Would Classifying Obesity as a Disease Improve Health Outcomes?

Obesity As A Disease:  2 Sides to the Debate

Obesity as a Disease debate

Various individuals and organizations have referred to obesity as a disease dating back to at least the 17th century, and possibly earlier–Hippocrates recognized the increased mortality risk of being overweight. However, members of both the general public and the medical community remain divided on this issue. While some arguments focus on whether obesity meets or does not meet the criteria for a specific definition of disease, other arguments directly address financial incentives for research and patient care, as well as the ability to offer treatment.

The financial and treatment arguments are particularly pertinent to the discussion of how classifying obesity as a disease might improve health outcomes; these arguments are considered in more detail below, along with arguments related to public policy, prevention programs, public perceptions and patient stigma.

So, would classifying Obesity as a disease improve health outcomes?

Classifying obesity as a disease: Maybe YesIs obesity a disease?

More widespread recognition of obesity as a disease could result in greater investments by government and the private sector to develop and reimburse obesity treatments. Some argue that the Food and Drug Administration (FDA) would face increased pressure to approve medications for obesity, and would therefore reframe their approval process to focus on the ability of pharmaceuticals to decrease adipose tissue rather than to improve other markers of metabolic health, such as blood pressure and lipid levels. There is current interest in developing a “limited use” approval pathway that could facilitate the clinical review and FDA approval of prescription drugs. Antibiotics and drugs to treat obesity have been identified as appealing candidates for such a pathway. More effective medications on the market would likely spur physicians to prescribe, and patients to expect, pharmaceutical interventions for obesity. In turn, third party payers would be harder pressed to deny coverage. Public policy and prevention programs related to obesity may benefit from the greater urgency a disease label confers. More funding for obesity-prevention programs, particularly for children and adolescents, could lead to improved health outcomes for years to come. It is likely that a number of public policies related to healthy eating and physical activity, such as funding and regulations for K-12 meal programs and physical education, would receive greater attention and resources. Employers may be required to cover obesity treatments for their employees and may be less able to discriminate on the basis of body weight. Public perceptions may shift as a consequence of more extensive recognition of obesity as a disease, with greater appreciation of, and emphasis on, the complex etiology of obesity and the health benefits of achieving and maintaining a healthy weight.8 Lack of self-control, laziness, and other detrimental character attributes might be less likely to be associated with obese individuals, and in turn reduce stigmatization. The disease label also may provide greater motivation for some individuals to lose weight or maintain a healthy weight. While increased emphasis on obesity may increase stigma (see below), some have argued that such consequences would oblige the medical community to take greater action to protect patients’ rights.

Classifying Obesity as a Disease: Maybe NoShould obesity be considered a disease?

Concern exists that more widespread recognition of obesity as a disease would result in greater investments by government and the private sector to develop and reimburse pharmacological and surgical treatments for obesity, at the expense of clinical and public health interventions targeting healthy eating and regular physical activity. “Medicalizing” obesity could intensify patient and provider reliance on (presumably costly) pharmacological and surgical treatments to achieve a specific body weight, and lead to prioritizing body size as a greater determinant of health than health behaviors. Given the limitations of BMI (discussed above), this could also lead to the overtreatment of some people, such as those who meet the criteria for obesity, (i.e., BMI > 30) but are metabolically healthy.

A similar concern is that obese individuals, who improve their eating, physical activity, and sleeping habits, yet fail to lose enough weight to change their BMI classification, would still bear the “diseased” label and be pressured to receive medical treatment by clinicians, health insurers, and/or employers–even though their improved lifestyle behaviors are significant factors in preventing, delaying, and reducing the severity of obesity-associated outcomes. While some argue that BMI should be excluded from the definition of obesity in deciding whether or not obesity is a disease, the fact remains that BMI is currently the prevailing clinical measure of obesity.

It is possible that public policy and prevention programs related to obesity may be diminished if increased government financing of research into medical treatments reduces funds available for public health prevention programs. Similarly, the medicalization of obesity could detract from collective social solutions20 to environmental forces that shape people’s behaviors and impact a number of conditions beyond just obesity. Thus, public efforts to enhance the built environment to make healthy eating and physical activity choices easier may receive less attention, despite providing substantial health benefits at every body weight; in turn, this could slow the improvement of health outcomes for all Americans. In addition, employers may raise health insurance premiums, limit hiring of obese individuals, and/or curtail employee wellness programs that incentivize weight loss or maintaining a healthy weight.

Public perceptions may shift as a consequence of more extensive recognition of obesity as a disease, but not in a manner than improves health outcomes. For instance, some individuals may conclude that health behaviors matter little in disease development and management, which may decrease their motivation to eat healthfully and be physically active. In addition, an increased clinical emphasis on obesity could potentially offend or otherwise alienate some obese individuals, particularly if the emphasis is on achieving an ideal weight rather than healthy eating and physical activity behaviors.19 Assuming the current BMI cut-points remain the primary clinical indicator of obesity, such stigma would likely also impact people who are otherwise healthy, but who nevertheless meet the criteria for obesity (BMI > 30).

Areas Requiring Further Research:

Obesity as a disease needs further research

If obesity is to be considered a disease, a better measure of obesity than BMI is needed to diagnose individuals in clinical practice. Further research is also warranted into the physiologic mechanisms behind why some obese individuals (e.g., the metabolically healthy obese) do not develop adverse health outcomes related to excess adipose tissue. This is particularly relevant given the difficulties most people have in achieving sustained weight loss. In addition, much more research is needed to develop effective and affordable obesity prevention and management strategies at both the clinical and community levels.

The above is an excerpt from the full report.  To read the full AMA Council on Science and Public Health Report on “Is Obesity a Disease?” click here.

Houston Facial Plastic Surgeon, Russell W.H. Kridel, M.D., is current Chair of the AMA Council on Science and Public Health.