Obesity is a Disease?

The question mark at the end of the title is there not so much because I'm questioning whether obesity is a disease but because I wonder why anyone thinks it's useful to say so.

At the recent annual meeting of the American Medical Association, our nation's largest organization of doctors, the House of Delegates adopted a resolution calling for the AMA to "recognize obesity as a disease state with multiple pathophysiological aspects requiring a range of interventions to advance obesity treatment and prevention.”

By and large we have thought of obesity as a risk factor for other diseases rather than a disease in its own right.  So the obese are more likely to have abnormal levels of lipids in the blood (cholesterol, triglycerides) and to have adult-onset diabetes.  That makes obesity indirectly a contributor to cardiovascular disease, including heart attacks and strokes.

It helps to have a definition.  The definition we use is based on body mass index (BMI), which is an imperfect but mostly workable measurement of whether a person's weight is in a desirable range.  It is calculated from height and weight.  If your BMI is higher than 25, you're considered overweight.  Once it reaches 30, you're obese.

The reason it's imperfect is that some people with relatively large muscle mass may be quite fit and healthy, and have a percent body fat that is low enough to be enviable, yet have a BMI that is higher than "desirable."  That is because muscle is denser than fat, and so it contributes more to body weight.  Take two people of the same weight.  The one with more muscle and less fat takes up less space; his/her body has less volume.  That person is thinner, trimmer, and (all other things being equal) healthier.  So if you're muscular and have a relatively low percent body fat, your BMI may falsely suggest you are overweight or even obese.

There are many online calculators, such as the one found here: http://www.nhlbi.nih.gov/guidelines/obesity/BMI/bmicalc.htm

Knowing, then, that obesity puts one at risk for serious health problems, why does it matter if we call it a disease rather than an important risk factor for disease?  Well, the supporters of the AMA resolution think it places more emphasis on the importance of helping people (patients) do something about it. They hope that it will cause health insurers to be more likely to pay for interventions that doctors can offer to patients.

This is the part that I don't get.  I don't claim comprehensive knowledge of what health insurance policies pay for - maintaining such a database could be a full-time job - but it is my sense that it is already pretty widespread practice for them to pay for interventions, especially surgical ones, if patients meet certain criteria (meaning a BMI over a given number, evidence that their obesity has caused other significant health problems, and failure of non-surgical approaches like diet and exercise).  Maybe it's the part about evidence the patient's obesity has caused related troubles that could change.  Maybe the idea is that insurers would pay for surgery even before those other problems have set in.

What gives me pause, however, is the concern that the push for more and earlier intervention will fail to emphasize behavioral intervention.  I work in a health system where there is a lot of surgery for obesity.  Surgeons do things to the digestive tract that make it difficult for patients to eat too much or for the GI tract to absorb calories (and important nutrients, too).  In the emergency department, of course, we see many patients with complications of surgery, so we get a skewed perspective on this.  The patients who have surgery that works well for them and never have any problems don't come to see us in the ED.  That having been said, what I see in my work reinforces my belief that lifestyle changes are a much better approach than surgery, because their side effects (the things that happen besides weight loss) tend to be good rather than bad.  When one eats a more healthful diet, reduces caloric intake, and gets regular exercise, the things besides weight loss that one experiences are generally positive.  The effects on overall health go beyond what can be attributed to weight loss alone.

Whatever your politics, it's obvious which one
 could teach the other about healthful lifestyle

So try this thought experiment. Suppose we take some people who are quite obese and manage them two different ways.  The first group gets "bariatric surgery."  The subjects in the second group are assigned a life coach focused on health with special emphasis on diet and fitness. They have regular meetings with the life coach, are urged to keep a diary of their habits related to eating and exercise, and have frequent phone conversations, text messages, e-mails (depending on how plugged in they are to what kinds of communication), all designed to get them to eat a more healthful diet and to get plenty of regular exercise of the sort that will promote health.  This is just an overview of how the coaching would work.  I haven't worked out all the details, but it's easy to see how it could be done.

My hypothesis: the "life coach" approach would work better, the patients' overall health would improve more, and just as fast, with no complications (short-term or long-term), with long-lasting benefits.  Remember, exercise of the right kind does good things for strength and balance and has been associated with improved cognitive function as age advances.  My secondary hypothesis is that the overall cost, especially taking surgical complications into account, not to mention long-term effects on health, would be lower (quite possibly much lower) for the non-surgical approach.

Here I must make a disclosure, because it is a very important source of bias affecting my perspective.  I have struggled all my adult life to maintain ideal body weight.  I have had two periods of my life characterized by unhealthful lifestyle (poor diet, little exercise) when I gained many pounds, and righted the ship, or reversed course (or any metaphor you like) only after being confronted with evidence that overcame my denial.  The second (and more dramatic) time this happened was a bit more than a decade ago.  A few years "off the wagon" wrought their havoc, over which time I found myself repeatedly buying clothes in bigger sizes with nary a thought about why that was happening or that I should do something about it.  When back pain from a herniated lumbar disk caused a dear friend who is a radiologist and was reviewing my MRI with me to look me in the eye and tell me to lose weight, that finally broke through my denial.  My medical friends will appreciate the richness of that experience: getting sound medical advice from a doctor in a "non-patient-care" specialty.

So I took this fat bull by the horns and adopted a regimen of healthful diet and regular calorie-burning exercise.  In twelve months I lost just over 100 pounds. Nine years later I'm still fit.  My diet could be more prudent some days, and I still tend to eat when I feel stressed, but my exercise regimen has kept my physique - and, I believe, my health - where it belongs.

I believe I am no better than anyone else at breaking old habits or forming new ones.  In fact, I'm probably not as good at that as most people.  So my own experience has convinced me that the "cure" for this "disease" lies in behavioral (lifestyle) change, not surgery or drugs.

In recent decades we have medicalized so many things.  And behavior is foremost among them. When I was a youth, a lad with a bad temper was said to have a bad temper and was dealt with using punishment for bad behavior and rewards for self-control.  Now we label it "intermittent explosive disorder."  Are psychiatrists and other mental health professionals any better at dealing with this than caring and persistent parents and teachers? I'm not convinced.  When a young person consistently flouts authority and is constantly disobedient, does it help to give it a diagnostic label ("oppositional-defiant disorder") and send the youth to sessions with counselors and therapists? And does drug therapy help any of this?  Again, I'm not convinced.

We have medicalized alcoholism.  We call it, and treat it as, a disease.  Likewise for other forms of substance abuse and dependence.  If you go to a meeting of Alcoholics Anonymous, you will hear participants refer to it as a disease.  But look at the Twelve Steps.  They describe taking a "moral inventory," and the alcoholic works toward (and seeks help with) the removal of "shortcomings" and "defects of character."  There is nothing in the Twelve Steps about a disease. Now, of course, the Twelve Steps were around for a long time before the disease model appeared.  But AA has not revised the Twelve Steps.  I think that's because they work.

Not just the fitness industry, but
everyone who thinks fitness is important

So I believe if obesity is a "disease," it is a behavioral disease.  And the treatment is changing behavior. Not for everyone, to be sure.  Some people have metabolic disorders.  (You cannot treat an under-active thyroid with behavioral change.)  And some people cannot change their behavior no matter how hard they try.  But a lot more obese people should be trying, and trying a lot harder, before they resort to medical or surgical treatment.  I teach medical trainees all the time that our interventions should be three things: safe, effective, and cheap.  Changing behavior meets all three requirements much better than going under the knife.

Is obesity really a disease?  I don't know.  And I don't think it matters.  Call it a disease, or don't call it a disease, but it is a problem, and for the vast majority of people the solutions lie within themselves, not in the interventions offered by doctors.

Racism and the Trayvon Martin Shooting

The verdict is in.  We have all had time to mull it over.  The furor on both sides should be settling down.  That seems not to be happening, but it may just be that the need to fill airtime on the 24-hour cable news channels and space on all of the online news outlets means that this case won't be let go so easily.  And there is still the matter of the investigation by the Department of Justice into whether civil rights charges should be brought against George Zimmerman.

Last year, a couple of months after the shooting, I wrote about the law and the ethical considerations surrounding the use of lethal force in self defense.  Those who missed that can find it here [http://bobsolomon.blogspot.com/2012/04/stand-your-ground.html], and I won't go back over all that now.  If you didn't read it then, I suggest you do so now if you want to understand that part of the context of the incident, because the propriety of Florida law is once again being debated.

One thing that's important to understand about Florida self-defense law is that the "stand your ground" statute didn't figure into the criminal trial, because counsel for the defense did not bring it up but rather relied solely on traditional considerations in a self-defense case.  Was the defendant's decision to use lethal force based on a reasonable fear that he was in immediate peril of death or grievous bodily harm? The hurdle the prosecution had to clear to reach a guilty verdict was a high one.  Their answer to this question was no, and they had to prove that Zimmerman's actions were unreasonable beyond a reasonable doubt.  That's a daunting challenge, and their case was not strong enough to meet it.

The jury was not deciding any question having to do with race.  Their job was to place themselves in the moment - Zimmerman's moment - and decide whether any reasonable person in the same or similar circumstances might have had that same fear and acted accordingly, responding to the situation with lethal force. We know what they decided.

What about the Justice Department's investigation?  As I understand applicable law, they would have to conclude that Zimmerman's actions represented a hate crime - that is, his shooting of Trayvon Martin was motivated by race-based hatred of the young man.  I believe they will be unable to make such a case, and I believe that's because that isn't what happened.

Nevertheless, the Zimmerman-Martin case is most assuredly about race, and racism, and race relations in the United States.  It isn't difficult to see how, once one begins to trace the killing to its origins.

Why did Zimmerman see Martin as a suspicious figure who might be where he was for illegal purposes?  Because he was black.  Zimmerman, as a neighborhood watch volunteer, was participating in that watch because of neighborhood crime.  There had been a series of burglaries committed by young black men.  So a young black man walking down the street in that neighborhood naturally raised Zimmerman's suspicions.

There is a perception, based chiefly on statistics, that a disproportionate amount of crime - street crime, ordinary property crime, and violent crime - is committed by young black males.  Why are the statistics what they are?  The briefest economic analysis yields a straightforward answer.  Most ordinary property crime is economically motivated.  And thus the disproportionate involvement of young black males, who disproportionately belong to the urban underclass, with high and stubbornly persistent unemployment, directly follows.  Similarly, the urban drug culture is an alluring source of income to unemployed youth, and at the same time leads directly to gang violence.  The statistics are clear on that as well: most young black men who are killed on our city streets are killed by other young black men, and that is mostly in the context of drug-related gang violence.

So the interaction of Zimmerman and Martin was initiated by simple and straightforward profiling:  Martin fit the profile of those who had been engaged in crime in the neighborhood Zimmerman was patrolling.

This sort of profiling has been a hot topic of debate.  But one cannot escape its logic.  And that logic is based on crime statistics.  Those crime statistics exist because we have a large black urban underclass, and that, in turn, is largely a product of the history of race relations in this country.

Over five hundred years ago, white Europeans began transporting enslaved black Africans across the Atlantic ocean to the New World.  Traders included the Portugese, the Dutch, and the English.  The African slaves were used to work mines (especially gold) and plant and harvest crops (most notably sugar and cotton, as well as tobacco).  African slaves were brought to the English colonies as early as 400 years ago (first in Virginia).  In the earlier years of this trade, many enslaved Africans died during the voyage across the sea.  In the New World, many died at hard labor; it was cheaper to import new slaves than to keep the ones already here healthy.  It also did not, until much later, seem economically sensible to have them reproduce, because children of slaves consumed resources without performing any labor for more than a decade, and again it was thought more efficient simply to keep importing new ones.  For an excellent review of this ghastly subject in recent human history, I recommend the Pulitzer Prize-winning book Inhuman Bondage, by David Brion Davis, who has written numerous other books on slavery.

Our Founding Fathers incorporated the idea that "all men are created equal" into the Declaration of Independence in 1776.  But over a decade later, when they drafted the Constitution in 1787, they did not eliminate the great evil of slavery, instead including it in a compromise that allowed the importation of slaves to continue until 1808 and counted a slave as three fifths of a person for the purpose of enumerating the population and determining states' representation in the United States House of Representatives.  The issue of slavery in the new nation alternately simmered and boiled over the next seven decades.  Several further compromises were forged to maintain slavery in the South and govern the degree to which it was permitted to expand into newly settled territory.  Finally, when Abraham Lincoln, whose views in favor of abolition were well known, was elected in 1860, the southern states, led by South Carolina, seceded from the Union, plummeting the nation into a Civil War, fought both to preserve the Union and ultimately to put an end to slavery through the Emancipation Proclamation (1863) and the Thirteenth Amendment to the Constitution (1865).

For a decade after the Civil War, we went about the business of Reconstruction, but the cause of racial equality was lost.  The separation of the races was validated by the Supreme Court in 1896 (Plessy v. Ferguson), which pronounced that "separate but equal" public accommodations for blacks and whites were acceptable, ignoring the fact that the continued acceptance of separation of the races served to assure unequal treatment.  Not until 1954 (Brown v. the Board of Education of Topeka, Kansas) did the Court reverse itself and recognize that segregation stood in the way of equality.  In the 1960s we enacted civil rights legislation in an effort to correct entrenched unequal treatment in many spheres of American life.

Where are we yet another half century later?  The very existence of a black urban underclass answers that question in a most disheartening and emphatic way.  We cannot read statistics telling us there are more young black men in prison than in college without understanding that we have so very far to go.

I believe we will eventually overcome the legacy of two and a half centuries of African slavery in this land, followed by another century and a half of segregation and discrimination.  We should not prosecute George Zimmerman under federal civil rights statutes.  He did not kill Trayvon Martin because Martin was black. But most assuredly the two of them were face to face in what became a violent confrontation because Martin was black, and because that fact made Martin a target of suspicion for a volunteer in a neighborhood anti-crime initiative.

We must change the way our society works so that crime statistics do not paint a picture of the disproportionate involvement of young black men in property crime, and violent crime, and in drug-related gang violence.  At the same time we work to reform our society to change those statistics, so men like Zimmerman will not naturally suspect men like Martin of criminal purposes, we must also effect a change in the bitter statistics that tell us most young black men killed in this country are killed by other young black men engaged in criminal enterprises that have become a substitute for robust and lawful economic opportunity.