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.
Next, in my miniseries on arguments I commonly hear against the notion of calling obesity a disease, is that it is “just a risk factor” for other diseases.
This may be true, if you just (wrongly) considered elevated BMI as your definition of obesity, because no doubt, people with higher BMI levels carry a higher risk for obesity related complications including type 2 diabetes, sleep apnea, fatty liver disease, hypertension – just to name a few. (Note that increased risk is not the same as actually having the condition!).
However, when you use the actual WHO definition of obesity, namely, “accumulation of excess or abnormal fat that impairs health”, obesity is no longer just a risk factor – it is now (by definition) impairing your health, which makes it far more than just a risk factor.
So while someone with a BMI of 35 may be at risk of developing obesity (not the same as having it), when their excess fat actually starts impairing their health, it de facto becomes a disease in its own right.
Even then, one might argue that obesity itself is not the disease, rather the complications of obesity are the real disease.
This notion is both right and wrong.
There are many conditions that are both diseases in their own right as well as risk factors for other diseases or complications.
Take type 2 diabetes for instance – it is both a disease in itself but also a risk factor for coronary heart disease or end-stage kidney disease.
Take hypertension – a disease in its own right but also a risk factor for strokes and heart attacks.
Take gastro-oesophageal reflux disease, which is also a risk factor for Barrett’s disease and oesophageal cancer.
Take fatty liver disease, which is also a risk factor for cirrhosis.
Gall bladder stones, which is also a risk factor for pancreatitis.
Multiple sclerosis, which is also a risk factor for neurogenic bladder and pyelonephritis.
The list goes on and on.
So just because obesity is also a risk factor for a wide range of other medical problems, it does not make obesity any less of a disease in its own right.
When excess or abnormal body fat affects health – it’s a disease. When it doesn’t, it’s at best a risk factor.
That, is perhaps a subtle but important distinction.
Continuing in my miniseries on arguments I hear against calling obesity a disease, I now discuss the objection, that doing so promotes a sense of helplessness or even hopelessness in people who carry extra weight.
First of all, as noted previously, carrying extra weight is NOT the definition of obesity. For someone to have obesity they need to be carrying weight that is actually due to excess or abnormal fat tissue AND there has to be some negative impact of that fat tissue on their health – otherwise they do not have obesity!.
That said, I am not sure how calling obesity on changes anything in terms of helplessness or hopelessness.
Yes, the effective options to better manage obesity are limited and most people will likely struggle simply not to gain even more weight – but that fact doesn’t change whether you call obesity a disease or not.
Indeed, there are many diseases for which we lack effective treatments (e.g. Alzheimer’s disease, multiple sclerosis), this does not make any of them any less of a disease.
As for hopelessness, just because you are diagnosed with a chronic disease doesn’t mean everything is hopeless.
In fact, there are many people living with chronic diseases that are controlled and well managed (e.g. diabetes, hypertension, sleep apnea), who do just fine (with treatment) and go on to live long and productive lives.
Obviously, we need better treatments for obesity but even without those, people living with obesity can change the course of their disease by identifying and addressing the root causes of their weight gain (e.g. depression, PTSD, emotional eating, etc.) and adopting behaviours, which even if not resulting in any noticeable weight loss, can markedly improve their health and well-being.
Again, whether you call obesity a disease or not is completely irrelevant to whether or not you feel helpless or hopeless – the management approach would be the same, except that hopefully it will shift attention to a chronic disease strategy that requires long-term sustainable management rather than an acute intervention that is unsustainable.
If we are serious about providing patients with help and hope, let us get serious about finding and providing better treatments for this disease.
Over the past months, I have been involved in countless discussions and debates about whether or not obesity should be considered a chronic disease (as it has by the American and Canadian Medical Associations and a number of other organisations).
I therefore thought it perhaps helpful if I discussed each of the common pros and cons on this issue in a series of blog posts.
To begin this short series, I’d like to discuss perhaps the most common argument against calling obesity a disease, namely, the well-known shortcomings of BMI.
As regular readers will know, I have long railed against the use of BMI as a clinical definition of obesity as it is neither a direct measure of body fatness nor does it directly measure health. In fact, its specificity and sensitivity to pick up health problems commonly associated with obesity (such as type 2 diabetes or hypertension) is so limited, that it would not even remotely meet the criteria commonly applied to other diseases for diagnostic testing.
Thus, especially around the BMI cut off of 30 (widely used to “define” obesity in Caucasians), anywhere from 5-25% of individuals would be considered pretty healthy by almost any clinical measure. Even at higher BMI cut offs, it is not all that difficult to find individuals with very mild to non-existent health problems related to their size (as in EOSS 0-1).
While some of these individuals may well go on to develop health problems over time, “risk for” a disease is generally not considered a “diagnosis” of that disease. Thus, even if an elevated BMI may indicate increased risk of obesity, it cannot be used to “define” an individual as having the “disease of obesity”.
This shortcoming of BMI has been widely (albeit perhaps not widely enough) recognised, which is exactly why, for e.g. the Canadian Medical Association, in their declaration of obesity specifically states that,
“BMI is a useful operational definition for obesity but should not be used as the defining characteristic of the disease….in the case of individuals who are very obese, issues of definition and measurement are not relevant.” (emphasis mine)
Similarly the WHO in its definition of obesity states that,
“BMI provides the most useful population-level measure of overweight and obesity as it is the same for both sexes and for all ages of adults. However, it should be considered a rough guide because it may not correspond to the same degree of fatness in different individuals.” (emphasis mine)
So, if not BMI, what exactly should be used as the defining characteristic of obesity?
This brings us to the actual WHO definition of obesity, which states that obesity is defined as
“…abnormal or excessive fat accumulation that may impair health.”
It is as simple as that!
If your body fat affects your health you have “obesity” – if it doesn’t you don’t.
So what is the BMI cutoff for obesity, you may ask – the simple answer is – there is none!
Whether excess or abnormal body fat affects your health or not is not something you can measure by simply stepping on a scale or pulling out a measuring tape.
Answering the question of whether or not someone has obesity always takes a medical exam and tests, at the end of which your health professional should be able to determine whether or not you have “obesity” or just “adiposity” (the medical term for “fatness”).
So if BMI cannot be used to define “obesity” – how can obesity be a disease?
Because, whether or not your body fat is affecting your health (the actual definition of obesity as a disease) has nothing to do with BMI.
Obesity is a “clinical diagnosis” based solely on the clinical assessment of whether or not the quantity (e.g. body fat%) or quality (e.g. visceral fat) of your body fat is affecting your health.
Thus, the argument against the use of BMI to define obesity is not really an argument against obesity as a disease at all. It is just an argument (and a very valid one at that) in favour of finding (or rather applying) a better definition of obesity in clinical practice.
So while doctors should by all means examine patients with a higher BMI for the presence of “obesity” – they should NOT use BMI alone to define it.
Thus, diagnosing obesity in clinical practice is far more like diagnosing “depression” or “ADHD” (where you do not have a numeric cut off but rather a clinical symptom score) than diagnosing diabetes or hypertension (where you do have a numeric cut off).
Even the most vocal critic of considering obesity a disease will likely agree that when obesity affects your health it deserves to be treated (how, is an entirely different discussion).
On the other hand, even the most enthusiastic proponents of obesity as a disease will hopefully agree that when excess body weight does not affect your health, there is no documented benefit of “treatment”.
That is really all that this discussion is about.
Today’s guest post comes for Carla Prado, PhD, Assistant Professor and CAIP Chair in Nutrition, Food and Health, University of Alberta, Edmonton, Canada
Although obesity is often conceived as excess fat mass, we now know that individuals with obesity may have normal, high or low muscle mass.
Low muscle mass (sarcopenia) is a debilitating condition associated with poor physical function, morbidity and mortality.
The simultaneous appearance of obesity and sarcopenia (sarcopenic obesity) is an emerging area of interest as its prevalence is at rise.
Importantly, sarcopenic obesity is the worst‐case scenario as both excess fat and low muscle mass have its own (and perhaps synergistic) metabolic and health‐related consequences.
As a “hidden condition”, sarcopenia in individuals with obesity is undetectable by use of body weight or body mass index.
The need for sophisticated measurements of body composition has limited our ability to fully understand this condition, as well as to establish preventive and treatment strategies, limiting the translation between research and clinical practice.
This is about to change.
As of October 1st, 2016, sarcopenia will have its own diagnostic code (ICD‐10 code). The World Health Organization International Statistical Classification of Diseases and Related Health Problems (ICD) is a standard tool used to report diagnosis and in‐patient procedures.
Hopefully, this will mean that the official record and identification of sarcopenia in medical records will improve our understanding of the epidemiology, health management and treatment of this condition.
According to the Aging In Motion Coalition, the establishment of an ICD‐10 Code represents a major recognition of the importance of sarcopenia, removing barriers to treatment and research on several fronts.
Such barriers include awareness and attention, clear indications for treatment, and reimbursement.
We expect Canada will champion the study of sarcopenia and sarcopenic obesity with special calls for funding, advocacy and public awareness.