What is a disease
That is, of course, the million dollar question, and as you have learned, it is a complicated one. We are biological beings and, to the best of our knowledge, we are in balance internally and externally. This equilibrium, let’s call it lightness of being, is a dynamic process; we tend to focus on the inner ease of being, but the growing concern about the socio-economic determinants of health expresses the ease of being with the external environment.
If you take illness and break it down into two parts, illness, then we have an experiential sense of how to define illness. Again, most internal diseases have been given disease status, but in reality they are a phenotype with many underlying features and causes. Diabetes, the disease of glucose regulation, is type I and II, and some suggest it is pre-diabetic. More specifically, obesity encompasses many internal and external ones external diseases. Internal concerns include diabetes and cardiovascular disease; the external diseases including body shaming and a visceral bias towards the obese. These external diseases can be cultural rather than biological, as anyone who has seen Rubens’ work knows.
In 2013, the AMA’s House of Delegates defined obesity as a disease, against the objection of its Advisory Council.
“That our AMA: (1) recognizes obesity and overweight as a chronic disease (de facto disease state) and an urgent public health problem; (2) recommend that providers receive adequate financial assistance and payment from third party payers to ensure that providers are incentivized to treat the complex diseases associated with obesity; (3) Working with third party payers and government agencies to recognize obesity treatment as an essential medical benefit; and (4) create a comprehensive ICD code for medical services for the treatment and management of obese and overweight patients. “ [emphasis added]
I added the emphasis because all three of these points concern payment for treatment, be it WW (the old Weight Watchers), medication, or our most popular bariatric surgery right now. For the cynics among us, this could be seen as selfish on the part of the doctors.
Report of the Science and Public Health Council
Rereading the report from these AMA experts shows how little has changed as obesity is a treatable condition. While we could argue that we can tell obesity by seeing it, that’s not enough for those paying the bills – they want quantifiable, objective criteria. The most common is the BMI or body mass index. It’s a cheap, easy-to-use (weight and height only) screening tool, but the report notes
“The relationship between BMI and obesity (as well as the disease risk described below) varies depending on age, gender, ethnicity, socio-economic status, stature and physical education. These variations generally reflect population-specific differences in body composition, fat distribution, causes of obesity, and genetic susceptibility. As a screening tool for obesity, the BMI shows a low sensitivity, especially for BMIs below 30. “
The basics – the BMI is much better at identifying non-obesity. Of course, these standardized cutoff values are subject to revision, just as we continue to lower the criteria for hypertension.
The Council noted that designating obesity as a disease would involve “greater government and private sector investment in the development and reimbursement of treatments for obesity”. This includes medication, surgery, and obesity prevention programs. It could also mean that weight discrimination could be illegal. But more importantly, obesity as a disease would change social perception.
“Lack of self-control, laziness, and other adverse character traits are less likely to be associated with obese people and, in turn, reduce stigma.”
Obesity, on the other hand, as a disease would make obesity “medical”, making the pill or knife more dependent on alternatives
Public perception may shift due to a wider recognition of obesity as a disease, with greater appreciation and emphasis on the complex etiology of obesity and the health benefits of achieving and maintaining a healthy weight. Additionally, the environment could move away from “healthy eating and physical activity” as BMI, like pain (which ushered in the era of opioid diversion), became a vital sign. After all, obesity as a disease would lead to higher insurance costs.
Are Obesity in Our Control?
This is really the concern that underlies obesity as a disease.
“Obesity is a disease that, like sexually transmitted diseases, is blamed on the patient. Finding that the treatment does not work is attributed to a lack of strength.”
Edwin Astwood, MD
“The assumption that obesity is not a disease, but a consequence of a chosen lifestyle, exemplified by overeating and / or inactivity, is consistent with the assumption that lung cancer is not a disease as it is caused by an individual choice to smoke.”
It’s hard to imagine a way to stigmatize a person more dramatically than calling them a smoker! Fat and body embarrassment are cultural memes and represent a lack of control or willpower. The obese remain victims, but now it is less of a social, cultural victimization; they have a disease after all. And we don’t shame them with illnesses, do we? For advocates of obesity as a disease, fat embarrassment and employer bias all contribute to increased stress, which in turn encourages stress eating and reluctance to exercise in public places like gyms.
We gain weight as we age, about 2 pounds a year, in our middle years. And “during or after weight loss the urge to eat increases disproportionately and energy consumption drops, which creates the” perfect storm “for weight gain” – this is where biology is at work.
Obesity, as with many problems, is both inside and outside of our control at the same time. It might be better off obesity because of our underlying genetics, our metabolic state, and our lifestyle choices. The relative contribution of each one will vary individually. I have made some bad lifestyle choices at times and they have been reflected in my weight. I try to make better decisions, but it’s tough, but a lot easier than any other pill, let alone surgery. For morbidly overweight people, their metabolic and biological changes are almost insurmountable; a knife or drug can restore the balance between their decisions and the underlying physiology.
The Council’s report to the AMA ends on this note.
“Rather than trying to determine whether obesity meets the arguably arbitrary disease criteria, the more important question is,” Would health outcomes be improved if obesity was viewed as a chronic medical condition? “
To the extent that paying for treatment could improve results, the answer is yes. If the goal is to reduce stigma, then shifting victimization from cultural norms to the “flaws of our cells” is not the solution.
Swell: “Obesity is a disease, recognize it as such,” Medpage
AMA recognizes obesity as a disease at NY Times
AMA’s Report from the Council on Science and Public Health, Is Obesity a Disease?