Does the process of diseasification hold any promise in obesity?

In a thoughtful, measured and well-reasoned blog post, 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 is associate dean, clinical research education and director, Center for Public Health Sciences, Albert Einstein College of Medicine. He blogs at The Doctor’s Tablet.

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  • Guest

    My sister-in-law, now:

    “Don’t JUDGE me, it’s not my FAULT I’m fat, it’s a DISEASE!”

    Next, she wants “fattism” declared a Hate Crime.

    As for the claim that “the overweight seem to be the last social group that it is deemed acceptable to malign” ….. you haven’t seen how smokers are treated lately?

    Or maybe it’s next on the AMA agenda to have smoking deemed a “disease” and to make it illegal for employers, insurers, etc. to discriminate against them!

  • Suzi Q 38

    It is a food disease.
    You forgot that sex addicts also have a disease.
    Same with alcoholics.

  • guest

    The same thing is happening in psychiatry. THe DSM has changed to pathologize everything. Not surprising since the pharmaceutical industry were involved in the new DSM. New disease equals more meds to treat means more money in their pockets. pretty clever.

  • Tiredoc

    S: “I’m fat”
    O: Fat
    A: Fat
    P: Labs, counseling, acupuncture, medication, physical therapy, surgery. Take your pick.

    Just because you don’t know how to fix it doesn’t make it not a problem. If the patient complains about it, it has a physiological basis, and there’s something we can do, what’s wrong with treating it?

    • Suzi Q 38

      Because “fat” can be treated at Weight Watchers for $12.00 a week, or Myfitnesspaidot com for FREE.
      Going outside and walking or riding your bicycle is free, too.
      If not there is the gym.
      If you don’t like the gym, clean your house or apartment at a rapid pace.

      Eat salads at dinnertime.

      No meds, no surgery.

      • Chris

        I adopted two active dogs from the shelter. They are my personal trainers, I absolutely positively HAVE TO walk them for at least 30 minutes twice a day, rain or shine. The excuses I used to make for myself, don’t fly with these guys! And they aren’t really very expensive to keep, considering how they help me. I have lost 30 pounds since March, nice and slow and steady, and this is something I could easily keep up for a lifetime (unlike grapefruit diets and Jazzercize classes!).

        More doctors should prescribe dogs :)

        • Suzi Q 38

          What a good idea!

        • Tiredoc

          Do you have a recipe? (Sorry, couldn’t resist!)

        • Disqus_37216b4O

          I like dogs, but I couldn’t eat a whole one.

    • ErnieG

      “Treating it” also means spending vast amounts of (insurance) money on a condition that is not, for most people, medically treated…rearranging decks on the Titanic type of thing. Obesity is clearly a lifestyle, mostly food, issue. There, of course, parties other than the patient responsible for the “bad food” supply in this country that favors high processed, high calorie, poor nutrition, cheap food, but this is not an issue individual docs can fight. Perhaps the AMA…wait, they pretty much don’t care about generalist, just having a place for specialists at the table. What better way than making obesity a disease, so that specialist can “treat it”, and generalist can “clean up” the mess.

    • guest

      LOL. Good note.

  • Tiredoc

    It never fails. A post pops up about obesity and this crowd comes out. As a physician, I’ve never found that telling people that they’re fat, lazy and stupid changes behavior. And telling fat people that it’s easy to lose weight, that’s a good one too. And finally, after all that blaming fat peope for being defensive and not sitting there and get berated for their moral failure.

    The top 4 medications to treat obesity are phentermine, topiramate, bupropion, and metformin. In addition, testosterone is making inroads and is Victoza and Byetta. The first 4 are generic and inexpensive. All 4 of them in combination are less than $100 a month. Testosterone, Victoza and Byetta are off-label and are not covered by insurance. The laboratory evaluations would be drawn anyway because fat people are sicker. I have yet to have a patient that I listed “obesity” in the problem list that cost anywhere near what people pay out of pocket for useless dietary supplements.

    Yes, there are fat people that are addicted to food with absolutely no metabolic abnormalities. There are also a ton of fat people (pun intended) with basal insulin in the 100s, or polycystic ovarian patients. I have yet to write a prescription for a patient that comes to me with a complaint of obesity that is off label. There’s almost always something other than lazy or stupid underlying the condition.

    I am not a diet clinic doctor, but when you’re specifically trying to deal with mitigating risk factors in obese, poor, smoking patients they come as a package deal. Treat them with respect, and learn that if it’s a problem for the patient and they ask you for help, it’s your job to figure out how to do it ethically and compassionately.

    • ErnieG

      I agree with you in so far as telling people they are fat and lazy won’t work…but that does not mean that the next step is medications either. The data for the medications used to treat obesity is pretty crappy. It seems pretty damn obvious that obesity for most people is a lifestyle issue, and while we have no reason to disrespect them nor treat their co-morbidities (such as we treat lung cancer, COPD, etc in smokers), it seems clear that obese patients need to feel empowered to create the change in their lives to get better. If the treatment for obesity is not within their power, then they and physicians will continues to putz around with meds. And I do feel that a good part of obesity is that many are ignorant about food- It shocks me when I speak to patients about food groups how they are unable to recognize what a protein, carb, and fat are.

      • Tiredoc

        You’re right about the meds. Just throwing them at the patients and hoping for the best is about as effective as the new fibromyalgia “treatments.” However, if they’re diabetic cranking up the insulin sensitizers and maximizing dietary education can be quite effective. Likewise for the PCOS patients. Topamax is pretty decent for the obese patients with migraines. I’ve never had much use for phentermine or bupropion.

        Most of the time as a doctor I see my job as helping sustain the effort of the patient. All the diet industry cares about is 3 months and 30 lbs. For more than that, sustained lifestyle change is key.

  • Frank Lehman

    But Judge, you can’t convict me of drunken driving. The problem is that I have this alcoholism disease. It must be a disease, since religion (ie. going to AA Meetings) did not cure it.

  • Sara Stein MD

    I think the benefit of diseasism is increased insurance coverage, research dollars, education, all in the name of early prevention, early treatment in order to prevent or delay endstage disease. I treat obesity every day. Good people come in my office. They have tried, they are exhausted and defeated, and they are willing to try again. I have a tool box that includes behavioral health, medication, surgery, physical therapy and fitness, nutrition, specialists. Some people need them all. Some people need one or two. Who cares if someone has to take a pill everyday to manage their obesity – maybe they won’t need multiple shots a day to manage their diabetes.

    For those of you who have the easy answers re eat less and move more, congratulations on your success. You have arrived at the ENDPOINT. May you never have a bad back or a ruptured tendon that interferes with your exercise schedule. May your healthy food budget always be intact, along with your home, your kids, your marriage, your job, your mental health. May you continue to know all the answers the rest of us cannot figure out for the starting point.

    Meanwhile we’ll just keep trying to match the right patient with the right treatment to remit their obesity. Sounds like a disease to me.

  • drjoekosterich

    We need less medicalization of life and life choices- not more. People are overweight/obese if they choose to consume more energy than they expend. This is a choice not a disease.

  • Joy Chan

    “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”
    What do you mean by this? I would have though lowering BMI does reduce risk of obesity related disease. Do you meant the actual treatments used do not reduce the risk? Or that the treatments don’t reduce BMI, and therefore do not reduce the risk?

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