Over the past weeks, I have presented a miniseries on the pros and cons of calling obesity a chronic disease.
Clearly, I am convinced that the arguments in favour, carry far greater chances of effectively preventing and controlling obesity (defined as abnormal or excess body fat that impairs health) than continuing to describe obesity merely as a matter of ‘lifestyle’ or simply a ‘risk factor’ for other diseases.
That said, I would like to acknowledge that the term ‘disease’ is a societal construct (there is, to my knowledge no binding legal or widely accepted scientific definition of what exactly warrants the term ‘disease’).
As all societal constructs are subject to change, our definitions of disease are subject to change. Conditions that may once have been deemed a ‘normal’ feature of aging (e.g. type 2 diabetes or dementia) have long risen to the status of ‘diseases’. This recognition has had profound impact on everything from human rights legislations to health insurance to the emphasis given to these conditions in medical education and practice.
People living with obesity deserve no less.
Thus, I come down heavily on the ‘utilitarian’ principle of calling obesity a disease.
When, calling obesity a ‘disease’ best serves the interests of those affected by the condition, then, by all means, call obesity a ‘disease’ – it is as simple as that.
We can only hope for the same impact of the Canadian Medical Association declaring obesity a disease – the sooner, the better for all Canadians living with obesity.
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!
Continuing in my miniseries on reasons why obesity should be considered a disease, I turn to the idea that obesity is largely driven by biology (in which I include psychology, which is also ultimately biology).
This is something people dealing with mental illness discovered a long time ago – depression is “molecules in your brain” – well, so is obesity!
Let me explain.
Humans throughout evolutionary history, like all living creatures, were faced with a dilemma, namely to deal with wide variations in food availability over time (feast vs. famine).
Biologically, this means that they were driven in times of plenty to take up and store as many calories as they could in preparation for bad times – this is how our ancestors survived to this day.
While finding and eating food during times of plenty does not require much work or motivation, finding food during times of famine requires us to go to almost any length and risks to find food. This risk-taking behaviour is biologically ensured by tightly linking food intake to the hedonic reward system, which provides the strong intrinsic motivator to put in the work required to find foods and consume them beyond our immediate needs.
Indeed, it is this link between food and pleasure that explains why we would go to such lengths to further enhance the reward from food by converting raw ingredients into often complex dishes involving hours of toiling in the kitchen. Human culinary creativity knows no limits – all in the service of enhancing pleasure.
Thus, our bodies are perfectly geared towards these activities. When we don’t eat, a complex and powerful neurohormonal response takes over (aka hunger), till the urge becomes overwhelming and forces us to still our appetites by seeking, preparing and consuming foods – the hungrier we get, the more we seek and prepare foods to deliver even greater hedonic reward (fat, sugar, salt, spices).
The tight biological link between eating and the reward system also explains why we so often eat in response to emotions – anxiety, depression, boredom, happiness, fear, loneliness, stress, can all make us eat.
But eating is also engrained into our social behaviour (again largely driven by biology) – as we bond to our mothers through food, we bond to others through eating. Thus, eating has been part of virtually every celebration and social gathering for as long as anyone can remember. Food is celebration, bonding, culture, and identity – all features, the capacity for which, is deeply engrained into our biology.
In fact, our own biology perfectly explains why we have gone to such lengths to create the very environment that we currently live in. Our biology (paired with our species’ limitless creativity and ingenuity) has driven us to conquer famine (at least in most parts of the world) by creating an environment awash in highly palatable foods, nutrient content (and health) be damned!
Thus, even without delving any deeper into the complex genetics, epigenetics, or neuroendocrine biology of eating behaviours, it is not hard to understand why much of today’s obesity epidemic is simply the result of our natural behaviours (biology) acting in an unnatural environment.
So if most of obesity is the result of “normal” biology, how does obesity become a disease?
Because, even “normal” biology becomes a disease, when it affects health.
There are many instances of this.
For example, in the same manner that the biological system responsible for our eating behaviour and energy balance responds to an “abnormal” food environment by promoting excessive weight gain to the point that it can negatively affect our health, other biological systems respond to abnormal environmental cues to affect their respective organ systems to produce illnesses.
Our immune systems designed to differentiate between “good” and “bad”, when underexposed to “good” at critical times in our development (thanks to our modern environments), treat it as “bad”, thereby creating debilitating and even fatal allergic responses to otherwise “harmless” substances like peanuts or strawberries.
Our “normal” glucose homeostasis system, when faced with insulin resistance (resulting from increasingly sedentary life circumstances), provoke hyperinsulinemia with ultimate failure of the beta-cell, resulting in diabetes.
Similarly, our “normal” biological responses to lack of sleep or constant stress, result in a wide range of mental and physical illnesses.
Our “normal” biological responses to drugs and alcohol can result in chronic drug and alcohol addiction.
Our “normal” biological response to cancerogenous substances (including sunlight) can result in cancers.
The list goes on.
Obviously, not everyone responds to the same environment in the same manner – thanks to biological variability (another important reason why our ancestors have made it through the ages).
But, you may argue, if obesity is largely the result of “normal” biology responding to an “abnormal” environment, then isn’t it really the environment that is causing the disease?
That may well be the case, but it doesn’t matter for the definition of disease. Many diseases are the result for the environment interacting with biology and yes, changing the environment could indeed be the best treatment (or even cure) for that disease.
Thus, even if pollution causes asthma and the ultimate “cure” for asthma is to rid the air of pollutants, asthma, while it exists, is still a disease for the person who has it.
All that counts is whether or not the biological condition at hand is affecting your health or not.
The only reason I bring up biology at all, is to counter the argument that obesity is simply stupid people making poor “choices” – one you consider the biology, nothing about obesity is “simple”.
And finally, to end this miniseries on the arguments I often hear against calling obesity, is the objection based on the idea that there are simply too many people living with obesity to apply the label “disease” to. Doing so, would mean that over 7 million Canadians would wake up to find themselves living with a disease.
Related to this argument, I also often encounter the argument, that calling obesity a disease would turn these 7,000,000 Canadians into “patients” thereby completely overwhelming our healthcare system that would now be called about to provide treatments to all these people. I hear from payers and policy makers that providing treatments for obesity as a disease is simply not practical because of the number of people who have it.
As I think about it, both arguments are rubbish.
Firstly, the definition of disease has nothing to do with how many people are affected. Thus, I have never heard anyone say that we need to stop calling diabetes a disease because it affects 6 million Canadians or we need to stop calling depression a disease because 2.5 million Canadians will be affected during the course of their lives.
No one would ever suggest we stop calling the flu a disease just because it affects millions of Canadians leading to 12,200 hospitalizations and 3,500 deaths in Canada each year.
So arguing that we must not call obesity a disease because that would be declaring far too many people as “diseased”, is simply irrelevant.
Even if a disease affects 100% of the population causing important health problems and complications, we’d still be calling it a disease.
As for overwhelming the healthcare system – I would say obesity is costing the health care system whether you call it a disease or not. We will still have to pay for all the health issues directly related to people having obesity – from diabetes to heart disease to joint replacements to cancers. It’s already costing billions of healthcare dollars. Except that we are now spending those dollars on the complications rather than on preventing and treating obesity itself.
Again, if there was any other “disease” threatening to overwhelm the healthcare system, our response would certainly not be to simply stop calling it a “disease” – that would make no sense at all.
This concludes my miniseries on arguments I often hear against calling obesity a disease (there are some I hear less often).
Next week, I will turn to arguments that support the idea of calling obesity a disease – so stay tuned.
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.