OP-ED

Is Obesity a Disease? I Vote No

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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Nike Free Run 3 men
Guest

000 years ago.5 June 2011Last updated at 19:42 GMT Golan: Israel troops fire on pro-Palestinian protesters Israeli troops have fired on pro-Palestinian protesters in the Israeli-occupied Golan Heights Gaza and East Jerusalem. During the demonstrations, which operate from bases outside Yemen. A switchover to digital TV is under way. Television is the main news source in cities and towns. perovskite is also used in mobile phone base stations, and was instigated to mark last year’s International Year of Chemistry and next year’s International Year of Crystallography. but spent only a year in charge of that team before being promoted to… Read more »

Krysta Gierisch
Guest

I get these type of comments all the time. #13 actually made me laugh aloud. This is funny but sad. I own several blogs, and on some of the older ones I’ve completely given up trying to moderate them.

Fitness
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valentine
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valentine

Oh. My. God. “And so is obesity. Our bodies, physiology, and genes are much the same as they ever were.” SO not true. Please read this, which includes actual science instead of your antiquated “calories in, calories out” long-disproven premise: http://www.nytimes.com/2012/01/01/magazine/tara-parker-pope-fat-trap.html?pagewanted=all&_r=0 I’m overweight. I used to be obese. I’m also adhd with some ocd. And schedule iii and iv drugs work: they quiet my flighty reiterative mind so I can concentrate about other issues instead of “I want to eat, I wonder what’s in the fridge, I should eat, I want food” over and over and OVER endlessly. Yes, people… Read more »

Sarah Lyon
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Sarah Lyon

One of the biggest problems that is leading to obesity is that healthy food is more expensive. Fruits and veggies and healthy options are just not as easy to obtain because when you are living with only a small amount for food – it’s better to buy pasta and rice instead of the vegetables you should be eating. Part of it is cultural – kids that don’t grow up eating veggies, won’t eat them as adults. Part of it is simply inertia – it’s hard to change. But quite a lot comes down to money. There are a lot of… Read more »

Karen
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Karen

I wish doctors would demand of their obese patients and just overweight patients that they eat less, eat better, get out and walk, do something other than sit home and do nothing or go out and eat or drink. Overweight, by and large, is too many calories in and not enuf out.. So you all want a namby pamby dr who says, no, its ok to be overweight and to be grossly overweight. I can give you meds for your blood pressure, for you yeast infections, for your poor circulation, for your whatever…but no, don’t bother to eat better, or… Read more »

Anonymous
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Anonymous

It’s not as easy as you think. Have you ever tried?

Larry
Guest
Larry

What if everything you’ve said re: obesity not being a disease is true, including the fact that it’s a medical issue? Let’s look at some other facts. Obesity is extremely difficult to overcome. Many, if not almost all, obese people spend their entire adult lives trying to lose weight, exercise more, & eat in a healthy manner. They want to be thin. They want to be healthy. They’ve been scared half to death by physicians who tell them about the increased risks of being heavier than normal. Want to make a guess at how many of them actually succeed? How… Read more »

Brian
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Brian

I find it interesting that there is no mention of food addiction in the post of any of the comments. I imagine just about everyone knows people who have tried and failed to quit smoking many times. However, you don’t often hear much about food addictions as a contributing factor to obesity. WebMD has an interesting article on this topic and how “highly palatable foods” including those high in sugar, fat and salt triggers the release of dopamine. I’ll admit to having struggled with my weight my entire life and I think there is something to this considering the number… Read more »

Kathleen Fink
Guest

Lipedema is a disease where abnormal fat cells do not respond to diet or exercise yet it is often mistaken for simple obesity. It is estimated that 11% of women have Lipedema (Lipoedema in Europe). While there are risks of considering Obesity overall as a disease given the tendency to develop a pill, it is important that research dollars be directed to the subject as it is so complex and the common assumption that is all about diet and exercise as well as the tendency to blame the obese for their own condition is getting in the way. At least… Read more »

Sumathi
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Sumathi

Past 10 years I was shunned by so many doctors who would not believe that I did regular exercise ( 1 hour on the treadmill & 2 days of weights ) & portion control too – I counted calories…still I could not lose the 40 lbs I needed to. They thought I was cheating and thats why could not lose the weight. My thyroid tests said normal..but i used to be tired all the time..showed symptoms of under active thyroid…I was so depressed and occasionally thought of ending life. My husband left me for another woman. I took most basic… Read more »

Karen A
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Karen A

I say a hearty NO! Lazy humans who are given everything and have to spend no time at all on working, cleaning, volunteering, walking a dog, swimming….our society demands nothing of anyone who receives govt support…..we should demand a min of eight ours a week volunteering to save animals. Work at a shelter, build houses for Habitat, clean streams, pick up litter, cut grass for parks, anything to get moving. Less food stamps for packaged foods, desserts, pop, sugar……less fed support for the farm bill that sports poor eating…hell, less support for farms period. Education of the masses on eating… Read more »

Sheila, FNP
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Sheila, FNP

Some unfortunate commentary in this thread, and they sadden me because they serve (perhaps unintentionally) to shame the obese patient, which is inappropriate and counterproductive. It is grotesque to begrudge the poor their food assistance because they have legitimate health problems, and disease or not, obesity is “medically legitimate.” We needn’t victimize, feel sorry for. or iinfantilize the patient, but we must respect them. So many more of our tax dollars go to causes much less worthy than public health, (far too many)! Neither obesity nor it’s euphemisms should be in the same sentence with the word “disgusting.” Those of… Read more »

Larry
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Larry

Karen A. If you’re a doctor I’m glad you’re not mine.

Blake H
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Blake H

I think the reason the AMA decided to label obesity as a disease is because they want to see a call to action. It will empower public health agencies to take action. If we had any other condition that was causing the morbidity and mortality that obesity has and continues to cause, action would have already been taken. As with most things, education is the key to prevention, and we must do a better job educating the public at large.

Dr. Rick Lippin
Guest
Dr. Rick Lippin

To medicalize obesity is a huge mistake and a fraud born out of greed based on treatments. We need both individual (behavioral change) AND institutional (public health) prevention. One without the other can lead to too much victim blaming.

To really understand a root cause of obesity check out http://www.unnaturalcauses.org

Dr. Rick Lippin
Southampton,Pa

CAERMD
Guest
CAERMD

Gosh, reading the comment section is like reading a CNN comments section. Did you pay all these people to post their positive comments? Facts: We are a fast food nation, we are video game/computer nation, we are a process food nation. Alcoholism is well accepted as a disease and I have no problems not feeling sorry for these people. So the people who can not control eating two servings get pushed aside by some Preventive Medicine MD. Well, try spending some time with me in my Emergency Room. Obesity is the root cause of pretty much the majority of what… Read more »

Yolanda McCain-Lee Rn, BSN
Guest
Yolanda McCain-Lee Rn, BSN

Lifestyle modifications to control obesity are very important. The US FDA began requiring labeling for chain restaurants. I really don’t believe that this is the cure for the epidemic. In reality most individuals may not understand how calories or how the excessiveness leads to obesity. Maybe if the amount of time it takes to work off and menu item was placed along with the calories, individuals would be more alarmed. This is an extreme measure, however, just putting the calories are not solving the problem. Education is ultimately the key to winning this battle.

Judy
Guest
Judy

The treatment for alcoholism is primarily non-pharmecuetical, while the recommendation for obesity is, as noted previously, using drugs lifelong.

Lee
Guest
Lee

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… Read more »