Viewpoint: Defining Obesity as a Disease May Do More Harm Than Good

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The label is supposed to improve awareness and treatments for the condition, but similar proclamations about alcoholism and other addictions haven’t been so successful.

Rejecting the advice of one of its own committees, the American Medical Association (AMA) will now classify obesity, which affects about one-third of Americans, as a disease, similar to diabetes and cancer. While there is no standard criteria for such definitions, the designation could contribute to de-stigmatizing obesity, lead to wider coverage of treatments by insurers — Medicare and other insurers currently exclude reimbursement for weight-loss drugs — and greater willingness by doctors to address and treat the condition among their patients.

“Recognizing obesity as a disease will help change the way the medical community tackles this complex issue that affects approximately one in three Americans,” the AMA said in a statement from board member Dr. Patrice Harris,  “The AMA is committed to improving health outcomes and is working to reduce the incidence of cardiovascular disease and Type 2 diabetes, which are often linked to obesity.”

As admirable and well intentioned as those goals are, however, there is little precedent that disease labeling will make them achievable. A recent review of studies on conditions like addictions and other psychological problems that can have genetic causes found that such classification generally does reduce the blame heaped on people with the disorders, both by themselves and society. But the labels also increased pessimism about recovery, probably because people assume that as diseases with biological and genetic bases, they are immutable. One study on alcoholism, for example, found that the more people bought into the idea that addiction was a “chronic relapsing disease” over which they were “powerless,” the worse their relapses were. Although the label didn’t increase relapse itself, it made it worse if it did occur — and the majority of people with alcoholism will relapse at least once.

There is also some danger that making obesity a disease may lead to some unintended, and potentially harmful, consequences. Consider the example of alcoholism; in 1956, the AMA medicalized alcoholism, with the hope that doctors would begin to ask about and treat cases of excessive drinking and address the medical problems, including liver damage, in a more consistent and effective way. As a result, there is certainly greater awareness of the problems — both social and medical — that alcoholism can cause.

But when alcoholism is seen as a disease, doctors and patients are also more likely to believe that overindulging can’t be stopped without professional help or attending groups like AA — and that it must be treated with total abstinence. The disease concept wound up creating a ghettoized treatment system aimed only at severe cases, with few options for the vast majority of people with alcohol problems who don’t require such extreme measures.

In fact, the American Psychiatric Association’s disease manual, which was revised this year, reflects an ongoing trend of “medicalizing” normal behavior, leading to inappropriate use of psychiatric medications to treat them. Previous editions of the diagnostic manual included two, discrete categories of substance-misuse problems: abuse, which was considered time-limited and amenable to treatment beyond abstinence; and dependence, which was basically chronic addiction. Now there is only “substance-use disorder,” which covers mild, moderate or severe cases  — suggesting, for people educated in the idea of alcoholism as disease, that college binge drinkers have the same disease as skid-row alcoholics.

(MORE: Mental-Health Researchers Reject Psychiatry’s New Diagnostic ‘Bible’)

Viewing genuine addictions as diseases is certainly an improvement over seeing them as moral weaknesses — and no doubt the same is true with respect to unhealthy weight. But is being heavy a disease that always warrants a diagnosis, treatment plan and “correction”? The AMA Council on Science and Public Health, which advised against considering obesity a disease, noted that it is more of a risk factor for other conditions, such as diabetes, heart disease and high blood pressure than a disease in itself. In other words, it has the same relationship to disease as heavy drinking does to alcoholism: it’s a risk factor, not a disorder. The committee also noted that there are no standard criteria for drawing a line between healthy and unhealthy weights. After a year of study, it argued [PDF]:

Without a single, clear, authoritative, and widely accepted definition of disease, it is difficult to determine conclusively whether or not obesity is a medical disease state. Similarly, a sensitive and clinically practical diagnostic indicator of obesity remains elusive.

Body mass index, which is the most commonly used measure that incorporates height and weight, can incorrectly label muscular, healthy people as being overweight, while also misclassifying some people with unhealthy levels of fat and insulin resistance as being of healthy weight.

The council also noted that the relationship between being overweight and mortality is complicated — some studies actually found a protective effect of being mildly overweight — suggesting that we are far from understanding the myriad ways in which weight and health are connected.

(MORE: Viewpoint: My Case Shows What’s Right — and Wrong — With Psychiatric Diagnoses)

In addition, incorrectly categorizing people who can control their lifestyle by changing their diet or becoming more physically active as being unable to do so without medical help could lead to unnecessary surgery, drug treatments and other interventions that come with side effects and complications. College binge drinkers typically cut down on their own after graduation; similarly, most people with mild weight problems do not require medical attention.

All of this doesn’t discount the fact that weight is indeed connected to higher risk of some health problems, such as heart disease and diabetes. But it does suggest caution in viewing obesity itself as a disease. Some obese people do have food addictions that may be driven by genetic and metabolic conditions that are clearly not simply failures of willpower. But not everyone who is obese has such problems.

Telling all obese people that they have a disease could end up reducing their sense of control over their ability to change their diet and exercise patterns. As experience with addictions has shown, giving people the sense that they suffer from a disease that is out of their control can become self-defeating. So the disease label should be used sparingly: just as not all drinking is alcoholism, not all overeating is pathological. These lines are hard to draw, but they can have profound effects on exactly what the AMA is hoping to achieve: greater awareness and more effective treatment of obesity.

28 comments
binarycpu
binarycpu

I have a project I am trying to get traction for. I am making a documentary called "Labels" which will address how labels placed on people by society is harmful. Bully, victim, or target are labels applied to children, and it's harmful. These labels also apply to other areas besides just children.  Criminals, School Labels, Homeless, Sexuality, etc.  Please, if you can help raise funds to make this project get traction, the kickstarter project is here: 


https://www.kickstarter.com/projects/binarycpu/harm-with-labels-including-how-society-contributes/


If you can't donate, I understand, but PLEASE share this with others. It's time to break down these labels and see the real damage done.

aliberaldoseofskepticism
aliberaldoseofskepticism

Hmm...Remember when homosexuality was a mental disorder? Yeah, that didn't help destigmatize it either.

We must understand that obesity is a risk factor, though. For a number of diseases.

laportama
laportama

It's hard to believe that entities as big as the AMA don't think through the massive sociopolitical upheaval that their seemingly altruistic decisions make. There is no intervention on Earth that does not have risks, which are tangible, benefits, which are theoretical, alternatives and IMPONDERABLES, which my aeronautical engineer brother Paul responded to as "the unknown unknown".

I  take it back. It;s not hard to believe. Orwell and Rand described it repeatedly. Emphasis on "seemingly".

Another IRONY here is that this link is called "HealthLand". Analogous to "HealthCare" being neither about "Health" Nor about "care", Healthland is neither about health nor about land. 

To market, to market...

John
John

I have always thought a disease was something you developed either from contact, an air borne pathogen, or by genetic predisposition. 

When did labeling conditions one develops due to lifestyle rather than by pathogenic means  become commonplace?

schroeea
schroeea

I don't know how I feel about obesity being defined as a disease, but I definitely believe that being overweight or obese is due to an eating disorder.   Granted, there are people who do not eat healthy and do not exercise, but for the most part everyone I know like that accepts their weight as their own decisions.  Then, there are others who are overweight due to genetics or a prescription they may be on.  My brother is overweight, but that's a side effect of the anti-psychotics that he's on for Schizophrenia. 


However, I do believe that many of the morbid obese or even overweight, have an eating disorder that they have a hard time controlling and I really believe that's where medical science needs to move towards.  I'm not talking about the people who are "weak," I'm talking about the people who satiate their emotions with food.  Similar to an alcoholic, food brings them pleasure and helps them hide away from stress and other issues that are bothering them.  I think what overweight and obese people need medically and publically (I'm looking at everyone saying losing weight is SO easy and using mean names towards overweight people like you know exactly who that person is) is more support.  More ways to get power over food and their body and to essentially treat the real mental disorders that's causing the person to overeat and lead a sedentary lifestyle.

21stcentury
21stcentury

Obesity isn't a disease; it is our youth culture's unwillingness to assist family and neighbors in need.  Every post menopausal woman I know is either overweight (many are obese) or eating like birds (and seriously cranky) to maintain their weight. Tell those women their lifestyle isn't up to snuff because they are too busy working all day and taking care of others at night. 

bojimbo26
bojimbo26

Obesity is a disease ? BS . It's in the genes as everything else .

joukot
joukot

If obesity is not a disease then high blood pressure is not a disease. Defining something as a disease does not exclude sensible limits and common sense.

AlphaJuliette
AlphaJuliette

For some reason we in the US simply cannot accept responsibility for our own actions.  Obesity is a problem with lifestyle and is not a disease.  We have to make ourselves accountable to that.

FrancisMulhare
FrancisMulhare

One of the main problems here is the use of BMI. Sure it is easy and simple but that is really all that can be said for it. It basically defines people as overweight , or even obese, who by other measures clearly are not. The gold standard in all of this are the MetLife tables which have calculated the weights at which you become more likely to die prematurely. Using myself as an example..under the bmi formula at 68 ins and 165 lbs i am classified as overweight but according to the Met tables I could add another 9 lbs before my risk of premature death increases. In the meantime my bodyfat is 13% and I am running 40 miles a week. Shaq , in his playing days, had a bmi of 31 (obese) but (despite what Kobe said) he was one of the fittest athletes on the planet. BMI needs to be scrapped. Why not use bodyfat % instead. Granted the methods used to calculate are a little inaccurate but everyone can immediately tell the difference between say John Candy and Sylvester Stallone.

rensbj
rensbj

Wow..Calling obesity a "disease"? Isn't obesity is the condition that causes disease. Otherwise we need  to call things like cigarette smoking the "disease" that causes lung cancer. Common sense is indeed dead....

Meshell
Meshell

Whatever happened to a person taking responsibility for the consequences of  his or her own actions, i.e., lifestyle? Whatever happened to an adult practicing some self control? I have a hard time reconciling the fact that in our American society it seems as if we're expected to feel sorry for the obese when there are other human beings, particularly children, literally starving to death around the world and even in our own backyards. I'm sure people have their excuses for why they are forced to eat enough for two or more people in one sitting repeatedly, or to consume liter after liter of soda when water is pretty much free available and regulated (at least tap water anyway) here in the US. Unless there is some other medical condition preventing a person from being able to get around, I can't imagine that people are really forced to park their cars in front row parking spaces of stores versus the other end of the parking lot where they would actually have to walk to get inside. Or god forbid, avoiding drives throughs altogether and actually getting out of their cars to get inside. I see people in wheelchairs or on prosthetics in excellent physical shape competing in the Special Olympics. If they can manage to do some physical activity, why can those who are still fortunate enough to have all of their working limbs do the same? Other developed countries don't have nearly the same rate of obesity and alcoholism that we do, so what the heck is our problem? Maybe it really boils down to culture issues (and chronic laziness?). Maybe it's because people in other countries actually have to walk to get from A to B, there are no drive through establishments and are forced to use stairs because most establishments don't come with escalators or lifts. Well, those are my thoughts and I'm sticking to them, right, wrong or indifferent!

RalphAllen
RalphAllen

A new diet pill approved by the FDA called Belviq just went on the market.  Diet and exercise were part of the Belviq clinical trials. The most important breakthrough is that people who take Belviq with diet and exercise were 2 times more likely to lose 5% body weight and 3 times more likely to lose 10% body weight than the people who just did diet and exercise alone. The label states that if you do not lose 5% of your body weight in 12 weeks then consider stopping. Those that do respond in 12 weeks go on to lose over 10% of their body weight in one year.Losing 22 pounds for a 220 pound man is life changing. So commentsabout average weight loss are misleading and incorrect since over 40% of the patients lost a significant amount of weight.

Belviq makes you more likely to succeed because it helps you feel full more quickly, reduces cravings, and helps control "food issues". It is not a 'magic pill', it merely helps people willing to diet and exercise more likely to succeed.

Belviq has a second mode of action to reduce blood sugar which may end up preventing diabetes in many cases. Diabetics and pre-diabetics who took Belviq, regardless of weight loss, saw their blood sugar numbers drop by double digit percentages. IE HbA1c -0.9 and fasting glucose feel -27. The cost of medications to reduce HbA1c levels exceeds the cost of Belviq. (seeArena'sBloomDN phase III trial) These reductions in diabetic symptoms plus the weight loss at the same time makes Belviq a medicalbargain.

With an estimated 40 million new cases of Diabetes expected over the next 10 years at a cost of over $400 billion per year to the US Health Care System, and the associated heart disease, strokes, blindness and amputations, any tool that will prevent this preventable disease from ballooning is a good tool to have. People who are borderline diabetic may benefit a great deal from Belviq whether they lose a lot of weight or just a little.

frumer71
frumer71

If obesity is a disease, don't we all have it? Anyone can become obese if they eat poorly, to excess, and don't get enough exercise. Some of us are just able to manage the disease better than others. Can I now get my gym membership covered as a medical expense? I agree wholeheartedly with the author: "Telling all obese people that they have a disease could end up reducing their sense of control over their ability to change their diet and exercise patterns."

Winston
Winston

A couple of additional thoughts...

What impact will this have on insurance rates? 

Specifically, how much more unaffordable will having to pay for the gastric surgery of middle-aged obese people will this make rates for healthy young people - 37% of nation being obese? 

Will it drive even more young people to bypass ACA insurance, and pay the nominal and unlikely to be enforced penalties instead?

Regarding your points on the new APA manual, couldn't agree more, soon facecrime will become treatable as an antecedent to thoughtcrime and become a source of treatment, hence revenue, for the thought police...

laportama
laportama

We've lost track of the concept of Dis-Ease.

aliberaldoseofskepticism
aliberaldoseofskepticism

Not quite. Genes exist within an environment. To say "nature versus nurture" is to completely miss the point.

notLostInSpace
notLostInSpace

@lonemavericks Excellent point.  Follow the money.  Lawyers have worked over asbestos and tobacco, need a new "evil" industry to fight.  Mcdonalds will be "found" to cause a disease!  Big Pharma will like this too.  Big winners for lawyers and pharma, probably new treatment centers etc.  The losers: us, as usual.

joukot
joukot

@AlphaJuliette Smoking causes lung cancer which is certainly a disease, alcohol causes liver cirrhosis which certainly is a disease, lack of exercise causes osteoporosis which certainly is a disease. Diseases are always caused by something, but they do not ask if we are accountable for that or not. Diseases are not moral issues. But they are easier to cope with if we recognize the causes.

dawnowens
dawnowens

@RalphAllen Or, people could just go on a raw vegan diet for a month... and see what happened as far as quality of life and weight adjustments.   I think your beloved 'Belviq' is the reason this particular change in diagnoses just happened to come out now. More shill crap for the pharmaceutical industry.  

gumshoo
gumshoo

@RalphAllen Work for a pharmaceutical company, much?  Ridiculous post.  Gluttony is not a disease, it's weakness.  This, coming from someone who has lost 85 pounds - I have walked the walk.

aliberaldoseofskepticism
aliberaldoseofskepticism

Only chiropractors say "dis-ease" like that. And really, George Orwell (who had a point) and Ayn Rand (whose books are quite unique for having a perpetual motion machine, and that's the least insane part of them) are the same? Really?

notLostInSpace
notLostInSpace

@gumshoo @RalphAllen Most overweight people cannot lose the weight on their own.  Some % of them can't because they are "weak".  A greater number cannot because of a multitude of reasons (some excuses), many of which are legitimate.  If a drug can help someone, it should be tried.  I don't know how you lost your weight gumshoo, but many are losing it through gastric surgery, which in my mind is worse than a drug.