the state of obesity, is based on being able to prove causality and thus far, research has not made the causal connection between obesity and morbidity and/or mortality. There is an epidemiological approach by which causal relationships can be determined.¹⁷ Currently, there are many clinical observations and ecological studies that make some statistical associations between obesity and certain diseases. However, the studies that can determine whether these observations are real have not been performed. Gordis has put forth guidelines for judging whether an association is causal. [These guidelines include determination of temporal relationship; strength of the association; dose-response relationship; consistency of the association; effect of removing the exposure; biologic plausibility; extent to which alternate explanations have been considered; and specificity of the association.] The kinds of studies that can establish those determinations are not yet available. At best it can be concluded that obesity is a mediating factor for the diseases it is associated with, but true causality has yet to be determined.

The argument that obesity should be considered a disease may be a case of the end justifying the means. It is true that the ability to call a condition a disease gives enhanced credibility to the condition and its outcomes. It allows the public health community to feel confident and justified about the call to action and enlisting aid to fight the condition's untoward effects. To classify a condition as a disease strengthens public health's voice and position. In the case of obesity, it may even help enlist the aid of the government, scientific revenues, and social concern that is lacking in the current effort to control the epidemic. While it is true that obesity-related illnesses deserve far more attention than they currently receive, it does not necessarily follow that obesity should be classified as a disease. Even if obesity is not classified as a disease, its public health impact is severe enough that the AMA should advocate strongly for policies such as reimbursement for obesity in addition to its co-morbid conditions and increased awareness of its effects. Based on the arguments of technical definition and the fact that no one has yet proved that obesity in and of itself is a disease state, it seems premature to classify obesity as a disease, but this question deserves further careful study.
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Body Mass Index (BMI) and Routine Measurement of Waist Circumference as the Sixth JCAHO Vital Sign

The BMI, which describes relative weight for height, correlates with both morbidity and mortality. The relative risk for cardiovascular disease (CVD) risk factors and CVD incidence increase in a graded fashion with increasing BMI in all population groups. BMI is significantly correlated with total body fat content. Moreover, calculating BMI is simple, rapid, and inexpensive, and can be applied generally to adults.¹⁸

There are a number of other accurate methods to assess body fat (eg, total body water, total body potassium, bioelectrical impedance, and dualenergy X-ray absorptiometry), but no outcome data exist to indicate that one measure is better than any other for following overweight and obese patients during treatment. Because measuring body fat by these techniques is often expensive and is not readily available, a more practical approach for the clinical setting is the measurement of BMI. Epidemiological and observational studies have shown that BMI provides an acceptable approximation of total body fat for the majority of patients.¹⁸ The use of BMI to assess overweight and obesity and to monitor changes in body weight is endorsed by several institutions, including the National Heart Lung and Blood Institutes (NHLBI) and the United States Preventive Services Task Force (USPSTF).¹⁹

Fat located in the abdominal region is associated with greater health risks than that in peripheral regions. Nonetheless, the presence of increased total abdominal fat appears to be an independent risk predictor when BMI is not markedly increased. Therefore, waist or abdominal circumference, as well as BMI, should be measured not only for the initial assessment of obesity, but also as a guide to the efficacy of weight loss treatment.¹⁸ In commenting on this report, the Endocrine Society noted that measurement of BMI is useful for assessing risk in the initial evaluation of adult patients, but subsequently, changes in body weight are sufficient for assessing the effects of treatment.

It is important that clinicians realize that although BMI is an inexpensive, reliable, and easy-to-apply measure, it is a qualified predictor of risk. Certain population groups' potential risk profile does not fall neatly into the established and accepted categories for overweight and obesity. Multiple studies have shown that African-Americans' risk of the complications of obesity does not begin until BMI is greater than 30, suggesting that morbidity and mortality from obesity-related disorders may not have the same relation to BMI in African-Americans as they do with Caucasian populations.^20,21 Shiwaku et al showed that in the Japanese population, the risk of obesity-related disorders began at a lower BMI than in Caucasian populations.²² BMI is also less sensitive in predicting risk in individuals of short stature.^18,23 Similar considerations may apply to the relative value of waist circumference. In commenting on this report, the American Association of Clinical Endocrinologists noted that waist measurement is most useful in patients whose BMI is <35; above this value, waist measurement adds little clinical information.

Given the correlation between BMI, waist circumference, morbidity, and mortality; the ease with which BMI and waist circumference can be measured in the clinical setting; the recommendations that have been established for its use by institutions such as the USPSTF and NHLBI; and the severity of the obesity epidemic, BMI and waist circumference can and should be monitored as vital signs within the clinical setting. Back to top

Childhood Obesity and School-based Interventions

Studies conducted within school settings suggest they may be a logical place to focus anti-obesity efforts.²⁴ Because children spend more of their weekly awake and productive hours in schools than with their families, schools may be considered a natural ally in the fight against obesity.

The AMA National Summit on Obesity also focused on anti-obesity efforts in schools. Recommendations from the Summit centered on specific components of the CDC's Coordinated School Health Program (CSHP) and how they are applicable in the management of childhood overweight and obesity. Since 1992, the CDC has sponsored the CSHP, which currently supports 20 states in managing the health of the child and adolescent population. Substance abuse, sexual behaviors, and obesity are some of the targeted (preventable) health behaviors.²⁵

The CSHP is a planned and coordinated school-based program, designed to enhance child and adolescent health, which consists of 8 interrelated components: healthful school environment; health services; health education; physical education; counseling, psychological, and social services; nutrition services; family and community involvement; and health promotion for staff. The CDC provides guidance through its manual to those responsible for developing CSHP infrastructure at state and local levels. The CSHP's strong infrastructure effectively uses finite fiscal, technical, and human resources to meet a wide range of health problems affecting children and youth; coordinate independent programs and services provided to children, youth, and families by multiple organizations; and respond to the changing health priorities routinely faced by policymakers in health and education organizations.²⁶

These approaches were chosen because of the belief that:

Schools by themselves cannot, and should not be expected to, address the nation's most serious health and social problems. Families, health care workers, the media, religious organizations, community organizations that serve youth, and young people themselves also must be systematically involved. However, schools could provide a critical facility in which many agencies might work together to maintain the well-being of young people. ²⁷

The CSHP model is promising not only because of the multifaceted ecological approach, but because many of its 8 components, when individually assessed, have yielded promising results in the management of obesity. Sallis et al demonstrated that increased school physical activity in physical education classes and throughout the day, combined with nutritional interventions, reduced BMI in boys.²⁷ Gortmaker et al found that a school-based intervention that educated children in healthy food choices and increased physical activity resulted in decreased obesity among girls.²⁸

Analysis of the role of school nutrition and the effect of a la carte meals and snack bars on weight suggest a need for standards to counter the negative effects on school children's diet and weight. Cullen et al found a significant decrease in fruit, juice, and vegetable consumption from 4th to 5th grade when 5th graders were given a choice of a la carte meal offerings.^29,30 A study by Kubik et al found an inverse relationship between fruit and vegetable consumption and a la carte offerings.³¹

Warren et al evaluated a family- and school-based pilot program aimed at the prevention of obesity in children. They found small but significant improvements in nutrition knowledge and fruit and vegetable intake. Even though there was no change in overweight and obesity, the investigators concluded that future initiatives should be "long-lasting, multi-faceted, and sustainable, involving all children in a school, should target the whole environment and be behaviorally focused."

Cho and Nadow examined what can happen when all the components of the CSHP model do not function simultaneously. They found that even when funding sources and resources were available, lunch programs alone cannot achieve a sustainable success without changes in students' preferences for unhealthy food, and parental and community involvement in fostering students' healthy eating behaviors.³²

In commenting on this CSA report, the American Academy of Pediatrics recommended that school health programs should comprise nutrition for the life cycle, including breastfeeding, food guides, and healthy choices. Back to top

Other Medical Specialty Society Comments

Several medical specialty society reviewers commented on the need for a redesign of medical school curricula to facilitate training of physicians in obesity prevention and treatment, as well as the need for changes in reimbursement practices in this area.

Conclusion

The war on obesity cannot be fought only on the clinical front. It requires a collaborative and coordinated effort by many groups, and physicians (as natural leaders) are in the unique position of being able to negotiate many of those arenas. More attention to both prevention and treatment is needed. Focusing on schools is logical since that is where children spend a large amount of their time, eat many of their meals, and have many opportunities for physical and nutritional education. Physicians can be advocates for development of this "medium" so that its value and ability to contribute to treating and preventing obesity can be strengthened. It is important to recognize that even within this area of focus, the best results can be obtained when physicians, families, and communities work together to support our schools and children.

RECOMMENDATIONS (Adopted AMA Directives)

The following statements, recommended by the Council on Scientific Affairs, were adopted by the AMA House of Delegates as AMA directives at the 2005 AMA Annual Meeting:

1. The AMA will work with the Centers for Disease Control and Prevention to convene relevant stakeholders to evaluate the issue of obesity as a disease, using a systematic, evidence-based approach. (Directive)
2. The AMA continues to actively pursue measures to treat obesity as an urgent chronic condition, raise the public's awareness of the significance of obesity and its related disorders, and encourage health industries to make appropriate care available for the prevention and treatment of obese patients, as well as those who have co-morbid disorders. (Directive)
3. The AMA encourages physicians to incorporate body mass index (BMI) and waist circumference as a component measurement in the routine adult physical examination, and BMI percentiles in children recognizing ethnic sensitivities and its relationship to stature, and the need to implement appropriate treatment or preventive measures. (Directive)
4. The AMA will promote use of its Roadmaps for Clinical Practice: Assessment and Management of Adult Obesity primer in physician education and the clinical management of adult obesity. (Directive)
5. The AMA's school health advocacy agenda will include funding for school health programs, physical education and physical activity with limits on declining participation, alternative policies for vending machines that promote healthier diets, and standards for healthy a la carte meal offerings. The AMA will work with a broad partnership to implement this agenda. (Directive)
6. The AMA will collaborate with the Centers for Disease Control and Prevention, the Department of Education, and other appropriate agencies and organizations to consider the feasibility of convening school health education, nutrition, and exercise representatives, parents, teachers and education organizations, as well as other national experts to review existing frameworks for school health, identify basic tenets for promoting school nutrition and physical activity (using a coordinated school health model), and create recommendations for a certificate program to recognize schools that meet a minimum of the tenets. (Directive)

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References

1. National Center for Health Statistics. 1999-2002 National Health and Nutrition Examination Survey (NHANES).
2. Overweight prevalence. National Center for Health Statistics. Available at: http://www.cdc.gov/nchs/fastats/overwt.htm. Accessed January 21, 2005.
3. Wolf AM, Colditz GA. Current estimates of the economic cost of obesity in the United States Obesity Res. 1998;6:97-106 .
4. Wee CC, Phillips RS, Legedza AT, et al. Health care expenditures associated with overweight and obesity among US adults: importance of age and race Am J Public Health. 2005;95:159-165.
5. Thompson D, Wolf AM. The medical-care cost burden of obesity Obesity Reviews. 2001;2:189-197.
6. Burton WN, Chen C, Schultz AB, Edington DW. The economic costs associated with body mass index in a workplace, J Occup Environ Med. 1998;40:786-792.
7. Thompson D, Edelsberg J, Kinsey KL, Oster G. Estimated economic costs of obesity to U.S. business. Am J Health Promotion. 1998;13:120-127.
8. Rosmond R. Aetiology of obesity: a striving after wind? The International Association for the Study of Obesity. Obesity Reviews.. 2004;5;177-181.
9. Tremblay A, Doucet E. Obesity: a disease or a biological adaptation? Obesity Reviews. 2000;1:27-35.
10. National coverage analysis tracking sheet for obesity as an illness Available at: http://www.cms.hhs.gov/mcd/viewtrackingsheet.asp?id=57. Accessed January 10, 2005.
11. Greenway F, Smith R. The future of obesity research. Nutrition.. 2000;16:976-982.
12. Conway B, Rene A. Obesity as a disease: no lightweight matter. The International Association for the Study of Obesity. Obesity Reviews. 2004;5:145-151.
13. Bray GA. Obesity is a chronic, relapsing neurochemical disease. Int J Obesity. 2004;28:34-38.
14. Peeters A, Barendregt JJ, Willekens F, Mackeback JP, Al Mamun A, Bonneus L. Obesity in adulthood and its consequences for life expectancy: a life-table analysis Ann Intern Med. 2003;138:24-38.
15. Heshka S, Allison DB. Is obesity a disease? Int J Obesity. 2001;25:1401-1404.
16. Mokdad AH, Ford E, Bowman BA, et al. Prevalence of obesity, diabetes, and obesity related health risk factors, 2001. JAMA. 2001;289:76-79.
17. Gordis L. Epidemiology, 2nd ed. WB Saunders; 2000.
18. National Heart Lung Blood Institute Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults NIH publication No. 98-4083. September 1998.
19. United States Preventive Services Task Force. Screening for obesity in adults. Released November 2003. Available at: http://www.ahcpr.gov/clinic/3rduspstf/obesity/obesrr.htm. Accessed January 10, 2005.
20. Sanchez AM, Reed DR, Price RA. Reduced mortality associated with body mass index (BMI) in African Americans relative to Caucasians. Ethnic Dis. 2000;10:24-30.
21. Patt MR, Yanek LR, Moy TF, Becker DM. Assessment of global coronary heart disease risk in overweight and obese African-American women Obesity Res. 2003;11:660-668.
22. Shiwaku K, Anuurad E, Enkhamaa B, et al. Overweight Japanese with body mass indexes of 23.0 -24.9 have higher risks for obesity-associated disorders: a comparison of Japanese and Mongolians Int J Obes Relat Metab Disord. 2004;34:152-158.
23. Lara-Esqueda A, Aguilar-Salinas CA, Velazquez-Monroy O, et al. The body mass index is a less sensitive tool for detecting cases with obesity-associated co-morbidities in short stature subjects Int J Obesity. 2004;28:1443-1450.
24. Story M. School based approaches for preventing and treating obesity. Int J Obes Related Metab Disord. 1999;Suppl 2:S43-51.
25. Health youth. Investing in our nation's future. Available at: http://www.cdc.gov/nccdphp/bb_healthyyouth/. Accessed January 21, 2005.
26. Centers for Disease Control and Prevention, Center for Chronic Disease Prevention and Health Promotion. Coordinated School Health Program. Available at:  http://www.cdc.gov/HealthyYouth/CSHP/. 27. Sallis JF. McKenzie TL, Conway TL et al. Environmental interventions for eating and physical activity: a randomized control trial in middle schools. Am J Prev Med. 2003;24:209-217.
28. Gortmaker SL, Peterson K, Wiecha J, et al. Reducing obesity via a school based interdisciplinary intervention among youth: Planet Health. Arch Pediatr Adolesc Med. 1999;153:409-418.
29. Cullen KW, Eagan J, Baranowski T, Owens E, de Moor C. Effect of a la carte and snack bar foods at school on children's lunchtime intake of fruits and vegetables. J Am Diet Assoc. 2000;100:1482-1486.
30. Cullen KW, Zakeri I. Fruits, vegetables, milk, and sweetened beverages consumption and access to a la carte/snack bar meals at school. Am J Public Health. 2004;94:463-467.
31. Kubik MY, Lytle LA, Hannan PJ, Perry CL, Story M. The association of the school food environments with dietary behaviors of young adolescents. Am J Public Health. 2003;93:1168-1173.
32. Cho H, Nadow MS. Understanding barriers to implementing quality lunch and nutrition education J Community Health. 2004;29:421-435.
33. Dorland's Illustrated Medical Dictionary, 24th edition.
34. Merriam-Webster's Dictionary, 10th edition.
35. Stedman's Medical Dictionary, 27th edition.
36. Encyclopædia Britannica. 2004. Available at http://www.britannica.com/eb/article?tocId=9110618. Accessed December 30, 2004.
37. Taber's Cyclopedic Medical Dictionary, 18th edition.
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Appendix

Disease: "A definite morbid process having a characteristic train of symptoms; it may affect the
"A condition of the living animal or plant body or of one of its parts that impairs normal functioning" Merriam-Webster's Dictionary, 10th ed.

"1.An interruption, cessation, or disorder of body function, system, or organ. Syn: illness, morbus, sickness 2.A morbid entity characterized usually by at least two of these criteria: recognized etiologic agent(s), identifiable group of signs and symptoms, or consistent anatomic alterations."³⁴

"a harmful deviation from the normal structural or functional state of an organism. A diseased organism commonly exhibits signs or symptoms indicative of its abnormal state."³⁵

"A pathological condition of the body that presents a group of clinical signs, symptoms, and laboratory findings peculiar to it and setting the condition apart as an abnormal entity differing from other normal or pathological condition."³⁶

Obesity: "An excess of subcutaneous fat in proportion to lean body mass….no single cause can explain all cases of obesity. Ultimately it results from an imbalance between energy intake and energy expenditure. While faulty eating habits related to failure of normal satiety feedback mechanisms may be responsible for some cases, many obese persons neither consume more calories nor eat different proportions of foodstuffs than non-obese persons. Contrary to popular belief, obesity is not caused by disorders of pituitary, thyroid, or adrenal gland metabolism."³⁴

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Resolution 421 (A-04)

Resolution 421 (A-04), introduced by the New York Delegation and referred to the Board of Trustees at the 2004 American Medical Association (AMA) Annual Meeting, asked:

That the American Medical Association urge the Centers for Medicare and Medicaid Services (CMS) to change the coverage issue for bariatric surgery so that obesity with the appropriate body mass index (BMI) is in itself considered as the appropriate criteria for coverage of this service under the Medicare Program; and

That the AMA urge CMS to recognize that obesity is a disease unto itself and Medicare beneficiaries should not be discriminated against by the requirement of a co-morbidity before having their disease treated.

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