Regular readers of these pages will be well aware that I am a strong proponent of the ‘medical’ model of obesity.
While I am the first to point out that not all people with adiposity (increased body fat) are necessarily ill (as in individuals with EOSS Stage 0), it is also evident that increased body fat can indeed affect multiple organ systems as well as significantly reduce quality of life.
Thus, while we may quibble about the exact definitions of ‘obesity’ (i.e. versus ‘adiposity’), for those, whose health is affected by excess body fat, it is clear that a medical model better suits their health care needs (irrespective of whether or not this care focuses on weight loss or on generally promoting their health).
Now, the American Association of Clinical Endocrinology (AACE) has released a Position Statement on obesity and obesity medicine, in which they clearly denote obesity as a ‘disease’.
The characterisation of obesity as a disease is based on The American Medical Association’s essential criteria common to all definitions that constitute a disease, namely: (a) an impairment of the normal functioning of some aspect of the body; (b) that has characteristic signs or symptoms; and (c) results in harm or morbidity to the entity affected.
As the position statement points out,
“Obesity meets these 3 conditions. First, obesity is an altered physiological and metabolic state, with environ- mental, genetic, and hormonal determinants, which results in increased morbidity and mortality. Current data provide undeniable evidence for an obesity-centric model of disease with impairment of normal functioning including appetite dysregulation, abnormal energy balance, endo- crine dysfunction including elevated leptin levels and insulin resistance, infertility, dysregulated adipokine signaling, abnormal endothelial function and blood pressure eleva- tion, nonalcoholic fatty liver disease, dyslipidemia, and systemic and adipose tissue inflammation. Some aspects of obesity that lead to an impairment in body function are anatomic and relate to the increase in body fat mass per se such as osteoarthritis, immobility, lymphedema and/or venous stasis, and to some extent sleep apnea. However, critical aspects may also be physiologic, such as the impact of body fat mass on insulin resistance and its associated trait complex with progression to T2DM and cardiovascular disease.”
The statement also notes that although some ‘environmental’ contributors to weight gain and related impact on health may well be under the control of the individual, there is accumulating evidence of environmental factors that may be well beyond the control of affected individuals (e.g. availability and affordability of healthy foods, environmental toxins, endocrine disrupters, but also, sociocultural beliefs and attitudes). On the other hand, there is also clear evidence for the role of genetic susceptibility and a distinct and complex pathophysiology.
Thus, seeing obesity as a simple matter of ‘lifestyle’ choices or simply a ‘cosmetic’ issue, belies both the complex aetiology as well as the very real impacts of this condition on health and functioning.
As the authors point out,
“To say that obesity is not a disease but rather a consequence of chosen lifestyle (i.e., overeating and/or inactivity) is equivalent to saying that lung cancer is also not a disease because it was brought about by volitional cigarette smoking.”
As I have noted in previous posts, the statement describes the important implications of characterizing obesity as a disease state:
“..recognizing obesity as a primary disease state has salient social, political, economic, and transcultural implications. The classification of obesity as a disease will help mobilize society towards the importance of prevention and treatment, and enlist the aid of government, health care providers and payers, and scientific and professional organizations. The disease designation fosters change in attitudes and in the financial support needed for more intensive scientific investigation, drug discovery, resources for patient care, and the development of improved strategies for both prevention and treatment. In the end, it will require a collaborative and coordinated effort by physicians, scientists, pharmaceutical companies, health care payers, government, and patients to mobilize the efforts necessary to combat obesity, ameliorate the suffering of patients, and reduce the social costs of this disease.”
The document also makes important recommendations with regard to medical training and certification of endocrinologists in ‘obesity medicine':
“AACE proposes development of a certification process for clinical endocrinologists after successful completion of a formalized AACE educational program in obesity medicine. This coordinated education and certification process would focus on the needs and special expertise of the clinical endocrinologist.”
Obviously, given the multitude of individuals affected, obesity management cannot just be the domain of specialists. Indeed, I firmly believe that all health practitioners need to be educated on the the aetiology, prevention and management of obesity – which is exactly why the Canadian Obesity Network’s 5As of Obesity Management were developed for use by all primary care practitioners.
As I have said before, not recognizing obesity (not adiposity!) as a disease, is simply an expression of weight-bias and constitutes nothing less than discrimination of individuals affected by this condition.