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Arguments Against Obesity As A Disease #5: Reduces Personal Responsibility

In my miniseries on arguments that I often hear against calling obesity a chronic disease, I now turn to the objection that declaring obesity a disease would reduce or even abolish personal responsibility. The argument being, that the term “disease” carries the connotation of being inevitable and will thus reduce motivation in patients to do anything about it. This is complete nonsense! When has calling something a disease ever taken away an individuals “responsibility” to do what they can to avoid or ameliorate it? Take for example type 2 diabetes – a very avoidable and modifiable condition. Calling diabetes a disease does not mean that the individual can do nothing to prevent it or that, once it occurs, the patient can do nothing to change the course of the disease – of course they can and should and often do! Or take people with a high risk of heart disease or lung disease or bone and joint disease or even cancer – in no instance do we expect less of patients to do their part in helping manage these conditions just because we call them “diseases”. There is even a term for this – it is called “self-management” – a key principle of chronic disease management. The course of almost every chronic disease can be changed by whether or not patients change their diet, follow their exercise program, monitor their symptoms, take their medications, come in for their visits – all a matter of “responsibility” if you so wish. So just how exactly would calling obesity a disease take away from any of this? Frankly, I cannot help but sense that people who use this argument most often, are erring on the side of “shame and blame” and probably still see obesity largely as a matter of personal “choice” rather than the complex multifactorial problem that it actually is. Indeed, the opponents often appear “morally” opposed to the very notion of accepting obesity as a disease, as it now gives people the “excuse” to not do anything about it. Sorry, but this whole line of arguing reeks of nothing less than weight bias and discrimination. As far as I can tell, calling something a disease often leads to exactly the opposite response – when obesity happens (and it can happen to anyone), it places a tremendous mental, physical and social burden on the people who get it – no matter what you call it. People living with obesity… Read More »

Arguments Against Obesity As A Disease #4: Distracts From Obesity Prevention

Continuing in my mini series on the pros and cons of considering obesity a chronic disease, I would like to now discuss the perhaps most illogical argument against recognising obesity as a disease that I often hear, “Calling obesity a disease will reduce our efforts at prevention”. This argument makes virtually no sense at all, as I cannot think of a single “preventable” disease, where calling it a “disease” would have reduced or thwarted prevention efforts. Whether the aim is to prevent heart disease (dietary recommendations, fitness, smoking cessation), cancers (physical activity, healthy diets, smoking cessation, sunlight exposure), infectious diseases (vaccinations, food safety, hand washing, condom use), road accidents (helmets, seat belts, speed limits), in no instance has calling something a “disease” ever stopped us from doing the utmost for prevention (although more can always be done). Rather, if you truly embrace the concept that obesity, once established, becomes a life-long problem for which we have no cure (the very definition of “chronic disease”), we should be doubling or even quadrupling our efforts at prevention. After all, who would want to be stuck with a chronic disease, if it can indeed be prevented? Governments, NGOs and individuals should be even more enthusiastic about preventing a “real” disease than simply modifying a “risk factor” (which sounds a lot less threatening). Indeed, if I was working in population health, I’d be all for emphasizing just how terrible and devastating the disease of obesity actually is – all the more reason to double down on efforts to do what it takes to prevent it. In fact, considering obesity a “real disease” would put all the folks working hard to prevent obesity right up there on par with those working to prevent “real” diseases like cancer, HIV/AIDS, or Alzheimer’s disease. Thus, the argument that calling obesity a “disease” would somehow distract from efforts to prevent it makes absolutely no sense at all. @DrSharma New Orleans, LA

Arguments Against Obesity As A Disease #3: Obesity Is Modifiable And Preventable

Continuing in my mini series on arguments that I often hear against considering obesity a chronic disease, I turn to another common argument, “Obesity cannot be a disease because it is preventable and modifiable.” That may well be the case (although, we must admit that we are doing a remarkably poor job of either preventing or modifying it), but so what? There are 100s of diseases that are both preventable and modifiable – and yet no one would argue that they should not be considered diseases. In fact, virtually all “lifestyle” diseases (by definition) are preventable and modifiable. Take for instance strokes and heart disease – most strokes and the vast majority of heart attacks are both preventable and modifiable (once they occur). So are diabetes, osteoarthritis, obstructive lung disease and many forms of cancer, not to mention the many infectious diseases that are both preventable and modifiable. There are even a number of in-born genetic diseases that may be preventable or modifiable (e.g. phenylketonuria). Thus, the fact that a disease can be prevented or modified (once it occurs) says nothing about whether something qualifies as a disease or not. That said, as recently pointed out by Ted Kyle, for all practical purposes, obesity is proving pretty hard to modify and even harder to prevent in real life. It may therefore be more accurate (and honest) to say that obesity is “theoretically” preventable and modifiable – while we await large-scale real-life examples demonstrating that this is in fact the case, and not just limited to relatively rare exceptions like the 1990’s catastrophic economic crisis in Cuba. Let’s remind ourselves that there is a vast difference between “efficacy” and “effectiveness” of proposed measures to “prevent” and “modify” obesity. But even if we did have ample proof that obesity can indeed be prevented or modified by most people, it still says nothing that would speak against recognising excess or abnormal body fat that affects your health as a disease. @DrSharma Berlin, Germany  

Arguments Against Obesity As A Disease #2: Inconsistent Relationship Between Body Fat And Health

Yesterday, in my brief series on the pros and cons of calling obesity a chronic disease, I addressed the issue of BMI as a poor definition of obesity (understood here as “abnormal or excess body fat that affects health”). Another common argument I hear from those who do not support the notion of obesity as a chronic disease, is that there is an inconsistent relationship between body fat and health. This is no doubt the case. Indeed, whether or not your body fat affects your health depends on a range of factors – from your genetic predisposition to certain “complications” to the “nature” of your body fat, factors that cannot be captured or assessed by simply stepping on a scale. Often, this variability in the relationship between excess body fat and its impact on health, is used to argue against a “causal relationship” between the two. This argument is often presented along the lines of, “If obesity is a disease, how come I don’t have diabetes?”. Where the direct impact of excess body fat on health should be evident,  is when the amount of excess fat poses a direct “mechanical” problem that impedes physical functioning. This impact, however, is likely to vary from one person to the next. A good example of this, is obstructive sleep apnea, where an increase in pharyngeal fat deposition is directly and causally related to the airway obstruction. The causal relationship of pharyngeal fat and the symptoms is directly evident by improvement in symptoms following surgical removal of the excess fat (an operation that is seldom undertaken due to possible complications and redeposition of fat). There is also substantial evidence that significant weight loss (such as induced by bariatric surgery) results in a dramatic improvement in apnea/hypopnea index and sometimes even in complete resolution of the problem. Yet, not everyone with excess weight develops obstructive sleep apnea. One of the factors that explains this variation, is the anatomical dimension of the pharyngeal space, which varies significantly from one person to the next. So, just how much excess fat in the neck region results in symptoms (if any) will necessarily be highly variable. This is not an argument against the relationship between excess body fat and obstructive sleep apnea, it is just the expected variation between individuals that is evident in many diseases. Likewise, when the amount of excess fat impairs the body’s capacity to perform essential functions (from mobility… Read More »

Arguments Against Obesity As A Disease #1: BMI Is Not A Good Measure Of Health

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… Read More »