THCB

Obesity and the AMA

Last week’s announcement by the American Medical Association’s (AMA’s) council on science and public health cheered me. It said that the AMA should not designate obesity a disease, because doing so was unlikely to improve health outcomes and because the most widely utilized obesity metric — the body mass index or BMI — was simplistic and flawed. It’s a reasonable and principled stance, which should have been the first clue that it was doomed.

The AMA’s board and delegates proceeded to snatch defeat from the jaws of victory by ignoring their own scientific council and labeling obesity as a disease. To be clear, the decision is almost purely symbolic; it has no legal force or authority, but it does up the ante in the debate with insurers and employers over what care elements should be covered and reimbursed. In other words, this is about money. Obesity: the new ATM for the health care system.

I’m just curious about where physicians have been for the past, oh, thirty years. Since 1980, as Americans have morphed into the fattest culture in the history of Western civilization, physician supply per 100,000 population has increased about 50%. Per capita medical care spending has increased from roughly $1,100 to over $8,400. 1980 was also the last time that roughly half of US adults were normal weight. Now, only about a quarter of American adults have a normal BMI.

Were US physicians blindfolded as they encountered patients growing incrementally larger with each visit? Were they keeping their mouths shut about the obvious — gee, I really think you should get out for some walking and limit the snacks — because they were awaiting a chance to make more creative use of ICD and CPT codes?

Obesity’s journey from maladaptive response of normal physiology to disease happened on their watch, and watching is apparently what they did best. Until now. With wellness mania in full swing, the AMA has decided to get in on the act of medicalizing normal so that we can all become patients sooner rather than later. Why waste time waiting for people to get sick when you can just tell them that they’re sick now, even if they’re not, treat them, even when it’s unnecessary, and get paid for doing it. C’mon on down, the price is right!

This decision’s willful disregard of salient facts is staggering: first, most obesity is not the result of a disease process or a frank genetic defect, it’s the result of algebra. We eat more and move less than our ancestors, even of just four generations ago. Second, a surprising number of obese people are still quite healthy. Third, the ones who work hard enough to improve their fitness level will do more for their survival than those who remain unfit, regardless of BMI. Fourth, telling everyone who’s obese that they are sick is a cruel canard that encourages dependency on the professions in such a way that must make Ivan Illich roll over in his grave.

So, here’s the challenge for the AMA. Since you’ve now told the culture to show you the (obesity-related) money, here’s what we taxpayers and funders of your enterprise want: win the war on obesity using a very clear metric…restore the status quo ante…the distribution of BMI in American adults in 1980. And, while you’re at it…fix the industry’s obsession with overdiagnosis and overtreatment because there’s no money to be made in the obverse. Finally, measure both fitness and health-related quality of life in all these “sick” people so we can see how much they really benefit from your efforts. Still think that medicalizing a lifestyle problem was the best step toward long-term success? Fat chance.

Vik Khanna is a St. Louis-based independent health consultant with extensive experience in managed care and wellness.  An iconoclast to the core, he is the author of the Khanna On Health Blog.  He is also the Wellness Editor-At-Large for THCB.

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25 replies »

  1. Folks, once again let me reiterate you read the BMJ link in my earlier post for an overview of the science on obesity, which does not support the conventional wisdom repeated in some of the posts here. For instance, exercise has many health benefits but one of them is NOT, surprisingly, weight reduction. The science to date (inadequate) suggests that obesity may CAUSE overeating, not vice-versa. At best conventional wisdom has confused correllation with causation in the link between lifestyle factors and obesity. There is also a remarkable degree of simple bias against obese people that is hidden under guise of “scientific” advice.

    There is some evidence that aspects of nutrition influence obesity, and those have not been adequately explored. For instance, lately the news is out that saturated fat has not been the villain we thought. Yet decades of low-fat advice from so-called experts coincided with an alarming rise in the rate of obesity. I don’t hear the AMA suggesting they ought to take another look at their own advice translating the scientific evidence to their patients. I think physicians like most of us find it counter-intuitive to think that dietary fat doesn’t necessarily lead to bodily fat or clogged arteries. But that intuition is simply not supported by the science to date.

    So, Vic and friends, it’s very important in addressing a health issue as laden with bias and prejudice as obesity to make sure you insist on science.

  2. Lot of talk here – but not much science – kind of like what the AMA just did with their own Science Councils recommendations (1 ) the BMI is not only not a good measure of health – it is really not a measure of health at all (read about the person who invented it – Quetelet) – 2) many obese people are metabolically healthy (25-30%) -how does that fit with that they are diseased? 3) speaking of not fitting with the disease thing, let’s not forget the ever-growing list of so-called obesity “paradoxes” – see the recent work by Blair et. al. 4) the evidence that fat people eat more than thin people is inconclusive at best – especially in children – 5) there is no effective weight loss intervention in the literature that works for any but a small minority of folks – I am talking long term – not short term during the program weight loss – 5) there is growing evidence of iatrogenesis in attempting to lose weight through dieting particularly by talking about dieting and weight loss to children – articles available on request – could go on forever – bottom line – this decision has nothing to do with science or health and everything to do with $$$$$$$ – what a shame – Jon

  3. James D,

    Is obesity the lifestyle decision, or is it the decision to not eat healthily and to not be physically active that leads to obesity? Would you similarly consider hyperlipidemia and hypertension a lifestyle decision, or are they the result of poor lifestyle decisions?

    I think these are important questions for us to ask and answer, so that we can come to the right solutions.

    This is a great bolg!

    Steve

  4. Leah, I disagree. For most people, obesity is definitely a lifestyle decision. Either they eat healthful foods or they don’t. Either they exercise or they don’t.

    A (small) minority of obesity incidences arise due to health problems – e.g., thyroid issues – but this number is not large by any stretch of the imagination. An equally small, if not smaller, number of obese people actually have the genetic predisposition to being obese. Otherwise, it’s down to choices. Had you said “obesity is not always a lifestyle choice,” I would’ve agreed with you.

    Are there mitigating factors? Yes. Availability of healthful foods is scarce in some areas. Subsidies enable the cheapness of many junk foods, which some low-income families buy because of money issues. Some cultures also value being larger, including sects of Latinos and blacks.

    Does misinformation abound about nutrition and exercise? Well, it’s more evident in the former than the latter. It’s not difficult for someone to turn off the TV and go for a freakin’ walk.

    American medicine can’t (or won’t) succeed in finding “real help” for obese people. Almost by definition, American medicine is disease management, not prevention/reversal. Look at how the vast majority of medical schools educate: it’s all reactive, not proactive. There’s no money to be made when people don’t need drugs.

  5. Medicalizing obesity is another bad joke being played on the population. The fact remains that for some people, it is a remarkably unhealthy state which is not a lifestyle choice as much as it is the outcome of multiple personal, social, economic and behavioral variables. To change them is exceedingly difficult, especially by a single health ace provider without any social context or source of support. That is not to say it is impossible.

    As for the money and the AMA, you will not find a friend of the old AMA here, but I am fighting from win to reinforce the beginnings of a new AMA, focuses don population health, not the immediate peculiarly needs of its membership. If not docs, then who? Just got to engage people to work in the same direction…

  6. Vic, this is a very thoughtful and interesting approach to the issue. One thing I would caution: obesity is not a lifestyle choice. Most obese people would, literally, be willing to cut off an arm if they could lose the fat. Where American medicine has failed us is in finding real help for obese people. Even the best studies show weight loss of 8-10% in the participants that didn’t drop out of the studies–that’s not enough for most obese people to move into the “overweight” category. Alot of the guidance given by medical societies are not science based. There’s a terrific article in BMJ about this.http://www.bmj.com/content/346/bmj.f1050

    But great blog.

  7. You can draw any conclusions you wish and I note you have come up with quite a few rationals that may or may not have some substance. Let us look at it this way. Patients with heart disease enter a physicians office with a disability and a fear of death. Along with medical care physicians might even start that patient on physical therapy with the hope of autonomous patient exercise when the PT is over and he might even get a dietician to advise appropriate diet for the patient. Despite the patient’s disability and threat of death the patients all too frequently go back to their former life styles as soon as the services are no longer paid for by third party payers.

    There is no “breach of trust”. Physicians are just one of the messengers and their suggestions don’t fall on deaf ears. People make a lot of bad decisions.

    We agree that broader coverage for obesity doesn’t fix the problem. Take note that the AMA doesn’t represent the normal practicing physician and has a very low physician membership, 17% when I last looked. It likely is less today based upon the events over the past couple of years. The AMA at times has kept its membership in the dark while making agreements to the disadvantage of the practicing physician. A lot of the 17% are academics or presently enrolled in medical school. Please separate in your mind the practicing physician from the AMA.

  8. Hi Melissa. Thanks for the follow-up. Always happy to joust with you. I was very clear in my first response that preventive care was not COST-effective. Lots of things are effective, but their price (in QALYs) may not make them cost-effective, and for the interventions you cite the evidence is modest to non-existent. The USPTF recommendation on physician counseling for weight loss (a B level recommendation) notes it’s worth doing because it’s harmless, but that it also needs to be intense (12 to 26 visits), and that there is NO evidence of sustainability or avoidance of long-term adverse health events.

    Further, the Cochrane Collaboration report on smoking cessation counseling by physicians concludes that it offers a very small incremental improvement over an unassisted quit rate. Neither the Cochrane Collaboration nor the USPTF addresses cost effectiveness. JT Cohen’s paper on cost-effectiveness of clinical preventive services (NEJM, 2008) is one of the most widely cited papers on the topic, and it shows clearly that very few clinical preventive services save money.

    Look forward to hearing back from you!

  9. So, if I understand your lament correctly, all physicians can do is suggest, but the ultimate power to change is out of their hands, and they’ve been suggesting the right things all along. Which leaves us, then, with the inescapable conclusions that: a) their suggestions either fall on deaf ears or are so inchoate that they don’t provide meaningful guidance; b) physicians and other health professionals are not be the right messengers because survey data show that they do a pretty lousy job of practicing what they are supposed to be preaching; and, c) if patients truly are discarding suggestions once they depart the office then the breach of trust between people in need and people who are supposed to be helping them might just be unbridgeable.

    It is completely unclear how labeling obesity a disease, and (the inevitable) push for broader coverage and reimbursement policies on the part of payers fixes any of those things.

  10. “where physicians have been for the past, oh, thirty years.”

    Physicians have been practicing medicine and despite what you think informing patients about their weight, diet and exercise. Your sarcasm wasn’t helpful though it might make some people feel good. Physicians really aren’t paid to do much in that regard for the payments are based upon the diseases they treat. Physicians are not dictators. They can only suggest and then check the weight on the next visit. If a disease state enters then insurers will pay for dietitians, physical therapy and the like otherwise the suggestions provided by physicians can simply be discarded by the patients after they leave the office. If a patient wants assistance in changing their lifestyle they have many opportunities to do so, but most of the time they will be responsible for the bill.

  11. I am not sure I agree Vik. Studies show that there is a higher unassisted quit rate among smokers if a doctor talks with them; overweight people who talk with their doctor are more likely to attempt to lose weight. So do I expect a physician in part to be a lifestyle coach – you bet I do. Do I believe that preventive care is more than screening? Yup I do – the discussions that physicians can have about maintaining health is probably the most important thing we can have a doc to do. But as in my first post, we don’t reimburse them for this role. As always – it’s enjoyable to discuss these issues with you!

  12. Indeed, Plate. When I coach executives on lifestyle, I always start small, often aiming to correct the most minute detail of their daily habits. Once they see a positive effect, they’re hooked and bigger changes are much easier to make. Behavior change is linking one concept/idea/trick to another. Pretty soon it all starts to work together. I’ve done it for myself. I was the chubby, unathletic kid. As an adult, however, I’ve been a body builder, runner, and cyclist. I took my inspiration and direction from friends, but it can come from anywhere.

  13. James,

    Thanks for the support. I think you are correct that UA’s program has a strong nutrition focus, but they effectively ignore exercise. A sad but true reflection of medicine’s long-standing ignorance, stupidity even, about the effects of exercise on everything from healthy body weight to premature morbidity and mortality to mental health. Literally nothing that a conventional US physician can do or say about maintaining good health is as powerful as the simple phrase: go workout…whatever that might be.

  14. Even with these challenges some people face, there is still a way to maintain a healthy lifestyle. Taking baby steps is key

  15. Another thing too is that a lot of the processed food that has no nutrition value whatsoever is that it’s also cheap. So your typical person that has rent due in a few days that just got paid slave wages is going to look for those dollar menus at McDonalds. Not only cheap but tasty as well since people in general can even hardly crack an egg let alone make an omellete.

    Then there is the time issue as well, combine that with Frankenstein synthetic ingredients that kicks off our inflammation via autoimmune system and you have a recipe for disaster.

    I myself try to maintain discipline by eating organic whenever I can though its not easy

  16. Vik,

    To your comment about medical schools — you’re right on the money. Only a select few medical schools put any emphasis on applied nutrition/exercise science. The only ones that come to mind are integrative medicine programs similar to the University of Arizona’s. I know they include nutrition… not sure about exercise, though.

  17. To learn about medicalizing America’s social problems see- http://www.unnaturalcauses.org and learn why obesity is far more prevalant in low SES groups.

    No pun intended but the AMA is very late “coming to this table” if it ever really will?

    Dr. Rick Lippin
    Southampton,Pa

  18. Hi Melissa, and thanks for chiming in. I agree with you that docs don’t do as much for themselves as they could. It’s a big problem, no pun intended. On the preventive medicine side, however, there’s a bigger issue. Most clinical preventive medicine is not cost-effective (excepting perhaps immunizations). Prevention, which is different, is cost-effective. No one should expect physicians to be lifestyle coaches, just as we should not expect lifestyle coaches to diagnose and treat. To my knowledge few medical schools require coursework in applied nutrition and not a single one in applied exercise science.

  19. Vik, great observations as always. I agree with you – I am disappointed in a lifestyle choice being labeled an illness.
    However, a couple of additional thoughts: 1) It’s not just the public (aka patients) who have gotten fat – it’s also physicians. It’s sometimes very hard to be a role model and advisor if your glass house is all to apparent. 2) Our healthcare system does not reward providers for preventive care. The only way docs can make money is to treat illness – so it’s difficult to expect them to be lifestyle coaches 3) the education of doctors focus on illness – not prevention (or nutrition or lifestyle coaching etc). So let’s not just point fingers at doctors (or providers) – let’s just look in the mirror and understand that for a multitude of societal issues, obesity is now a major threat to the longevity of many.

  20. Casey: thanks for your note. You raise a number of important issues about the food supply, but I think that it really boils down to the ability to make good choices, even with all the imperfections in the food supply. For example, at our house (two adults, one child, two dogs), we eat food purchased predominantly from discount and club stores. All five beings are normal weight and highly fit, and we eat plenty of stuff from boxes, bags, and cans. We also eat plenty of fresh and frozen. Packaging aside (virtually all food is processed to some degree), it’s what in the package that counts. You can eat Lucky Charms or rolled oats. Both come out of a cardboard container; only one is nutrient-rich.

  21. We’re Cro Magnons with smartphones. Until we all wake up and smell that particular pot of coffee, we’ll be stuck where we are: medicalizing the bejayzus out of every human frailty without actually getting at some root causes. Like, say, the food-industrial complex.

    A trip to the local supermarket will tell anyone all they’d need to know about the current condition of the American diet: we got 17 versions of everything; it all comes in boxes, cans, or bags; it’s totally cheap, dudes; it’s a nutritional wasteland.

    Giving companies like Monsanto citizen status and massive subsidies in the federal budget via the annual farm bill is nuts, and is another part of the problem. We’ve weaponized our food, and shot ourselves in the [pick a body part] with it. It’s taken us 30+ years to get here … how long will it take for us to navigate out of our slough of lard-butt despond?

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