Is obesity a disease?

Whenever I used to attend meetings of the Wales division of the National Obesity Forum, the chair, Dr Nadim Haboubi, invariably opened the day with the same rally cry: obesity should be classified as a disease. “It is a disease”, he stated categorically, and therefore should be called as such. I never usually gave it much thought – why debate semantics? Why not put all effort into solving the problem?

I dropped Nadim an email last week to let him know that the American Medical Association (AMA) had announced the classification of obesity as a disease. Then I started thinking about the whys, wherefores and consequences for the first time…

Definition of disease

The Merriam-Webster medical dictionary defines disease as “an impairment of the normal state of the living animal or plant body or one of its parts that interrupts or modifies the performance of the vital functions, is typically manifested by distinguishing signs and symptoms, and is a response to environmental factors (as malnutrition, industrial hazards, or climate), to specific infective agents (as worms, bacteria, or viruses), to inherent defects of the organism (as genetic anomalies), or to combinations of these factors.”

The original AMA ruling (Resolution 420 (A-13) can be seen here and it opens by noting that the American Medical Association’s Council on Science and Public Health Report 4, A-05, identified the following common criteria in defining a disease: 1) an impairment of the normal functioning of some aspect of the body; 2) characteristic signs or symptoms; and 3) harm or morbidity.

Having set out this definition, the AMA resolution needs to prove how it claims obesity meets these three criteria (I have put the verbatim quotations from the AMA resolution in italics and quotation marks, just to be clear):

1) Obesity as an impairment

The exact words used here are as follows:

“There is now an overabundance of clinical evidence to identify obesity as a multi-metabolic and hormonal disease state including impaired functioning of appetite dysregulation, abnormal energy balanced, endocrine dysfunction including elevated leptin levels and insulin resistance, infertility, dysregulated adipokine signaling, abnormal endothelial function and blood pressure elevation, nonalcoholic fatty liver disease, dyslipidemia, and systemic and adipose tissue inflammation.”

2) Obesity as characteristic signs or symptoms

The exact words used here are as follows:

“Obesity has characteristic signs and symptoms including the increase in body fat and symptoms pertaining to the accumulation of body fat, such as joint pain, immobility, sleep apnea, and low self-esteem.”

3) Obesity as harm or morbidity

The exact words used here are as follows:

“The physical increase in fat mass associated with obesity is directly related to co-morbidities including type 2 diabetes, cardiovascular disease, some cancers, osteoporosis, polycystic ovary syndrome.”

Does obesity meet the AMA’s own definition of a disease?

All three of the component parts of the definition above can be challenged:

1) Obesity as an impairment

Obesity per se can be an impairment, but it is not in all cases, or even many cases? Super morbid obesity (defined as a BMI in excess of 50) can be an impairment to the point of immobility, but the medical classification of obesity starts at a BMI of 30 and I do not accept that this automatically makes someone impaired.

Most of the Lions (rugby) squad lining up on Saturday 22nd June, to edge past the Australians, are obese on a BMI scale. I dare you to call them impaired! Lisa Riley, in 2012’s Strictly Come Dancing showed herself to be one of the fittest, most agile, most captivating contestants – she also happened to be clinically obese. Impaired?! No way.

Looking at the AMA clause for obesity as an impairment, I suggest that they have made the usual error of association and not causation. Obese people might have endocrine dysfunction (hormone system not working optimally), they might have high blood pressure, they might have nonalcoholic fatty liver disease but a) many non obese people can have these impairments too and b) not all obese people will have these impairments. Therefore, this clause fails on both the logical tests of – is this a definite impairment of obesity and only obesity?

The infertility reference was interesting. Again – some obese people have difficulty conceiving, some normal weight people have difficulty conceiving, many underweight women will have difficulty conceiving. Infertility can be associated with obesity, or any other weight – it is not a defining characteristic.

2) Obesity as characteristic signs or symptoms

My first thought was to accept point (2), but further consideration shows this to be worthy of challenge also. On first sight, one might think obesity has characteristic signs and symptoms “including the increase in body fat…” It almost seems tautological to say we can define obesity by observing body fat. However, we’re back to the rugby squad again – technically obese – but ‘overweight’ because they have turned body fat to muscle, not because they exhibit visible body fat. There may be visible body fat on an obese person, but there does not have to be.

It is also unreasonable to assert that “joint pain, immobility, sleep apnea and low self-esteem” are characteristic signs or symptoms of obesity. I have joint pain and some immobility due to a hip injury and subsequent operation. I’m not obese. A friend of ours suffers from sleep apnea. His body description would be “beanpole.” Anorexics have chronically poor self-esteem – clearly not obese.

Again – the words used by the AMA are not experienced by all obese people or unique to obese people and therefore fail logical test.

3) Obesity as harm or morbidity

The AMA makes the most classic association/causation error on this point. The AMA states “The physical increase in fat mass associated with obesity is directly related to co-morbidities including type 2 diabetes, cardiovascular disease, some cancers, osteoporosis, polycystic ovary syndrome.”

Does obesity cause type 2 diabetes? cardiovascular disease? cancer? or do the same things that cause obesity cause those outcomes? Is obesity but another symptom of, for example, processed food consumption – along with type 2 diabetes and heart disease?

Poly cystic ovary syndrome is a complex hormonal condition and is associated with obesity (obese women are more prone to PCOS and PCOS sufferers are more likely to be obese). Is the same hormonal dysfunction responsible for the obesity and the PCOS? Can avoidance of processed food help with both PCOS and obesity? My answer to those two questions is yes. The AMA see PCOS as a harm resulting from obesity. I do not see obesity as a harm per se. I see obesity as a symptom – the body’s way of telling us that harm has already been done.

Other arguments in the AMA judgment

I highly recommend reading the first page and a half of the AMA judgment – down to the bit where they announce the resolution. After setting out their definition of disease and then presenting their case for why they think obesity meets this definition, they add some other supporting arguments. In doing so they appear to have anticipated a number of counter arguments that would likely be made and seem to be trying to address these up front. They all fail in my view:

– There’s a plug for bariatric surgery and a claim that while “bariatric surgery can dramatically reduce early mortality, progression of type 2 diabetes, cardiovascular disease risk, stroke risk, incidence of cancer in women, and constitute effective treatment options for type 2 diabetes and hypertension” there are some “hormonal and metabolic abnormalities“, which are not reversible even after weight loss.

Surely this confirms that the weight (obesity) is not responsible for the “hormonal and metabolic abnormalities”, but that something else is – for example – processed food?

– The document notes that half the adult population may be obese by 2040. Quite the opposite of being used as an argument for defining obesity as a disease, this has been one of the major points of argument against by various opinion pieces written since the announcement. It has not been well received by the majority of medical professionals and/or obese people that, overnight, one third of Americans have been labeled “diseased”.

– The AMA resolution notes that the World Health Organization, the Food and Drug Administration (FDA), the National Institutes of Health (NIH), the American Association of Clinical Endocrinologists, and the Internal Revenue Service recognize obesity as a disease. That’s not an argument to follow suit in itself.

– One of the worst additional arguments presented by the resolution is as follows: “Progress in the development of lifestyle modification therapy, pharmacotherapy, and bariatric surgery options has now enabled a more robust medical model for the management of obesity as a chronic disease…” i.e.  now is a good time to call obesity a disease because we have ways of treating it!

a) we don’t have healthy ways of treating obesity – government options are bad dietary advice and/or surgery and b) this is one of the major arguments against the classification of obesity as a disease. It has been seen by many commentators and journalists as a cynical attempt to attract funding.

This is confirmed in the resolution statement itself:

Therefore be it RESOLVED, That our American Medical Association recognize obesity as a disease state with multiple pathophysiological aspects requiring a range of interventions to advance obesity treatment and prevention.”

The resolution REQUIRES a range of interventions to advance obesity treatment and prevention. This was no semantic clarification of words. This has been a phenomenally lucrative move for providers of obesity treatment and prevention. I laughed out loud at the “Fiscal note” at the end of the resolution. Every change in policy is required to estimate a financial impact of the change. A policy change to make breast cancer medication available with no financial constraints could cost millions of dollars. The fiscal note of this change was declared as “Minimal-less than $1,000.” The direct costs maybe, but absolutely no way does this reflect the indirect costs that can now follow.

If obesity is seen as a lifestyle condition (the greedy/lazy attack) then there is little obligation on insurance companies/public health bodies to treat it. The minute obesity is defined as a disease, there is a moral obligation to treat disease. We have opened the doors to funding, more bariatric surgery, more Research & Development effort going in to developing drugs, more likelihood of drugs being approved (something may be viewed as better than nothing), more money for surgeons and drug companies – not less obesity.

No wonder The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) commended the American Medical Association (AMA): “The AMA’s announcement is a tremendous step forward in legitimizing the severity of the obesity epidemic in our nation,” said Dr. Gerald Fried, SAGES President. “AMA’s decision will increase coverage and patient access to necessary treatment options for the disease, including weight-loss surgery…”

Other views

Forbes had an interesting angle on profit – that this might harm the ‘food’ industry – if it can be claimed that they are now responsible for a disease. That’s just about the only positive angle I can think of with this resolution and I’ll wait to see if it actually happens.

One of my favourite opinion pieces came from obesity expert, Dr. David Katz – in the Huffington Post. Katz also raises the cost issues and makes some nice analogies with other scenarios (drowning) to stimulate thought. He concludes that obesity is not a disease and expresses concern that calling it a disease may do harm.

Now that I have had occasion to think about Dr Haboubi’s rally cry, I sincerely hope that the British Medical Association doesn’t follow America’s lead. I do not think that almost a third of British people have become diseased overnight. I think that obesity is a natural response to an unnatural diet.

Posted in Gov. Policy, Obesity
10 comments on “Is obesity a disease?
  1. avatar Louise says:

    Surely the definition of obesity is the most unsatisfying one here?

    As you correctly point out, weight is far from being the best measure of this. Body fat percentage (from a reliable method) would be a better and more accurate way to discern the obese, though I realise it is a harder number to come by.
    I wonder how many seemingly ‘healthy weight’ folks would be classed as overweight or obese if this measure was widely used?
    Before I became interested in health, nutrition and exercise, I was relatively slim (UK size 12), around 11 stone, but had a body fat percentage (as measured with a BodPod machine) of 35%. Now, even though I weigh a little more (11st 5lbs – at 5ft 7 I think I am technically – or very close to – ‘overweight’ by BMI standards) and I am a similar size, but due to turning to exercise and a good, ‘real food’, diet I am now 18% BF.

    Thanks Zoe – very interesting article (the only teeny critique I would have is that you cannot ‘turn body fat to muscle’ without the help of alchemy, but I get where you are going with that…!

  2. avatar Fiona says:

    Great article Zoe and interesting comments from your readers.

    My initial thoughts are that obesity is not a disease, it seems to be a consequence of addiction and bad advice. If the government did a u-turn on smoking, there is still hope for us :)

    Since reading your research, and more background reading myself, there are too many companies that make money out of our obesity to have any non-government help to fix the problem. The ones that manufacture the junk purported to be ‘healthy’, and the ones that produce drugs to make us feel more normal after eating the junk.

    I also agree that high BMI/obesity doesn’t have to impact health. I have bone problems (since I was a ‘normal’ child), but since I was about 20 have had BMI 48. In the last 10 years I’ve been identified with high BP, high cholesterol and more recently hypoglycaemia. Over that time, my BMI didn’t change… I know now what caused it. And like others, my statins are becoming redundant, but my GP isn’t interested in how I’ve done it. BMI still 48, and I’m coming out the other end ditching the conditions and the medications thanks to your work. I might just buy her a copy of your Obesity Epidemic. I’m certain she has no idea what causes high cholesterol, but she’s a wee skelf of a girl anyway… and thinks that keep telling me to eat the balanced plate will help *sigh*

    LIke all things when you are growing up, you can choose to take the advice offered to you – from parents, elders, NHS, government – but at the end of the day it’s YOUR body, and you only get one of them. Who do you listen to for feedback? The advice-givers? Or your body??

  3. avatar Ann says:

    Yes Obesity is a disease, but a very complex and serious one. Just think of the “big” diseases that can affect anyone of us – Arthritis, Asthma, Diabeties, these can be diagnosed and treated by the medical profession. But along comes Obesity. The Obese patient will, unlike other ill people, will have had years of people staring and making comments such as “Just stop eating” and slef confidence will have been replaced by self-loathing. Why do the vast majority of obese people not have full length mirrors in their homes? A question never taken seriously. The Obese patient seeking help will have a multiplex of conditions and will also need specialised counsilling. Obesity is a multi layered disease needing “Case Connference” type treatment crossing from general medicine to mental health to physical therapy and counselling. Not attacking obesity in this fashion is (in my uneducated opinion)part of the reaason that it is proving so difficult to treat.

  4. avatar Mark says:

    Paul energy balance isn’t static. The energy needs of an adolescent is much different when that person becomes an adult, this is well known. For the vast majority, with the exception of genetic outliers and it’s well established that exits, energy balance does matter.

  5. avatar Jessica says:

    But the NHS would argue that they advised people to the best of their belief. They would point to the teaching that they have had and say, “Look, it’s not our fault we were taught the wrong thing.”

    Is there any one person we can point to and say, “You saw these facts, but you chose to ignore them”? The government would say it relied on scientists, the scientists will say, “We gave you the facts”, the government will say, “We relied on you to interpret the facts” – I hope a good precedent has been set for smoking – we’re going to need it! I get most annoyed with the BBC when they put up stuff on “Have your say” and then don’t follow up comments like “Low carbing” works. I guess they believe all the “Fad diets don’t work” and so on. And “Embarrasing bodies” – have you seen the desperate stories on there? They make me so upset, these people begging for help from a programme which doesn’t.

    Anyway, back to the blinkered NHS, curiously, at my last doctor’s appointment, I as told that I had put on weight, and she had my weight a year ago as 92kg. I cannot think why the nurse would have that figure. My clothes are in the process of falling down, so I’ve definitely lost. My specialist told me I had lost weight from the last time he weighed me which was after the 92kg figure. I’m wondering if they have taken a bogus figure in an attempt to make it look as though low carbing doesn’t work. She was going to go through my diet and then checked herself by saying, “Oh, whatever you’re doing, it’s working” and didn’t. Interesting then that she isn’t asking questions like, “HOW are you doing that?” Doesn’t she want to know? Won’t it help her other patients?

  6. avatar Paul says:

    It is an interesting concept. Obesity is a symptom of an underlying issue, generally a hormonal issue to do with the disruption of insulin.

    I think Zoe would agree that the heavy promotion of carbohydrates since 1984 and the demonisation of fat has resulted in permanent damage to many peoples’ insulin receptors (including mine, which can only be kept under control by eating a high fat diet). That the damage is permanent can be observed by looking at a teenager who can eat anything without putting on weight, but suddenly in their twenties, they eat the same foods, but suddenly put on a lot of weight – so clearly not an energy balance question).

    It follows that if a large percentage of the population have done permanent and irreversible damage to themselves through avoiding saturated fat and eating what they were told to eat. There are then two issues:-

    1. A large proportion of the population has a chronic condition which is life-threatening, which I would conclude IS a disease; and

    2. The NHS may actually be responsible for the condition due to its advice

    The problem for the NHS is that, logically, it should treat obesity as a disease on clinical and moral grounds. BUT, an acceptance of obesity as a disease MAY eventually lead to legal action against the government if it accepts that the advice to eat more refined carbohydrates was clinically wrong.

    The problem with this is a measure of cognitive dissonance, where it (the NHS) thinks that obesity is a lifestyle choice, but at the same time, accepting that obesity has underlying chronic hormonal issues. This is explained by the fact that the NHS is not one ‘person’, but an organisation made up of many people, and the official advice on diet conflicts with the observation of those at the coal face dealing with obese people.

    My view is that obesity IS a disease, and within 15 years we will see lawsuits being prepared as it becomes increasingly apparent that the NHS conducted a massive health experiment on the population with no intervention study to back up the experiment.

  7. avatar Jessica says:

    But should we have it labelled a disease to try and get across the idea that at the moment, people can’t help being obese? I mean, I know that they can if they eat the correct diet, but trying to change 20 years of government brain washing is more painful than trying to put my head through a brick wall. In the meantime, people are treating the obese as a sub set of ‘human’. I can see money better spent on investigating obesity being diverted away from people who “just want to be fat” and research on type 2 diabetes being shifted onto more ‘deserving’ causes because type 2 is a ‘self-inflicted’ condition.
    If we could change the mental attitude to show that if you are convinced that low fat/high carb is the way to lose weight, you will be unable to avoid being fat, people out there would be less likely to throw around the “Lazy porkers” label….

  8. avatar Mark says:

    Zoe I enjoyed this piece and your arguments. My personal view with regards to obesity has been that it is primarilly a symptom. That is obesity is caused by chronic postivie energy balance that results in a hypertrophic response in the fat organ/adipocytes, that is or may be patholoigical. This pathological response results in the known disregulations and can lead to multiple diseased states. The single largest contributor to this disregulation is foods that are energy dense with low nutrient content and low in volume. However it’s much more complicated than that for some, that is known, but for those without what appears to be a genetic disorder that predisposes them to serious obesity, other factors are at play and I don’t think it takes rocket science to determine where the starting point is.

  9. avatar Tom Welsh says:

    I think the Merriam-Webster definition you cite includes a single word that might be interpreted as making obesity a “disease”. That word is “malnutrition”. Not in the sense of “inadequate calories”, to be sure. But malnutrition can also mean “inappropriate or unhealthy food”. In that sense, many people who slurp their carbs are malnourished in more ways than one. They may not be getting enough protein and fat; but also, if their metabolism is damaged, even what food they do eat may be going to build up their fat reserves rather than their other vital organs.

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