Tuesday, February 14, 2012

Is Obesity a Disease?


Way smarter folks than me have duked this one out before, and while obesity has its own slot in the International Statistical Classification of Diseases (ICD-9), the debate of whether or not it's truly definable as a disease is often a heated one.

My take?

Personally I'd describe obesity as the natural consequence of placing a collection of truly ancient genes, genes forged over millions of years of incredible and constant dietary insecurity and upheaval, into an insane, calorific, modern day, dietary utopia. In other words? Obesity and overweight are our bodies' normal, natural, responses to the world they find themselves living in.

But unlike many other natural responses to our environments, obesity frequently carries with it real risks to both quality and quantity of life. Yes there are certainly people even with class III obesity who are exceedingly healthy, but that truth certainly wouldn't negate the case for obesity as a disease as many diseases have varied penetrances, and for a large percentage, especially at its extremes, obesity carries marked medical impact.

So is obesity an actual "disease"?

While I'd happily argue that obesity is a disease of the modern day environment, I'll more happily argue that unless we label obesity a disease, even if you happen to think it's not, we're less likely to see real formative changes in the way we deal with and view obesity as a society.

The fact is that right now the accepted global viewpoint is that if obesity is a disease it's a disease of willpower, of gluttony, of sloth. Consequent to that viewpoint we see tremendous, hateful and harmful weight bias that starts as bullying in elementary school and continues unabated for life.  Stereotype and bias targeting those people with obesity impacts upon their access to healthcare, employment, human rights and societal acceptance. Weight stereotyping also fuels the nonsensical weight loss quackery that steals money and hope, the well intentioned but misdirected public health campaigns that vilify obesity without offering tangible targets for change, and it's what allows medical schools and other allied health professional training programs, to virtually ignore thoughtful obesity related education - even if only to impress upon the students a non-blame based, you can in fact be fit and fat, approach.

Now there are indeed arguments that can be made regarding the risks of defining obesity as a disease, but when I've heard people discuss these risks, I've always been struck by the fact that those risks most commonly identified already exist. People already face discrimination by insurance companies consequent to weight, they already face difficulties with promotions/employment because of their weight, they already are labeled because of their weight, etc.

Were obesity to become accepted as a chronic disease, one that reflects a natural consequence of ancient genes in a modern day toxic environment, over time I would expect to see a change in societal attitudes. And there has been precedent for such a change - depression. The 60s and 70s saw society believing that people with depression need only, "pull themselves up by their bootstraps", yet now depression is readily accepted as a condition deserving of care, attention, empathy and most importantly, a lack of blame.  Shifting the focus to obesity as a disease might also lead to environmental targeting of blame and consequently, environmental targeting of treatment.

My hope is that one day obesity will be seen as a modern day scourge, a day when the trite advice "all you need to do is eat less and exercise more" is seen by the general public as over-simplified nonsense, a day where obesity's not thought to be about personal weakness, a day where obesity's known to have a a wide and varied penetrance, a day where obesity's treatment would range from absolutely nothing in those with no medical consequences, to behavioural therapy, to drugs, to surgery, and one where allied health professionals were skilled enough to know when and if obesity's treatment was actually necessary.

A day when people who struggle with obesity aren't made to feel like if they just wanted it badly enough, they'd magically wake up with a mindset that ultimately would see them to permanent weight loss, because the thing is, one thing people don't lack is desire, and if desire and strength of conviction were actually all that were required, no one would be reading this blog post, and everyone would be whatever weight they dreamed of being.

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39 comments:

  1. But what is the solution?

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  2. Nice editorial ... submit it to all the newspapers in North America. And, thank you for addressing the "Eat Less, Exercise More" issue. Sadly, it's a bunch of garbage that even the experts still cling to.

    I believe a recent M&Ms commercial stated the problem beautifully ... its tagline: Salty, Sweet. Impossible to resist.

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    1. Anonymous5:39 pm

      Impossible, except for all the people that resist them.

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    2. Anonymous7:08 am

      Yeah, Anonymous. And I bet you are one of the few (1 in 3) of us who always does. Congratulations on your iron will. *golf clap*

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  3. Re: "...a day where obesity's known to have a a wide and varied penetrance, a day where obesity's treatment would range from absolutely nothing in those with no medical consequences, to behavioural therapy, to drugs, to surgery..."

    Here's the issue with that from my point of view. (For reference, I'm in the U.S.]

    Too much of health care deals with "treating" the disease versus eliminating the disease. A label of "disease" will lead to more reliance on the drugs and surgery than the behavioural therapy. Let's educate people and use regulatory "nudges" to move people into eating in a healthier manner. We already are in a situation where people would rather stick an insulin needle in them while they eat the entire danish ring...

    Also, as mentioned, being overweight does not equate to a lack of fitness/health, so to classify overweight/obesity as a disease would throw too wide of a net.

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  4. This post is great. I work at CDC, but not in a Division that focuses on obesity---I want to accidently send the hyperlink to my entire address book!

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  5. Liz W.8:57 am

    Well said, Dr. Yoni!

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  6. While I think an educational effort is absolutely needed, and the more people who understand the complexities of weight regulation the less stigma, counterproductive diets, and bad advice to go around, I agree with Labdaddy about how it will be treated by medical and pharmaceutical industry. Not that I think a pill will exist anytime soon, but the search for a solution that will enable the "consumer" to make no lifestyle changes will rage on.

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    1. Anonymous7:14 am

      I think that on the whole we are a sick society that is driven by profit at the cost of public health. With 2/3 people losing the battle they spend their entire lives fighting (by tryiing to make those so-called lifestyle changes you seem to think they are trying to avoid) it is clear that this is a public health issue and needs to be treated as such by all of us. We need to work together to create a culture and environment of healthy living and THAT should be our #1 priority.

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  7. Anonymous11:05 am

    Both Labdaddy and Julie did a great job giving examples of the bias you were talking about Yoni. " .. enable the 'consumer'" was especially nice. No matter what, it comes down to them eating less, moving more, and watching what they eat. This advice has been around forever and has been as effective as telling a person suffering with depression to "pull themselves up by their bootstraps" was.

    Even those who succeed in losing weight only have a 5% chance of keeping it off over 5 years. There are deeper things at play here.

    We see so many people struggling to lose weight, following the advice, stuck in a huge battle with some dysfunction in their bodies. There are some good books out there that talk about the dysregulation that drives hunger and lowers metabolism to keep the weight on. If it was as easy as the advice makes it sound we wouldn't have the increase in obesity and low success rates at keeping the weight off.

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  8. While I agree with most of what you have so eloquently stated, I disagree that depression is now considered a disease that warrants "care, attention, empathy and most importantly, a lack of blame." I think there is still a very pervasive attitude of people who suffer with depression should "pull themselves up by their bootstraps", even by people with medical training. I am a veterinarian, and I used to work with another highly-educated veterinarian who is always one to stay on top of her CE and read all the current literature (both human and veterinary medicine). Yet when a friend of hers attempted suicide (another veterinarian), she stated very bluntly "I know it's a disease and she can't help it or simply snap out of it, but that's what I want to tell her to do." Another colleague of mine, who dealt with post-partum depression, found that she too had that attitude until she went through it herself, and even her husband (again, another highly-educated veterinarian who is very current on human and medical literature) did not understand at all. I have dealt with depression myself and have had the misfortune of dealing with doctors who you could tell did not believe that this was not a condition one could simply snap out of if one chose to do so. It has come to the point that I don't even mention what I deal with to anyone but the most trusted people. To me, this is not acceptance and understanding.

    I also deal with obesity, and again, I deal with many weight biases against me. The only understanding I have ever received is from people who have been overweight/obese themselves. I unfortunately think we will always have a long way to go. It's especially unfortunate, as both require a lot of energy and effort to deal with as it is, but when such energy has to go into trying to make others understand, it feels like you're fighting a losing battle before you even begin. Is it any wonder why both of these issues continue to be such major problems?

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  9. I disagree with obesity being labelled as disease. There are already way too many excuses being used by people as to why they are obese and when we label it as a disease, it gives people something to grab hold of and say "look it's not my fault I am obese".

    Also, by classing it as a disease, we are opening up area for treatment outside of the obvious. We have pills and surgery. People would rather take very toxic drugs to counter the issues of obesity than give up crap food and lose weight.

    How would it be if people did not have the option of drugs and instead had NO CHOICE but to eat right and lose weight? That their life depended on it?

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    1. Anonymous12:01 am

      ... Really? ... Guess I should "pull up my bootstraps!"

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    2. Anonymous12:35 pm

      As someone who has personally struggled with both obesity, and the previously mentioned comparison of Depression/Anxiety, these are my thoughts.

      You - and only you - are responsible for your personal health

      Obesity, depression and fill in the blank (alcoholism, anxiety, etc) can be classified as diseases, but in the end does it matter? How does this change who is responsible for treating or "curing" these diseases? Going to a doctor for depression or obesity and they will present you with the options that exist. Drug Management, Behavioral Changes, inpatient options (surgery for obesity or hospitalization for depression).

      It is still up to you how you want to lead your life. All these snarky, "I guess I should just pull myself up by my bootstraps then" comments seem to imply someone else is responsible for fixing your health and you shouldn't have to handle it because it's not your fault, it's a disease. Well the same goes for cancer and any other sickness or illness. Doctors are advisers that you employ, it's still your choice in how you want to handle things. That's why you sign consent forms to be treated!

      Calling these things diseases does not mean they are no longer your own problems. Do some research and decide how you want to live your life. Do you want to continue eating junk food and deal with medications for high blood pressure, cholesterol and diabetes? Do you want to eat healthfully and consciously and lead an active med-free life?

      In the end it's up to you and only you, it's your head that will be on the pavement, not your doctor's!

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    3. @scarlettica8:21 am

      There is a middle ground between failing to take responsibility for your health and pulling oneself up by the bootstraps. That's where to focus should be. Neither shame and blame nor ignorance will heal. By offering support and compassion to someone with obesity, you are not saying "It's good to stay obese", you are saying "Your worth as a human being is not defined by your weight ". I know from experience that this approach, this compassion, is a more effective weight loss support than any amount of negativity.

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  10. I agree with you. Obesity is a multifaceted "disease" which is due to - exactly as you stated - our prehistoric genes' response to the modern environment. In other words, we live in a diseased culture, here in North America, that promotes consumption (buying and eating) and a sedentary lifestyle. Disease is also related to obesity when it is due to an eating disorder or other psychopathology (it's a huge problem for schizophrenics and among other populations with serious mental illnesses), it's also related to physical illness and disability. In both cases sometimes certain populations face great barriers to living a healthy lifestyle or must take medications that affect appetite and/or metabolism.

    Obesity is also related to poverty, something that is always overlooked when people stigmatize obese individuals.

    In my opinion, the reason why obesity is increasing in North America is because of the growing disparity between the rich and poor, the growing proportion of working poor (limited accessibility of healthy food), and our increasingly toxic food environment/lifestyle. In addition, health-washing, untruthful marketing, misinterpretation of research in media, etc. make it difficult for most people - even educated folks - to understand how to navigate their way through the grocery store! Couple this with not enough intervention from the government to protect the public from large corporations profiting off of the garbage they are selling and the future looks very bleak.

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    1. Couldn't have said it better. Agree 110%.

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  11. Anonymous12:42 pm

    I'm being fully serious, have you ever thought about getting into the political side of this issue? We need people like you in our government, if I had my way I'd give you Leona Aglukkaq's job. A girl can dream can't she?

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  12. Anonymous12:54 pm

    I read this this morning and I am still trying to recover, I am active, I have desire and strength of conviction and yet I am still obese. I berate myself daily for not having enough will power or strength of character. I will never have enough strength to win this battle and this just about laid it all out there. So why am I even trying? Why don't I just accept that where I am at is the best place I can be, I swim, I bike, I walk, I hike I am an active person of value who feels like she has none and never will have any and after reading this I cancelled all my training for the rest of the week because my will has just been saped.

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    1. Anonymous3:05 pm

      Yeah, I'm thinking you probably ought to re-read the post. Take your time, perhaps your emotions got the best of you, but what Dr. Freedhoff's saying would be great, is exactly what you're already doing.

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    2. Anon, if you were staying active for your health, because of how it makes you feel, and for enjoyment instead of for weight loss, would you still feel that way? That approach is called Health at Every Size, and if you're interested, you can find out more by Googling it.

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    3. Anonymous12:52 pm

      Love yourself first. Your weight is just your relationship with gravity. Your BMI is a bullsh*t excuse for avoiding real discussions on body difference. I do 5 1/2 hrs of cardio activity, weight lifting as well as general walking and swimming. I am still "morbidly obese" on the scale. Feel good about you. Decide you want your clothes to fit better. Eat natural foods (no chemicals or highly processed) your body (and mind) will thank you.

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  13. This is a good post and you certainly make some valid points. However, I don't agree that labelling "obesity" as a disease will lessen the stigma. Unfortunately, there's a stigma attached to having a chronic disease.

    And, at the base, people come in a wide variety of sizes. Some are unusually tall, some are unusually short, some are unusually thin, some are unusually fat. Why would we draw a cutoff line in the middle of one side of the bell curve and label everyone over it as diseased?

    Why would we do it on one side of the bell curve and not the other? People with BMIs under 18 and on average less healthy than people with BMIs between 30 and 40.

    Why would we do it with BMI and not height? Very short and very tall people tend to be less healthy than average.

    And of course the definition of obesity captures everyone with a large build - fat, muscular, and both together; very healthy, less healthy, and disabled. People with BMIs over 25 or 30 are very different from one another.

    Finally, there's the issue of diagnosis. If my BMI varies between 29 and 31 every month, am I constantly getting and losing a chronic disease? When I get PMS and gain 5 pounds in water weight, suddenly I have the "disease of obesity?" That's absurd.

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  14. Beautifully written! I to, think that you should submit this to many newspapers. It would be something refreshing on the constant 'chatter' on obesity.

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  15. Anonymous10:52 am

    Does labeling obesity as a disease serve the people 'suffering' from it, or the people who make a living treating it? It is what it is - if it quacks like a duck and it walks like a duck, it's very likely a duck. Is smoking a disease (aka nicotine addiction?) Does it matter?

    But, if it's classified as a disease, and parents of obese children don't do anything to try to treat or cure the disease, doesn't that make them negligent? It would if the kids had diabetes.

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  16. Anonymous11:01 am

    The fallacy that many of the commenters arguments are based on is that weight loss and management are a simple exercise in physics based on calories in, calories out. However, body weight is an extremely complex equation of physiological and psychological factors such as genetics, hormones, gut flora, diet composition, and, yes, quality of diet.

    My heart goes out to the woman above who struggles with obesity and berates herself for something she may well have little control over. It's like berating yourself for not being able to will away cancer or multiple sclerosis.

    Our best chance of treating obesity is in prevention. Prevent children from being raised on crappy, high sugar, low nutrient diets. Encourage physical activity. I believe obesity is preventable in most people, but is very, very difficult to "cure" once it exists unless we gain a better understanding of the physiological factors that make it so refractory to treatment. Just look at the statistics.

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  17. I'm struck by your statement: "a day where obesity's treatment would range from absolutely nothing in those with no medical consequences" - how does one determine that a given obese individual has no medical consequence? And what about the risk of future medical consequences that may be mitigated by addressing the obesity?

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    1. Scales don't measure health, just weight.

      EOSS a good place to start, and risks aren't guarantees.

      http://www.weightymatters.ca/2011/08/new-staging-system-reveals-new-truths.html

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    2. I don't at all mean to suggest that scales measure health. By definition risks aren't guarantees. But certain risks are worthy of mitigation. IMHO (and I presume yours too) there's definitely a role for prevention - i.e. not waiting for the onset of frank end-organ pathology to intervene.

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    3. Absolutely. Though truthfully, the data to date suggests that an active individual with a healthful diet and no comorbid medical conditions doesn't require treatment and that for at least a 16 year stretch (I think that was the length of the EOSS data set), at least mortality is not increased.

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    4. I'm curious - is it known or has it been estimated what percentage of obese folks are active and eat a healthful diet?

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    5. From the same EOSS data - not a huge number and it appears to be dropping:

      http://www.weightymatters.ca/2011/08/why-are-there-less-fit-and-fat-folks.html

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    6. Very interesting post. Thanks!

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  18. Anonymous11:03 am

    http://www.merriam-webster.com/dictionary/disease If people took their personal bias out of this subject and looked at the definition of disease, perhaps there would be no question about if obesity is a disease or not.

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  19. There are a number of things to consider about the idea. Is obesity a primary, or a secondary, medical condition? For some, it's primary, the result of massive overconsumption of products containing known obesagens (is that a word? it should be) such as hydrogenated fats and high-fructose corn syrup. For others, obesity is secondary to other medical conditions (large, sudden-and-permanent weight gain is a known side-effect of many antidepressant drugs, and there have been some papers suggesting that obesity in type 2 diabetes is the result of insulin resistance, rather than the cause of it.)

    But that's a red herring if the reason for the classification is social acceptance. We still don't fully accept people with visible physical handicaps and visible chronic health conditions. We're not sure how to interact with people with tics, people confined to wheelchairs, people less endowed with reasoning and language capacity... Classifying obesity as a "disease" gives the world-at-large one more reason to hate, ignore, and put down those of "ample" size.

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  20. Anonymous11:20 am

    @ dee.calarco: "If my BMI varies between 29 and 31 every month, am I constantly getting and losing a chronic disease?" No, you're getting and losing the symptom of the disease. Just as an alcoholic is not always drunk... a depressed person is not always depressed... a psoriatic does not always have lesions...

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  21. Paulette G12:33 pm

    Very well written article. The important first step is recognising the problem and assigning it a place in the healthcare spectrum. As a disease, it no doubt will be treated rather than prevented at the early stages (this is what we do in North America), but it is still a start. There have been heavy individuals all through history (or Rubens would never have had subjects, nor would the expression Reubenesque have become a descriptor for a woman who is not by any means slim. So some people have always been more inclined to be heavy. The troube is with food available at every corner (and several places between the corners) one never go far before eating.. something... anything. Anti fat stereotypes have been around for a long time as well. In the 60`s I grew up hearing a lot of fat name calling by kids and adults. The main issue stated was that the fat individuals must be lazy & gluttonous. So that is not new either. It has just become more and more prevelent - both the number of obese individuals and the nastiness about excess weight. We have created a very difficult environment for ourselves, and to recognize that our environment is a problem, we must start looking at disease states created by that environment. Then perhaps we can move on towards managing the issue and even prevention. - For starters lets teach kids nutrition all through school and cooking as soon as they are old enough to start with the easier stuff.

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  22. If classifying obesity as a disease provides increased financial support to treat those who need help, I'm all for it. However, I think it's important to recognize that obesity is NOT healthy. Sure, some peoples' bodies may not show the effects as quickly as others (e.g. hyptertension, unfavorable cholesterol profile, diabetes, arthritis, etc.) but in embracing the individual and rejecting prejudice against them, physicians should still counsel patients about the risks of being obese. Campaigns that promote acceptance of obesity can miss the mark in my opinion - of course a person's value and loveability has nothing to do with their body fat. We should fight against prejudice and bullying while still maintaining that obesity is not healthy from a medical perspective.

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