Let’s Put The Obesity-Is-A-Disease Debate to RestMonday, May 9, 2016
Having just completed a tour de force, first as President of the International Congress on Obesity in Vancouver and then as an invited plenary speaker at the Scientific Meeting of the German Diabetes Society in Berlin, I have had ample opportunities to discuss how best we can make better progress in obesity prevention and treatment.
Amongst the many experts I spoke to virtually no one believes we will make any progress whatsoever, as long as the notion persists among the public and decision makers, that obesity is simply a lifestyle choice and that its impact on health are overstated.
Thus, I would like to draw your attention to a timely article by Scott Kahan and Tracy Zvenyach, published in Current Obesity Reports on current policies and their implications for preventing and treating obesity.
Here is what the authors have to say about several of the arguments often posed by those opposed to calling obesity a disease:
Obesity is self-imposed; it is a “lifestyle choice,” not a disease. While we could argue these points—for example, there is as much or more of a genetic contribution to obesity as there is to diabetes—we’ll simply point out that numerous well-accepted diseases are driven by modifiable individual behaviors, such as type 2 diabetes, hypertension, cardiovascular disease, many cancers, and so forth.
Obesity is a risk factor for disease, therefore it is not a disease itself. There is no stipulation against a condition being both a risk factor for other diseases and a disease itself. Many conditions fit both criteria, such as diabetes, which is both a risk factor for myocardial infarction and a disease itself, or hepatitis, which is both a risk factor for cirrhosis and a disease in itself.
Patients don’t deserve treatment because they haven’t appropriately taken care of themselves. Of course, affected individuals with diabetes, cardiovascular disease, or other preventable, behavior-related diseases do not experience systematic denial of care on the basis that they haven’t already managed the disease on their own.
“Medicalizing” obesity by characterizing it as a disease will be counterproductive (ie, will get in the way of prevention; will lead patients to rely on clinical treatments, such as medications or surgery, in lieu of lifestyle changes). Characterizing other behavior-related conditions, such as diabetes or cardiovascular disease, as “diseases” has not necessarily impeded prevention efforts or behavioral changes. In fact, clinical treatments in many cases have been extremely effective, such as the reduction in cardiovascular mortality over the second half of the twentieth century, largely driven by improved medical treatment of affected individuals. To be sure, prevention and lifestyle modification should be primary, just as they are for other behavior-related health conditions, but should not obviate the opportunity for clinical treatment, when appropriate.
Treatment doesn’t work. While this sense of futility is common, the evidence clearly points otherwise. Moreover, the belief that treatment is futile may be rooted in misunderstanding of treatment goals, which is not to “cure” obesity or achieve normal weight, but rather to lose sufficient weight to improve health, functioning, quality of life, and disease risk, which begins to accrue with as little as 3–5 % body weight loss. Regardless, availability of effective treatment is not a precondition for designation of disease, and many diseases do not have effective treatments or known cures, such as Alzheimer’s disease.
Treatment would be too costly. This is debatable, as some treatments have been shown to be acceptably cost-effective, such as bariatric surgery, and others are believed to have potential for cost savings, such as the Diabetes Prevention Program. Nonetheless, cost of treatment is not a definitional criterion for disease, and of course many diseases have exorbitant treatment costs. Moreover, despite recent Medicare and private health insurance coverage for various obesity treatments, as described below, utilization rates are astoundingly low.
As the authors further point out,
..countless authoritative scientific organizations and government agencies have characterized obesity as a disease, including the National Institutes of Health, Food and Drug Administration, and American Medical Association, and World Health Organization, among many others [e.g. the Canadian Obesity Network, Canadian Medical Association]. Further recognition of obesity as a disease by reputable, scientific organizations is instrumental to disseminate evidence-based knowledge and dispel misinformation and unscientific views. A clearer understanding of obesity as a disease and medical necessity for chronic disease management are key elements for policymakers to understand as they interpret, adopt, and develop health policies for people living with obesity.
While there are clearly issues that remain in terms of better clinical diagnostic criteria for the assessment of obesity (which still largely relies on BMI despite its known limitations), for the vast majority of people living with overweight and obesity who experience health problems, these definitions do not matter.
Also, just because someone does not experience symptoms from a disease, does not mean the disease does not exist or that they don’t have it.
For e.g. many people with heart disease, diabetes, hypertension or even cancer, are entirely unaware that they are in fact living with a disease, which may not reveal itself for years or even decades, during which time they may appear and feel perfectly healthy.
Clearly discussions about whether or not obesity is a disease are a mere distraction from the real task of preventing those who don’t have obesity from getting it and of getting treatments to those who have it.