Is Obesity a Disease? I Vote No

Is Obesity a Disease? I Vote No

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There is a certain irony in the nearly immediate juxtaposition of the rare introduction of a new FDA-approved drug for weight loss (Belviq) to the marketplace and the recognition of obesity as a “disease” by the AMA. A line from the movie Jerry Maguire comes to mind: “You complete me!” Drugs need diseases; diseases need drugs.

And that’s part of what has me completely worried. The notion that obesity is a disease will inevitably invite a reliance on pharmacotherapy and surgery to fix what is best addressed through improvements in the use of our feet and forks, and in our Farm Bill.

Why is the medicalization of obesity concerning? Cost is an obvious factor. If obesity is a disease, some 80 percent of adults in the U.S. have it or its precursor: overweight. Legions of kids have it as well. Do we all need pharmacotherapy, and if so, for life? We might be inclined to say no, but wouldn’t we then be leaving a “disease” untreated? Is that even ethical?

On the other hand, if we are thinking lifelong pharmacotherapy for all, is that really the solution to such problems as food deserts? We know that poverty and limited access to high quality food are associated with increased obesity rates. So do we skip right past concerns about access to produce and just make sure everyone has access to a pharmacy? Instead of helping people on SNAP find and afford broccoli, do we just pay for their Belviq and bariatric surgery?

If so, this, presumably, requires that everyone also have access to someone qualified to write a prescription or wield a scalpel in the first place, and insurance coverage to pay for it. We can’t expect people who can’t afford broccoli to buy their own Belviq, clearly.

There is, of course, some potential upside to the recognition of obesity as a disease. Diseases get respect in our society, unlike syndromes, which are all too readily blamed on the quirks of any given patient and other conditions attributed to aspects of character. Historically, obesity has been in that latter character, inviting castigation of willpower and personal responsibility and invocation of gluttony, sloth, or the combination. Respecting obesity as a disease is much better.

And, as a disease, obesity will warrant more consistent attention by health professionals, including doctors. This, in turn, may motivate more doctors to learn how to address this challenge constructively and compassionately.

But overall, I see more liabilities than benefits in designating obesity a disease. For starters, there is the simple fact that obesity, per se, isn’t a disease. Some people are healthy at almost any given BMI. BMI correlates with disease, certainly, but far from perfectly.

The urge to label obesity a disease, and embrace the liabilities attached to doing so, seems to be a price the medical profession is willing to pay to legitimize the condition. It may also be an attempt to own it (and the profits that come along with treating it), whereas that right and responsibility should really redound to our entire culture. Is it necessary for obesity to be a disease for it to be medically legitimate? I think not.

Carbon monoxide poisoning is medically legitimate, but it is not a disease — and there’s a good reason for that. It is poisoning, so the fault lies not with our lungs, but with what is being drawn into them. Your lungs can be working just fine, and carbon monoxide can kill you just the same. Perfectly healthy, disease-free bodies can be poisoned.

None would contest the medical legitimacy of drowning. If you drown, assuming you are found in time, you will receive urgent medical care — no matter your ability to pay for it. If you have insurance, your insurance will certainly pay for that care.

But drowning is not a disease. Perfectly healthy bodies can drown. Drowning is a result of a human body spending a bit too much time in an environment — under water — to which it is poorly adapted.

And so is obesity. Our bodies, physiology, and genes are much the same as they ever were. Certainly these have not changed much in the decades over which obesity went from rare to pandemic. What has changed is the environment.

We are awash in highly-processed, hyper-palatable, glow-in-the-dark foods. We are afloat in constant currents of aggressive food marketing. We are deluged with ever more labor-saving technological advances, while opportunities for daily physical activity dry up.

We are drowning in calories. And that’s how, in my opinion, we should make obesity medically legitimate: as a form of drowning, not as a disease.

With drowning, we don’t rely on advances from pharmaceutical companies. No one is expecting a drug to “fix” our capacity to drown. Our capacity to drown is part of the normal physiology of terrestrial species.

Our capacity to get fat is also part of normal physiology. Obesity begins with the accumulation of body fat, and that in turn begins with the conversion of a surplus of daily calories into an energy reserve. That’s exactly what a healthy body is supposed to do with today’s surplus calories: store them against the advent of a rainy (i.e., hungry) day tomorrow. The problem that leads to obesity is that the surplus of calories extends to every day, and tomorrow never comes.

Thinking of obesity as a form of drowning offers valuable analogies for treatment. We don’t wait for people to drown and devote our focus to resuscitation; we do everything we can to prevent drowning in the first place. We put fences around pools, station lifeguards at the beaches, get our kids to swimming lessons at the first opportunity, and keep a close eye on one another. People still do drown, and so we need medical intervention as well. But that is a last resort, far less good than prevention, and applied far less commonly.

There is an exact, corresponding array of approaches to obesity prevention and control; I have spelled them out before.

Disease is when the body malfunctions. Bodies functioning normally asphyxiate when breathing carbon monoxide, drown when under water for too long, and convert surplus daily calories into body fat. Perfectly healthy bodies can get obese. They may not remain healthy when they do so, but that is a tale of effects, not causes.

The most important reasons for rampant obesity are dysfunction not within our individual bodies, but at the level of the body politic. We do need medicine to treat obesity, but more often than not, it is lifestyle medicine. Lifestyle is the best medicine we’ve got — but it is cultural medicine, not clinical.

That’s where our attention and corrective actions should be directed. If calling obesity a disease makes us treat the condition with more respect, and those who have it with more compassion, and if it directs more resources to the provision of skill-power to adults and kids alike, it’s all for the good. But if, as I predict, it causes us to think more about pharmacotherapy and less about opportunities to make better use of our feet and our forks, it will do net harm. If we look more to clinics and less to culture for definitive remedies, it will do net harm. If we fail to consider the power we each have over our own medical destiny, and wait for salvation at the cutting edge of biomedical advance, it will do net harm.

Long before labeling obesity a disease, the AMA lent the full measure of its support to the Hippocratic Oath and medicine’s prime directive: First, do no harm. Obesity is much more like drowning than a disease. Calling it a disease has potential in my opinion to do harm. And so it is that I vote: No.

David Katz, MD, MPH, FACPM, FACP, is the founding (1998) director of Yale University’s Prevention Research Center. This piece first appeared at The Huffington Post.

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41 Comments on "Is Obesity a Disease? I Vote No"


Guest
Peter1
Jun 23, 2013

“We know that poverty and limited access to high quality food are associated with increased obesity rates. So do we skip right past concerns about access to produce and just make sure everyone has access to a pharmacy?”

Yes, because that keeps the money flowing to corporations, and from corporations to politicians. This all about corporate control of our political system. Enjoy your freedom.

Guest
Jun 23, 2013

I’d have to agree. I have a stomach, though at 75 I have a “right.” :-) And at 6′ and 225# I’ll have to live with it. But to you younger folk, eat right. Don’t ever let your body get bloated. It’s the FOOD, dummy!

Guest
Jun 23, 2013

Although obesity is not a disease, my daughter who was diagnosed with schizophrenia because of obesity. Her insurance did not cover her medication because of obesity. I hope there be a law that supports of inclusion of obesity or any body-weight-related issue to medical insurance.

Guest
ytisebo
Jun 23, 2013

Everything is a disease. Look at ICD 10. Why not obesity.

So volume food discounters create the sisease so that the drug makers can use their drug disease to cure the food disease. Just wonderin if Walmart has an investment in VIVUS?

BTW, CPOE is a disease as well, requiring more intellectual power to solve than the patients’ diseases.

That is rapidly becoming the number one cause of iatogenic illness.

Guest
Jun 28, 2013

Right on! Everything causes PTSD as well. Even now a hospital stay. We are a nation of ill and disabled individuals. Were it not for insurance requiring ICD and CPT’s for payment, all of this nonsense would disappear.

Guest
Sheila, FNP
Jun 23, 2013

Thank you for an outstanding piece, giving voice to what many of my colleagues and I have been thinking. Health Promotion is my number one priority, every patient, every day. My job just got a lot harder, after all, they have a disease, it isn’t their fault and there is nothing they can do, so efforts at lifestyle modification will probably be a waste of time, right? I have dedicated my life and career to promoting patient self efficacy and change behaviors. I’ve helped some people, but by and large I feel as though I’ve accomplished nothing and am even less likely to now. No one wants improvement, they want validation, myself included I suppose. Some days I wish I’d followed my 1st career path into physics. Unless I want to do diabetes care, I don’t see a future for myself in healthcare anymore. I’m truly depressed and saddened. I feel useless.

Guest
Jun 23, 2013

Labeling obesity as a disease just perpetuates the false belief that drugs and surgery are the first choice in treatment of disease. Obesity is essentially a lifestyle disease and must be treated with lifestyle change. Great article.

Guest
Cassie Stegeman
Dec 9, 2013

I agree with your comment. Obesity is a lifestyle disease just like an alcoholic or drug abuser.

Guest
stop_eating
Jun 23, 2013

I am a glutton for diagnostic accuracy. Why not just call the heavy weights prader willi syndrome?

Guest
Jun 23, 2013

Very thought provoking article. I’ve always thought that obesity is the cause of a lot of diseases, and the result of our modern way of living.

Guest
Jun 23, 2013

Dr Katz

I 100% agree. Obesity is a lifestyle problem. Society has made it too easy to get and stay obese. I’m currently writing a blog post about the very issue, and my perceived solution to the problem.

The answer: social pressure. If everyone you know holds you to keeping diet, you can probably lose weight.

Guest
tom
Jun 23, 2013

One out a of a thousand cases of obesity has a true disease cause. The rest, no. The other 999/1000 obesity cases are caused by eating too much food.

Calling obesity a disease tells people that obesity is out of their control, a very destructive notion.

Guest
Jun 23, 2013

Actually, many would support a premium on body fat…

Guest
CPR
Jun 23, 2013

What is important to understand is that neither of the drugs being brought to market will melt fat off anyone’s body. They are to be used as adjuncts to behavior therapy. Belviq, in particular, works on satiety…helping people recognize the signal from their brain that says “you’ve had enough”. There are patients who will plow through that signal and keep eating (as many of us will do this upcoming 4th of July), but some won’t. Some will get just the boost they need for their behavior change efforts to work…and make no mistake…most users will have tried and failed to lose weight time and again.

Finally, note that the labeling on both drugs requires that patients lose 5% or more of their weight within the first 12 weeks, or their prescription is not to be renewed. So, those who habitually eat through the “stop” sign for Belviq, will have the drug for only about 3 months.

It would be great if we could engineer society to keep people from drowning…and I applaud efforts to improve nutrition, put PE back in schools, build neighborhoods with sidewalks…all of it. In the meantime, there are lots of people drowning under their own weight. If these pills can help, I say “Great.”

Guest
Josie
Jun 23, 2013

Obesity is a symptom– not a disease. It’s a slippery slope to identify it as a disease mostly because the assessment of the patient is then complete at the diagnosis of obesity without a need to look at the issues that have led to it. This can lead to a one size fits all approach for treatment mostly benefiting big pharma not the patient. If someone is undereducated about nutrition it would require a much different treatment than for someone who is anxious and eats to self-medicate. Consider the paranoid schizophrenic who eats compulsively because they think someone is after their food supply or the indigent family who stretches their food stamp dollars buying cheap eats and overly processed foodstuffs at the dollar store. It all leads to obesity, but a diet pill just isn’t going to cut it for a cure.

Guest
Cassie Stegeman
Dec 9, 2013

I agree it’s not one size fits all! A pill isn’t a cure for obesity, it’s about a lifestyle change and the cause for being obese. Someone who is uneducated about proper diet and nutrients is very different than someone who is obese due to emotional or mental reasons for overeating.

Guest
Jun 23, 2013

I agree wholeheartedly with Dr. Katz that obesity is not itself a disease. Not only are many obese people not ill with a treatment-worthy comorbidity, many who work at it are quite fit even without weight loss. Their fitness level aligns their morbidity and mortality risk with that of their lighter weight (undiseased in the AMA’s view), unfit peers. Labeling as “disease” a phenomenon that is is the inevitable and normal consequence of maladaptive behavior is ludicrously illogical.

I disagree, however, that this is particularly about big pharma. This is about a health care system, generally, in which trade groups — the AMA particular — keep telling us that physicians are the keepers of the flame of policy legitimacy. Unfortunately, the system suffers from both a dysfunctional sense of entitlement (go ahead and tell the CEO of your local hospital that is should be stripped of its tax-exempt status, taxed, and regulated like a utility) and a ravenous need to find new patients. The best way to do that (and to cause the dominoes of coverage, reimbursement, and revenue to fall their way) is to keep lowering the bar for what constitutes disease.

Guest
Yolanda McCain, RN, BSN
Jun 24, 2013

Outstanding perspective Dr. Katz! I do agree that obesity is in fact not a disease. However, obesity is medically legitimate. Research lends that many individuals have a strong genetic predisposition for obesity. However, obesity is usually the result of a disregulation of eating and poor lifestyle choices. More emphasis should be placed on patient education, improving access to quality foods, and streamlining resources which provide assistance with modifying lifestyle and behavioral choices. Additionally, medical treatment options such as Belviq are designed to be used temporarily in conjunction with dietary changes and exercise. Medical alternatives such as Belviq and bariatric surgical interventions are temporary solutions aimed at treating obesity. I agree with you Dr. Katz, the best medicine is lifestyle modification.

Yolanda McCain, RN, BSN

Guest
Jun 24, 2013

Hats off to Dr. Katz!

Calling obesity a disease is a tactic of MEBS, or Medicalize Everything Business Strategy. Wherever in healthcare there’s conceivably a buck to be made, MEBS agents will sniff it out.

A report issued in 2011 by the National Heart, Lung and Blood Institute (NHLBI) advocated checking all American kids age nine and up for serum cholesterol, and then medicating high-fat kids. Taking into account that the condition might be a lifestyle effect rather than a disease, the report mentioned deploying “intense lifestyle management” along with drugs, but didn’t say what that management might consist of. (In fact, there’s been so little development of effective behavioral intervention in obesity that the response will essentially be drugs.) So kids at risk will be medicated—presumably along with the drugs they already take for their attention deficit disorder.

Are we surprised that half the authors of that NHLBI report have had drug industry ties? And what sort of financial windfall might accrue to the MEBS-proficient when obesity is officially a disease?

Guest
Jun 24, 2013

Yea, Jeff, but that’s our “free market” system. It’s too bad that we do not have an honest political system, where politicians regulated without pocketing a piece of the action. ALL of our problems in healthcare, even ObamaCare, are driven by campaign bribes.

Guest
Lee
Jun 24, 2013

Interesting points – I side with Dr. Katz. An earlier comment said something about obesity “causing” other diseases. I am not sure that is entirely true – that scenario overlooks the fact that the causes of the obesity may also be the causes of the disease. obesity is caused by, in the most simplistic of terms, consuming more calories than one uses during the course of a day. The root of the problem is the cause of that – what makes people consume way more than they need and do it chronically over time?

In my experience it seems that people are too lazy to change their habits or simply do not understand their bodies well enough to regulate their weight. I have also heard it said that “obesity” is an entirely different and more complex issue than simply being “overweight.” Allegedly, in obese people there are many more behavioral health factors at play whcih perpetuate a cycle of overconsumption.

I am not sure that education and information are necessarily the only answer. Education and information are available to those who need it or want it – in spades – the problem lies in motivating the people who could benefit from losing weight to actually not only care about being overweight but become actively involved in their health and actually modifying their behavior to accomplish a goal of becoming thinner.

I wonder if a “herd immunity” type of effect is also applicable to obesity. If one looks at maps of the country morbid obesity is concentrated in some specific areas – one has to wonder if just living with and among heavy people all the time accelerates the incidence of obesity in those areas. One wonders what could happen if a critical mass of people in those concentrated areas of obesity suddenly started a movement towards eating more healthily.