Let’s Put The Obesity-Is-A-Disease Debate to Rest
Monday, 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:
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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.
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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.
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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.
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“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.
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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.
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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.
@DrSharma
Edmonton
Monday, May 9, 2016
Dr. Sharma I wish you would send this post to all the provincial and the federal health ministers. If they would all tackle this issue in a coordinated sensible fashion as you outline, I’m sure the health care costs in this country would definitely decline!
Monday, May 9, 2016
Please feel free to forward this post to any health minister, civil servant, hospital administrator or anyone else you feel should read this – I promise you the effect is probably the same coming from you or from me (I do wish I had more clout with them, but I don’t)
Wednesday, May 11, 2016
I deal with these kinds of arguments — it’s a lifestyle CHOICE (aka you could thin only if you tried harder; you’re just lazy), too many of My Tax Dollars go to your care (yes, I’m in the US), you are 100% going to get diabetes and heart failure and die before you’re 40 (get a time machine, bud), etc.
Part of the issue, I think, is that obesity is a risk factor for many diseases, but the average person doesn’t understand the difference between a risk factor and a cause. When I point out that obesity is ONE of the risk factors for diseases, I’m mocked because “that’s like saying smoking is only a risk factor for lung cancer.” Technically, it is, but it’s some absurdly high risk. Conversely, last time I looked, only about 40% of obese people ever become diabetic – a much lower rate and risk than smoking is for lung diseases, and weight gain, or difficulties losing weight, is more of a risk factor than just being obese.
I feel the burning need to ask about a few points you’ve made:
1) You already pointed out that obesity is risk factors for T2DM and CVD are genetic. But what is the percentages of non-obese people having CVD? Are they unicorns or is the genetic component the primary factor? (Remember Jim Fixx?)
2) You said: 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.
Yes, they do — if they’re obese. Obese people are regularly denied decent health care, because doctors believe that obese people are non-compliant (otherwise they’d be losing weight!) and aren’t worth their effort. I hope you know the Rudd Center’s work, as there have been studies that show that (too) many doctors feel this way. I’ve heard a mountain of anecdotes (which aren’t data) but that there are studies, too, makes my heart sink.
And I’ll tell you of another unicorn. When I was diagnosed with DM it was T2DM. A C-peptide test backed this up. They kept trying oral drug after oral drug and none worked. I was on a calorie restricted diet and losing weight while my BG climbed. Eventually new doctors started insulin. And nobody checked the C-Peptide levels again — for 20+ years. Because I’m obese (of course I gained the weight back), because I’m insulin resistant (like most obese diabetics), everyone assumed I must be a T2. (And I’ve since learned that verapamil, which I’ve been taking for 30 years for migraines, can also extend the so-called “honeymoon phase.”)
I’ve heard stories that match my own – trying to be seen for a serious infection only to find the doctor won’t help you until you agree to go on a diet. Going to a hospital, after an injury, with back pain so severe one of your legs is completely numb and not working, only to be told “Well, of course you’re incontinent. That’s common with obesity. If you lose weight you’ll fix your back.” Being told — at 26, with a blood pressure of 100/40 — that you’ve had a stroke and will die before you’re 30. (It was a complicated migraine.) I lost the use of one leg thanks to a doctor who insisted -despite numerous dopplers over 3 months- I had a blood clot because “all fat people get blood clots in their leg.”
But lastly, after all my ranting :), I want to say this: I have piles of respect for you. You and Dr Freedhoff are the ports in the storm. The sometimes few medical professionals speaking up in a world that shouts out about how “obesity is always dangerous, period.” I may not always agree with you, and to me, that’s fine, because in the end you are the voices of reason.
Thank you. For reading this (if you have) and, especially, for what you do.
Wednesday, May 11, 2016
Thank you for your long comment – very much appreciated. To answer your questions: there are of course many other (albeit less common) risk factors for type 2 diabetes and heart disease. This is why you can also find these problems in some lean individuals. I also agree, that the people with all kinds of health problems meet bias, but this tends to be even worse when they present with obesity.
Saturday, May 14, 2016
Having worked with an organization specialized in cardiovascular disease for many years, I can tell you that obesity is not the biggest risk factor for heart disease or stroke. The #1 risk factor for stroke is high blood pressure. Obesity is just one of many ‘controllable’ risk factors for cardiovascular disease, and they are: high blood pressure, smoking, physical inactivity, a poor diet (high in sat fat and sugar), stress, abuse of alcohol, high cholesterol (now debatable) and excess weight. But obesity certainly is not the greatest of these as you seem to suggest. And thin people having heart attacks is not a unicorn or rare event. It is quite common. Genetics plays a major factor in heart disease just as it does in obesity. Genetics determines how tall you will be and how much you will weigh, and what diseases you will get. Obesity is a disease of society because we live in an environment that breeds obesity (with convenience and fast food, a reliance on cars, elevators, escalators, and 40 hour a week office jobs) while simultaneously stigmatizing it. Some people are just more genetically predisposed to gain weight from these environmental factors than others. The sooner we tackle the real cause of the problem, the sooner we can reduce its prevalence around the world. Important note: the rates of obesity has risen in nations around the world simultaneously and directly in correlation with the rise in the number of fast food franchises opening in those nations.
Monday, May 16, 2016
Actually smoking is by far the biggest risk factor of them all. For strokes, hypertension comes first, for coronary artery disease it’s high cholesterol, for kidney disease it seems to be diabetes – point is that obesity contributes to them all. People smoke to control their weight, obesity is by far the most common risk factor for hypertension and diabetes – only cholesterol seems to have little to do with excess weight. Given the prevalence of obesity across the population, even a (relatively) small risk adds up to large numbers. Of course skinny people have heart attacks and strokes because not all heart attacks or strokes are “atherosclerotic” but even atherosclerosis can occur in skinny people – cholesterol, the prime risk factor for this is highly genetic.
p.s. correlation does not prove causality, there are scores of “things” that have risen simultaneously with the obesity epidemic.