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The statements from august medical authorities were grand and sweeping. This was important news, they said. This would change everything. Pay attention, patients, they said. The experts have spoken, and their word should be taken as final.
Obesity is a disease.
Last month, the House of Delegates of the American Medical Society decided to declare that obesity is "a disease state with multiple pathophysiological aspects requiring a range of interventions to advance obesity treatment and prevention."
Those are lot of big words, but the meaning is simple and clear: People struggling with obesity- and their doctors-should know that their condition is complicated and needs serious attention. Folks with diabetes are recognized as having a chronic disease that requires management and folks. fighting obesity should be given the same courtesy.
"This is clearly a landmark day for the millions of Americans affected by obesity," said Dr. Jeffrey Mechanick, who serves as president of the American Association of Clinical Endocrinologists. That group sponsored the AMA resolution.
What will the definition mean? Dr. Ethan Lazarus, a delegate for the American Society of Bariatric Physicians, outlined it this way during the June meeting.
"Classifying obesity as a disease will reduce weight bias," he said. "It means that medical students and residents will receive training in what obesity is, and in the best treatment approaches. It means that the medical community will have incentive to research and develop new and better prevention and treatment strategies.
"But most importantly, it communicates to individuals affected by obesity that this is a chronic disease, not a problem of personal responsibility," he said.
Another grand and sweeping statement. But is it really that simple? Is it as cut-and-dried as classifying this grave and spreading condition as a disease? Will it really lead to better health care outcomes?
What's Actually Going on?
There's no question that obesity is a complicated problem, and that it's spreading. As the years have passed and more and more people have gotten heavier and heavier, the supposed explanations (and diet books) have multiplied:
-People are eating too many carbohydrates. Or maybe they're eating too much fat. Maybe it's the kind of carbohydrates or fats they're eating.
-People aren't moving around as much-they're stuck to their couches watching endless television shows or playing endless video games. They're even sitting down for hour after hour at work.
-There are chemicals in our water and environment that are reprogramming our bodies to pack on the pounds. Or our food is somehow tinkered with by global conglomerates to make it ever tastier and ever more fattening.
-Genetic factors make certain types of people much more likely to gain weight. It's our ancestors' fault for being so efficient at conserving energy.
And yet none of these explanations has covered everything. Patients keep gaining weight. Doctors and researchers (and health writers) keep trying to figure out what's going on. Maybe, then, the AMA's move is the only sensible one. It tells us that obesity-in the final equation-has to be treated as a full-on, deadly serious disease.
"Similar to many other medical conditions, obesity is a complex, multifactorial chronic disease, requiring a multidisciplinary treatment approach," Mechanick said. "This approach must encompass the best standards of care, both in terms of the treatments chosen, and the care coordination and clinical environment in which they are delivered. Because of the complex nature of obesity and its variety of impacts on both physical and mental health, effective treatment requires the coordinated services of providers from several disciplines and professions."
In other words, general practitioners can't just scold obese people and hand them a diet plan. They need to see if other specialists are needed. They need to see if there are deep-rooted problems present, perhaps overlooked in the past. They need to show the same attention and care that they would to, say, a type 1 diabetes patient who needs regular, specialized treatment.
And that's one of the key points. Extra attention and extra specialists and extra care costs extra money. Both for treatment of individuals and for research of obesity more generally. And until now, there have been barriers.
"Adoption of this policy position by the AMA will help advocates in the obesity community address a number of key hurdles to individuals receiving critical medically necessary obesity treatment services," Mechanick said.
Who could argue with that? Actually, some people could.
Hearing the Criticisms
The problem, these critics suggest, is that money is what's actually driving this move. More research? Fine. But what Mechanick seemed to suggest is that obese people need more "medically necessary obesity treatment services."
What might those be? Bariatric surgery, for one. And given that obesity isn't covered by most insurance plans, this decision could well be a boon for specialists who perform that operation. With obesity considered a disease, more insurance companies might decide to pay them for their services, and they might have more customers.
The American Society for Metabolic and Bariatric Surgery was indeed quick in praising the AMA's move. The society is the biggest group of such medical specialists in the world.
"We are at a tipping point. The scientific consensus and the mountain of evidence that have been built around the disease of obesity and its treatment cannot be ignored," said John Morton, secretary-treasurer for the society and an associate professor at Stanford University. "Now patient access to proven treatments needs to improve so scientific consensus is aligned with coverage policy."
The group's president praised the move, too.
"Many private health insurers, employers and state health plans specifically exclude the treatment of obesity and severe obesity from their coverage policies," said Jaime Ponce. "Recognition of obesity as a disease by the AMA sends a powerful message that access to evidence-based treatments across the spectrum of the disease are medically necessary and should be treated in similar fashion to treatments for type 2 diabetes, heart disease, or high blood pressure."
It's important to not to be cynical here. Most people don't go into medicine simply to make money. And bariatric surgery and related treatments have shown themselves to be remarkably effective for some patients. In other words, these medical professionals believe sincerely that what they're doing is in the best interests of patients.
But let's state the obvious. Altering the finances around obesity-changing what's covered by insurance and how much funding researchers receive-isn't guaranteed to change anything about obesity itself. At best, these changes will allow more people struggling with obesity to receive quality medical attention. Will that attention solve their problem? Will it stem the larger tide of obesity and obesity-related problems in our society?
For that matter, if we say that obesity isn't related to personal responsibility, are we giving more people more leeway to indulge in self-destructive behaviors? Does a certain amount of societal opprobrium keep obesity from being an even worse problem?
We just don't know.
In the Final Estimation
However you define obesity-disease, condition, breakdown of willpower, societal issue-it's a real and growing threat. And human beings are problem-solving creatures.
It's therefore natural and defensible to try everything in our power to address a problem like obesity. The AMA should be commended for taking it seriously and urging medical providers to work together, with dedication and seriousness, to help patients. The organization's motives were commendable.
But we can't allow a new definition-and the extra the dollars that could flow because of it-to think that we're actually solving anything. That's up to the patients and the doctors and the researchers. If they have new resources, they need to make sure they're deployed to do the most good. And they need to follow through.
As do all of us.
Solving a problem like obesity won't be done quickly or through symbolic gestures or with piles of cash. It will likely take a society-wide rethinking of norms and values, of nutrition and medicine, of activity and leisure. It won't be simple. It won't be easy. But it is necessary.
2 comments - Jul 16, 2013
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