Monday, June 16, 2008

Is Obesity a Disease?

I left readers with photos of three incredibly fit men on Friday - each is an elite athlete in the octagon, practicing mixed martial arts, at the top of their game.

I asked one question, aside from the UFC, what do they share in common?

Many answered they all share the common BMI classification "obese" - although that is correct, the answer I was going for was they're all "diseased" and in need of medical treatment for their obesity according to the authors of a new white paper published by the Obesity Society.

That's right, if the opinions expressed in this white paper are adopted, the men pictured would all be considered suffering a chronic, debilitating disease which needs treatment by healthcare professionals.

The committee that drafted the position paper took the unusual step to discard the evidence-based (forensic) model and opted for a philosophical argument from a utilitarian perspective.

While they credit themselves for taking this approach because "there can be no higher authority than reason," they ignore the important qualification for something to be declared a disease - is it a disease?

This abandonment of evidence, data and scientific inquiry undermines their approach by simply skirting the true purpose to determine if something is rightly, indeed, a disease state. To get around this wee inconvenience, instead they argue "...the utilitarian argument can address the question "should obesity be declared a disease?" as opposed to "is obesity a disease?"

The ramifications of this mind-bending mental-gymnastics are far-reaching, the authors ignore the moral and ethical can of worms opened if their position is adopted, with their beliefs trumping evidence as they remain steadfast in the belief that it doesn't matter *if* obesity is a disease, it should be declared one anyway because,

"Many obese people are desperate for treatment - the number of people who self-treat and those treated by commercial programs is larger than the number currently treated by the medical establishment. If obesity were considered a disease and entitled to the same considerations given to other diseases, treatment paradigms would change fundamentally...If treatment were covered, more physicians would be likely to engage patients in treatment protocols. The FDA would come under pressure to approve obesity drugs, and physicians would be more likely to use obesity drugs in treatment...With this increased attention, medical treatment options, especially drug treatment, likely would become more aggressive. Medical treatment and obesity surgery would be given more attention by physicians, health administrators, insurance companies, and employers, resulting in greater access by patients to higher quality care."

For those unaware of the various philosophical approaches, Utilitarianism is the idea that the moral worth of an action is solely determined by its contribution to overall utility, that is, its contribution to happiness, satisfaction, preferences or pleasure as summed among all persons affected. This is a form of consequentialism - the moral worth of an action is determined by its outcome - the ends justifies the means.

Because it is an 'ends justifies the means' line of thinking, it can be characterized as a quantitative and reductionist approach to ethics. And to be sure, this issue has far reaching ethical and moral implications - in the stroke of a pen, this perspective potentially takes 1/3 of our population and defines them as diseased, in need of medical intervention and treatment, by way of the crudest measure of obesity - the BMI.

As the three men in Friday's post highlight, obesity as defined by BMI is unreliable, thus flawed as a measure to determine if one is obese. This flaw isn't news, it's well established in the medical and research community as problematic, which is a reason why many continue to suggest the utilization of more refined measures, like waist-hip ratio and/or an actual measure of body fat percentage.

But even this well known flaw does not stop the authors from even suggesting the BMI standard be LOWERED to classify obesity! That's right, not only do these folks think we should abandon medical standards and wax lyrical about how obesity should be declared a disease, they also feel the BMI needs to be lower too!

Sandy Szwarc at Junkfood Science has a well written article about the paper already, so I'll skip the points she already made. I'll note here that one sentence bears repeating about why the philosophical approach in this paper is wrong, "By this logic, or course, poverty could be a disease... Black or ethnic minority a disease... Old age a disease... Homosexuality a disease... Ugliness a disease... Low intellect or literacy a disease."

In addition to the points made by Sandy, a big issue remains - what about the legal issues and medical ethics involved if obesity were declared a disease?

First and foremost is that should obesity be declared a disease, therefore a chronic medical condition, it would then follow that only licensed healthcare professionals would be qualified to treat obesity. The treatments would, of course, include a handful of diet pills, lifestyle interventions and/or bariatric surgery. Fully medicalized as a disease, obesity would no longer be 'treated' outside the licensed medical community because anyone offering services to the obese would be practicing medicine without a license since all disease treatments are the protected domain of licensed healthcare professionals.

More importantly however, is the problematic position "declaring obesity a disease" becomes for the healthcare professional. We'll explore these issues throughout the coming week.

What do you think? Should obesity be declared a disease? Why or why not?

17 comments:

  1. "There can be no higher authority than reason": but rational thought does not occur in a vacuum. It is informed by available information, particularly existing scientific evidence and the implications for treatment outcomes. Ignoring this information is inherently irrational, and it is easy to show that greater utility can be achieved by proper inclusion of available relevant information.

    Obesity (defined as excess bodyfat, not in terms of BMI) is a symptom of a disease, generally due to some underlying hormonal or nervous system problem. For most obese people, the evidence strongly supports the hypothesis that obesity is caused by excess insulin, in turn brought about by overconsumption of carbohydrates. If you want to call something a disease, it's the underlying hormonal disturbance. Treating the one symptom of obesity ignores all of the other metabolic problems brought about by the root cause.

    We need to pressure the FDA to adopt evidence-based dietary recommendations and educate the public, rather than wasting valuable resources approving drugs that only treat one symptom and probably do little to actually improve health.

    ReplyDelete
  2. Anonymous10:36 AM

    The medicalization of nearly everyone
    seems to be coming ever nearer and is something that is very scary. I bet the drug companies are slavering away over this!
    When are doctors going to wake up, take back their practices and reawaken their ethics? One wonders if doctors have been compromised too much to regain their profession's status and respect.

    ReplyDelete
  3. Barbara11:03 AM

    If obesity is a disease, so is having blonde hair. Geez, the continued medicalization of everything these days is enough to drive one mad!

    No, I do not think obesity is a disease. I also think part of the problem of obesity is the dietary recommendations these days. If we have an obesity problem, it's because all the crap being sold to the masses as 'healthy' is utter garbage. When the medical establishment finally acknowledges that it's the foods we're being sold that are a problem, maybe then we can tackle obesity. No way can the medical community do a turn-around with obesity with the current standards of a low-fat diet, excercise, pills, potions and surgery. All that will do is make a sicker population!

    ReplyDelete
  4. Anonymous12:00 PM

    We are conflicted right now over definitions. I am sure that both the medical and the common sense definitions of health and of disease mask real problems. In part the ADA Dx definitions of diabetes are written to avoid defining tens of millions of Americans as diabetic and therefore diseased. Those ultra-athletes in the previous post will need to pay special attention as they age to avoid actual obesity. Our friends who check out with BGs of 120 2 1/2 hours after a Big Mac Meal are not diabetic, but their metabolish is not exactly healthy either. And to be healthy means to some the ability to function. As we are very old, we don't need very much health to be indeed healthy. Most people have some sorts of ongoing disease process, whether competative athletes who beat up their bodies (hopefully for lots of lucre), to the various genetic vulnerabilities most of us probably have a few of. The paper you are reacting to is astoundingly unscientific. There is no emperical studies, I gather, for about anything they say. They do represent one strand of bureaucratic plundering. The building code is based on a lot of experience, but also a lot of skyblue speculation. The former is scientific and useful. The later is expense creating and full of unintended bad consequences.

    ReplyDelete
  5. Peter1:44 PM

    Follow the money....

    If obesity is classified a disease, pharmaceuticals become the only approved agents for treatment.

    If obesity is classified a disease, only doctors, nurse practiioners, RN's, Registered Dietitians and other "licensed" healthcare professionals are legally allowed to "treat" the obese.

    If obesity is classified a disease, sugery becomes an instant payday as millions now qualify for surgical treatment.

    If obesity is classified a disease, public policy may be created to levy taxes on foods believed to be contributing to obesity. Think red meat, butter, and fast foods like burgers and hot dogs.

    If obesity is classified a disease, insurance companies now have an opportunity to levy additional charges and/or nullify policies on those with "pre-existing" conditions.

    If obesity is classified a disease, it is not far off the mark to consider public policies to treat millions across the population. Think fat farms you may be forced to be committed to to make you comply.

    Obesity as a disease can be used to disqualify millions from adoption since chronic disease is often used as a reason to tell a couple no to adoption.

    Obesity as a disease can be used to further a socialist agenda for healthcare in this country too!

    ReplyDelete
  6. Anonymous2:10 PM

    Obesity is NOT a disease!

    ReplyDelete
  7. I don't think scientists should be in the business of "declaring" diseases, though. That is a good point that once you declare a disease, anything can be declared a disease.

    It seems to me that obesity isn't a disease in itself, but a symptom of metabolic syndrome. The same as diabetes, CHD, acne, high cholesterol, and a host of other disorders. Those are "diseases," as defined by medicine.

    If we go with the definition of a disease as "an abnormal condition of an organism that impairs bodily functions, associated with specific symptoms and signs," I guess obesity can be a disease. But so could a lot of other things.

    If the government and doctors have had zero to nil effectiveness in most of the cases of obesity (bar a few exceptional doctors), what will a declaration and carte blanche for drug manufacturers do to fix the problem?

    Another question that comes to mind is where does accountability come in? Are we supposed to accept the insult that our health is out of our own control and surrender our health to "professionals?"

    No.

    ReplyDelete
  8. Anonymous3:17 PM

    A disease is something which, for the most part, one cannot control or manage on their own without medical intervention.

    Given that anyone who is obese has the power within their reach to totally annihilate their condition, without any drugs or surgery, that alone speaks that obesity is not a disease.

    The problem isn't a matter of willpower or gluttony or sloth as the conventional wisdom holds. It is specifically the witholding of information that allows a person to control the outcome effectively.

    All one needs to reverse their obese state is food. Yes food. The right food. Not the crap that lines the shelves, in pretty boxes and bags, but real food. Meat, eggs, cheese, nuts, beans, butter, olive oil, chicken, lamb, heavy cream, and all that's good in the world is all you need.

    Obesity is not a disease.

    ReplyDelete
  9. Paula3:23 PM

    Of course the powers that be wish to have obesity declared a disease. It'll make it impossible for anyone except a doctor or someone else licensed by the state to treat, it'll mean a steady stream filing into RD's offices, lots more money for the drug companies and a huge jump in stomach amputations. All for what? To win the war against obesity, the disease de jour of our nation!

    ReplyDelete
  10. What really is a disease? Before civilizations, were there any true diseases? Did Oog and Og suffer cancers? Arthritis? Diabetes? Obesity?

    If diseases are products or outcomes of modern civilization - unnatural living, eating, breathing, etc. then yes - obesity is a dis-ease.

    What we fear, of course, is by classifying it as such, the Harpy's move in for the kill. This is par for the course. There will always be those who seek to profit off of the innocent ignorance of the few.

    It is our job to educate the doctors, parents, teachers and caregivers that though obesity is a disease, like all other dis-eases the cure is a lifestyle that is in harmony with nature. Eating real foods, sleeping real hours, and creating a happy life.

    But those who suffer obesity need to want to do something about it. Some do, some don't. And that is their choice.

    ReplyDelete
  11. "This abandonment of evidence, data and scientific inquiry undermines their approach by simply skirting the true purpose to determine if something is rightly, indeed, a disease state. To get around this wee inconvenience, instead they argue "...the utilitarian argument can address the question "should obesity be declared a disease?" as opposed to "is obesity a disease?"
    "

    This is the same thinking that got us into our current low fat, food pyramid mess. Declaring obesity a disease would mandat more of the same failed low fat dogma, which won't work and create another cash cow for big pharma.

    ReplyDelete
  12. Oh God, someone has trotted out the "socialist agenda" bugaboo. If we had a national healthcare system in this country and if reason and sanity ruled the day (but I repeat myself), perhaps more cases of diabetes could be prevented because someone like me could just walk into a lab, get a glucose tolerance test, not be set back on my rent or my bills in doing so, and find out that I had a developing problem. I wouldn't just have to guess based on outer symptoms. Neither would anyone else.

    I view healthcare as a national defense issue: illness and non-war-related injury kill lots more people than war does! There is nothing inherently "socialist" about using bad information to enforce bad public policy. There IS something inherently "socialist" about pooling resources to tackle a very expensive problem. Unless you like the idea of going it alone, being constantly turned down for care, having to wait until the very last minute to be treated for a problem which has spiraled out of control, and so on. If that's what you call "freedom," I'd gladly give it up.

    ReplyDelete
  13. Anonymous9:45 PM

    Is utter mind boggling stupidity a disease? If so then I suggest that 85% of politians and the medical fraternity qualify as being diseased!!!

    ReplyDelete
  14. Anonymous3:49 PM

    Children before advancing to the next grade should be checked for proper BMI and pass physical fitness test. Those children who cannot come up to standards by the next year are worthless to society and should be sent to internment camps for conversion into biofuel.

    Adults must pass similar tests before applying for any new employment, renewal of driver's license. Adults who fail will immediately be converted to biofuel.

    Anyone over the age of 50 is exempt from testing as they will automatically be interned and converted to biofuel.

    All smokers, drug users, and drunkards will immediately be converted to biofuel. They aren't human anyway.

    These rules do not apply to individuals with a net worth of $1,000,000 or more or families with net worths of $10,000,000 or more.

    ReplyDelete
  15. Conlin Novak1:07 PM

    Seems we have a fan of "A Modest Proposal" on our hands.

    To declare obesity a disease would be to give an excuse to those that dont have the will to help themselves. Obesity is not a disease, its an epidemic of mass hysteria. Speaking as a person that has been obese in the past, the only "cure" for this so called "disease" is self determination, which people seem to lack nowadays. There is no need to bring healthcare and corrupt politicians into an argument such as this. This argument concerns only one thing, a persons will power to say no to the 23rd donut. Any one who would argue against this statement ould be daft, and should take a good look at society before opening their mouth. See if you can see motivation in those that cry for obesity as a disease, and you'll come up lacking.

    ReplyDelete
  16. RAZWELL's blog refutes the GROSSLY MISINFORMED commentors on here.

    ReplyDelete
  17. It makes me sick that people can claim obesity as a disease. I have had some discussions with obsese people and they make this claim as if they could do nothing to prevent it. Just as Conlin N said, these people lack the self-discipline because they claim that its a disease and therefore they have no control.

    As per my Microbiology lecturers at university, a disease is ONLY caused via an invasion of a microbial agent, like bacteria or viruses. Anything outside of that scope, say something genetic is in fact a DISORDER, since the gene is not functioning properly, thus it is "not in order" therefore disorder.

    Now, yes there are some who may have hormonal problems which can affect fat loss, (my ex had PCS which does this), however as described in the article someone can be overweight / obsese and still be fit, my ex walked everyday so its safe to say that she was fit. Yes it can be harder for them to stay fit too, however does that automatically allow people to give up?

    Yet the people who spend all day on their bed eating junk food literally have no excuse. People need to take responsibility for their own actions.

    ReplyDelete