American Endocrinologists Declare Obesity a Disease
Monday, October 29, 2012
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.
AMS
Toronto, ON
Monday, October 29, 2012
that is such awesome news!
Monday, October 29, 2012
I don’t suppose that they will start treating the PATIENT instead of their thyroid test results when they have most of the symptoms of low thyroid? I hope this is at least the first step towards that.
Monday, October 29, 2012
I also think that labeling obesity as a disease has the potential to attract more attention and resource. However, from a scientific standpoint, body fat gain is rather seen as a normal physiological adaptation (normal consequence) of today’s environment. The White Paper published a couple of years ago by Allison and colleagues was also clear about that and the expert panel based their decision on a utilitarian approach (as opposed to a scientific approach). This perception of obesity also means that body fat gain is probably better than not gaining fat at all if one maintains poor chronic lifestyle habits in the modern obesogenic environment. Fat gain can at least provide some good things (e.g. increase in leptin levels) to maintain body homeostasis. That being said, labeling obesity as a disease will probably be helpful in the management and treatment of obesity but less so in the prevention of obesity. In the long run, prevention of obesity is the only viable option to address the problem. As long as we don’t address the key drivers of obesity (e.g. reducing the gap between the rich and the poor) it will be almost impossible to succeed.
Tuesday, October 30, 2012
Declaring Obesity as a disease is beneficial as a majority of obese people especially in the Middle East ,are not willing to manage obesity unless well known health hazards occur when health checks are performed -There s no clear realization that obesity might be the cause of cardiovascular, psychological or otherwise health related problems -Its always treated as a harmless sometimes accepted symptom until damage is evident in a lab report .Obviously as a weight feature it s not enough for an individual to realise that excess fat ,be it visceral or subcutaneous might be the underlying factor behind hypertension or irregular lipid profile
If on the other hand it becomes natural for people to consider themselves sick if they are obese they will do something about it much sooner
In my own humble opinion as an Obesity Management specialist there are no Healthy Obese they just dont realise what s wrong
Thursday, November 1, 2012
Dear Dr. Sharma,
I appreciate the clear distinction you make between adiposity (a natural human variation in size and a positive aspect of human diversity) and obesity, which may be carefully and appropriately staged (according to specific guidelines and classification criteria) and thoroughly assessed, for example, in relation to:
1) commonly associated health risks,
2) evidence of disease symptoms and processes,
3) socially constructed material conditions of living,
4) culturally created barriers to change (factors over which individuals have little or no control—and which may contribute significantly to increases in the prevalence of obesity among populations), and
5) subjective yet crucial self-reports of individual patients’ descriptions and experiences of obesity-related and size-related suffering and trauma.
The latter may include emotional and mental suffering related to social stigma, discrimination, bias, and self blame—as well as social conditions of exclusion, isolation, restriction, and limitations (such as the following) which contribute to:
A) greater economic insecurity, more uncertainty about future outcomes, and higher levels of chronic stress
B) increased unemployment
C) decreased access to safe transportation and secure housing
D) increased safety concerns and health risks resulting from (in some instances) socially-sanctioned targeting for physical violence (assaults), chronic bullying, verbal aggression (threats of violence), and sexual harassment
E) increased exposure to hostile work environments
F) decreased access to compassionate, unbiased medical care
G) increased work/living conditions of greater social injustice and oppression may alter (worsen) mental health status by limiting needed sources of social support, by compromising (or overwhelming) available coping options, by fostering mistrust for help-seeking efforts, and by cementing self doubt towards one’s own perceptions of reality
Lastly, if re-categorizing obesity as a disease will serve to draw far more professional (and public) attention to the social and cultural factors which influence, transform and/or worsen disease/health outcomes, then such a reframing of obesity within the medical model might expand possibilities for more diverse and improved—and more compassionate—treatment approaches.
Moreover, a powerful enough revision could enhance human understanding of diseases as social constructs created by and observed through the lenses of human discourses—rather than viewing diseases as scientifically objective, inevitable or (apriori) absolutes existing within individual physical bodies, as if (somehow) human bodies function in isolated, separate realities apart from our cultural practices, our social institutions, and our language games.
Understandably, based on historical evidence of previous transformations in social and medical realms, I won’t hold my breath for the emergence any time soon of significant changes in the ways that professionals view, treat, and understand obesity.
Friday, November 2, 2012
If they’re going to classify obesity as a disease, I think that they need to stop defining it according to BMI.
Monday, November 5, 2012
I agree with the general consensus that the medicalisation of obesity will hopefully lead to less stigma, and the notion that the obese person is responsible for his/her condition. Thank you Arya for bringing this position statement to our attention