This post was written by Florian Kastler (Global Health LL.M. 2011), visiting researcher at Georgetown University Law Center. Any comments or questions about this post can be directed to firstname.lastname@example.org.
By a decision overriding its own council on Science and Public Health, the house of delegates of the American Medical Association (AMA) has officially recognized “obesity as a disease state with multiple pathophysiological aspects requiring a range of interventions”, moving it from a major public health problem. Soon after this decision, a number of specialists have both criticized and supported this recognition by the AMA.
Why is this decision controversial?
An article in the NY Times provides a great overview of the different opinions on this matter.
On the one hand, it is argued by the AMA that the disease classification will have a general positive impact by helping “change the way the medical community tackles this complex issue” and lead to “greater investments by government and the private sector to develop obesity treatments.” The AMA believes that increasing the attention on obesity could improve reimbursement for obesity drugs, surgery and counseling. Indeed, Bruce Japsen anticipates that this recognition “should give a boost to sales and continued development of prescription diet drugs”.
For individuals, it might help reduce the stigma of obesity, which considers obesity “simply as a result of eating too much or exercising too little”. As the AMA’s notes in its decision “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.”
Further, it is argued by members of the AMA that, in the future, “employers may be required to cover obesity treatments for their employees and may be less able to discriminate on the basis of body weight”. The hope is that it will have an impact similar to the recognition of the danger of tobacco consumption or the importance of driving safety. It puts “obesity on the same path as treatments for addictions to alcohol or tobacco, and mental health problems, such as depression.”
On the other hand, opponents argue that obesity should not be recognized as a disease because the measure usually used to define obesity, the body mass index (BMI), is simplistic and flawed. Indeed, some people with a BMI above the level that usually defines obesity are perfectly healthy while others below it can have dangerous levels of body fat and metabolic problems associated with obesity. Thus the Council on Science and Public Health concluded “given the existing limitations of BMI 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.” Some argue that there are “no specific symptoms associated with obesity and that it is more a risk factor for other conditions than a disease in its own right.”
Specialists fear that because it would define one-third of Americans as being ill, it would lead to more reliance on costly drugs and surgery rather than lifestyle changes and self-discipline. There is indeed a risk of shifting the responsibility from the individuals to the state or the private sector. Individuals might think that because it is a disease, they should be able to take a pill and “cure” obesity. Obesity is obviously not that simple. In some limited cases, obesity can have positive health benefits such as increasing bone mass and reducing the risk of osteoporosis.
As argued by Maia Svalitz, the parallel with other addictions such as alcoholism has its limits: “the labels also increased pessimism about recovery, probably because people assume that as diseases with biological and genetic bases, they are immutable”. She concludes that “the disease label should be used sparingly: just as not all drinking is alcoholism, not all overeating is pathological.”
While the debate is still on going, it should be put into perspective with the burden of obesity in the world and in the US.
Why a controversy considering the importance of the ‘obesity epidemic’?
Having discussed the different views on the recognition of obesity as a disease, I can only feel both surprised and a bit disappointed by this (unnecessary) controversy and the numerous oppositions it has stemmed. First of all, we must remember that obesity, which was seen and, to a certain extent, is still seen in many parts of Africa, as a symbol of wealth, was rapidly identified as a health concern during the Antiquity. Indeed, Hippocrates developed theories on preservation of health and explained that “it is very injurious to health to take in more food than the constitution will bear, when, at the same time one uses no exercise to carry off this excess “. This recognition has continued throughout history including in the 18th century, when Malcolm Flemyng, a physician, stated that “corpulence” (i.e. obesity) can be a disease in some cases.
It is crucial to understand the impact of obesity in the world. According to the WHO, worldwide obesity has nearly doubled since 1980 and in 2008 35% of adults aged 20 and over were overweight and 11% obese. More than 40 million children under the age of five were overweight in 2011. Obesity has reached epidemic proportions globally, with at least 2.8 million people dying each year as a result of being overweight or obese. Surprisingly, overweight and obesity are linked to more deaths worldwide than underweight.
At a national level, during the last 20 years, there has been a dramatic increase in obesity in the United States and rates remain high, according to the Centers for Disease Control and Prevention. The U.S. obesity rate increased almost 50% between 1997 and 2012. Today, more than one-third of American adults (35.7%) of are considered obese. The trends for children are even more worrisome: 17 % (12,5 million) of children and adolescents aged 2 to 19 are obese. Overall, childhood obesity has more than doubled in the past 30 years. A recent report by the Robert Wood Johnson Foundation states evidence suggests that by 2040 roughly half the adult population may be obese.
Therefore, the need for a change in the perception of obesity must happen now especially since this decision is in line with the approach taken by the international community and other domestic institutions.
Why a controversy when there is a strong international and domestic support?
As soon as 1997, the WHO recognized obesity as a disease stating that “obesity is a chronic disease that requires long-term strategies for its effective prevention and management.” Further, the International Statistical Classification of Diseases and Related health problems 10th Revision (ICD-10) has classified obesity as a disease and differentiates obesity due to excess calories, drug-induced, extreme or morbid. This International Classification is widely recognized and is applied by a number of countries. For instance, in France, obesity is considered as a disease allowing surgeries to help patients suffering from obesity, such as gastric ring surgery, to be reimbursed. At the hospital of Strasbourg, it was decided in November 2012, and for the year to come, that 50 doctors could prescribe physical activity to obese, which would be reimbursed by the healthcare system.
This classification has also been supported at a domestic level as mentioned by the AMA’s resolution. The Food and Drug Administration as well as the National Institutes of Health (NIH) and the American Association of Clinical Endocrinologists have all recognized obesity as a chronic disease. Similarly, the Obesity Society officially issued its support for classifying obesity as a disease in 2008. Further, the Internal Revenue Service has said that obesity treatments can qualify for tax deductions (Internal Revenue Service Ruling 2002-19). In 2004, Medicare removed language from its coverage manual saying obesity was not a disease. Still, in Medicare Part D, the prescription drug benefit, includes weight loss drugs among those it will not pay for, along with drugs for hair growth and erectile dysfunction.
Therefore, the disease classification should not be seen as a harmful decision. Rather, it should be considered as an important milestone in tackling the burden of obesity.
The decision taken by the AMA is subject to a number of criticism mainly because of the counterproductive effect it might have on the motivations of the individuals to change their habits. In my opinion, this decision goes in the right direction both from an international and domestic standpoint. I am not saying that any condition or disorder should be recognized as a disease. However, in the particular case of obesity, where evidence shows that it has disastrous consequences, there should be no room for doubt. It should be reminded to the opponents of the decision that in any event, despite its influence as the largest single group of doctors, the AMA has no legal authority.
In any case, the focus should not be on how to classify obesity between disease, condition or disorder but rather on how policy makers could act collectively to prevent it. Indeed, whether a disease or not, obesity calls for action at all levels: international, regional and domestic. The disease classification should not be seen as undermining the fight against obesity but as a supplementary step forward. The most important challenge is for both the public opinion and the policy makers to understand the burden of obesity and the health related risks. I think that the disease classification could help to achieve this goal. I fear that the reluctance to recognize obesity as a disease might be symptomatic of a lack of interest in combating obesity. Further, the controversy around this classification might shift the attention away from prevention policies.
To conclude, I believe that the decision by the AMA at minimum will be harmless and that the controversy is missing the point. I deeply hope though that this decision will help raise awareness to the public of the existence of an “obesity epidemic” and encourage the medical community and policy makers to take obesity more seriously.
The views reflected in this expert column are those of the individual authors and do not necessarily represent those of the O’Neill Institute for National and Global Health Law or Georgetown University. This blog is solely informational in nature, and not intended as a substitute for competent legal advice from a licensed and retained attorney in your state or country.