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Health & Wellness

Is Obesity a Disease?

American doctors vote yes, BU profs weigh in on debate

26

An overdue bow to science or a clever dodge of the real problem? The American Medical Association’s decision Tuesday to classify obesity as a disease left the weight of expert opinion, so to speak, unsettled.

“Long time coming—I have been fighting for this for over 20 years,” says Caroline Apovian, a School of Medicine professor of medicine and pediatrics and director of the Nutrition and Weight Management Center at Boston Medical Center. Obesity researcher Daniel Miller is more circumspect. The School of Social Work assistant professor fears that the decision “will prompt people to further identify obesity as a purely medical problem, and one that is best treated by pharmaceuticals or surgery,” leaving what he calls the root causes—social and environmental influences—in the dust. Miller agrees, however, that if the decision “means access to treatment for some who otherwise might not be able to get it, that is obviously a good thing.”

Then there’s the wait-and-see school. Whether the AMA made the right call depends on whether it “will reduce the number of obese Americans and the gravity of their obesity,” says Alan Sager, a School of Public Health professor of health policy and management. And take-two-pills-and-call-me-in-the-morning hasn’t worked to date to stem the wave of weight, he says: “Doctors have never been the most powerful actors in combating obesity,” which has mushroomed because of such things as the cost and distribution of good foods and changes in exercise patterns.

Apovian says the disease designation is justified by research showing that weight gain in animals correlates to damage in the gut-to-brain signaling system. “The body does not recognize how much fat is being stored,” she says. “Therefore, you do not feel full, and keep eating.”

The vote by the AMA, the country’s premier doctor group, fired up numerous questions, ranging from the best way to treat this newly defined disease to the implications for insurance and social attitudes toward the overweight. The newest disease affects more than one-third of Americans and costs $147 billion a year in medical bills. The AMA’s verdict—which contravened the recommendation of its own study committee—cited a need to destigmatize obesity, which some doctors say is not subject solely to people’s control, and the fact that obesity has some effects of disease, such as interfering with the body’s function.

Daniel Miller, Boston University School of Social Work SSW, Caroline Apovian, Boston University School of Medicine MED, Boston Medical Center Nutrition and Weight Management Center, Alan Sager, Boston University School of Public Health SPH

Professors Daniel Miller (from left), Caroline Apovian, and Alan Sager. Miller photo by Michael Malyszko. Apovian photo courtesy of Apovian. Sager photo by Kalman Zabarsky

Opponents counter that a disease must be diagnosable, and the diagnostic tool for identifying obesity, body mass index, is unrealistic and unreliable. Professional athletes have clocked in as overweight under versions of the BMI, because muscle weighs more than fat.

Critics contend also that obesity is a risk factor for diseases like diabetes or heart ailments, rather than a disease itself. They predict more runaway medical costs if overweight people now turn to surgery and drugs rather than to diet and exercise.

If carrying excess pounds is a disease, should eating better and physical activity be considered best-practice treatment? Apovian says no, because our body chemistry often renders those tactics alone futile: “The body thinks it is starving and is going to get you back to that set point by making you very, very hungry. This is the essence for why it is a disease.”

On this point, Miller agrees with Apovian, saying individual responsibility is one strand in a complex causation web that can include environmental factors well beyond a person’s control. Poor neighborhoods, for example, are often nutrition “deserts,” with few stores that sell healthful food. For that reason, Apovian argues, the government should classify such neighborhoods as medically underserved, a designation now given to areas with a shortage of health care providers. “Bad food, hopefully, in the next few years will be seen as poison,” she says. “Just like we did with tobacco.”

Sager doubts that such a designation will be made. He points out that free-market advocates have blocked government action on helping underserved populations, and their philosophy is sure to extend to government promotion of stores carrying healthful foods. Also, he says, legally speaking, “no one is obliged to do anything different because the AMA has voted to rename obesity a disease.”

Apovian believes the decision actually will aid President Obama’s goal of “bending the cost curve” in medicine. In some cases, she says, insurance companies already cover bariatric (stomach-reducing) surgery; if the AMA’s vote pushes them to pay for diet and exercise programs to prevent obesity, diabetes, and heart disease, it will save money in the future treating those problems. Sager predicts “a modest effect” in expanded insurance coverage from the AMA decision.

Should the new definition of obesity influence attitudes toward the obese? For example, nonobese travelers applauded a requirement by some airlines that obese passengers purchase two seats instead of squeezing into one seat and overwhelming the person next to them. If obesity is a disease, doesn’t that policy become discrimination?

“Yes, absolutely. Make the seats bigger, for God’s sake,” says Apovian.

Air Canada has an intriguing third way. It gives a free second seat to obese fliers who present a doctor’s note to the airline.

26 Comments
Rich Barlow

Rich Barlow can be reached at barlowr@bu.edu.

26 Comments on Is Obesity a Disease?

  • Edward Bernstein MD on 06.20.2013 at 6:17 am

    Excellent and balanced article . By rhe way -what is obesity and what is dis- eaae? Is it a chronic relapsing condition or a continuum/spectrum similar to alcohol and drug use disorders abd addiction with genetic bio- psycho-social and environmental determinants? Clarity and agreement on the meaning and mechanisns of obesity would be most helpful to begin to address social stigma and to protect the health of the public against extremes we often see today in self punishing dieting on the one hand and compulsive stress reducing comfort eating on the other. We can learn from the long standing debate on to what extent is unhealthy alcohol and drug use a dis- ease.

  • JP2014 on 06.20.2013 at 8:24 am

    This is ridiculous. Obesity should be considered part of a disease if someone has a thyroid problem that they cannot control or some debilitating disease which limits their ability to process food, exercise and/or diet correctly. Frankly, this is a way of making parents feel better because they let their fat children sit around and watch tv all day instead of sending them out for exercise.

    I have family who are fat and who literally sit around and feel sorry for themselves. They do not have a medical condition, other than type II diabetes. They also eat excessively and do not exercise.

    I feel awful for those who, because of some underlying medical condition, cannot lose or gain weight. But we as a society cannot apologize for the other fat people who will take this as justification for being lazy.

    In a time where medical expenses are high, we can’t afford to inflate our medical costs by inventing diseases, when we can fight other diseases which may help people with their weight.

    • person123 on 06.20.2013 at 9:44 am

      I agree with this. I mean I have the utmost sympathy for people who aren’t happy with themselves but it seems to create this notion that problems are “disorders” and can be solved by a pill or surgery. It’s not impossible to lose weight, albeit very difficult, especially when someone is obese, but hiding behind the defense of an illness is a bit of a cop out. Virtually everyone on earth has some sort of difficulty, and putting a blind eye to the fact that we are both sedentary and unhealthy is a bad thing.

      It isn’t fair to feel contempt for obese people, but certainly just accommodating obesity by making larger seats sends the wrong message. The predisposition to weight gain is certainly genetic in some ways, but one often isn’t born obese, they become so by way of their lifestyle. We need a cultural shift in America which puts an end to pill-popping as shortcuts.

    • Big Bubba (formerly) on 06.23.2013 at 3:05 am

      I’m an individual who has been challenged with the disease of obesity. I don’t hide behind it’s label just as I don’t hide behind the labels of heart disease, etc… I also don’t hide behind the label of obesity as a condition for folks that choose those semantics… Or, the label of heart condition.

      I firmly believe that genetic, social, environmental, & psychological factors can influence the disease. Furthermore, reliable treatment options are available. I’m no longer obese because through very hard work I fought the disease with psychotherapy for Binge Eating Disorder, gastric bypass surgery, mindful eating habits & exercise with a personal trainer.

      Many folks believe that gastric bypass is the easy way out. Ha! That’s ignorance. The surgery is one tool in the disease management process. One still must eat mindfully and exercise to manage the disease. Additionally, gastric bypass is the best option for successful and long-term treatment (see Cleveland Clinic).

      Am I cured? No! I will be required to eat mindfully, exercise, continue psychotherapy for the rest of my life. If I do not do so? The disease will rear its ugly head. I won’t allow it to control me. I’ve come too far to do otherwise.

      For folks who want to keep the semantically argument going… have at it! It means very little to my success to argue! The teeter-totter of the argument will only convince those on either side of it. For me, I recognized it was a disease in my life and did something about it!

  • BUPH Undergrad Student on 06.20.2013 at 9:28 am

    I was listening to the radio yesterday and heard talk show hosts debating this news. An announcer made a point to say on air, “don’t go buy the large bag of Doritos and instead buy a bag of vegetables. It’s as easy as that”. But it’s not as easy as that. Some poor neighborhoods without healthy foods (aka Food Deserts) do not have access to vegetables and healthy alternatives to a ‘Large Dorito Bag’. It’s hard for those in good neighbors to imagine those in impoverished areas, and we take even buying a bag of vegetables for granted. Although I agree, there are Americans who choose to not exercise and to eat bags on bags of Doritos, but let’s not forget those who can’t help it. This new classification will help those in poor neighborhoods (which is great) but it’s going to take much much more but this is the first step. So well done AMA!

    • Anonymous on 06.20.2013 at 11:39 am

      I do not necessarily agree that in areas of poverty people cannot afford vegetables. There was a time when I had to be on food stamps and was very careful with what I bought. When I compared the price of junk food, processed food, and so on, compared to vegetables, meat, fruit, and, this latter food was actually cheaper. I am not saying everyone who is impoverished can even afford those kinds of food and I understand that. But if they can afford a big bag of Doritos or super size their fast food, or other things of that nature, they can sure as heck afford meat, veggies, fruit, and some starch.

      I agree with the comments that say if someone has a medical condition that makes it hard to gain or lose weight, that is understandable. I have a thyroid condition and it is a slow process for me to lose weight and to keep it off, however, I am not obese, but I am not lazy either. However, the people who just eat junk food all day, sit around all day, and cry me a river because they are overweight or obese, I have no sympathy for. I am not saying everyone has to be stick thin either, but if someone actually eats right, is active, and is at least trying to maintain their weight, good for them. I do not know how I feel about calling obesity a disease. Yes, it is a problem in America, but I agree with some of the other comments, that if it is called a disease, for the obese who are just plain lazy, this will be cop-out for them. I think there are other ways that America can fight and help the obese without calling it a disease.

      • BUPH Undergrad Student on 06.21.2013 at 9:25 am

        Totally in agreement. It’s all about Food security I guess. You had the opportunity to use food stamps for healthy foods in your neighborhood, but there are stores that do not accept food stamps for certain healthy foods and accept food stamps for only unhealthy foods (because of price differences). Or, there are stores that label unhealthy foods as healthy (i.e. fruit juices, dairy products…etc.) These neighborhoods don’t give their constituents fair treatment.

        What I was trying to get at in my post was yes, this classification may help, but more importantly there should be an emphasis on building healthier neighborhoods and communities (because there will always be those better off who will choose to eat 1000000 bags of doritos, we should try to help those who can’t help it).

        Anyway, there is an excellent documentary called “Unnatural Causes” which I watched many times in my many classes (professors seems to love this documentary, which is great because I love it too).There is a section on neighborhoods and health. Here is a link to the documentary with the more relevant episode if you are interested! It’s great! Thanks for the response too, really well thought out :)

        http://www.unnaturalcauses.org/episode_descriptions.php?page=5

    • Jake on 06.21.2013 at 6:00 pm

      Even Walmart has lettuce…

  • M on 06.20.2013 at 9:43 am

    Clever way to boost the pharmaceutical industry and take any responsibility away from the individuals. How do we supposedly contract this ‘disease’? Is it genetic? Because that would suggest that all those people who successfully overcame their obesity via exercise and a healthy diet actually altered their genetic make up.

    Also, how is it that so many individuals in countries like the US and UK have this ‘disease’, while in other countries this is simply not the case? I think a closer look at the food system here in the US would be much more useful, and would help explain why it is so hard for many people to lose the weight: High fructose corn syrup abounds, treats such as soda and ice creams come in GIGANTIC portions (even when a small is requested), and farmers have to jump through many hoops at great expense to have their food certified as organic, while the way is free and clear for others to mess with our food and use GMO’s as they see fit (which, btw, are banned in many non-obese European countries).

    I absolutely agree that a percentage of obese people DO suffer from clinical problems that make it difficult-impossible to lose the weight, and I do not wish this response to be considered as an attack on them, but to make a blanket statement that obesity is a disease seems irresponsible to me.

    • David Keefe on 06.20.2013 at 9:51 am

      Drug and alcohol addiction is also a disease – how do you contract that? I agree with addiction being classified as such, and while I haven’t given it the requisite thought and information finding, I tend to agree with classifying obesity as a disease, too. Not all diseases are treatable with pharmaceuticals, and some require major lifestyle changes and various therapies/counseling.

  • SarahL105 on 06.20.2013 at 10:27 am

    It is in the interest of the medical-industrial complex to classify obesity as a disease. More disease, more treatment, more drugs, more intervention, more profit.

    If an obese person has done all he/she can to change their eating habits and lack of exercise to a more healthy lifestyle without being able to lose weight,then medical intervention should occur ALONG WITH CONTINUED HEALTHY LIFESTYLE CHANGES. Personal responsibility should be the main factor in this equation.

    When obese people experience the effects of obesity such as type 2 diabetes and heart disease without choosing a healthier eating and exercise, they are choosing to hurt themselves, but they are also driving up the costs of healthcare for the rest of society.
    Although it may run counter to the medical community’s philosophy of the “doctor as the expert” that community needs to promote and encourage patient responsibility far more than they do now. Labeling obesity as a disease tells the patient that “they need to be treated first”, and that the answer to their problem lies outside of their control. This approach towards obesity will not motivate people to change to a healthier lifestyle, and yet, shouldn’t that be the ultimate goal?

  • Fat Cat on 06.20.2013 at 11:16 am

    For many years now the medical and pharmaceutical communities have treated the symptoms of obesity while leaving the underlying cause untouched. As people gain weight they inherently begin to develop one or more of the characteristic symptoms of the metabolic syndrome. Some develop hypertension first and go on to develop hypercholesterolemia and diabetes while for others the onset of these symptoms may be reversed. In the end they all end up on meds for these three conditions while at the same time they remain obese.

    Targeting obesity as a disease is the best approach and ironically despite what many people think will ultimately lead to patients using less not more drugs.

  • BrJames on 06.20.2013 at 12:21 pm

    I can see both sides of the coin.

    At my heaviest, I weighed 360lbs. That was when I was a junior in high school. Now, entering my junior year at BU, I am down to 219lbs and am continuing to lose. I was able to do that without a single diet pill, supplement, or professional program.

    While this would seem to be a strong argument against obesity being a disease, I recall that, while I was at my heaviest, I felt the NEED to keep eating. On days that I consumed less than I was accustomed to, I felt a constant anxiety telling me that I needed food. Couple that with the fact that I was living in house a where the staple foods were pasta, ground beef, and starches; see where this turns shades of gray?

    What it took for me to actually start working towards losing the weight is when I told my parents that I NEEDED healthy foods, and even then it took me months to figure out the right balance to combat hunger. My parents gave me grief too, because it added an extra $50-$70 a month to grocery bills, and the volume of food I felt I needed was still very high, even though it was better for me. It took me over a month of going to bed every night feeling like I was starving and fighting the urge for midnight snacks before I started adapting to the lighter meals.

    Also note, exercise was like torture. Even going on a mild jog made it feel like I was having an asthma attack, and that could deter me from trying again for days. My area wasn’t safe to run in, and the only gym in town cost $30 a month that I didn’t have. I had to figure out my own ways to exercise, and it took extreme effort to lose weight in the beginning, and it was SLOW.

    When I cam to BU though, things got easy. We have Fitrec, which I made and have stuck to a DAILY 2-hour routine to, and in the dining halls I try my best to stick to Sergeant Choice when they actually produced something appetizing and mushroom-free.

    I have lost nearly 100lbs since I got here. But returning home to where my parents still stalk up on starch and fat, I find losing a pound at home impossible, and often come back heavier than when I left after a break. That’s why I am staying in Boston this summer: I need an environment that will allow me to maintain a healthy lifestyle. And even here, it’s extremely difficult to fit in time for Fitrec, and to afford healthy eating. Even now, I technically fit in the “obese” category, but a lot of my weight is muscle now.

    While I question the word “disease” in this decision, I believe that something needs to done to help those who do have the benefits I have had. It took a lot more than self-discipline. It took money, support, research, a change in environment, and a LOT of hunger pain to combat all the extra weight that I had carried since I was seven.

    The help I think people need, though, is access to healthy food, assistance with an exercise program, and a JUDGEMENT-FREE support system. If this decision will make these things available to people, I fully agree with it. If it is going to be an excuse to throw ineffective drugs and surgery promotion at people, I am completely against it. I am proof that those things aren’t always necessary and shouldn’t be the first option if healthier alternatives are available. I also know I am fortunate to have been able to afford to lose the weight on my own, and that I am not suffering from long-term complications from my former lifestyle. Not everyone is that lucky, though, and at least this whole debate came to some conclusion that will put more active focus to treating obesity.

    • Eddie on 06.21.2013 at 11:18 am

      Thanks BrJames for your story and insight! Wish you the best as you continue to live a healthy life.

  • Jane on 06.20.2013 at 12:36 pm

    Why doesn’t BU Today ask the people it interviews whether they have any financial conflicts of interest? What these people say will, indeed, be affected by their financial conflicts. Your readers have a right to know. Readers: If you go to ProPublica: Journalism in the Public Interest, you’lll see that one of the people interviewed was paid $5,000 by GlaxoSmithKline in 2012 – yes, the money appears to have gone to someone through the practitioner, but it’s all the same. Wouldn’t you like to know why? I would. Until BU Today does its due diligence and asks about and publishes information about financial conflicts of interest, I think it is doing us all a disservice.

    • JP2014 on 06.21.2013 at 5:54 am

      Nice work Jane!

  • diabetes blue feet on 06.20.2013 at 12:39 pm

    We must recognized obesity as a “side effect” illness, prevalent obesity is in fact a modern day phenomena created by the proliferation of food chemicals which have been approved by the Food and Drug administration. The astronomical increase in obesity over the past 40 years cannot be blamed on simple “overeating” or gluttony, it is a fact that processed foods such as high fructose corn syrup and other chemicals have polluted the food supply.

    Processed foods and chemical additives are directly linked to obesity. In plain English, the people have been sold obesity for food manufacturer profit.

  • SarahL105 on 06.20.2013 at 1:29 pm

    To use Sarah’s argument, but substituting alcoholism for obesity:

    It is in the interest of the medical-industrial complex to classify alcoholism as a disease. More disease, more treatment, more drugs, more intervention, more profit.

    If an alcoholic has done all he/she can to change their drinking habits without being able to stop being an alcoholic,then medical intervention should occur ALONG WITH CONTINUED ALCOHOL ABSTINENCE. Personal responsibility should be the main factor in this equation.

    When alcoholics experience the effects of alcoholism without choosing to abstain from alcohol, they are choosing to hurt themselves, but they are also driving up the costs of healthcare for the rest of society.

    Although it may run counter to the medical community’s philosophy of the “doctor as the expert” that community needs to promote and encourage patient responsibility far more than they do now. Labeling obesity as a disease tells the patient that “they need to be treated first”, and that the answer to their problem lies outside of their control. This approach towards alcoholism will not motivate people to change to a healthier lifestyle, and yet, shouldn’t that be the ultimate goal?

    • California apple on 06.21.2013 at 6:47 am

      Very nice point Sarah!

  • Jimmy Rustle on 06.20.2013 at 7:52 pm

    From the NBC article on this, quoting AMA officials http://www.nbcnews.com/health/obesity-disease-doctors-group-says-6C10371394:

    “Employers may be required to cover obesity treatments for their employees and may be less able to discriminate on the basis of body weight.”

    “More widespread recognition of obesity as a disease could result in greater investments by government and the private sector to develop and reimburse obesity treatments,”

    How about no, the last thing I want is to have to pay tax dollars (or for employers to have to pay for) medical treatment for people that were undisciplined enough to become fat. Also, employers obviously want someone who has a sharp appearance and can represent their company well. Fat people cannot fit this role and logically it should be a factor in hiring decisions.

    • girl on 06.25.2013 at 9:22 am

      So, should racial discrimination be allowed, then, if your clients might not think that someone of a certain race “represents your company well”? Discrimination should not be allowed, no matter what the case is, even though it is rampant in America. Employers should have to cover similar treatments to what they would cover for any other sort of addiction (if they do), like nutrition counseling, etc.

  • Jimmy Rustle on 06.20.2013 at 8:02 pm

    More effective way to eliminate obesity:

    Make the tax rate 99.9% for people over 12% bodyfat, this will make you either:

    1. die from starvation
    2. get fit from starvation

    People under 12% bodyfat pay no taxes, because that’s what’s good for society.

    Fit people are more productive, have more energy, and are stronger mentally.

    • Chris on 06.22.2013 at 11:49 pm

      Sorry, but I’ve known many lazy skinny people and many hard-working overweight people. Your stereotypes are unfounded.

    • girl on 06.25.2013 at 9:25 am

      First of all, you don’t get “fit” from starvation. You might lose weight, but being fit and healthy is different from being skinny with no muscle mass because you’re malnourished. Seconding Chris, I know a LOT of lazy skinny (rich) people who are no benefit to our society besides their money. And the mental strength comment? Many overweight/obese people are also depressed, and whether that is due to their weight or not, it takes a lot of strength to be able to cope with depression and get yourself out of it. You have nothing to back up any of your claims.

  • Ricardo Furtado on 06.23.2013 at 3:13 am

    Great article, but I have my doubts about people willing to accept that “bad food” is poison. The worst things in life almost always appear to be the best – and people are always lured to these bad things. Thus, is the case with the so called “bad foods” – simple examples would be the case of pizzas, burgers, fries – people know that these foods are bad.

    But do people stop eating them? No!

    And that is why we have companies who run multi-billion dollar enterprises just by selling pizzas, burgers and fries. I doubt if people will think that bad foods are poison as people just cannot resist the temptation to eat these kinds of foods. There are some things in life that just have to be accepted and nothing can be done about them.

    And one of these things is the fact that people will continue to eat foods like burgers, fries, pizza – as they are tasty and people find it hard to resist them.
    No matter how hard they may be – and no matter what harm it may cause them by way of putting on weight and other health issues. That is just the way life is. Thanks for sharing this article.

    Regards

    Ricardo

  • Lisa on 06.29.2013 at 11:01 am

    Muscle does not weigh more than fat. This is a big misconception and I was surprised to see it in this article.

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