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.

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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.

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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.