Something is changing the bodies of Americans. 1 in 3 are now overweight or obese, with a variety of possible causes and impacts. But how important is this, medically? And what ought physicians to do about it? Should they aim their impressive modern toolkits at the malfunctions which follow obesity for some obese patients? Or at obesity and body size, itself? Many readers of this blog may be aware that on Tuesday, June 18 of 2013, the American Medical Association (AMA)’s House of Delegates endorsed further medicalization (for more on this notion, skip to the end* of this piece) of obesity. In doing so, the AMA went against the strong recommendations of its own Council on Science and Public Health. Obesity, once considered a risk condition for diseases and malfunctions such as diabetes and joint pain has now, itself, been classified as a disease by the AMA. Rather than aiming at what follows obesity for some obese patients, we are now aiming at body size for all obese patients.
Holley Mangold, Olympic athlete, member of the 2012 U.S. Weightlifting team. Her personal record in the combined snatch and clean-and-jerk is 562.2 pounds. With obesity defined as a disease, she is by definition unhealthy. Photo credit: Scripps Howard News Service.
As the AMA acknowledged in its resolution, the organization is by no means the first to make this classification: “The World Health Organization, Food and Drug Administration (FDA), National Institutes of Health (NIH), the American Association of Clinical Endocrinologists, and Internal Revenue Service recognize obesity as a disease.” Indeed, the American Association of Clinical Endocrinologists and the American College of Cardiology pushed hard to have the AMA recognize obesity as a disease even after the Council on Science and Public Health recommended against it.
This will not, of course, instantly change medical practice. Other relevant professional organizations with interests in the classification of obesity as a disease may agree or disagree. However, when a body of physicians such as the AMA makes such a determination, it opens the way for changes to disease coding—and increased use of existing coding—in clinical settings. Conditions with established codes under the ICD-10 (International Classification of Diseases) and other coding systems have different classifications for conditions which are thought to be diseases vs. those which are not. In fact, the ICD distinguishes between obesity of different types in its classification, where obesity is largely considered a form of “hyperalimentation” (over-eating) with exceptions made for drug-induced obesity. Oddly enough, it may be that if the AMA probes on this further, a more sophisticated nosology may arise than the ICD’s which seems to allow for some metabolic causes, drug-induced causes, and otherwise classifies obesity as “hyperalimentation.” After all, the AMA’s resolution hints at the possibility for a complex causal chain when it says that “obesity [is] a disease state with multiple pathophysiological aspects requiring a range of interventions to advance obesity treatment and prevention” and notes that the insurance giant CIGNA has classified obesity as a “complex” disease.
Coding changes record-keeping and the ease with which coded conditions can be tracked across the population, as well as changing access to treatment from insurance providers. However, it can also lend increasing strength to the for-profit industries which depend on our collective aversion to being or becoming fat. As UCLA medical sociologist Abigail Saguy wrote earlier this year in the Washington Post, fat stigma in clinical settings works to the detriment of fat patients when they are stereotyped as lazy and noncompliant, but also when health care providers correlate a patient’s fatness with the patient’s medical conditions without first ruling out alternative causes: “…as many medical researchers have pointed out, it’s not clear whether obesity causes diabetes, whether diabetes causes obesity or whether both conditions are caused by a third factor, such as poor nutrition, stress or genetics.”
Though Saguy doesn’t say as much, it’s worth pointing out to folks with an interest in quality argumentation and good reasoning in medicine that this is an example of the classic fallacy of false cause. In this case, I suggest that strong social assumptions about obesity causing—or being—ill health lead to the privileging of that causal chain above others, irrespective of the objective evidence. This appears obvious, and alternatives—third factors causing both obesity and diabetes, for instance—appear counter-intuitive. We can see the cementing of this causal assumption in the portion of the AMA resolution which says, “The suggestion that obesity is not a disease but rather a consequence of a chosen lifestyle exemplified by overeating and/or inactivity is equivalent to suggesting that lung cancer is not a disease because it was brought about by individual choice to smoke cigarettes.” By analogy, it is obesity which kills patients, says the resolution, not the conditions which arise from obesity. Such a tight causal connection may not bear up under simple considerations as that the rate of people with diagnosed lung cancer who do not die from their cancer is significantly less than that of diagnosed obese people who do not die from merely being obese, but rather from conditions which correlate with obesity—and also appear in non-obese persons. This brings up a key issue, perhaps the key issue, with classifying obesity as a disease: what does this do to the notion that an obese person can be healthy?
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HAES defines a “healthy weight” as the weight at which a person settles as they move toward a more fulfilling and meaningful lifestyle. This includes, but is not limited to, eating according to internally directed signals of hunger, appetite, and satiety and participating in reasonable and sustainable levels of physical activity.
Alas, with further classification of obesity as a disease per se, a category such as “healthy obese people” who eat well and exercise sustainably is definitionally—conceptually—nonsensical despite the evidence in favor of precisely such a notion.
With obesity a disease, a person who is healthy by all other standards but is overweight or obese can no longer be considered healthy except by those who reject this nosology. Treatment imperatives cannot help but follow, likely even for U.S. Olympic Athlete Holley Mangold. If the target of therapy is body size, thin persons will continue to be missed because they are assumed to be healthy and fat persons will continue to be targeted because they are assumed to be ill. And it is primarily a change in body size that will constitute a treatment effect. When obesity was a risk condition, alone, it could be argued that the target was reduction in rates of heart disease, diabetes, joint pain, etc. Now, those may best be described as sequelae of obesity. Much can be justified in the quest to treat body size. We can see this in the three treatment modalities prescribed by the AMA in the resolution: “lifestyle modification therapy, pharmacotherapy, and bariatric surgery options.” How much of a “nudge” or even outright manipulation will providers feel they can or even should give to patients to get them to consent to treatments aimed primarily at reducing body size? How much more will providers and even ethicists be willing to resort to shaming fat patients to incentivize compliance?
It is an act of irresponsible hyperbolae to claim “This changes everything!” But it is irresponsible medicine and facile ethics to claim that it changes nothing or that what is changed is only for good.
* Recent years have seen increasing medicalization of risk conditions such as high cholesterol in both adults and children, as well as increasing medicalization of mental conditions which might once have been described as “normal sadness” or, before the new DSM-V, healthy grief. Medicalizing risk conditions raises its own distinct set of concerns as I have discussed elsewhere in my short article, “Paying for the Possibility of Disease…”
PJW Note: This was originally posted June 25, 2013, moving to top in view of the current discussion. Have a look at this NY Times article as well.
