Tuesday, June 25, 2013

Is Obesity A Disease?

The AMA recently adopted a policy stating that obesity is a disease:
“Recognizing obesity as a disease will help change the way the medical community tackles this complex issue that affects approximately one in three Americans,” said AMA board member Patrice Harris, M.D. “The AMA is committed to improving health outcomes and is working to reduce the incidence of cardiovascular disease and type 2 diabetes, which are often linked to obesity.”
The internets have been all a flutter about this, if you happen to read health and fitness and diet blogs like I do.  While this policy decision has no binding authority, the opinions of the AMA are often influential in guiding government policy and insurer practices.  On the one hand, I'm kind of hopeful that maybe this means things like preventative care and gym memberships and delicate hormonal tests to show what is happening within an individual's body will receive more focus from providers and reimbursement from insurers.

On the other hand, I am really, really cynical.

First of all, there's this information from Dr. William Davis, who Tom Naughton cited on his blog:
Well, it’s hard to know how the internal discussions at the AMA went until we get a look at the transcripts. But let’s take a look at the Obesity Action Coalition (OAC). I believe it tells the whole story. 
The OAC Board of Directors is filled with bariatric surgeons, such as Drs. Titus Duncan and Lloyd Stegemann, people who make a living from procedures and surgeries like gastric bypass and lap-band. The largest contributors to the OAC? Eisai Pharmaceuticals, maker of BELVIQ, the new drug for weight loss; Ethicon EndoSurgery, makers of laparoscopic operating room supplies; Vivus, Inc., another obesity drug maker; the American Society for Bariatric Surgeons; and Orexigen, developer of the combination drug naltrexone-buproprion for weight loss, now in FDA application stage. (Recall that naltrexone is the opiate blocking drug taken by heroin addicts but now being proposed to gain approval for weight loss.)

In other words, while it is being cast as something being done for the public good, the motivation is more likely to be … money: Bariatric surgeons gain by expanding the market for their procedures to patients who previously did not have insurance coverage for this “non-disease”; operating room supply manufacturers will sell more equipment for the dramatically increased number of surgical procedures; obesity drug manufacturers will have the clout to pressure health insurers to cover the drugs for this new disease.
Second, my own personal gut reaction (Gut!  Ha!)  to all of this is that obesity isn't a disease, but a manifestation of other problems, like insulin resistance or other hormonal imbalances.  For example, excess amounts of cortisol (the so-called stress hormone) have been shown to increase belly fat.  Further, some people are more insulin-resistant than others and thus can tolerate fewer carbohydrates in their diets.  There's a whole mess of biochemical reactions going on in our bodies, influenced by diet, exercise, and other environmental factors, and one of the results can be obesity.
Another big glaring issue for me is, how are we defining "obese"?  Are we still using BMI to determine who is "obese"?  Because there are loads of articles and analyses out there about the flawed nature of the BMI.   For one, it doesn't take body composition into account, and so you get professional athletes who are "overweight" or "obese", per the BMI.  Not to mention recent reports that people who are fit but slightly overweight, per the BMI definition, actually have pretty good health markers, such as cholesterol, blood pressure, blood sugar and resting heart rate.  Or the research indicating that overweight and even slightly obese people might  have lower mortality rates than "normal"-weight people.  From the New York Times article:
The report, in The Journal of the American Medical Association, suggests that B.M.I., a ratio of height to weight, should not be the only indicator of healthy weight. “Body mass index is an imperfect measure of the risk of mortality,” and factors like blood pressure, cholesterol and blood sugar must be considered, said Dr. Samuel Klein, director of the Center for Human Nutrition at Washington University School of Medicine in St. Louis.
I'm not saying this is perfect research, I'm just saying there are a lot of factors playing into what makes someone obese, and there are a lot of unknowns.  After trying to lose weight for a few years and only gaining, I am solidly in the "obese" category.  However, I don't want to pop a pill, with whatever side effects come along with that.  I want to figure out what's going on in my body and try to work within that knowledge.  Maybe making obesity a disease means that more investigation into the complex causes of it will get funded, but, to me, labeling obesity as a disease seems way too simplistic.

1 comment:

Molly said...

I realize that this is a simplification, but I think that part of the rationale for categorizing obesity as a disease is to destigmatize obesity, a kind of public health initiative to address shame and negative emotional factors that can indirectly contribute to obesity. Whether that will be a successful outcome or whether the psychological effect of declaring obesity a disease will be a reduction in healthy lifestyle behaviors (ie, I have a disease, so what's the point) probably depends on the individual, I wonder what the aggregate response will be.