Saturday, September 28, 2013

The Nutrition Debate #147: AMA: Obesity is a Disease (for billing purposes)


The New York Times article begins, “The American Medical Association has officially designated obesity as a disease…” I know, this is ‘old news,’ but with all the coverage I thought it needed a little time to cool off. Besides, it ties in nicely now with the last two columns, #146 “Medicare to Pay for Obesity Counseling” and #145, “Gastric Bypass vs. Medical Therapy for Metabolic Syndrome,” and the next column, #148, “Obesity, a Condition of Genetic Susceptibility?”

The AMA call was a tough one for a variety of reasons not least of which is that there is no general agreement in the scientific community on the definition of disease. The Times piece explains, “Those arguing against it [the designation of obesity as a disease] say that there are no specific symptoms associated with it and that it is more of a risk factor for other conditions than a disease in its own right.” In fact, in making the designation, the AMA delegates at their annual convention overrode a recommendation against doing so by a committee that had studied the matter for a year.

The committee said that “obesity should not be considered a disease mainly because the measure usually used to define obesity, the body mass index, is simplistic and flawed,” according to The Times. The committee argued that “some people with a B.M.I. 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.” The committee wrote, “Given the existing limitations on 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.”

See The Nutrition Debate #142, “I'm Sorry... Confessions of a Weight Loss Consultant” to see how, when and by whom obesity was redefined, and read #141, “...the Ultimate Oxymoron: Diet Food” to see why it was and who benefits.

The AMA finessed the B.M.I business by “simply defining obesity as an excess of body fat sufficiently large to cause reduced health and longevity,” according to a long piece in Forbes by Chris Conover. According to Conover, “they answered the question of ‘should we consider obesity a disease’ largely on utilitarian grounds that the social benefits of doing so will outweigh the costs.” Conover then goes on to totally and brilliantly demolish that argument.

Besides, Conover says, “the AMA is (late) to the party.” He notes that the National Institutes of Health declared in 1985 that “obesity is a serious health condition that leads to increased morbidity and mortality.” And The National Heart, Lung and Blood Institute commented in 1995 that “obesity is a multifactorial chronic disease developing from multiple interactive influences of numerous factors.” He cites the Surgeon General’s 2001 Call to Action to Prevent and Decrease Overweight and Obesity, and Michelle Obama’s 2009 Taskforce on Childhood Obesity. Even the IRS more than a decade ago considered obesity to be a disease, and Medicaid jumped on the bandwagon in 2010. Medicare has too for counseling and surgery, but not for reimbursement for weight loss drugs.  What then could the AMA’s motive be in defining obesity as a disease now?

The Times gives us a clue (if we needed one) to a pecuniary motive for the AMA action. One advocate commented, “I think you will probably see from this physicians taking obesity more seriously, counseling their patients about it.” And, The Times noted, “…it could help improve reimbursement for obesity drugs, surgery and counseling.” They note, “Two new obesity drugs – Qsymia…and Belviq…have entered the market in the last year,” and “Qsymia has not sold well for a variety of reasons, including poor reimbursement…” At the Huffington Post, self-described policy wonk and blogger Larry Cohen enthusiastically huffed, “After the AMA announcement, some members of Congress introduced a bill to expand Medicare reimbursements for weight-loss drugs and weight-reduction treatment.” The Washington lobbyists jumped in exaltation.

Another view is that designating obesity as a disease, like alcoholism or other addictions, “would reduce the stigma of obesity that stems from the widespread perception that it is simply the result of eating too much or exercising too little.” And then The Times piece cracks the door open just a bit with, “Some doctors say that people do not have full control over their weight.” Are they hinting that obesity may be a condition of genetic susceptibility? (Again, see my next column, #148, next Wednesday.) Another naysayer would remark “that ‘medicalizing’ obesity by declaring it a disease would define one-third of American as being ill and could lead to more reliance on costly drugs and surgery rather than lifestyle changes. Some people might be overtreated because their B.M.I. was above a line designating them as having a disease, even though they were healthy.”  I agree. Besides, if the treatment is merely treating a symptom (obesity), rather than the underlying disease, doesn’t that solidify in the medical protocols a wrong treatment modality for a non-existent disease? The AMA finessed that too in their final resolution by saying that obesity was a “multimetabolic and hormonal disease state” (thus avoiding using “disease” as a noun) that leads to unfavorable outcomes like type 2 diabetes and cardiovascular disease.”
What might the underlying disease be? Obviously, neither The Times nor the AMA subscribes to Gary Taubes’s Alternative Hypothesis that insulin resistance, the metabolic disregulation that characterizes type 2 diabetes, is what leads to fat accumulation (obesity). The Times later posted that the article now “correctly noted” (NOT) that “obesity can lead to type 2 diabetes.” As Taubes (and others) have pointed out, The Times together with most of the “old school” medical establishment has got the “cause and effect” of obesity exactly backwards. Oh well, it’s still a long road back to sanity.

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