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Is Obesity a “Disease” or a Trojan Horse? The Debate Inside The AMA.

Posted Jun 24 2013 10:01pm

Posted on | June 21, 2013 |

The vote of the A.M.A. House of Delegates is in – obesity is a disease.(1, 2) But what exactly does that mean? To say that the issue is complex and controversial is an understatement. Just take a look at the debate that preceded the AMA vote.

Against Declaring Obesity A Disease:  The AMA Council on Science and Public Health, voted “no” in part because the measure of obesity, the Body Mass Index or BMI is a flawed measure. Their words: “Given the existing limitations of B.M.I. to diagnose obesity in clinical practice, it is unclear that recognizing obesity as a disease, as opposed to a ‘condition’ or ‘disorder,’ will result in improved health outcomes.” Other issues: No specific symptoms associated with the condition; “medicalizing” the condition defines 1/3 of Americans as ill; declaring it a disease will lead to over-treatment and an explosion of expensive drug treatments each with its own risk profile.

For Declaring Obesity A Disease: Obesity is filled with societal bias and stigma. Making it a disease lessens personal guilt and exposes the condition to discussion and transparency. It’s not simply that you can’t control your intake or that you refuse to exercise. There’s more to it than that. The “disease” mantra will likely result in increased basic science research and reimbursement for treatments by insurance plans. After all, it does impair bodily functions and thus fits at least some criteria for disease.

At the end of the day, AMA delegates rejected the conclusion of their own scientific council. In doing so they sided with several AMA specialty organizations including the American Association of Clinical Endocrinologists and the American College of Cardiology whose resolution argued that obesity was a “multimetabolic and hormonal disease state”.(1,2)

The debate left me with a bit of deja-vu.

Ten years ago, during the wild first weeks that followed the release of Viagra, the first effective treatment for erectile dysfunction, much of the debate avoided the issue of effectiveness (most agreed it was effective) and focused on the question, “Should insurers reimburse for this treatment?”(3) Two years later, states far and wide and most nations around the world, as well as their insurers covered Viagra.

The reason why is that by then erectile dysfunction had been accepted as a “marker disease”.(3,4) What did that mean? It meant that population research showed that for every 1 million men who saw their doctor for evaluation of erectile dysfunction (encouraged to take that initiative because Viagra existed), 15,000 would be diagnosed with diabetes, 50,000 with heart disease and 150,000 with hypertension. These diagnoses would be followed by therapy, which for many would occur years before it would otherwise occur, saving lives and money (even after reimbursing for Viagra).

What we learned from that “experiment” was that prevention is spawned on by motivation and that early detection and effective chronic disease management can be facilitated by addressing disorders of high importance to human beings which contribute to or “mark” the presence of disorders that carry a high burden of disease and cost for the nation.

If ED was the “marker disease” of choice for 2000, obesity is the “marker disease” for 2013. Occurring in ever growing numbers of our citizens, young and old, the presence of obesity carries with it high rates of diabetes, hypertension, heart disease, arthritis and cancer. Taken as a whole, this chronic disease burden insures a high misery index and low productivity.

Obesity is enormously troublesome to individuals, families and communities. Many or most obese individuals are motivated to loose weight for a range of reasons including physical and mental health, self-value and self esteem, and the desire to be more productive and well. Most fail after embracing popularized, ever changing approaches that lack a strong research basis and sound methods to sustain behavioral gains.

Two issues continue to bother me. First is the distressing lack of basic medical science understanding of nutrition and the far reaches of disordered nutrition – obesity on the one hand and anorexia on the other. The latest research on the human microbiome seems to indicate that we are feeding our microbes more than ourselves and have outsourced many of our homeostatic functions to these micro-organisms. So the “disease” of obesity or anorexia for that matter may have more to do with a faulty microbiome in the gut than brain directed misbehaviors by us.(5,6,7)

My second concern with the “disease” declaration is that it seems so “old school”. By this I mean the process of labeling a condition before you understand it, reacting and overreacting to it with treatments that mask the symptoms and often further cloud our understanding of what we know and don’t know.

What I do believe is that obesity is a “Trojan Horse” for chronic disease. What if health professionals had access to nutritional based programs that could be accessed and managed in the home? What if highly motivated obese individuals knew they could receive access to the program and personalized support from the health team they trust by coming in for an evaluation of their obesity. What if that basic evaluation (as with ED) were able to uncover, through evidence based research, the actual causes of early chronic disease – gut microbes or otherwise, rather than relying on the latest pill or stomach banding procedure? And what if those who succeeded early became the trainers of those who were yet to succeed?

Might obesity be leveraged as a motivator to accomplish a real understanding of the pathogenesis of chronic disease, instigate home-based behavioral changes, and create sustainable integration and personalized relations with a health care team. If so, obesity would do the heavy lifting for our conversion from an interventional to a preventive system. And that would significantly “lighten the load” for all of us.

For Health Commentary, I’m Mike Magee

References:

1. Pollack A. A.M.A. recognizes obesity as a disease. June 18, 2013.NYT. http://www.nytimes.com/2013/06/19/business/ama-recognizes-obesity-as-a-disease.html?_r=0

2. AMA News Room: AMA Adopts New Policies on Second Day of Voting at Annual Meeting. June 18, 2013. http://www.ama-assn.org/ama/pub/news/news/2013/2013-06-18-new-ama-policies-annual-meeting.page

3. Viagra Should Be Covered By Insurance Plans. PR Newswire. Aug. 20, 1998. http://www.prnewswire.com/news-releases/viagra-should-be-covered-by-insurance-plans-pfizer-tells-california-managed-care-regulators-76273912.html

4. Billups KL et al. Erectile Dysfunction is a marker for cardiovascular disease. J Sex Med. 2005 Jan; 2(1): 40-50. http://www.ncbi.nlm.nih.gov/pubmed/16422903

5. Magee M. “You” are not you, but “We”: How the microbiome may change everything. May 24, 2013. http://healthcommentary.org/?p=5656

6. Pollan M. “Some of my best friends are bacteria”. NYT Magazine. May 19,2013. http://www.nytimes.com/2013/05/19/magazine/say-hello-to-the-100-trillion-bacteria-that-make-up-your-microbiome.html?pagewanted=all&_r=0

7. Lozupone CA et al. Diversity, stability and resilience of the human gut microbiota. Nature.489:7415, Sept. 13, 2012.

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