Is obesity a disease? Clinicians disagree
■ Advocates for this designation say it will mean that this problem will be taken more seriously. Those opposed say it will negate personal and societal responsibility.
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According to J. Michael Gonzalez-Campoy, MD, PhD, an endocrinologist from Eagan, Minn., patients who have a body mass index of more than 30 have the disease of obesity. They need to be advised on lifestyle changes, prescribed medication if appropriate and referred for surgery as necessary. In other words, the condition is serious.
"Obesity is a disease, and it should be treated like any other disease," said Dr. Gonzalez-Campoy, chief executive officer of the Minnesota Center for Obesity, Metabolism and Endocrinology.
Paul Handel, MD, a Houston urologist who works on obesity issues, also believes obesity is a serious problem. It is not a disease in its own right, he believes, but leads to many serious diseases and should be addressed by policies that encourage individual responsibility and lead to societal changes that nurture healthier lifestyles.
"If we consider obesity a disease, what it really implies is that individuals have no control over what's happening, and, therefore, as a nation and as a culture, we need to commit more of our resources to treating the complications of the weight and obesity problem rather than saying it's a preventable event that really demands a societal response," said Dr. Handel, vice president and chief medical officer at BlueCross BlueShield of Texas.
These two physicians take obviously divergent positions in the ongoing debate about solutions to America's weight problem. The discussion turns on a very basic question: Should obesity be defined as a disease?
The answer is not clear cut.
On one side are doctors who say it should be labeled as a disease because of its link to significant morbidity and mortality. Some medical societies, particularly those focused on bariatric medicine and endocrinology, recognize it in this manner. Beyond these specialties, the American Academy of Family Physicians adopted policy in 2004 declaring obesity a disease.
"Conditions that cause people to have adverse health outcomes, heart attacks, breathing problems, diabetes, anything that would cause those things, I think would be legitimately labeled as a disease," said AAFP President Larry Fields, MD.
Still, the subject has been a matter of passionate debate at the past two American Medical Association annual meetings with Dr. Handel and Dr. Gonzalez-Campoy -- both AMA delegates -- contributing. The AMA continues to recognize obesity as a major public health threat and works to reverse its grasp. It does not classify it as a disease.
"Whether you call it a disease or not, it's a very important public health problem, and it's a condition that requires great attention," said AMA Trustee Ron Davis, MD.
Perception is everything
Those in favor of such a designation argue that it will cause more physicians and patients to approach obesity more seriously. Scientists will be funded to develop more effective interventions. Patients will be able to get the treatment they need, and third-party payers will pony up for weight-reduction services.
"Primary care counseling services are sometimes difficult to code appropriately. Categorizing obesity as a disease would probably help that," said Michael Gamble, MD, a family physician in Dugger, Ind.
Others are not convinced it would make obesity be viewed more gravely and inspire action.
"If you call it a disease, then patients don't have to fully take ownership for their lifestyle habits," said Gregory Dean Smith, DO, a family physician and president of OccMed Colorado, a company that runs numerous occupational clinics in the state. "It becomes an excuse."
There is also significant doubt among those who are hesitant that applying the label automatically will ensure insurance reimbursement. The Centers for Medicare & Medicaid Services concluded last year that the critical issue was not whether obesity was a disease but rather whether services to address it were "reasonable and necessary."
The agency does not generally reimburse for weight-reduction services, but there are signs that it may be warming to the idea. In November 2005, CMS said it would cover bariatric surgery for Medicare enrollees with disabilities who are younger than 65 and meet certain criteria, but declined to provide the coverage for older patients. A final decision is expected this year.
From the perspective of the private insurance industry, the disease label is not necessarily the integral piece that will lead insurers to pay.
"Calling something a disease does not mean it's automatically covered, and we're seeing a greater emphasis on coverage for things that are related," said Susan Pisano, spokeswoman for America's Health Insurance Plans. "The key issues are whether there's evidence the intervention works and a willingness on the part of employers to pay for it."
Needless or necessary label?
Physicians who don't want to use the disease moniker say labeling obesity a risk factor, medical condition or symptom should be sufficient for proper reimbursement.
"I don't think the behavior of insurers should dictate how we define various medical conditions," Dr. Davis said. "Nonetheless, it's important that public and private insurers pay for the treatment of obesity."
Advocates for the disease label agree that in an ideal world, obesity should not have to be reclassified in order for it to be covered. But the current situation is simply not adequate.
"You can't get reimbursed for a symptom or a risk factor," said Melanie Jay, MD, a general internist who runs a weight-management clinic at Gouverneur Diagnostic and Treatment Center in New York City. "When the patient comes to see me, I can't bill for obesity. I have to bill for their osteoarthritis, hypertension, diabetes -- things related to their obesity and because of their obesity."
Truly tackling the problem, others say, will take more than ensuring that physicians are paid for these services, and defining obesity as a disease puts too much emphasis on the medical sphere. "What we ought to be doing is the basic research on behavior and behavior modification and realign our society so that we can indeed furnish less-caloric food," Dr. Handel said. "We need to get back to making our communities safe so that our kids can go out in the front yard and play, and so we can go out for a walk after dark in our neighborhoods and work off dinner."
Those in favor say that reclassifying obesity doesn't detract from these efforts and that it would be possible to both label it as a disease and actually increase the responsibility of the wider world because it would be taken more seriously as a health problem. "It's not one or the other. It's both," Dr. Gonzalez-Campoy said. "We need to very aggressively have in place public health measures that foster healthy behaviors."
Considerable debate also surrounds how the disease label for those who are obese will impact individual patients, particularly with regard to stigma. Arguments on the pro side maintain that diagnosing obesity as a serious disease would remove the stigma of laziness or lack of willpower associated with heft.
"If it's not a disease, then what is it? Is it a moral issue? Is it a problem of self-control?" Dr. Jay asked. "For some people, it's more stigmatizing for them to be told that they just have to stop eating and exercise more."
Those opposed argue that the designation actually would stigmatize large numbers of people as diseased who don't feel sick and don't have any ill affects from extra weight. There also might not be much they can do about their size. Even the best weight-loss interventions have limited efficacy.
"Some people are born big. They're never going to not be big," said Tim Church, MD, PhD, MPH, medical director of the Cooper Institute, a nonprofit research center in Dallas focused on the link between living habits and health. "Other people as adults put on weight. But let's be honest. They aren't going to lose a lot of weight, and they aren't going to keep it off. Should we be labeling these people as diseased?"
This school of thought highlights one of the problems surrounding efforts to address obesity. An unhealthy diet and a sedentary lifestyle are confirmed as health risks, even among those who are a healthy weight. The evidence supporting obesity as an independent factor in morbidity and mortality is not as solid. Thus, there's always concern that reclassifying obesity as a disease would place too much emphasis on the scale.
"If you tell somebody to go out and starve, all you're going to do is induce a lot of metabolic changes that will eventually lead them to be fatter," said Dianne Budd, MD, an endocrinologist and assistant professor at the University of California, San Francisco. "If you tell someone to eat five servings of fruits and vegetables ... sleep seven to eight hours a night, do all the things that we know are really healthy, then you might actually prolong their life."
Still, those most in the pro-disease camp argue that the evidence and their own experience are sufficient to identify obesity as a disease unto itself and that putting obesity in the disease box is a matter of calling something what it is, even if the re-categorization does nothing more than create a new addition to the list of diseases circulating in the community.
"It absolutely is a disease," said Alan Wittgrove, MD, medical director of the Wittgrove Bariatric Center at Scripps Memorial Hospital in La Jolla, Calif. "Obesity is not just a risk factor for something else. It's THE problem. To say that it's a symptom or a condition is glossing it over."
But those uncomfortable with this approach maintain that such a change would be far more than semantics and great care should be taken before millions of people shift from being obese to having the disease of obesity.
"Obesity is a disease only if money or physiology actually dictate it," said John La Puma, MD, medical director of the Santa Barbara (Calif.) Institute for Medical Nutrition and Healthy Weight. "We have to take into account how patients actually feel, and the vast majority, even people who are morbidly obese, do not think they're sick."