by Barbara Berkeley, MD
As I said in an earlier post, obesity is more complicated than we make it out to be. To say it is a disease defines only one part of what obesity is and its facets are legion. Having said this though, it is obvious to those of us who treat ob/ow patients that elements of modern life have left many of us "broken" and are continuing to destroy us via harmful pathways that are self sustaining once established. This new dysfunction perpetuates itself and looks an awful lot like a disease. Most of those who fall into the obesity cycle are completely bewildered by these changes and utterly unprepared for dealing with them. At the time when we are most vulnerable and frustrated, the world turns against us by calling us weak-willed, slovenly and out of control. As our bodies settle into an irrevocable cycle of weight gain, we are told that we can turn it all off if we simply want it enough.
Doctors need to be particularly sensitive to the disease-like aspects of obesity. We need to understand that losing and maintaining weight is a Sisyphean task and we must figure out a way to engage our ob/ow patients with a great deal more compassion than we currently do. We also have to figure out how to provide patients with truly helpful strategies, not just exhortations to lose weight. We should be thinking about ways to treat obesity that involve step-wise drug therapy, just as we treat all of the other lifestyle related diseases we see so commonly. These treatments need not take the place of forming new diet constitutions and healthful habits, but should help in allowing patients to achieve these changes.
I wanted to share this editorial published on the physician site Medscape. This was written by a family doctor in response to an "Is Obesity a Disease" forum. You can "hear" my thoughts as I'm reading this (in red)!
Last month, the American Medical Association (AMA) decided to label obesity as a disease.[1] When I first sat down to write about this topic, I looked up the online definition of "disease." I need to quote the first definition here: "A disordered or incorrectly functioning organ, part, structure, or system of the body resulting from the effect of genetic or developmental errors, infection, poisons, nutritional deficiency or imbalance, toxicity, or unfavorable environmental factors; illness; sickness; ailment." I have a difficult time fitting obesity into this definition -- especially when you look at nutritional deficiency as one of the possible causes. (Are you kidding me? Why did you hone in on "deficiency"? The word after deficiency is imbalance. What could be a more perfect descriptor of the disease aspect of obesity than this definition? Obesity is, in fact, a number of disordered bodily systems that result from nutritional imbalance; an imbalance created and promulgated by those that sell food. And this definition even includes 'unfavorable envionmental factors'! Can there be any question that unfavorable changes in our environment, in the foods we make and promote, in obesogenic cultural changes, and in exposures to possibly weight promoting chemicals are hugely implicated in our current plight?)
The second definition had to do with diseases in plants. I then looked at the third definition: "any harmful, depraved, or morbid condition, as of the mind or society: His fascination with executions is a disease." I am not buying that either.
OK, so why did the AMA decide to declare that obesity is a disease? I figured it had to do with research or the recommendation of a subcommittee, but according to Geoffrey Kabat,[2] this is not the case either. In fact, he writes, it was a decision that went against the recommendation of the Council of Science and Public Health.[3] Really? Then why?
The reason: Make doctors more readily recognize and address obesity, hopefully to aid in reimbursement from insurance companies for the treatment of obesity -- and, to take it a step further, to promote payment for the 2 new obesity drugs that it just so happens recently came to market. Follow the money, folks. (Why does everything in the world have to come down to conspiracy theory? This is the lowest kind of reasoning in my view. The AMA could care less whether big pharma sells a new drug. As it happens, these drugs are not doing the blockbuster business one might have predicted. Declaring obesity a disease will not change that, although it might change physicians' perceptions that the only treatment for obesity is to tell the patient to go out and join a gym. We NEED new medications. We NEED research into this problem. And we NEED reimbursement for treatment.)
I am sorry, but it is not hard for primary care physicians to recognize obesity. We see it every day. We don't ignore it. We attack it head on. (You do??? I have virtually not seen a patient in over 20 years who was given any clear direction other than "you should lose weight" by their physician. OK. I understand that we docs were never taught to deal with obesity and never expected it to be such a epidemic. But let's at least be honest. We are downright pitiful about "attacking" obesity "head on".
That said, obesity comes in different shapes and sizes. The strict definition of obesity being a BMI greater than 30 kg/m2 does not always define the actual patient. I have several athletes who have BMIs of 30 kg/m2 or more who are in fabulous shape and health. I would not consider them diseased (and I have a hard time labeling them as obese). (Exactly to my point as it regards the gaps in knowledge about obesity that practitioners have. The people you describe are not obese and no one who deals with obesity would label them as such. BMI reflects weight, and conditioned athletes weigh more because of the density of muscle)I do not think that calling it a disease is going to make the average doctor change the way they look at the patient in front of them. (Here I think you may be right! Particularly if you are bound and determined to see only the character flaw and not the physiology).
It comes down to money. Obesitologists (does this specialty exist yet?) (Yes. We are called bariatricians and we have our own board certification through the American Board of Obesity Medicine, a presitgious scientific society, our own journal, and a number of postgraduate training programs. How did you miss that?) must have lobbied the AMA for the statement. (Very few of us belong to the AMA). Well, make that the bariatric surgeons. Talk about a specialty explosion. The hospital I work for has a "bariatric product line," and I am sure that they are applauding this label change. (At least your hospital is trying).
Do I agree with the change? Do I think that obesity should be considered a disease? Not really. I don't think that smoking is a disease. I don't think that laziness is a disease. I don't think that poor hygiene is a disease, so I need to be consistent and say that obesity is not a disease.
Honestly, I don't think that it really matters. I do not think that it will change how doctors look at obese persons. I don't think that it will motivate doctors to treat more aggressively (or take better care of themselves, for that matter), and I do not think that insurance companies will be any more likely to pay more when they are looking for ways to pay us less. It will, however create a lot of material for Jay Leno and other late-night comics for their monologues and for us to debate in Roundtables. (Nihilism is a very unfortunate position for doctors to take. We should be the optimistic, creative educators and helpers. My feeling is that this stance is simply a way of opting out of involvement with obesity, a condition that many doctors would prefer to avoid.
I guess it's the very reason we need more of those "obesitologists". If you don't want to wade in, please send these folks to us. We are truly looking for creative ways to help.)