Obesity: Lack of Will, Poor Lifestyle Choice, or Disease?

What is a disease?

That, of course, is the million-dollar question, and as you have come to learn, it is complicated. We are biological creatures, and to our best understanding, we are in an equilibrium internally and externally. That equipoise, let’s for the minute call it, ease of being, is a dynamic process; we tend to focus on the internal ease of being, but the increasing concern over the socioeconomic determinants of health expresses the ease of being with the external environment. 

If one now takes disease and breaks it in two, dis-ease, then we have an experiential sense of how to define a dis-ease. Again, most internal dis-eases have been given a status as a disease, but in reality, they are a phenotype with many underlying features and causes. Diabetes, the dis-ease of glucose regulation, has Type I and II, and some argue for a pre-diabetic condition. More to the point, obesity encompasses many internal and external dis-eases of being. The internal concerns include diabetes and cardiovascular disease; the external dis-eases including body shaming and a visceral bias against the overweight. Those external dis-eases may well be more cultural than biological, as anyone who has viewed the work of Rubens knows.

In 2013, over the objection of their council of experts, the AMA’s House of Delegates defined obesity as a disease. 

“That our AMA: (1) recognize obesity and overweight as a chronic medical condition (de facto disease state) and urgent public health problem; (2) recommend that providers receive appropriate financial support and payment from third-party payers, thus ensuring that providers have an incentive to manage the complex diseases associated with obesity; (3) work with third-party payers and governmental agencies to recognize obesity intervention as an essential medical service; and (4) establish a comprehensive ICD code for medical services to manage and treat obese and overweight patients.” [emphasis added]

I added the emphasis because all three of these points address payment for treatment, whether WW (the old Weight Watchers), medications or our current most favored, bariatric surgery. For the cynical amongst us, this might be considered self-serving on the part of physicians.

Report Of The Council On Science And Public Health

A re-reading of the report of those AMA experts demonstrates how little has changed now that obesity is a treatable condition. While we might argue that we can identify obesity when we see it, that is insufficient for those footing the bills – they want quantifiable, objective criteria. The most ubiquitous is the BMI or body mass index. It is a cheap, easily applied (involving only weight and height) screening tool, but as the report notes, 

“Associations between BMI and adiposity (as well as disease risk, described below) vary by age, gender, ethnicity, socioeconomic status, stature, and athletic training. These variations generally reflect population-specific differences in body composition, fat distribution, causes of overweight, and genetic susceptibility. As a screening tool for obesity, BMI demonstrates low sensitivity, particularly at BMIs below 30.”

The gist – BMI is much better at identifying the non-obese. Of course, those standardized cutoff values are subject to revision, just as we continue to lower the criteria for being hypertensive. 

The Council found designating obesity as a disease would bring “greater investments by government and the private sector to develop and reimburse obesity treatments.” That includes medications, surgery, and obesity prevention programs. It might also mean that discrimination based on body weight might be illegal. But more importantly, obesity as a disease would shift societal perceptions. 

“Lack of self-control, laziness, and other detrimental character attributes might be less likely to be associated with obese individuals, and in turn reduce stigmatization.”

On the other hand, obesity as a disease would “medicalize” obesity making the pill or knife the more relied upon alternatives

Public perceptions may shift due to more extensive recognition of obesity as a disease, with a greater appreciation of, and emphasis on, the complex etiology of obesity and the health benefits of achieving and maintaining a healthy weight. Moreover, as BMI became a vital sign, as did pain (which ushered in the era of opioid diversion), the environment might shift away from “healthy eating and physical activity.” Finally, obesity as a disease would result in higher insurance costs. 

Does Obesity Lie Within Our Control?

This is really the concern underlying obesity as a disease. 

"Obesity is a disorder which, like venereal disease, is blamed upon the patient. The finding that treatment doesn't work is ascribed to lack of fortitude." 

Edwin Astwood, MD

“The suggestion that obesity is not a disease but rather a consequence of a chosen lifestyle exemplified by overeating and/or inactivity is equivalent to suggesting that lung cancer is not a disease because it was brought about by individual choice to smoke cigarettes.” 

AMA Resolution

It is tough to think of a way to more dramatically stigmatize an individual than to call them a smoker! Fat and body shaming are culture memes and are stand-ins for lack of control or willpower. The obese remain victims, but now it is less a societal, cultural victimization; they, after all, have a disease. And we don’t shame those with illnesses, do we? To the advocates of obesity as a disease, fat-shaming and employer bias all contribute to increased stress that in turn promotes stress-eating and hesitancy of pursuing exercise in public venues, like gyms. 

We do gain weight as we age, roughly 2 pounds annually, in our middle years. And “during or after weight loss there is a disproportionate increase in the drive to eat and decrease in energy expenditure creating "the perfect storm" for weight regain” – there is biology at work here.  

Obesity, as with many problems, lies within and outside of our control simultaneously. It might be better to think of obesity due to our underlying genetics, our metabolic condition, and our lifestyle choices. The relative contribution of each will vary with the individual. I have made some poor lifestyle choices at times, and they have been reflected in my weight. I am trying to make better choices, but that is tough but far easier than another pill, let alone an operation. For the morbidly obese, their metabolic and biological changes are almost insurmountable; a knife or medication can restore a balance between their choices and underlying physiology. 

The Council report to the AMA ends on this note.  

“Thus, rather than trying to determine if obesity meets arguably arbitrary disease criteria, the more relevant question is “would health outcomes be improved if obesity is considered a chronic, medical disease state?”

To the extent that payment for treatment might improve outcomes, the answer is yes. If the goal is now to reduce stigma, then shifting victimization from cultural norms to the “fault of our cells” is not a solution. 

Sources: "Obesity Is a Disease, Recognize It as Such" Medpage

A.M.A. Recognizes Obesity as a Disease NY Times

AMA’s Report of the Council on Science and Public Health, Is Obesity a Disease