Obesity and heart disease

Contents

Health Risks of Being Overweight

On this page:

  • What kinds of health problems are linked to overweight and obesity?
  • How can I tell if I weigh too much?
  • Type 2 Diabetes
  • High Blood Pressure
  • Heart Disease
  • Stroke
  • Cancer
  • Sleep Apnea
  • Osteoarthritis
  • Fatty Liver Disease
  • Kidney Disease
  • Pregnancy Problems
  • How can I lower my risk of having health problems related to overweight and obesity?
  • Research
  • Clinical Trials

Overweight and obesity may increase the risk of many health problems, including diabetes, heart disease, and certain cancers. If you are pregnant, excess weight may lead to short- and long-term health problems for you and your child.

This fact sheet tells you more about the links between excess weight and many health conditions. It also explains how reaching and maintaining a normal weight may help you and your loved ones stay healthier as you grow older.

What kinds of health problems are linked to overweight and obesity?

Excess weight may increase the risk for many health problems, including

  • type 2 diabetes
  • high blood pressure
  • heart disease and strokes
  • certain types of cancer
  • sleep apnea
  • osteoarthritis
  • fatty liver disease
  • kidney disease
  • pregnancy problems, such as high blood sugar during pregnancy, high blood pressure, and increased risk for cesarean delivery (C-section)

How can I tell if I weigh too much?

Gaining a few pounds during the year may not seem like a big deal. But these pounds can add up over time. How can you tell if your weight could increase your chances of developing health problems? Knowing two numbers may help you understand your risk: your body mass index (BMI) score and your waist size in inches.

Body Mass Index

The BMI is one way to tell whether you are at a normal weight, are overweight, or have obesity. It measures your weight in relation to your height and provides a score to help place you in a category:

  • normal weight: BMI of 18.5 to 24.9
  • overweight: BMI of 25 to 29.9
  • obesity: BMI of 30 or higher

Waist Size

Another important number to know is your waist size in inches. Having too much fat around your waist may increase health risks even more than having fat in other parts of your body. Women with a waist size of more than 35 inches and men with a waist size of more than 40 inches may have higher chances of developing diseases related to obesity.

Know your health numbers

Below are some numbers to aim for.1,2

Measure Target
Target BMI 18.5-24.9
Waist Size Men: less than 40 in.
Women: less than 35 in.
Blood Pressure 120/80 mm Hg or less
LDL (bad cholesterol) Less than 100 mg/dl
HDL (good cholesterol) Men: more than 40 mg/dl
Women: more than 50 mg/dl
Triglycerides Less than 150 mg/dl
Blood sugar (fasting) Less than 100 mg/dl

Type 2 Diabetes

What is type 2 diabetes?

Type 2 diabetes is a disease in which blood sugar levels are above normal. High blood sugar is a major cause of heart disease, kidney disease, stroke, amputation, and blindness. In 2009, diabetes was the seventh leading cause of death in the United States.3

Type 2 diabetes is the most common type of diabetes. Family history and genes play a large role in type 2 diabetes. Other risk factors include a low activity level, poor diet, and excess body weight around the waist. In the United States, type 2 diabetes is more common among blacks, Latinos, and American Indians than among whites.4

How is type 2 diabetes linked to overweight?

More than 87% of adults with diabetes are overweight or obese.4 It isn’t clear why people who are overweight are more likely to develop this disease. It may be that being overweight causes cells to change, making them resistant to the hormone insulin. Insulin carries sugar from blood to the cells, where it is used for energy. When a person is insulin resistant, blood sugar cannot be taken up by the cells, resulting in high blood sugar. In addition, the cells that produce insulin must work extra hard to try to keep blood sugar normal. This may cause these cells to gradually fail.

How can weight loss help?

If you are at risk for type 2 diabetes, losing weight may help prevent or delay the onset of diabetes. If you have type 2 diabetes, losing weight and becoming more physically active can help you control your blood sugar levels and prevent or delay health problems. Losing weight and exercising more may also allow you to reduce the amount of diabetes medicine you take.

How much weight loss may prevent or delay diabetes?

The National Institutes of Health sponsored a large clinical study named the Diabetes Prevention Program (DPP) to look at ways to prevent type 2 diabetes in adults who were overweight.

The DPP found that losing just 5 to 7 percent of your body weight and doing moderately intense exercise (like brisk walking) for 150 minutes a week may prevent or delay the onset of type 2 diabetes.

High Blood Pressure

What is high blood pressure?

Every time your heart beats, it pumps blood through your arteries to the rest of your body. Blood pressure is how hard your blood pushes against the walls of your arteries. High blood pressure (hypertension) usually has no symptoms, but it may cause serious problems, such as heart disease, stroke, and kidney failure.

A blood pressure of 120/80 mm Hg (often referred to as “120 over 80”) is considered normal. If the top number (systolic blood pressure) is consistently 140 or higher or the bottom number (diastolic blood pressure) is 90 or higher, you are considered to have high blood pressure.

How is high blood pressure linked to overweight?

High blood pressure is linked to overweight and obesity in several ways. Having a large body size may increase blood pressure because your heart needs to pump harder to supply blood to all your cells. Excess fat may also damage your kidneys, which help regulate blood pressure.

Weight loss that will get you close to the normal BMI range may greatly lower high blood pressure. Other helpful changes are to quit smoking, reduce salt, and get regular physical activity. However, if lifestyle changes aren’t enough, your doctor may prescribe drugs to lower your blood pressure.

Heart Disease

What is heart disease?

Heart disease is a term used to describe several problems that may affect your heart. The most common type of problem happens when a blood vessel that carries blood to the heart becomes hard and narrow. This may keep the heart from getting all the blood it needs. Other problems may affect how well the heart pumps. If you have heart disease, you may suffer from a heart attack, heart failure, sudden cardiac death, angina (chest pain), or abnormal heart rhythm. Heart disease is the leading cause of death in the United States.3

How is heart disease linked to overweight?

People who are overweight or obese often have health problems that may increase the risk for heart disease. These health problems include high blood pressure, high cholesterol, and high blood sugar. In addition, excess weight may cause changes to your heart that make it work harder to send blood to all the cells in your body.

Losing 5 to 10 percent of your weight may lower your chances of developing heart disease. If you weigh 200 pounds, this means losing as little as 10 pounds. Weight loss may improve blood pressure, cholesterol levels, and blood flow.

Stroke

What is a stroke?

A stroke happens when the flow of blood to a part of your brain stops, causing brain cells to die. The most common type of stroke, called ischemic stroke, occurs when a blood clot blocks an artery that carries blood to the brain. Another type of stroke, called hemorrhagic stroke, happens when a blood vessel in the brain bursts.

How are strokes linked to overweight?

Overweight and obesity are known to increase blood pressure. High blood pressure is the leading cause of strokes. Excess weight also increases your chances of developing other problems linked to strokes, including high cholesterol, high blood sugar, and heart disease.

One of the most important things you can do to reduce your stroke risk is to keep your blood pressure under control. Losing weight may help you lower your blood pressure. It may also improve your cholesterol and blood sugar, which may then lower your risk for stroke.

Cancer

What is cancer?

Cancer occurs when cells in one part of the body, such as the colon, grow abnormally or out of control. The cancerous cells sometimes spread to other parts of the body, such as the liver. Cancer is the second leading cause of death in the United States.3

How is cancer linked to overweight?

Gaining weight as an adult increases the risk for several cancers, even if the weight gain doesn’t result in overweight or obesity. It isn’t known exactly how being overweight increases cancer risk. Fat cells may release hormones that affect cell growth, leading to cancer. Also, eating or physical activity habits that may lead to being overweight may also contribute to cancer risk.

Avoiding weight gain may prevent a rise in cancer risk. Healthy eating and physical activity habits may lower cancer risk. Weight loss may also lower your risk, although studies have been inconclusive.

What kinds of cancers are linked to overweight and obesity?

Being overweight increases the risk of developing certain cancers, including the following5:

  • breast, after menopause
  • colon and rectum
  • endometrium (lining of the uterus)
  • gallbladder
  • kidney

Sleep Apnea

What is sleep apnea?

Sleep apnea is a condition in which a person has one or more pauses in breathing during sleep. A person who has sleep apnea may suffer from daytime sleepiness, difficulty focusing, and even heart failure.

How is sleep apnea linked to overweight?

Obesity is the most important risk factor for sleep apnea. A person who is overweight may have more fat stored around his or her neck. This may make the airway smaller. A smaller airway can make breathing difficult or loud (because of snoring), or breathing may stop altogether for short periods of time. In addition, fat stored in the neck and throughout the body may produce substances that cause inflammation. Inflammation in the neck is a risk factor for sleep apnea.

Weight loss usually improves sleep apnea. Weight loss may help to decrease neck size and lessen inflammation.

Osteoarthritis

What is osteoarthritis?

Osteoarthritis is a common health problem that causes pain and stiffness in your joints. Osteoarthritis is often related to aging or to an injury, and most often affects the joints of the hands, knees, hips, and lower back.

How is osteoarthritis linked to overweight?

Being overweight is one of the risk factors for osteoarthritis, along with joint injury, older age, and genetic factors. Extra weight may place extra pressure on joints and cartilage (the hard but slippery tissue that covers the ends of your bones at a joint), causing them to wear away. In addition, people with more body fat may have higher blood levels of substances that cause inflammation. Inflamed joints may raise the risk for osteoarthritis.

For those who are overweight or obese, losing weight may help reduce the risk of developing osteoarthritis. Weight loss of at least 5 percent of your body weight may decrease stress on your knees, hips, and lower back and lessen inflammation in your body.

If you have osteoarthritis, losing weight may help improve your symptoms. Research also shows that exercise is one of the best treatments for osteoarthritis. Exercise can improve mood, decrease pain, and increase flexibility.

Fatty Liver Disease

What is fatty liver disease?

Fatty liver disease, also known as nonalcoholic steatohepatitis (NASH), occurs when fat builds up in the liver and causes injury. Fatty liver disease may lead to severe liver damage, cirrhosis (scar tissue), or even liver failure.

Fatty liver disease usually produces mild or no symptoms. It is like alcoholic liver disease, but it isn’t caused by alcohol and can occur in people who drink little or no alcohol.

How is fatty liver disease linked to overweight?

The cause of fatty liver disease is still not known. The disease most often affects people who are middle-aged, overweight or obese, and/or diabetic. Fatty liver disease may also affect children.

Although there is no specific treatment for fatty liver disease, patients are generally advised to lose weight, eat a healthy diet, increase physical activity, and avoid drinking alcohol. If you have fatty liver disease, lowering your body weight to a healthy range may improve liver tests and reverse the disease to some extent.

NASH Clinical Research Network

The National Institute of Diabetes and Digestive and Kidney Diseases funds the NASH Clinical Research Network, which comprises eight clinical centers located throughout the United States and a coordinating center at The Johns Hopkins University.

The NASH network researches the nature and underlying cause of NASH and conducts clinical studies on prevention and treatment.

Kidney Disease

What is kidney disease?

Your kidneys are two bean-shaped organs that filter blood, removing extra water and waste products, which become urine. Your kidneys also help control blood pressure so that your body can stay healthy.

Kidney disease means that the kidneys are damaged and can’t filter blood like they should. This damage can cause wastes to build up in the body. It can also cause other problems that can harm your health.

How is kidney disease linked to overweight?

Obesity increases the risk of diabetes and high blood pressure, the most common causes of chronic kidney disease. Recent studies suggest that even in the absence of these risks, obesity itself may promote chronic kidney disease and quicken its progress.

If you are in the early stages of chronic kidney disease, losing weight may slow the disease and keep your kidneys healthier longer. You should also choose foods with less salt (sodium), keep your blood pressure under control, and keep your blood glucose in the target range.

Pregnancy Problems

What are pregnancy problems?

Overweight and obesity raise the risk of health problems for both mother and baby that may occur during pregnancy. Pregnant women who are overweight or obese may have an increased risk for

  • developing gestational diabetes (high blood sugar during pregnancy)
  • having preeclampsia (high blood pressure during pregnancy that can cause severe problems for both mother and baby if left untreated)
  • needing a C-section and, as a result, taking longer to recover after giving birth

Babies of overweight or obese mothers are at an increased risk of being born too soon, being stillborn (dead in the womb after 20 weeks of pregnancy), and having neural tube defects (defects of the brain and spinal cord).

How are pregnancy problems linked to overweight?

Pregnant women who are overweight are more likely to develop insulin resistance, high blood sugar, and high blood pressure. Overweight also increases the risks associated with surgery and anesthesia, and severe obesity increases surgery time and blood loss.

Gaining too much weight during pregnancy can have long-term effects for both mother and child. These effects include that the mother will have overweight or obesity after the child is born. Another risk is that the baby may gain too much weight later as a child or as an adult.

If you are pregnant, check the sidebar for general guidelines about weight gain. Talk to your health care provider about how much weight gain is right for you during pregnancy.

If you are overweight or obese and would like to become pregnant, talk to your health care provider about losing weight first. Reaching a normal weight before becoming pregnant may reduce your chances of developing weight-related problems. Pregnant women who are overweight or obese should speak with their health care provider about limiting weight gain and being physically active during pregnancy.

Losing excess weight after delivery may help women reduce their health risks. For example, if a woman developed gestational diabetes, losing weight may lower her risk of developing diabetes later in life.

How many pounds should I gain during pregnancy?

Guidelines from the Institute of Medicine and the National Research Council, issued in 2009, recommend the following amount of weight gain during pregnancy6:

How can I lower my risk of having health problems related to overweight and obesity?

If you are considered to be overweight, losing as little as 5 percent of your body weight may lower your risk for several diseases, including heart disease and type 2 diabetes. If you weigh 200 pounds, this means losing 10 pounds. Slow and steady weight loss of 1/2 to 2 pounds per week, and not more than 3 pounds per week, is the safest way to lose weight.

Federal guidelines on physical activity (PDF, 14.2 MB) recommend that you get at least 150 minutes a week of moderate aerobic activity (like biking or brisk walking). To lose weight, or to maintain weight loss, you may need to be active for more than 300 minutes per week.. You also need to do activities to strengthen muscles (like push-ups or sit-ups) at least twice a week.

Federal dietary guidelines and the MyPlate website recommend many tips for healthy eating that may also help you control your weight. Here are a few examples:

  • Make half of your plate fruits and vegetables.
  • Replace unrefined grains (white bread, pasta, white rice) with whole-grain options (whole wheat bread, brown rice, oatmeal).
  • Enjoy lean sources of protein, such as lean meats, seafood, beans and peas, soy, nuts, and seeds.

For some people who have obesity and related health problems, bariatric (weight-loss) surgery may be an option. Bariatric surgery has been found to be effective in promoting weight loss and reducing the risk for many health problems.

Research

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) conducts and supports a broad range of basic and clinical obesity research. More information about obesity research is available at www.obesityresearch.nih.gov.

Clinical Trials

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and other components of the National Institutes of Health (NIH) conduct and support research into many diseases and conditions.

What are clinical trials, and are they right for you?

Clinical trials are part of clinical research and at the heart of all medical advances. Clinical trials look at new ways to prevent, detect, or treat disease. Researchers also use clinical trials to look at other aspects of care, such as improving the quality of life for people with chronic illnesses. Find out if clinical trials are right for you.

What clinical trials are open?

Clinical trials that are currently open and are recruiting can be viewed at www.ClinicalTrials.gov.

Obesity and Heart Disease


by Sunil Daniel, MD

Summer 2015

To view a PDF version of this article, CLICK HERE.
Obesity is a complex, chronic disease that should be properly assessed and treated seriously. It is second only to smoking tobacco as the leading cause of preventable death in the United States. According to Center for Disease Control and Prevention (CDC), in 2011-2012 more than one-third of adults (34.9 percent) and one-sixth (16.9 percent) of children and adolescents in the United States were affected by obesity.

Obesity is defined as having a body mass index (BMI) equal or greater than 30 kg/m2 which increases the risk for multiple chronic conditions such as type 2 diabetes, hypertension, heart disease, musculoskeletal disease, cancer, obstructive sleep apnea, kidney disease and abnormal cholesterol, among other health conditions. These chronic conditions not only have a great impact on the quality of an individual’s life, but they also contribute to higher healthcare cost and decreased work productivity.
According to World Health Organization, Cardiovascular Disease (CVD), defined as disorders of the heart and blood vessels, is the number one cause of death globally. Multiple risk factors contribute to CVD. These can be divided into modifiable and non-modifiable risk factors:

Obesity is an independent risk factor for CVD, negatively affecting the heart’s function and structure as well as the blood vessels’ inner lining. Obesity affects the heart through risk factors, such as:

  • Hypertension
  • Obstructive Sleep Apnea
  • Elevated Blood Glucose
  • Inflammation

Therefore, obesity has a major influence on CVD, contributing to symptoms such as heart failure, atrial fibrillation, coronary heart disease, stroke and venous thromboembolism.

Heart Failure
Based on National Health and Nutrition Examination Survey (NHANES) 2007-2010 survey data, about 5.1 million Americans 20 years of age or older in United States have heart failure. In 2009, 7.2 percent of deaths were due to heart failure. A higher BMI is associated with increased risk of heart failure–for every one unit of increase in BMI, the risk of heart failure increases by 5 and 7 percent in men and women respectively.
As body weight increases, its total blood volume and the amount of blood pushed by the heart into the body also increases, resulting in increased cardiac output. The increase in the body’s total blood volume also increases the volume of blood that returns to the heart, leading to dilation and enlargement of the right and left ventricle and increasing wall tension. Throughout time, the muscle wall of the left ventricle thickens, known as left ventricular hypertrophy, and this leads to heart failure. In right heart failure, the heart cannot pump blood to the lung for oxygenation, and in left heart failure, the heart cannot pump enough oxygenated blood to the body.

Atrial Fibrillation
Atrial Fibrillation (AF) is the most common type of arrhythmia, an abnormal heart rate or heartbeat rhythm. Under normal conditions, the upper and lower chambers of the heart contract and relax in a synchronized fashion to move blood from the upper to lower chambers, and pump blood out to the lungs and body. During AF, the upper and lower chambers of the heart are not synchronized. The upper chambers beat irregularly and too fast, resulting in ineffective transfer of blood into the lower chambers and out to the body. This also contributes to the slowing of blood flow and an increased risk of blood clot formation that, if pumped out of the heart, can travel to the brain, resulting in stroke.
Affecting three million Americans in 2005, AF has been projected to reach eight million by the year 2050. While increase in age, medical history of coronary heart disease, hypertension and heart failure predispose an individual to AF, obesity is also a major risk factor. One study showed that obesity increases the risk of developing AF by 49 percent, and the risk increases with a higher BMI.

Coronary Heart Disease
Based on NHANES 2007-2010 survey data, 15.4 million Americans above 20 years of age have Coronary Heart Disease (CHD). In 2009, CHD accounted for 49 percent of deaths due to cardiovascular disease. Atherosclerosis, plaque deposits on the inner walls of the blood vessel, is the cause of coronary heart disease. Plaque is made up of cholesterol, calcium, clotting material, and other substances. As the plaque builds up in blood vessels of the heart, it can partially or completely block the flow of the blood to the heart. This results in decreased delivery of oxygen to the heart muscles, causing chest pain (angina) and/or a heart attack.
Plaque deposition and build-up is a slow process, and it can start in individuals as young as 5 to 10 years of age. In general, obesity and excess fat around the abdominal area is associated with increased atherosclerosis. One study showed that obesity in adolescents and young adults accelerates the progression of atherosclerosis.

Stroke
Each year, 795,000 people experience a stroke, with 610,000 of them having their first attack. On average, every 40 seconds someone in United States has a stroke. Based on the NHANES 2007-2010 survey data, 6.8 million Americans above 20 years of age have had a stroke. A stroke occurs when there is lack of oxygen delivery to the brain. During this time, brain cells are very sensitive and within minutes of low or no oxygen delivery, they begin to die.
There are two types of strokes: ischemic and hemorrhagic. Ischemic stroke is the most common type of stroke, accounting for 87 percent of those experienced. It is caused by disruption to the flow of oxygenated blood to the brain. This disruption can be due to plaques or blood clots that have formed in the blood vessels that supply oxygenated blood to the brain (thrombotic stroke). The disruption of blood flow can also be caused by a plaque or blood clot that was formed outside of the brain and through blood flow lodges in narrow brain vessels.
Hemorrhagic stroke (13 percent of strokes) occurs when the blood vessel in the brain leaks or ruptures. Risk factors for stroke include hypertension, atrial fibrillation, obstructive sleep apnea, diabetes, physical inactivity and high blood cholesterol. Obesity is the common link among these risk factors.

Venous Thromboembolism
A common finding in severe obesity is leg swelling, which may be a consequence of the structural and functional effect of excess weight on the heart. Leg swelling and decreased mobility encountered in those with excess weight and obesity reduces the pumping function of the calf and leg muscles. This results in blood flow problems in the leg veins, and leads to malfunctioning of the valves in the veins. The risk of severe and sustained lower extremity venous flow problems (venous stasis) causes leg ulcers and skin infections. The risk of developing blood clots in legs, known as venous thromboembolism (VTE), and in lungs, known as pulmonary embolism, is also increased in obesity.

Weight-loss and Heart Disease
Moderate weight-loss of even 10 percent in those with excess weight and obesity can improve or even prevent obesity-related risk factors for CVD. Current therapies available for weight management include diet, physical activity, pharmacotherapy and bariatric surgery. Behavior modification to help with diet and activity is an important component of all of these treatments. A beneficial impact of weight-loss on the cardiovascular system is decreased stress on the heart, leading to improvements in its structure and function.
In a major clinical trial, an Intensive Lifestyle Intervention (ILI) involving group and individual meetings to achieve and maintain weight-loss through decreased caloric intake and increased physical activity was compared to a group that received usual care and education. Dietary strategies included portion-controlled diet, liquid meal replacements, and recommendations to use other portion-controlled items to promote adherence. The exercise goal was at least 175 minutes of physical activity per week, using activities similar in intensity to brisk walking. Behavioral strategies, including self-monitoring, goal setting and problem solving were stressed.

The ILI was successful in producing sustained weight-loss and improvements in cardiovascular fitness and CVD risk factors through four years of follow-up. A significantly greater decrease in the number of medicines used to treat their diabetes and blood pressure was also seen. Several research studies provide consistent evidence that those with severe obesity undergoing bariatric surgery have lower rates of heart attacks, strokes, and other heart disease-related complications after weight-loss.

Conclusion
Recent research has brought to light a paradox showing individuals affected by excess weight or obesity (Stage 1, BMI 30-34.9) have a slight protection against serious CVD complications compared to individuals with normal weight (BMI <25) who have CVD. However, the evidence is very clear and strong that those with severe obesity (BMI > 40) carry an extremely high risk for CVD complications, including sudden death. This highlights the importance of cardiovascular fitness regardless of weight status.
The American College of Sports Medicine recommends that most adults engage in moderate-intensity cardiorespiratory exercise training for more than 30 minutes per day on more than five days a week, for a total of more than 150 minutes per week. For greater weight-loss and enhanced prevention of weight regain, the recommendation is approximately 250 to 300 minutes per week of moderate-intensity physical activity.

About the Author:
Sunil Daniel, MD, is an obesity medicine physician with fellowship training in clinical nutrition and obesity management. His academic experience includes a faculty position in the Department of Nutrition Sciences at the University of Alabama at Birmingham (UAB). He has authored several scientific papers on obesity and its medical management. Dr. Daniel is a Duke University-trained Integrative Health Coach and an innovator who is passionate about developing mobile technology enabled weight-loss solutions that are both evidence-based and meaningful to the user. He takes pride in sharing with others his own success and challenges with weight-loss and weight maintenance.

Obesity and Heart Disease: What’s the Connection?

Obesity Can Compromise Your Heart’s Ability to Function

Research shows that obesity can raise your risk of developing atrial fibrillation, a rapid irregular heartbeat (arrhythmia) of the upper chambers (atria) of the heart that can promote the formation of blood clots and lead to stroke, heart failure, or other heart-related complications, according to the American Heart Association. In addition, obesity can lead to enlargement of the heart, which could be from untreated hypertension, Dr. Goldberg says.

Those Extra Pounds Force Your Heart to Work Harder

Yes, the extra weight you’re carrying does put the heart under increased stress, in particular during the relaxation phase of the cardiac cycle — what’s called the diastole. As the heart fills with blood, there’s higher pressure, Goldberg explains. “Over time, that can cause people to have heart failure symptoms.”

It’s not just the number on the scale that matters. Where the extra weight is distributed also affects your risk of developing heart disease. Simply put, greater amounts of belly fat — what’s often called central or abdominal obesity — is associated with greater inflammation, which is damaging to your heart, Goldberg says. Excess belly fat also increases triglyceride levels, which can contribute to plaque rupturing, Stevens notes. That’s why your waist measurement really does matter, in addition to your overall weight.

RELATED: Can Sleep Apnea Predict a Heart Attack?

Taking Action to Protect Your Heart

The news isn’t entirely bad, though. If you’re overweight or obese, slimming down can help you reduce your risk of developing heart disease. “When people lose as little as 5 pounds (lbs), we can start to see improvements in blood pressure, blood sugar, cholesterol levels, and inflammatory factors,” Goldberg says. All of these changes are beneficial for your heart.

Indeed, losing excess weight helps with primary prevention of heart disease, as well as secondary prevention (preventing another heart attack or other cardiac event if you’ve already had one), Goldberg says. For secondary prevention, she adds, “you’ll need to take medicine, but maybe less of it if you lose weight.”

It’s not an easy process, Goldberg admits, but the best ways to lose weight are to improve your diet and exercise habits with the goal of losing 1 lb per week. Keep in mind: “If your BMI is in the higher range, it’s safer to go into a medically supervised weight loss program than to try to do it on your own,” Goldberg says.

If you’re doing it on your own, stick with a diet that’s filled with fruits and vegetables, whole grains, low-fat dairy products, fatty fish and skinless poultry, nuts and legumes, and healthy cooking oils, such as olive, walnut, sesame, or grapeseed oils. Avoid added sugars, highly processed foods, and fried foods. On the exercise front, do a combination of “aerobic exercise and weight training to increase your muscle mass and decrease body fat,” Goldberg suggests.

There’s proof that taking these steps can make a difference to your heart health. A study published in May 2016 in the journal Preventive Medicine found that adults ages 18 to 35 with BMI between 25 and 40 who participated in a weight-loss program lost an average of 17.5 lbs, increased their levels of physical activity, and improved their total cholesterol, blood pressure, and blood sugar levels after six months. “Losing weight will reduce the risk of cardiovascular disease significantly — because it makes a difference in blood pressure, insulin sensitivity, and triglyceride levels,” Stevens says. “The great news is, what you do every day can make a difference.”

RELATED: Exercise Plan for Diabetes and Heart Health

Cover Story | Obesity and Cardiovascular Disease Risk

Adiposopathy

Adiposopathy refers to the pathogenic enlargement of adipose cells and adipose tissue that results in anatomic and functional abnormalities, leading to metabolic disease and increased cardiovascular disease risk. “Given that adipose tissue has no less potential for disease than any other body organ, the term adiposopathy is intended to identify adipose tissue organ pathology similar with the ‘opathies’ of other body organs,” says Bays. Specifically, adiposopathy is defined as adipocyte and adipose tissue dysfunction caused by positive caloric balance and sedentary lifestyle in genetically and environmentally susceptible individuals.9

Anatomic manifestations of adiposopathy include:

  • Adipocyte hypertrophy
  • Increased visceral, pericardial, perivascular and other periorgan adiposity
  • Growth of adipose tissue beyond its vascular supply with ischemia, cellular death and inflammation
  • Increased adipose tissue immune cells
  • Ectopic fat deposits in other organs9

Pathophysiologic manifestations of adiposopathy include:

  • Impaired adipogenesis
  • Pathologic adipocyte organelle dysfunction
  • Increased circulating free fatty acids
  • Pathogenic adipose tissue endocrine and immune responses
  • Pathogenic interaction with other organs9

These anatomic and pathophysiologic changes result in various clinical manifestations, including high blood glucose, insulin resistance, hypertension, adiposopathic dyslipidemia, metabolic syndrome, atherosclerosis and a host of other pathologies. In his review of adiposopathic changes that occur with increased body fat, Bays wrote, “A clinical application of Ockham’s razor suggests adiposopathy as the primary cause of most cases of metabolic diseases such as high glucose levels, high blood pressure and dyslipidemia, as well as most cases of cardiovascular disease.”9

Obesity and Inflammation in Cardiovascular Disease

Click image for a larger view.

Obesity promotes systemic inflammation, and inflammation can drive adipogenesis. Chronic systemic inflammation, along with increased accumulation of epicardial adipose tissue has been observed in people with obesity.10 “Most cardiologists are familiar with the ‘inside to in’ model of atherosclerosis, wherein atherogenic lipoproteins in the circulation become entrapped in the subendothelium and generate an inflammatory reaction that promotes atheromatous plaque,” Bays says. “It is increasingly recognized that the adiposopathic ‘sick fat’ surrounding the heart can also transmit inflammatory responses that promote heart disease. This is sometimes called the ‘outside to in’ model of atherosclerosis.”

Systemic inflammation promotes the expression of a proinflammatory phenotype in epicardial fat, particularly the adipose tissue surrounding the coronary arteries. Chronic inflammation and accumulation of epicardial fat is strongly associated with the presence, severity and progression of coronary artery disease, independent of visceral adiposity.10 Normal epicardial adipocytes are similar with adipocytes from brown adipose tissue, which burn fatty acids and nourish adjacent tissues. They secrete adiponectin, which minimizes inflammation and fibrosis in the coronary arteries and myocardium. In contrast, epicardial fat in obese people is more prone to lipolysis, leading to release of fatty acids and reactive inflammation. In obesity, adiponectin secretion from epicardial fat is reduced and proinflammatory adipokines are released, promoting infiltration of macrophages, destruction of microvascular systems and activation of fibrotic pathways (Figure).10

The most common myocardial disorder in people with obesity is HFpEF, characterized by ventricular fibrosis and decreased distensibility, along with modestly increased cardiac volume, relatively low natriuretic peptide levels and impaired renal function. Even modest volume overload leads to cardiac overfilling and disproportionate increase in cardiac filling pressures.10

Click image for a larger view.

Metabolically Healthy Obesity

Metabolically healthy obesity (MHO) refers to obesity without the presence of metabolic syndrome. People with MHO typically have intermediate levels of visceral adiposity and cardiovascular risk between those with normal weight and those with obesity.11 However, studies have found that at least half of participants with MHO at baseline convert to metabolically unhealthy obesity with increased risk of cardiovascular disease.11,12

“Reports of patients who are metabolically healthy, but with obesity are highly dependent upon how healthy is defined. With more strict definitions, it is rare to find such individuals. In these rare cases, the addition of time often transforms the apparently ‘healthy’ patient with obesity into a patient who ultimately expresses the complications of obesity, and thus becomes unhealthy.”

In the Nurses’ Health Study, 84 percent of 3,027 women with MHO at baseline converted to unhealthy phenotypes after 20 years of follow-up.12 The MESA study reported that 48 percent of participants with MHO developed metabolic syndrome and an increased risk of cardiovascular disease during a median 12.2 years of follow-up.

“Reports of patients who are metabolically healthy, but with obesity are highly dependent upon how healthy is defined. With more strict definitions, it is rare to find such individuals,” says Bays. “In these rare cases, the addition of time often transforms the apparently ‘healthy’ patient with obesity into a patient who ultimately expresses the complications of obesity, and thus becomes unhealthy,” he adds. “The concept of the obesity paradox is no longer as paradoxical when functionality of adipose tissue is the focus, as opposed to the amount of adipose tissue. The degree by which fat is functional or dysfunctional (from an endocrine and immune standpoint) is what helps determine the pathogenic potential of increased body fat. This is why the concept of adiposopathy or ‘sick fat’ is so important,” explains Bays.

Help Your Patients Move More

Click image for a larger view.

Encourage your patients to create a plan to move more. Suggest they think of three ways to more naturally fit in time standing or moving. For example:

  • Opt for an activity break to stretch and move rather than a snack or coffee break
  • Walk around or do leg raises during the next conference call
  • Keep stretching bands and/or hand weights near the TV and use commercials as a cue to get up and move
  • Set an alarm at the top of every hour and get out of the chair at work and home (some fitness devices can be programmed to do this, too)

Send your patients to CardioSmart.org for more tips on increasing physical activity. Download the infographic pictured here to support your conversations with your patients. Post it on the office wall to signal to your patients the importance of being active – and to get up and move!

Weight loss is recommended for all overweight or obese patients with comorbid conditions such as prediabetes, diabetes, hypertension and dyslipidemia.6 “Recognizing the pathogenic potential of adipose tissue may afford a clearer rationale toward recommending weight reduction to overweight patients. In other words, discussing how fat weight gain causes fat to become ‘sick’ and how losing body weight causes fat to become more ‘healthy’ might prove to be more productive than discussing the individual diagnostic components defining the metabolic syndrome,” Bays says.

The goals for management of adults with overweight or obesity are to improve health, quality of life, and body weight and composition.3 Because of the heterogeneity of obesity etiology and pathophysiology, response to treatment varies among patients. The rate of initial weight loss is the most consistent factor that predicts long-term weight loss success.7 An initial weight goal of 5-10 percent over six months is recommended, with an emphasis on dietary changes, increased physical activity and behavior modification delivered by a multidisciplinary team. Additional interventions include weight loss medications, medical devices and bariatric surgery.7

Evidence suggests that added sugar and certain saturated fat-containing foods increase risk for cardiometabolic disease by metabolic mechanisms that are not mediated solely by positive energy balance and fat gain. Certain dietary patterns or components appear to increase “energy in” or “energy storage as fat” through mechanisms not explained solely by their specific caloric contribution to the “energy in” side of energy balance.13

Sufficient polyunsaturated fat in the diet, with corresponding decrease in saturated fat, results in major blood lipid reduction. Replacement of saturated fatty acids with n-6 fatty acids is associated with lower cardiovascular disease risk; replacement with refined carbohydrates has a neutral or adverse effect.13 Consumption of fructose, high-fructose corn syrup or sucrose leads to greater increases in risk factors for cardiometabolic disease than isocaloric amounts of starch.13

Bariatric surgery reduces body fat, including epicardial fat, decreases inflammation and improves adipocyte and adipose tissue function, leading to reduced lipid levels and improvements in metabolic diseases.10 Cardiovascular disease risk factors are improved, including glucose metabolism, blood pressure, factors related to thrombosis, kidney function, adipocyte and adipose tissue function, inflammatory markers and vascular markers. “Some bariatric surgeries not only substantially improve cardiovascular disease risk factors but also reduce overall cardiovascular disease mortality,” Bays notes. Candidates for bariatric surgery include patients with a BMI ≥35 with one or more adverse health consequences and those with a BMI ≥40 with or without adverse health consequences.3

The Obesity Algorithm developed by the Obesity Medicine Society is a good place to start in developing management strategies for patients with overweight or obesity. It is a free education and patient management resource formatted in over 300 downloadable PowerPoint slides. “The Obesity Algorithm is a simplified, yet comprehensive discussion of obesity management, which can help clinicians develop strategies for treatment of patients with obesity,” says Bays.

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Clinical Topics: Arrhythmias and Clinical EP, Diabetes and Cardiometabolic Disease, Dyslipidemia, Heart Failure and Cardiomyopathies, Prevention, Atherosclerotic Disease (CAD/PAD), Atrial Fibrillation/Supraventricular Arrhythmias, Lipid Metabolism, Acute Heart Failure, Heart Failure and Cardiac Biomarkers, Diet, Exercise, Hypertension, Sleep Apnea

Keywords: ACC Publications, Cardiology Magazine, Adipocytes, Adipogenesis, Adipokines, Adiponectin, Adipose Tissue, Adipose Tissue, Brown, Adiposity, Atherosclerosis, Atrial Fibrillation, Bariatric Surgery, Behavior Therapy, Blood Glucose, Blood Pressure, Body Mass Index, Cardiac Volume, Cardiovascular Diseases, Coronary Artery Disease, Decision Making, Diabetes Mellitus, Diabetes Mellitus, Type 2, Diet, Dyslipidemias, Epidemiologic Studies, Exercise, Factor X, Fatty Acids, Fatty Acids, Nonesterified, Fatty Acids, Omega-6, Follow-Up Studies, Fructose, Glucose, Heart Failure, Hypertension, Inflammation, Insulin Resistance, Lipolysis, Lipoproteins, Longitudinal Studies, Macrophages, Metabolic Syndrome X, Myocardium, Natriuretic Peptides, Obesity, Obesity, Abdominal, Obesity, Morbid, Pediatric Obesity, Organelles, Overweight, Patient Care Team, Phenotype, Plaque, Atherosclerotic, Prediabetic State, Prevalence, Quality of Life, Risk Factors, Sleep Apnea Syndromes, Snacks, Social Responsibility, Stroke Volume, Sucrose, Thrombosis, Weight Gain, Weight Loss

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Obesity & Heart Disease

Obesity is a common problem in the United States. Current research suggests that one in three Americans is obese. Obesity and overweight are linked to several factors that increase ones risk for cardiovascular disease (coronary artery disease and stroke):

  • High blood lipids, especially high triglycerides, LDL cholesterol, and total cholesterol and low HDL cholesterol
  • High blood pressure
  • Impaired glucose tolerance or type-2 (also called adult onset) diabetes
  • Metabolic syndrome

Obesity and overweight are also linked to hypertension and an enlarged left ventricle (left ventricular hypertrophy), increasing risk for heart failure.

In addition, overweight and obesity can be related to some cancers, gallbladder disease and osteoarthritis.

Are you at increased risk?

To determine if your weight is linked to increase risk of heart disease, two measurements are used:

  • Body Mass Index (BMI)
  • Waist Circumference

Body Mass Index (BMI)

The BMI is a mathematical formula that factors a person’s height and weight in determining obesity. It may be less accurate for athletes or older persons who have lost muscle mass.

  • Underweight – Below 18.5
  • Normal – 18.5 – 24.9
  • Overweight – 25.0 – 29.9
  • Obesity 30.0 – and Above

Those who are overweight or obese and have two or more risk factors should lose weight to decrease their risk for heart disease. Use the body mass indicator below to calculate your BMI.

Waist circumference

Your waist circumference is the measurement of your waist, just above your navel. It is a good predictor of abdominal fat, a risk factor for heart disease. This risk increases with a waist measurement of over 40 inches in men and over 35 inches in women

A small decrease in weight can go a long way to decrease your risk for heart disease. Click here to learn about weight management strategies.

Make an appointment with a Preventive Cardiology registered dietitian to create a nutrition plan at 216.444.9353, or, toll-free 800.223.2273, ext. 49353. Individual counseling and group weight loss programs are available. For online assistance in creating a weight loss plan, check out our MyConsult Nutrition Counseling Service.

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What is obesity?

Obesity is a condition in which you have too much body fat. The body mass index (BMI) uses your height and weight to estimate how much fat is on your body. You can use the BMI to see if you are overweight or obese.

  • A healthy weight is a BMI of 18.5 to 24.9.
  • Overweight is a BMI of 25 to 29.9.
  • Obesity is a BMI of 30 or higher.

What are the effects of obesity on the heart?

Obesity changes in the structure and function of the heart. It increases your risk of heart disease.

The more you weigh, the more blood you have flowing through your body. The heart has to work harder to pump the extra blood. It stretches and gets bigger. The heart muscle gets thicker. The thicker the heart muscle gets, the harder it is for it to squeeze and relax with each heartbeat. Over time, the heart may not be able to keep up with the extra load. You may then have heart failure.

Obese people often have high blood pressure. High blood pressure also makes the heart work harder.

How can I lower my risk of heart disease and heart attacks?

You can lower your risk of heart disease and other illnesses by having a healthy weight and healthy blood pressure.

If you are overweight or obese and have heart disease, losing weight will lower your blood pressure and help your heart work better. A plan for losing weight should include:

  • Eating healthy foods
  • Eating fewer calories
  • Being more physically active.

Ask your healthcare provider to help you lose weight in a way that is safe and healthy. Ask about the best ways to get more exercise. You may also need to take blood pressure medicine or heart medicine.

Obesity and Heart Disease

Want to know your vulnerability to heart disease? Like it or not, one of the best ways to know is to get on the scale. If you’re unhappy with what the scale tells you, you’re not alone. Despite our national obsession with thinness, Americans are heavier and less active than ever before. Over half of us are overweight, and self-esteem isn’t the only thing at stake. Even a few extra pounds can be hard on your heart. If you’re on the heavy side, you have the power to reduce much of that danger. By losing weight, you can give your heart a well-deserved break.

How much weight is too much?

Perceptions of fat and thin can change with the times. For an objective view, doctors use a measure called body mass index (BMI). A 5-foot, 10-inch person who weighs 175 pounds has a BMI of 25, generally considered the upper limit for a healthy body. An extra 30 pounds would push him or her to a BMI of 30, a number that signals a serious weight problem. At 245 pounds, the person would reach a BMI of 35 and would be considered extremely obese.

The biggest shortcoming of the BMI measurement is that it can’t distinguish fat from muscle. A chiseled 6-foot-tall football player could easily have a BMI over 30, but no one would call him dangerously overweight. But when extra weight comes from fat, not muscles, even a small climb in BMI can make a big difference to the heart.

A study of nearly 116,000 nurses published in the Journal of the American Medical Association found that moderately overweight women (BMI between 25 and 28.9) were twice as likely as slender women (BMI less than 21) to develop coronary heart disease. For women with a BMI over 29, the risk nearly quadrupled. Likewise, a study of more than 29,000 middle-aged men found that a little heft (BMI between 25 and 29) led to a 70 percent increase in coronary heart disease.

In addition, research by the National Heart, Lung and Blood Institute adds more evidence that extra weight is bad for your heart: in a study of over 5,000 participants, the risk of heart failure increased with each additional point of a participant’s BMI (about 4 to 8 pounds). Men experienced a 5 percent risk increase with each additional point of BMI, while women had a 7 percent increase. In general, researchers found that the risk of heart failure was 34 percent higher for overweight individuals and 104 percent higher for people classified as “obese.”

Over the past 40 years, there has been a marked rise in obesity in the United States, which experts associate in large part with overeating, a rise in fast food consumption, and a sedentary lifestyle in which many Americans do little more than walk to and from their cars. Today, nearly 34 percent of American adults are considered obese (that is, they have a BMI over 30). That’s a lot of people with a higher-than-normal risk of developing heart disease.

Despite the increase in obesity, only 42 percent of overweight adults have been told by their doctors or healthcare workers to lose weight, according to a report in the Annals of Internal Medicine. In another recent survey, the National Consumers League (NCL) found only 12 percent of U.S. adults had been told by a doctor or other healthcare professional that they were obese. In fact, the NCL survey found that most obese respondents thought of themselves as merely overweight.

That’s the reason why government health officials at the U.S. Preventive Services Task Force recommend that doctors assess patients to determine their BMI. If they’re obese, they should make weight loss counseling part of their talks.

How does being overweight harm the heart?

An extra-large body needs an extra-large amount of blood. When you gain weight, your heart has to pump more blood than it did before. Instead of beating more often, the heart grows slightly larger so it can move more blood with each beat. It’s like a faucet that’s been opened up a notch. The increased flow often leads to high blood pressure, which is a major cause of heart disease.

Even if your blood pressure doesn’t climb, your heart can suffer from the extra workload. When the chambers of the heart grow larger, they slowly lose some of their squeezing power. Eventually, they may not be able to completely empty themselves with each beat. As blood starts pooling in your heart, you can develop congestive heart failure.

Excess body fat can set off a cascade of other changes in the body that raise the risk of heart trouble. If the fat is distributed in the midsection, the risk is higher; a waist measurement of more than 35 inches in women and 40 inches in men spells an increased risk of cardiovascular disease. Large amounts of belly fat can blunt the effects of insulin, making you vulnerable to type 2 diabetes, a condition that seriously threatens the heart. Extra fat in the body can also lead to extra fat in the blood. Overweight people often have high levels of artery-clogging LDL cholesterol. If too much cholesterol sticks to your arteries, a condition called atherosclerosis, you can suffer a heart attack or a stroke.

Extra weight can also be a sign that you’re hurting your heart in other ways. Many people are overweight because they eat high-fat diets and shun exercise. Other people who gained weight with pregnancy and age have found it difficult to get back on an exercise regimen. No matter how much you weigh, fat-filled foods and lack of exercise can damage your arteries and weaken your heart.

Finally, even taking into account its contribution to high blood pressure, excess cholesterol, and glucose intolerance, obesity alone is still associated with an increased risk of heart disease, according to a recent study published in the European Heart Journal.

What can I do to protect my heart?

Even if a lean, trim body seems like an impossible goal, a healthier heart is well within your reach. If you can lose just 10 to 20 pounds, your blood pressure will drop, your heart will shrink to a more normal size, your body will make better use of insulin, and your cholesterol levels will improve.

Many studies have cited the number of premature deaths due to complications from being overweight, such as diabetes and hypertension. If you shed some pounds and rein in your blood pressure and cholesterol, you’ve done your heart a big favor.

Lots of pills and diets promise to make the pounds fly away, but the slow and steady approach is still the best way to achieve long-term weight loss. By combining regular workouts with a low-calorie diet, you can reduce your weight by 10 percent in about six months. At a minimum, the American Heart Association and the Centers for Disease Control and Prevention (CDC) recommend 150 minutes of moderate exercise, or 60 to 75 minutes of vigorous exercise, each week. On at least two of those days, the CDC recommends muscle strengthening workouts that exercise all the major muscle groups. You should also aim to burn 500 to 1,000 calories more than you eat each day. It’s hard to control your weight, and even harder to lose those extra pounds, but don’t give up. After a physical check-up, start by incorporating 5 minutes of exercise into your daily routine, whether it involves a walk during your lunch break or doing errands on foot. Add a few minutes more each week until you’re getting 150 minutes of movement each week. The key is figuring out what it takes to make exercise a permanent part of your life, whether that means getting an exercise buddy, taking a dance class, or just walking rather than driving whenever possible.

Even if you never manage to lose a single pound, exercise and a healthy diet can offer potent protection for your heart. It’s possible to be fit even if you’re above your ideal weight. In fact, a few recent studies suggest that overweight people who are physically fit may actually live longer than those who are lean but inactive.

Extra weight isn’t a personal failing, and it isn’t a death sentence. But it is a strong warning. Now’s the time to take that warning seriously. With a few healthy lifestyle changes, you can remove a heavy burden from your heart.

U.S. Preventive Services Task Force. Screening for Obesity in Adults: Recommendations and Rationale. Annals of Internal Medicine, 2 December 2003, Vol. 139 Issue 11. p. 930-932

Mokdad AH, et al. Actual Causes of Death in the United States, 2000. JAMA. 2004;291:1238-1245

American Heart Association. Physical Activity. http://www.americanheart.org/presenter.jhtml?identifier=4563

Haskell W, et. al. Physical activity and public health: Updated recommendations for adults from the American College of Sports Medicine and the American Heart Association. Circulation. 2007; 116: 1081-1093.

National Center for Health Statistics. Overweight. December 2008. http://www.cdc.gov/nchs/fastats/overwt.htm

Kenchaiah S, et al. Obesity and the risk of heart failure. N Engl J Med 2002 Aug 1;347(5):305-13

If you were to walk into a room of women and ask if they considered themselves overweight, chances are a majority would be unsatisfied with their size. But when it comes to heart disease, we’re not talking about trying to fit into your skinny jeans.

When we say overweight or obese, it’s not about aesthetics. It’s about carrying excess weight to the point of straining your heart and raising your blood pressure, LDL (bad) cholesterol and triglyceride levels, and lowering your HDL (good) cholesterol, increasing your risk for diabetes.

Our bodies are made up of water, fat, protein, carbohydrates and vitamins and minerals. And if we have too much fat — especially if we’re carrying it primarily in the waist — the risk for heart disease issues goes up. That’s why it’s important to know your Body Mass Index (BMI), a numerical value of your weight in relation to your height.

Your BMI is a good indicator of whether you’re at a healthy or unhealthy weight. Here’s how it breaks down:

  • Underweight: Less than 18.5
  • Healthy weight: Less than 25
  • Overweight: Between 25 and 29.9
  • Obese: 30 or higher is considered obese.

To calculate your exact BMI value, multiply your weight in pounds by 703, divide by your height in inches, then divide again by the same number (height in inches).

The good news is, losing as few as 10 pounds can lower your heart disease risk.

The dreaded weight loss journey

It’s easy to start a diet. Sticking to it? Not so much. And even though we’ve all done it in the past, it’s never wise to follow a fad diet that drastically limits your food choices. You didn’t gain weight overnight, and you shouldn’t try to lose it all in the blink of an eye either. It simply isn’t healthy, or sustainable.

Here are few tips to help you get started:

  • Decide how to handle temptation. When you’re offered calorie-rich foods, turn them down nicely, but firmly. And try to dine at places where there are healthy options.
  • Be mindful of serving sizes. Eat slowly, take smaller portions and avoid seconds.
  • Cook foods in ways that help remove fat. Try baking, boiling, broiling, grilling, roasting or stewing. Don’t fry foods in oil.
  • Learn to decode nutrition labels. Avoid foods that are high in sugar, saturated fat, trans fat and calories.
  • Drink lots of water. And try to limit alcohol and other high-calorie drinks.

Keeping extra weight off can be as challenging as losing it. Many things will tempt you to go back to your old habits. And it takes commitment to stick to your new, healthy lifestyle. Just remember that when you do, you will have greater self-control, feel stronger, have better eating habits and fewer mood swings, and be in better shape.

And remember: Eating smart doesn’t mean dieting. It means eating certain foods in smaller amounts and eating high-calorie and high-fat foods less often. Your heart will thank you.

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