Sunday, July 7, 2013

Obesity the disease: Is it really about health?

The media and blogosphere lit up after the recent American Medical Association annual meeting.


The prestigious, 165 year-old organization of 225,000 doctors voted to recognize obesity as a "disease." Yup, let me say it again, according to the AMA, obesity is now considered a disease.

Now, of course, there are fairly convincing arguments on both sides of the spectrum (here is an interesting compilation of arguments from members of the Obesity Society). The popular obesity blog Weighty Matters lays out a pretty good listing of reasons against obesity as a disease. Interestingly, the article starts off by applying the common definition of disease, and seeing if obesity fits - "A particular quality, habit, or disposition regarded as adversely affecting a person or group of people."

At first glance this seems to make a lot of sense. Obesity is a quality or disposition that adversely affects an individual and society (a prime example being the health care costs associated with obesity).

This is the argument taken by Lee Kaplan, director of the Obesity, Metabolism and Nutrition Institute at Massachusetts General Hospital, associate professor of Medicine at Harvard Medical School, and chairman emeritus of the Campaign to End Obesity:
"The simple fact is that obesity is a disease, a chronic, frequently progressive, and rarely remitting disorder that triggers an additional 65 or more other conditions ranging from arthritis and sleep apnea to many forms of cancer."

On the other hand, will the AMA's announcement simply medicalize the issue rather than addresses the miriad of factors that influence it. Public health expert David Katz makes this point when illustrating the irony of the AMA’s announcement and the recent introduction of the first FDA-approved obesity drug into the market. This obviously begs the question of who really stands to benefit: those who suffer from obesity or big pharma? Dr. William Davis, the preventive cardiologist and best-selling author, answers in pretty simple terms:
"To the system, you are worth more obese than slender. You are worth more diabetic than non-diabetic. And you are worth more as a wheat-eater than as a non-wheat eater."
One might go as far as to say that this is a classic example of "disease mongering" - a phenomenon described by Lynn Payer as the ability to control the destinction between health and disease, thereby allowing drug companies to determine the size of their own markets. From the enlightening book The Bottom Line or Public Health,
"Since disease is such a fluid and political concept, the providers can essentially create their own demand by broadening the definition of diseases in such a way as to include the greatest number of people, and by spinning out new disease."
It wasn't long after the AMA's announcement that its implications were already being seen. Only a few days later, Members of Congress introduced the Treat and Reduce Obesity Act (H.R. 2415/S.1184), a bill that would  allow Medicare coverage of prescription weight-loss drugs.


The Wall Street Journal importantly points out that even if obesity is characterized as a disease, there is still a pretty big grey area in terms of how to actually measure and track obesity trends. Traditional "diagnosis" of obesity has been using the imprecise Body Mass Index, which is simply weight divided by height. One can easily guess why this can be a challenge -  just think of a fairly fit athlete with good dose of lean muscle mass. Unfortunately, BMI doesn't distinguish between fat mass or muscle mass, which, of course has some severe limitations. Other research has shown (see here) waist circumference to be a much better predictor of obesity-related health risk and subsequent health costs (see here).


Might characterizing obesity as a disease actually be counterproductive to prevention efforts? A new study released a few weeks ago found that if parents discuss weight issues with their children they are in turn more likely to diet, use unhealthy weight-control behaviors, and engage in binge eating. By classifying obesity as a disease, won't doctors be more apt to discuss it in terms of "treatment" options for their condition - i.e. in the context of weight (remember how obesity is classically measured - BMI = weight/height)? And, my fear, is that by framing conversations between health providers and children/adolescents and their parents in terms of weight alone, children and teens might turn to some of the same negative dietary behaviors mentioned in the study.

The current President of the AMA doesn't think so, and recently defended the organization's decision.
She makes the argument, "Recognizing obesity as a disease will encourage a dialogue between patients and physicians to determine which behavioral, medicinal or surgical options may be right for them." But an honest dialogue between physicians and patients about options is only as useful as doctors are informed and able to accurately communicate the range of options.

Take for example nutrition.

Now, I think doctors are good at a lot of things, but offering nutrition advice (i.e. behavioral option) is not one of them. And medical schools themselves agree with this statement. A 2010 survey found that among 105 accredited U.S. medical schools, only 26 (25%) required a dedicated nutrition course! In other words, medical students (or our nation's future doctors) from three out of four U.S. medical schools received ZERO training on nutrition. The average contact hours of nutrition instruction medical school students received was 19.5 hours, and this was about 3 hours LESS than the average time from 2004.


My biggest fear, however, is that by placing the emphasis on obesity we neglect the underlying physiological processes contributing to weight-gain in the first place. Some research has already suggested that the link between obesity and shorter life expectancy may not be as clear cut as we once thought (i.e. being obese might not be the real issue. More on this below). The research was published earlier this year in the Journal of the American Medical Association and found that "Grade 1 obesity overall was not associated with higher mortality, and overweight was associated with significantly lower all-cause mortality." (Yes, this is pretty ironic coming from the academic journal of the same professional organization that just a few months later deemed obesity as a disease.)

Dr. Peter Attia made a strong and eloquent case at this year's TEDMED conference about why obesity might not be the real issue. What if we have the causality backwards? What if obesity doesn't lead to issues of diabetes and metabolic syndrome, but the real issue (and whether our body stores or burns fat) has everything to do with insulin - i.e. the hormone at the crux of diabetes and metabolic syndrome? What if obesity is just a by-product of the metabolic firestorm caused by chronically consuming excessive sugar, starches, and refined carbohydrates?

What do you think - was the AMA's announcement beneficial or harmful?

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