Call obesity what it is: a disease

By | November 25, 2018

In 2013, the American Medical Association (AMA) announced its decision to classify obesity as a disease, moving against the recommendation at the time of a group studying obesity. Yet there are still those who believe that obesity is not a disease but rather a “condition,” and this has downstream ramifications for health policy, health care provider reimbursement, and, ultimately, societal health and well-being. But this is incorrect — the common arguments against obesity as a disease are insufficient. Some may argue that if obesity were a disease:

1. “… it will lead to excessive focus on medications and surgery to treat obesity”: We have seen trends since the 1980s showing a gradual increase in obesity rates, and numerous societal factors have been known to contribute. Despite ongoing policy based in behavioral interventions, prevalence rates of obesity continue to increase. At this point, aggressive interventions are warranted. To this effect, a label of disease would imply a personal and societal responsibility to develop and provide treatment. A comparable disease is colon cancer, where dietary factors (low fiber, high red-meat diets) clearly
contribute to it
, but patients receive screening, surveillance tests, and surgery or chemoradiation therapy as needed. We simply to do not fault patients for developing cancer, yet do so for patients with obesity.

2. “… it will result in over a third of the United States population having a disease”: There are many complications of obesity across all body system, and many of those with excess weight likely already suffer some sort of issue related to adiposity. Additionally, other diseases are also markedly common in society. There is no question of their disease status, such as hypertension, dyslipidemia, diabetes, and heart disease, yet we still treat those diseases as such. Why not obesity?

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3. “… obesity is only a risk factor for other diseases”: complications of obesity can be due to metabolic changes or from mechanical complications of excess adiposity. For someone with tibial bowing or knee osteoarthritis from excess weight, would one not desire to treat obesity to prevent these musculoskeletal complications from occurring, rather than waiting for these complications to manifest and then labeling those as diseases?

4. “… then it will adversely affect how doctors and society view patients with obesity”: There is robust data on the discrimination against individuals with obesity (weight bias/discrimination) in the context of health care and beyond. Some examples include one
finding that 24 percent of nurses were “repulsed” by persons with obesity, and other effects in hiring prejudice and wage disparities. People already discriminate against individuals with obesity, and so as a disease there will likely be little detriment and potentially positive effect as health care providers recognize that obesity is a disease to be treated. It is unfair to attribute obesity solely to individual behavior and vague concepts such as “willpower” when societal forces such as developments in food refinements and additives, corn subsidies and the rise of high-fructose corn syrup, food marketing, mass media and fast food also entice.

Obesity and excess adiposity, like other diseases, leads to shortened life expectancy, decreased quality-of-life and increased health care expenditures. Splitting hairs about whether obesity itself represents a disordered or dysfunctional organ system (i.e., disease) is missing the forest from the trees. If obesity is the root of numerous other diseases, then obesity treatment to prevent complications is the best approach, instead of waiting for more issues to develop before starting treatment. This represents a myopic and delayed approach to treating disease. Thus, irrespective of the semantics regarding the definition of disease, when obesity is classified as a disease, clinically meaningful and beneficial outcomes result:

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1. Recognition of a problem. Societal acknowledgment that obesity is the result of both environmental and genetic contributors, rather than being simply the result of maladaptive choices related to excess nutrition is essential. Hormonal, metabolic, psychological, behavioral, historical and societal factors have contributed to the current obesity epidemic. It would emphasize that obesity is something that we as a population need to address, rather than placing ownership on the individual. In affixing the label of “disease” to obesity, it will be made unequivocally clear that it is something to be eliminated if at all possible. Besides the controversial concept of metabolically healthy obesity, a large majority of people with obesity already have some complication, or it is only a matter of time.

2. More treatment. Doctors will likely be less apt to ignore obesity if it were a disease. Thus, patients with obesity would be more likely to receive treatment during the course of their doctor’s visit. By calling it a “condition” or some other precursor to disease, physicians who are already time-pressured may provide brief anticipatory guidance but would otherwise not allocate significant time just to address obesity as a problem.

3. More reimbursement. If more doctors treat obesity, there needs to be a more concrete reimbursement system to incentivize the time spent on obesity-related care. Obesity as a disease will facilitate the development of appropriate diagnostic codes and payment mechanisms for frontline providers providing obesity care. With the need for anticipatory guidance, behavioral counseling, and lifestyle-based treatments, it can be hard for physicians to provide comprehensive care and as a result, patients are referred to ancillary providers who may be ill-equipped to treat obesity. Thus, applying a disease label will lead to further efforts to develop payment pipelines for physicians, leading to increased management of obesity in the clinic.

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4. More research. The emotional valence of the disease label will spur legislators to promote measures to treat and prevent obesity. This would likely take the form of increased funding allocation towards the development of more behavioral, medical and surgical treatment modalities.

Obesity has reached pandemic proportions. We already classify obesity as a public health crisis, implicit in this designation are the harmful effects it has on our society. We have to treat it as it underlies so many other complications throughout our bodies. The least that we could do is to call obesity what it is: a disease.

Albert Do is a gastroenterologist.

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