Saturday, July 13, 2019

Retrospective #147:Obesity is a Disease (for billing purposes)

The New York Times article begins, “The American Medical Association has officially designated obesity as a disease…” This ties in nicely with my last two columns, #146, “Medicare to Pay for Obesity Counseling” and #145, “Gastric Bypass vs. Medical Therapy,” and the next, #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 making the designation, the AMA at their 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 (BMI), is simplistic and flawed.” The committee argued that “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.” The committee wrote, “Given the existing limitations on 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.”
According to an article in Forbes by Chris Conover, the AMA finessed the BMI business by “simply defining obesity as an excess of body fat sufficiently large to cause reduced health and longevity.” 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 went on to brilliantly demolish that argument.
Conover said, “the AMA is (late) to the party.” 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.” And 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 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. Why then is the AMA defining obesity as a disease now?
If we needed one, The Times gives us a clue to a 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 it noted, “…it could help improve reimbursement for obesity drugs, surgery and counseling. 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.
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,” and “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. But, if the treatment is merely treating a symptom (obesity), rather than the underlying disease, doesn’t that solidify a wrong treatment modality for a non-existent disease? The AMA finessed that too by saying that obesity was a “multimetabolic and hormonal disease state” that leads to unfavorable outcomes like type 2 diabetes and CVD.”
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).

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