There is a certain irony in the nearly immediate juxtaposition of the rare introduction of a new FDA-approved drug for weight loss (Belviq) to the marketplace and the recognition of obesity as a “disease” by the AMA. A line from the movie Jerry Maguire comes to mind: “You complete me!” Drugs need diseases; diseases need drugs.
And that’s part of what has me completely worried. The notion that obesity is a disease will inevitably invite a reliance on pharmacotherapy and surgery to fix what is best addressed through improvements in the use of our feet and forks, and in our Farm Bill.
Why is the medicalization of obesity concerning? Cost is an obvious factor. If obesity is a disease, some 80 percent of adults in the U.S. have it or its precursor: overweight. Legions of kids have it as well. Do we all need pharmacotherapy, and if so, for life? We might be inclined to say no, but wouldn’t we then be leaving a “disease” untreated? Is that even ethical?
On the other hand, if we are thinking lifelong pharmacotherapy for all, is that really the solution to such problems as food deserts? We know that poverty and limited access to high quality food are associated with increased obesity rates. So do we skip right past concerns about access to produce and just make sure everyone has access to a pharmacy? Instead of helping people on SNAP find and afford broccoli, do we just pay for their Belviq and bariatric surgery?
If so, this, presumably, requires that everyone also have access to someone qualified to write a prescription or wield a scalpel in the first place, and insurance coverage to pay for it. We can’t expect people who can’t afford broccoli to buy their own Belviq, clearly.
There is, of course, some potential upside to the recognition of obesity as a disease. Diseases get respect in our society, unlike syndromes, which are all too readily blamed on the quirks of any given patient and other conditions attributed to aspects of character. Historically, obesity has been in that latter character, inviting castigation of willpower and personal responsibility and invocation of gluttony, sloth, or the combination. Respecting obesity as a disease is much better.
And, as a disease, obesity will warrant more consistent attention by health professionals, including doctors. This, in turn, may motivate more doctors to learn how to address this challenge constructively and compassionately.
But overall, I see more liabilities than benefits in designating obesity a disease. For starters, there is the simple fact that obesity, per se, isn’t a disease. Some people are healthy at almost any given BMI. BMI correlates with disease, certainly, but far from perfectly.
The urge to label obesity a disease, and embrace the liabilities attached to doing so, seems to be a price the medical profession is willing to pay to legitimize the condition. It may also be an attempt to own it (and the profits that come along with treating it), whereas that right and responsibility should really redound to our entire culture. Is it necessary for obesity to be a disease for it to be medically legitimate? I think not.
Carbon monoxide poisoning is medically legitimate, but it is not a disease — and there’s a good reason for that. It is poisoning, so the fault lies not with our lungs, but with what is being drawn into them. Your lungs can be working just fine, and carbon monoxide can kill you just the same. Perfectly healthy, disease-free bodies can be poisoned.
None would contest the medical legitimacy of drowning. If you drown, assuming you are found in time, you will receive urgent medical care — no matter your ability to pay for it. If you have insurance, your insurance will certainly pay for that care.
But drowning is not a disease. Perfectly healthy bodies can drown. Drowning is a result of a human body spending a bit too much time in an environment — under water — to which it is poorly adapted.
And so is obesity. Our bodies, physiology, and genes are much the same as they ever were. Certainly these have not changed much in the decades over which obesity went from rare to pandemic. What has changed is the environment.
We are awash in highly-processed, hyper-palatable, glow-in-the-dark foods. We are afloat in constant currents of aggressive food marketing. We are deluged with ever more labor-saving technological advances, while opportunities for daily physical activity dry up.
We are drowning in calories. And that’s how, in my opinion, we should make obesity medically legitimate: as a form of drowning, not as a disease.
With drowning, we don’t rely on advances from pharmaceutical companies. No one is expecting a drug to “fix” our capacity to drown. Our capacity to drown is part of the normal physiology of terrestrial species.
Our capacity to get fat is also part of normal physiology. Obesity begins with the accumulation of body fat, and that in turn begins with the conversion of a surplus of daily calories into an energy reserve. That’s exactly what a healthy body is supposed to do with today’s surplus calories: store them against the advent of a rainy (i.e., hungry) day tomorrow. The problem that leads to obesity is that the surplus of calories extends to every day, and tomorrow never comes.
Thinking of obesity as a form of drowning offers valuable analogies for treatment. We don’t wait for people to drown and devote our focus to resuscitation; we do everything we can to prevent drowning in the first place. We put fences around pools, station lifeguards at the beaches, get our kids to swimming lessons at the first opportunity, and keep a close eye on one another. People still do drown, and so we need medical intervention as well. But that is a last resort, far less good than prevention, and applied far less commonly.
There is an exact, corresponding array of approaches to obesity prevention and control; I have spelled them out before.
Disease is when the body malfunctions. Bodies functioning normally asphyxiate when breathing carbon monoxide, drown when under water for too long, and convert surplus daily calories into body fat. Perfectly healthy bodies can get obese. They may not remain healthy when they do so, but that is a tale of effects, not causes.
The most important reasons for rampant obesity are dysfunction not within our individual bodies, but at the level of the body politic. We do need medicine to treat obesity, but more often than not, it is lifestyle medicine.Lifestyle is the best medicine we’ve got — but it is cultural medicine, not clinical.
That’s where our attention and corrective actions should be directed. If calling obesity a disease makes us treat the condition with more respect, and those who have it with more compassion, and if it directs more resources to the provision of skill-power to adults and kids alike, it’s all for the good. But if, as I predict, it causes us to think more about pharmacotherapy and less about opportunities to make better use of our feet and our forks, it will do net harm. If we look more to clinics and less to culture for definitive remedies, it will do net harm. If we fail to consider the power we each have over our own medical destiny, and wait for salvation at the cutting edge of biomedical advance, it will do net harm.
Long before labeling obesity a disease, the AMA lent the full measure of its support to the Hippocratic Oath and medicine’s prime directive: First, do no harm. Obesity is much more like drowning than a disease. Calling it a disease has potential in my opinion to do harm. And so it is that I vote: No.
David L. Katz is the founding director, Yale-Griffin Prevention Research Center.