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Next in my miniseries on the pros and cons of calling obesity a ‘disease’, I turn to the issue of medical education. From the first day in medical school, I learnt about diseases – their signs and symptoms, their definitions and classifications, their biochemistry and physiology, their prognosis and treatments. Any medical graduate will happily recite the role and function of ADH, ATP, ANP, TSH, ACTH, AST, ALT, MCV and a host of other combinations of alphabet soup related to even the most obscure physiology and function – everything, except the alphabet soup related to ingestive behaviour, energy regulation, and caloric expenditure. Most medical students and doctors will never have heard of POMC, α-MSH, PYY, AgRP, CART, MC4R, or any of the well studied and long-known key molecules involved in appetite regulation. Many will have at best a vague understanding of RMR, TEE, TEF, or NEAT. The point is, that even today, we are graduating medical doctors, who have at best a layman’s understanding of the complex biology of appetite and energy regulation, let alone a solid grasp of the clinical management of obesity. Imagine a medical doctor, who has never heard of β-cells or insulin or glucagon or GLUT4-transporters trying to manage a patient with diabetes. Or a medical doctor, who has never heard of renin or aldosterone or angiotensinogen or angiotensin 2 trying to manage your blood pressure. How about a medical doctor, who has never heard of T3 or T4 or TSH managing your thyroid disease? Elevating obesity to a ‘disease’ means that medical schools will no longer have an excuse to not teach students about the complex sociopsychobiology of obesity, its complications, prognosis, and treatments. As I mentioned in a previous post, suddenly, managing obesity has become their job. No longer will it be acceptable for doctors to simply tell their patients to control their weight, with no stake in if and how they actually did it. Thus, if there is just one thing that calling obesity a ‘disease’ can change, it is expecting all health professionals to have as much understanding of obesity as they are currently expected to have of diabetes, heart disease, lung disease, and any other common disease they are likely to encounter in their medical practice. Apparently, simply treating obesity as a ‘lifestyle’ problem or ‘risk factor’ was not enough – hopefully, recognising obesity as a ‘disease’ in its own right, will change the attention given to this issue in medical… Read More »
Next, in this miniseries on arguments for and against calling obesity a disease, I turn to the issue of stigma. One of the biggest arguments against calling obesity, is the fear that doing so can increase stigma against people living with obesity. This is nonsense, because I do not think it is at all possible for anything to make stigma and the discrimination of people living with obesity worse than it already is. If anything, calling obesity a disease (defined as excess or abnormal body fat that impairs your health), could well serve to reduce that stigma by changing the narrative around obesity. The current narrative sees obesity largely as a matter of personal choice involving poor will power to control your diet and unwillingness to engage in even a modest amount of regular physical activity. In contrast, the term ‘disease’ conjures up the notion of complex biology including genetics, epigenetics, neurohormonal dysregulation, environmental toxins, mental health issues and other factors including social determinants of health, that many will accept are beyond the simple control of the individual. This is not to say that other diseases do not carry stigma. This has and remains the case for diseases ranging from HIV/AIDS to depression – but, the stigma surrounding these conditions has been vastly reduced by changing the narrative of these illnesses. Today, we are more likely to think of depression (and other mental illnesses) as a problem related to “chemicals in the brain”, than something that people can pull out of with sheer motivation and will power. Perhaps changing the public narrative around obesity, from simply a matter of motivation and will power, to one that invokes the complex sociopsychobiology that really underlies this disorder, will, over time, also help reduce the stigma of obesity. Once we see obesity as something that can affect anyone (it can), for which we have no easy solutions (we don’t), and which often requires medical or surgical treatment (it does) best administered by trained and regulated health professionals (like for other diseases), we can perhaps start destigmatizing this condition and change the climate of shame and blame that people with this disease face everyday. @DrSharma Edmonton, AB
Next in my miniseries on arguments for calling obesity a disease is the issue of empathy. Our normal response to people who happen to be affected by a disease – including lung cancer and STDs – is at least some measure of empathy (even if residual stigma continues to exist). Even if the disease was entirely preventable and you did your lot to hasten its development, once you declare yourself as having diabetes, or heart disease, or stroke, or cancer, the expected social response is empathy – and not just from family, friends, and colleagues. Thus, diseases demand empathy – that’s the normal, ethical, humane response. But apparently not towards people affected by obesity. Here the response is blame, shame, disgust, jokes, name calling, and even physical attacks (spitting, pushing, shoving, beating – you name it). No empathy, so sympathy, no understanding, no compassion – i.e perhaps until we call obesity a “disease”. Then, suddenly, everything changes – because diseases demand empathy. Perhaps this is the real reason that some folks are so vehemently against calling obesity a disease – to fully accept that obesity is a disease, they would have to show empathy – not something they feel people living with obesity quite deserve. After all, how can you still make jokes and poke fun at people living with a disease? How can you still shame and blame people living with obesity, if we call it a disease? How can you still wage a “war” on obesity – take no prisoners? That’s definitely a spoiler! Think about it! @DrSharma Edmonton, AB
Next, in my miniseries on arguments to support calling obesity (defined as excess or abnormal body fat that affects your health), I turn to the impact on health care providers. Currently, most health care practitioners will happily limit their role in obesity management to warning their patients about the many health consequences of carrying excess weight and advise them to lose weight. They do not, however, see it as their job to actually provide treatment. This is in stark contrast to diabetes or hypertension, where doctors do see helping patients control their blood glucose or blood pressure levels as an essential part of their job. Here, simply telling patients that they need to lower their blood glucose or blood pressure would not be deemed enough. Helping patients control their blood glucose or blood pressure, happens to be an important part of their job description. One reason that health care providers have gotten away with simply telling patients to lose weight without actually helping them do so, is precisely because they have never viewed obesity as a disease. Rather, they (as much of the public) have looked at excess weight (and weight loss) as simply a matter of personal “lifestyle” – something that people with obesity should be able to manage on their own. This, incidentally is one of the main reasons why many doctors are not happy with obesity being called a disease. I have actually heard a colleague ask me, “Why should this be my job? Why can’t they (sic) just eat less and move more – how difficult can that be?”. That, is exactly the attitude adjustment that calling obesity a chronic disease can change. Perhaps not in the generation of doctors and other health professionals who have grown up thinking of obesity as a “lifestyle choice”. But hopefully, in the next generation of health care providers, for whom treating and helping their patients manage their obesity will be no different from treating and helping patients living with any other chronic disease. @DrSharma Edmonton, AB
Continuing in my miniseries on arguments in favour of calling obesity (defined as excess or abnormal fat tissue that impairs health) a disease, I turn to the perhaps most important reason of all – access to care. Currently, few health care systems feel obliged to provide individuals presenting with obesity treatment for their condition (beyond a few words of caution and simplistic advise to simply eat less and move more). Most health plans do not cover treatments for obesity, arguing that this is simply a lifestyle issue. In some countries (e.g. Germany), health insurance and health benefit plans are expressly forbidden by law to cover medical treatments for obesity. Although long established as the only evidence-based effective long-term treatment for severe obesity, many jurisdictions continue to woefully underprovide access to bariatric surgery, with currently less than 4 out of 1,000 eligible patients receiving surgery per year in Canada. Pretty much all of this can be blamed on one issue alone – the notion that obesity is simply a matter or personal choice and can be remediated by simple lifestyle change. Declaring obesity a disease can potentially change all of this. As a disease in its own right, health care systems can no longer refuse to provide treatments for this condition. In the same manner that no health system or insurance plan can refuse to cover treatments for diabetes or hypertension, no health system or insurance plan should be able to deny coverage for treatments for obesity. As a chronic disease, obesity care must now be firmly integrated into chronic disease management programs, in the same manner that these programs provide services to patients with other chronic diseases. How long will it take before this becomes accepted practice and funding for obesity treatments rises to the level of funding currently available for treating other chronic diseases? That, is anyone’s guess, but no doubt, declaring obesity a disease finally puts patients living with this condition on an equal footing with patients living with any other chronic disease. @DrSharma Edmonton, AB