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.