Diseasification of Obesity

 

Bathroom scale with faces instead of numbers

 

In a thoughtful, measured and well-reasoned blog post in these pages, Dr. Keith Ayoob recently discussed the AMA’s decision to classify obesity as a “disease.” As he concluded his post, Dr. Ayoob wrote: “I don’t care how obesity is categorized. I care about what’s being done about it…. We need to stop talking about whether obesity is or is not a disease and start talking about preventing it altogether.” This got me thinking: does the process of “diseasification” hold any promise at all in obesity? And are there downsides to this approach that should cause us concern?

“Diseasification” is a funny and not entirely real word, but I didn’t make it up. Sure, if you look for it in an online dictionary, you won’t find it—but if you Google it, you’ll find over 6,000 hits. Most seem to focus on one of the most problematic aspects of diseasification: that of classifying all sorts of mental states and psychological issues as diseases, a tendency that has arguably contributed to our nation’s overreliance on pharmacology to ease the vicissitudes of daily living. But some of these Google hits refer to issues in prevention, including obesity. While I didn’t coin the term, I think its meaning is self-evident: labeling as a “disease” a condition that is typically not so construed. Clearly, the AMA’s action would fit under this intuitive definition.

Of course, this begs the question: what is a “disease”? A typical definition of disease provides guidance, if not absolute clarity: “any deviation from or interruption of the normal structure or function of any body part, organ or system that is manifested by a characteristic set of symptoms and signs and whose etiology, pathology and prognosis may be known or unknown.” In holding obesity up to this standard, its appropriateness could hinge on whether a body with a body mass index (BMI) greater than 30 would be considered a “normal structure”; this in turn depends on how we define “normal.” Ironically, if we refer to a standard statistical concept of outliers—usually, the most extreme 5 percent or so of a population—then the more widespread our so-called national obesity epidemic, the more “normal” obesity becomes. Currently, more than a third of the entire U.S. population is obese; in certain states and in some ethnic/racial groups, the proportion is closer to half. Clearly, these are not “outliers.”

But I think the annals of preventive medicine have demonstrated that diseasification has its place. Let us look at a reasonably successful story of diseasification: that of hypertension. Some readers might be surprised that I’m considering this “diseasification”: after all, isn’t hypertension clearly a disease? Well, no, it’s not. There are no symptoms, illnesses or dysfunctions related to hypertension per se. Hypertension refers to an elevated blood pressure, where “elevated” was established in a discretionary (though certainly not arbitrary) manner. Coincidentally, about a third of all Americans fit the definition of people with hypertension, so these are also not “outliers” in the traditional sense. But what we do know is that high blood pressure is a major, modifiable risk factor for things that are diseases—important ones, such cardiovascular diseases, of stroke and heart attack. Moreover, we know that pharmacological efforts to lower blood pressure below established cutpoints leads to a reduction in the risk of such diseases. So diseasifying hypertension has led to helpful treatments and to a reduction in disease outcomes.

Obesity, however, is a wholly different animal. First, while obesity has been shown to be a risk factor for certain diseases—indeed, many of the same diseases predicted by high blood pressure—its association with those diseases is neither so strong nor so direct as that with hypertension. Moreover, healthcare practitioners do not have the sorts of treatments in their toolkits to treat obesity that they do for high blood pressure, and even more significantly, there is no direct evidence that using treatments to lower BMI will in turn reduce the risk of the real diseases that are associated with obesity—the ones we really care about. Thus, the presumed “upsides” of this new AMA-endorsed classification are hard to imagine. Given the lack of effective and proven therapies, what benefit do we seek? Prevention, as Dr. Ayoob indicated, is key—but our rapidly exploding national obesity prevalence isn’t caused by lack of adequate medical care; rather, it is due to wholesale changes in diet and lifestyle, largely promoted by corporate marketing, governmental policies, new technologies and changing norms of behavior. These are amenable (alas, not easily) to public health interventions and policy change, but not to increased doctor visits.

An open question is: if this relabeling of obesity has an impact on the stigmatization of the overweight, will it be for good or ill? On the good side, perhaps, is recognizing that it isn’t necessarily a sign of sloth or weakness of will, but something that may be beyond volitional control, much as classification as disease may have improved the situation for alcoholics or substance abusers. On the other side—do we really want to equate obesity with such things? I think we ought to heed lessons from the fat acceptance movement, and consider that the overweight seem to be the last social group that it is deemed acceptable to malign. Certainly, there are many fat people comfortable in their own bodies; do we really want to say to them, “Sorry, it doesn’t matter what you think, you’re sick”? Not a necessary corollary of diseasification, I think, but a cause for concern.

Paul Marantz, M.D., M.P.H.

Is obesity a symptom or a disease?

There’s a great scene in the classic West Side Story in which members of the Jets gang go through all the different things people say is wrong with them.

“The problem is he’s crazy, the problem is he drinks, the problem is his mother, the problem is he stinks.”

“I’m depraved on account ‘a I’m deprived!”

It’s satire, and it’s funny, and it’s a catchy song, but it illustrates the complexity of social and behavioral problems and their origins and solutions.  The theme still rings true, the most recent example being the recent labeling obesity as a disease by the American Medical Association.  Oh! The problem is I gotta disease!

This move effectively creates sick people where none existed.  Which takes said sick people off the hook.  Cancer is a disease.  Type 1 diabetes is a disease.  Plague is a disease.  Those are things that happen to you despite your best efforts and through bad luck, bad genes, bad karma, whatever your belief system might be.

Obesity is, with few exceptions, created by the person who is obese, or by his or her surrounding environment.  Moreover, obesity in and of itself is not even bad.  It can create disease, but is not a sickness itself. So a person with a BMI in the obese category who is otherwise completely healthy and happy  is now sick.  And the person who has sleep apnea, diabetes, high blood pressure, and poor circulation from a lifetime of doughnuts and pizza is also sick, but it’s not his fault, because he has a disease.  Wow. That ought to be a load off a lot of peoples minds.  Once you allow people to assume the sick role, personal responsibility tends to fade away.

Of all organizations, the members of the AMA should know the difference between a symptom and a disease.  It is basic first year medical school stuff.  Obesity, in people who are obese and also sick with the things associated with obesity, is a symptom.  All doctors know any isolated symptom can be caused by a host of different processes, some lethal, some benign.  A healthy person might be obese by classification.  Many football players would fall in this category.  A lot of sick NFL stars out there.

Obesity could be a symptom of low self-esteem, a symptom of poverty, a symptom of environment, a symptom of hormonal imbalances (in which case there is a disease, but it’s not obesity), a symptom of medication.  As Dr. Paul Farmer would say, “Sure, he’s got TB, but problem is he’s starving.”

Or, I guess semantically, obesity could be a cause of disease.  Pneumococcus is a cause of pneumonia.  Is pneumococcus a disease?  No, it’s a bacteria.  The thing about causes is, if you can treat the cause, the disease goes away.

Finally, the AMA has added another way for the health care industry to make money.  Label something a disease and suddenly drug companies, procedures, and specialists spring up from the earth ready to reap the benefits of the fact that now Medicare is going to pay for all this new stuff.  Because there are so many more sick people now.

That need drugs.  And surgery.  To treat their disease.

Shirie Leng is an anesthesiologist who blogs at medicine for real.

Obesity's new label a concern for employers

Don’t hire an overweight woman because she doesn’t fit your corporate sales image and face a possible discrimination lawsuit.

Call your employee “Fatty” instead of his name and open up your company to harassment charges.

A decision this summer by the American Medical Association to classify obesity as a disease, instead of a condition, has heightened concerns among employment law officials about such possible workplace outcomes.

Employees who are obese — possibly as few as 30 pounds over recommended body weight for their height, age and sex — are now more likely to be recognized as disabled with rights under the 2008 amendments to the Americans with Disabilities Act.

That can be a big, costly deal, given that one-third of American adults are classified as obese, on top of another one-third considered overweight. The U.S. obesity rate jumped nearly 50 percent from 1997 to 2012, according to the Centers for Disease Control and Prevention.

“Recognizing obesity as a disease will help change the way the medical community tackles this complex issue,” AMA board member Patrice Harris said in a statement explaining the reclassification.

The physician group’s new definition of obesity doesn’t in itself have any force of law, “but there’s a high probability it will make it easier for an obese employee to argue that he or she is disabled,” said Myra Creighton, a partner at Fisher Phillips, who specializes in advising employers about their obligations relative to workers with disabilities.

“It may be easier for employees to prove disability discrimination,” Creighton said. “And, if classified as a disease, it will be difficult for employers to argue that any level of obesity is not an impairment.”

Disability law says an impairment is something that affects a major life activity or body function — and that could include walking or sitting.

A portent of things to come emerged in a lawsuit settled last year after the Equal Employment Opportunity Commission had sued a BAE Systems subsidiary in Houston for disability discrimination. The commission had charged that the company regarded an employee as disabled and fired him because of his obesity even though he could perform his job.

To settle the case, the company agreed to pay the fired worker $55,000 and cover his outplacement services, train managers in disability law compliance, and post anti-discrimination notices in the workplace.

Studies have long confirmed a “beauty bias” — a tendency for employers to hire and promote attractive people over less comely ones. That bias includes a tacit preference for trim people over fat ones.

But such bias is nearly impossible to prove in a discrimination lawsuit. And obese workers, with extremely limited exceptions, have never had any specific anti-discrimination protections by law.

The AMA’s reclassification of obesity as a disease sparked conjecture that will change.

Creighton’s advice: “Employers should avoid any suggestion that the employee’s weight suggests the employee cannot do a particular job.”

Employment law attorneys and human resource officials now are watching to see if the EEOC expands its definition of a disability beyond its current “morbidly obese” distinction. That generally means someone weighs twice the normal body weight.

“Even if the EEOC does not rush to expand the definition of disability, employers should be aware that overweight employees may still be protected under the ADA,” wrote Shannon Morales and Elizabeth Rudnick in a legal post on lexology.com.

Under federal disability law, even if employees aren’t morbidly obese and aren’t limited in life functions, they still may qualify as protected by law if the employer “regards” them as impaired.

Thus, workers passed over for hiring or promotion because of obesity may be able to show they were denied jobs because the employer regarded them as impaired.

Ken Sigman, owner of Health and Benefit Systems, a consulting company in Leawood, worries that the AMA reclassification of obesity as a disease needs more input from nutritionists and other groups before it causes changes in workplace case law.

“Obesity is more of a risk factor than a disease,” Sigman contended. “And it can be temporary. People can lose weight. So I think the AMA may have gone a bit too far.”

Without a doubt, Sigman acknowledged, studies show that obesity correlates to higher risks of diabetes, heart disease, stroke and other metabolic syndromes. And those conditions lead to higher medical and pharmacy costs, more absenteeism, and higher workers’ compensation and short-term disability costs.

But he warned against employers making assumptions about who is obese. Body fat analysis can show surprising results, he said, sometimes proving, for example, that hulking football players have extremely low body fat or apparently “normal-sized” women have high fat indexes.

Obesity in adults is defined as having a body mass index, or BMI, of 30 or higher.

The AMA’s designation also spurred some criticism that “medicalizing” obesity could encourage doctors to prescribe more costly drugs and do even costlier weight-loss surgeries rather than encourage lifestyle changes.

But the AMA, joined by the American Association of Clinical Endocrinologists, the American College of Cardiology and others, said obesity was a “multimetabolic and hormonal disease state.”

“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,” the AMA resolution said.

Jack Bastable, a wellness consultant with CBIZ in Leawood, said employers’ current focus on the Affordable Care Act is overshadowing discussion of obesity rights in the workplace.

“But there’s no question among us in the industry that the light is shining brighter and brighter on obesity,” Bastable said. “It will get more attention. We lead the world in obesity, and that’s a complex issue. Everything from school lunches to the snack industry are trying to engineer changes, but it’s hard to change, and we really haven’t fully addressed about how to deal with obese people in the workplace.”

Is Obesity a Disability? – Law Blog



Associated Press

The above question is an important one in employment law. If the answer is “yes,” then obesity is covered by the Americans with Disabilities Act. That, in turn, means that obese people are afforded legal protection against discrimination based on their weight, and a sharp tool with which to enforce that protection in a court of law.

Historically, obese employees have had a tough time convincing judges they are disabled in lawsuits alleging employer discrimination, unless their obesity is a symptom of another disability. But the American Medical Association may have improved their case, according to employment lawyers. (Hat tip to Walter Olson at Overlawyered.)

In June, the AMA upgraded obesity from a condition to a disease.  Jon Hyman, a partner at Kohrman Jackson Krantz PLL in Cleveland. . . . . .

Obesity Covered Under Americans With Disability Act

Chris Christie

New Jersey Governor Chris Christie recently had gastric bypass surgery to help him lose weight.

See Also

The American Medical Association’s decision to call obesity a “disease” instead of a medical condition could make it harder to discriminate against fat employees, The Wall Street Journal Law Blog reports.

Now that obesity is a disease, people with body mass indexes of more than 30 are almost certainly covered under The Americans with Disabilities Act, attorney Jon Hyman told the Law Blog.

That 1990 law says employers have to provide disabled workers with “reasonable accommodations” to help them do their jobs. It also makes it illegal for employers to fire workers for being disabled.

“Conventional wisdom has been that normal, run-of-the-mill obesity, unlinked to an underlying medical condition such as diabetes, is not a disability protected from discrimination by the Americans with Disabilities Act,” Hyman has written on his blog. “This decision by the AMA, however, will likely flip that conventional wisdom on its head.”

The AMA’s decision isn’t legally binding but will likely influence courts, which have previously been reluctant to consider obesity to be a disability, Hyman told the Journal.

Back in 2006, the U.S. Court of Appeals for the Sixth Circuit ruled that obesity had to be the result of a “physiological condition” in order to be covered by the ADA. The court said it declined to provide ADA protection to everybody who has “abnormal” physical characteristics — if it did so, it ruled, people who were “extremely tall or grossly short” would get protection under the law.

Heartwise Ministries – Obesity: a Disease?

Obesity: a Disease?

The New York Times News Service has reported that the American Medical Association has officially recognized obesity as a disease, a move reportedly done to encourage physicians to take a more active role with their patients who have this condition. “Recognizing obesity as a disease will help the medical community tackle this complex issue now affecting one in three Americans,” stated Patrice Harris, a member of the association’s board.

 

I am unsure what this means since the definition of what constitutes a disease is debated. Still even though the AMA has no authority, having the nation’s largest physician group make the declaration would bring more focus to the disease or condition or whatever label is attatched. Morgan Downey, publisher of the online Downey Obesity Report believes it might improve reimbursement.

 

Two new obesity drugs Qysmia and Belviq have entered the market. We hear more and more advertising for obesity drugs, supplements which speed up the metabolism, and bariatric surgery. Everyone has a new diet plan. The question I want to throw out is why? Why do we have the problem? Why are there so many products on the market? Why are the rates of obesity soaring? Why do we need to call obesity a disease in the first-place?

 

I agree this is the nation’s greatest health issue. If we understand why, we might be able to make some headway. I would like providers to get reimbursed for sitting down with the patient and finding the “why” for each individual patient and working out a long- term plan. The why might be different for each individual. The why usually involves the brain and relationships and is not as simple as telling someone to take a pill, eat less or exercise more. Loving and not judging are two other important treatment considerations.

 

When the complexity is realized and the reasons why are addressed, we have a chance. With two In three affected, rising rates, and resulting medical conditions, we must do more than call this condition a disease. This is an economic crisis as well. We need to go to war against obesity as this condition is literally killing us. Obesity, Is it a disease? Is it a crisis? Is it a symptom of a sick world?

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In controversial vote, American Medical Association declares obesity …

The largest association of doctors in the US has voted to change its definition of obesity, in a move that could catalyze major changes in insurance coverage, research funding, and public perception of the condition.

In a vote held yesterday by the American Medical Association (AMA) at their annual conference, association delegates agreed that obesity — primarily characterized by a body mass index above 30 — ought to be treated as “a disease, requiring a range of medical interventions.” Research increasingly indicates, as the AMA noted, that obesity is a complex condition whose causative factors — like genetics or environment — are often beyond an individual’s control. Previously, the AMA and other medical organizations had all defined obesity as a “major public health problem.”

“Obesity is a driver of much suffering, ill health, and earlier mortality.”

While this new definition isn’t legally binding, the AMA’s vast influence means that it might very well transform how physicians, legislators and insurance companies address weight loss among those deemed obese. Doctors may be more likely to counsel obese patients on weight loss options, and surgical procedures to promote weight loss, like lap band or gastric bypass, might be covered more comprehensively by health insurance companies. The decision could also see more research dollars allocated to novel pharmaceutical or surgical options.

“[Obesity] is a driver of much suffering, ill health and earlier mortality, and people affected are too often subject to enormous societal stigma and discrimination,” said Theodore Kyle, advocacy chair of The Obesity Society, in a statement applauding the decision. “This vital recognition of obesity as a disease can help to ensure more resources are dedicated to needed research, prevention and treatment.”

Promote an over-reliance on medication and surgery

But the AMA decision isn’t without controversy. In fact, Tuesday’s vote diverges from earlier advice by an AMA panel, whose members warned that classifying obesity as a disease threatened to promote an over-reliance on medication and surgery, rather than lifestyle interventions. That panel also noted that the BMI, which is the key metric to determine obesity, carries significant flaws. Most notably, plenty of people with a BMI above 30 are, in fact, perfectly healthy. “Given the existing limitations of BMI to diagnose obesity in clinical practice, it is unclear that recognizing obesity as a disease, as opposed to a ‘condition’ or ‘disorder,’ will result in improved health outcomes,” the panel noted earlier this year.

U.S. Doctors' Group Labels Obesity a Disease – WebMD

U.S. Doctors’ Group Labels Obesity a Disease

By Steven Reinberg

HealthDay Reporter

WEDNESDAY, June 19 (HealthDay News) — In an effort to focus greater attention on the weight-gain epidemic plaguing the United States, the American Medical Association has now classified obesity as a disease.

The decision will hopefully pave the way for more attention by doctors on obesity and its dangerous complications, and may even increase insurance coverage for treatments, experts said.

“Recognizing obesity as a disease will help change the way the medical community tackles this complex issue that affects approximately one in three Americans,” AMA board member Dr. Patrice Harris said in a statement Tuesday. “The AMA is committed to improving health outcomes and is working to reduce the incidence of cardiovascular disease and type 2 diabetes, which are often linked to obesity.”

One expert thinks the AMA’s decision, approved Tuesday at the group’s annual meeting, could lead to greater coverage by insurance companies of treatments for obesity.

“We already treat obesity as a chronic illness,” said Dr. Esa Matius Davis, an assistant professor of medicine at the University of Pittsburgh. “But this decision will bring more resources into the picture because it will, hopefully, allow for more insurance coverage and that really has been the issue of getting people the help that they need,” she said.

Treatments for obesity — including drugs, nutritional counseling and surgery, if needed — often don’t get reimbursed by insurance companies, Davis said. That means many patients aren’t getting the care they need because they can’t afford to pay the out-of-pocket costs, she said.

If insurance covered these services “it would increase referrals and treatment and that would be a huge step in the right direction,” Davis said.

Right now, Davis gets insurance coverage for her obese patients by diagnosing them with high blood pressure or high cholesterol or diabetes, or other obesity-related conditions. But, that still leaves many obese patients out in the cold, she said.

The Obesity Society, which calls itself the leading scientific society dedicated to the study of obesity, applauded the AMA’s decision. “The passage of a new American Medical Association policy classifying obesity as a disease reinforces the science behind obesity prevention and treatment,” Theodore Kyle, advocacy chair, said in a statement.

“This vital recognition of obesity as a disease can help to ensure more resources are dedicated to needed research, prevention and treatment; encourage health care professionals to recognize obesity treatment as a needed and respected vocation; and, reduce the stigma and discrimination experienced by the millions affected,” he said.

Kyle said the AMA has now joined a number of organizations that have previously made this classification, including the U.S. National Institutes of Health, the Social Security Administration, and the Centers for Medicare and Medicaid Services.

Is Obesity a Disease? | BU Today | Boston University

The nation’s top doc group has voted to classify obesity as a disease.

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.

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.


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