Is Obesity A Lack Of Will, A Poor Lifestyle Choice, Or A Disease?

By Chuck Dinerstein, MD, MBA

There is no doubt that obesity is a growing global problem, lying at one end of the spectrum from its less talked but equally malnourished polar opposite, hunger. Some argue that defining obesity as a disease will change the trajectory of the problem for the better — time for a closer examination. 

What is a disease?

That, of course, is the million-dollar question, and as you have come to learn, it is complicated. We are biological creatures, and to our best understanding, we are in an equilibrium internally and externally. That equipoise, let’s for the minute call it, ease of being, is a dynamic process; we tend to focus on the internal ease of being, but the increasing concern over the socioeconomic determinants of health expresses the ease of being with the external environment. 

If one now takes disease and breaks it in two, dis-ease, then we have an experiential sense of how to define a dis-ease. Again, most internal dis-eases have been given a status as a disease, but in reality, they are a phenotype with many underlying features and causes. Diabetes, the dis-ease of glucose regulation, has Type I and II, and some argue for a pre-diabetic condition. More to the point, obesity encompasses many internal and external dis-eases of being. The internal concerns include diabetes and cardiovascular disease; the external dis-eases including body shaming and a visceral bias against the overweight. Those external dis-eases may well be more cultural than biological, as anyone who has viewed the work of Rubens knows.

In 2013, over the objection of their council of experts, the AMA’s House of Delegates defined obesity as a disease. 

“That our AMA: (1) recognize obesity and overweight as a chronic medical condition (de facto disease state) and urgent public health problem; (2) recommend that providers receive appropriate financial support and payment from third-party payers, thus ensuring that providers have an incentive to manage the complex diseases associated with obesity; (3) work with third-party payers and governmental agencies to recognize obesity intervention as an essential medical serviceand (4) establish a comprehensive ICD code for medical services to manage and treat obese and overweight patients.” [emphasis added]

I added the emphasis because all three of these points address payment for treatment, whether WW (the old Weight Watchers), medications or our current most favored, bariatric surgery. For the cynical amongst us, this might be considered self-serving on the part of physicians.

Report Of The Council On Science And Public Health

A re-reading of the report of those AMA experts demonstrates how little has changed now that obesity is a treatable condition. While we might argue that we can identify obesity when we see it, that is insufficient for those footing the bills – they want quantifiable, objective criteria. The most ubiquitous is the BMI or body mass index. It is a cheap, easily applied (involving only weight and height) screening tool, but as the report notes, 

“Associations between BMI and adiposity (as well as disease risk, described below) vary by age, gender, ethnicity, socioeconomic status, stature, and athletic training. These variations generally reflect population-specific differences in body composition, fat distribution, causes of overweight, and genetic susceptibility. As a screening tool for obesity, BMI demonstrates low sensitivity, particularly at BMIs below 30.”

The gist – BMI is much better at identifying the non-obese. Of course, those standardized cutoff values are subject to revision, just as we continue to lower the criteria for being hypertensive. 

The Council found designating obesity as a disease would bring “greater investments by government and the private sector to develop and reimburse obesity treatments.” That includes medications, surgery, and obesity prevention programs. It might also mean that discrimination based on body weight might be illegal. But more importantly, obesity as a disease would shift societal perceptions. 

“Lack of self-control, laziness, and other detrimental character attributes might be less likely to be associated with obese individuals, and in turn reduce stigmatization.”

On the other hand, obesity as a disease would “medicalize” obesity making the pill or knife the more relied upon alternatives

Public perceptions may shift due to more extensive recognition of obesity as a disease, with a greater appreciation of, and emphasis on, the complex etiology of obesity and the health benefits of achieving and maintaining a healthy weight. Moreover, as BMI became a vital sign, as did pain (which ushered in the era of opioid diversion), the environment might shift away from “healthy eating and physical activity.” Finally, obesity as a disease would result in higher insurance costs…


F. Kaskais Web Guru

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