http://www.medscape.com/viewarticle/...l&uac=166576EY
WFS
About the AMA announcing obesity as a disease and one person's thoughts.
Follow the Money
Bradley P. Fox, MD (Family Physician)
Last month, the American Medical Association (AMA) decided to label obesity as a disease.[1] When I first sat down to write about this topic, I looked up the online definition of "disease." I need to quote the first definition here: "A disordered or incorrectly functioning organ, part, structure, or system of the body resulting from the effect of genetic or developmental errors, infection, poisons, nutritional deficiency or imbalance, toxicity, or unfavorable environmental factors; illness; sickness; ailment." I have a difficult time fitting obesity into this definition -- especially when you look at nutritional deficiency as one of the possible causes.
The second definition had to do with diseases in plants. I then looked at the third definition: "any harmful, depraved, or morbid condition, as of the mind or society: His fascination with executions is a disease." I am not buying that either.
OK, so why did the AMA decide to declare that obesity is a disease? I figured it had to do with research or the recommendation of a subcommittee, but according to Geoffrey Kabat,[2] this is not the case either. In fact, he writes, it was a decision that went against the recommendation of the Council of Science and Public Health.[3] Really? Then why?
The reason: Make doctors more readily recognize and address obesity, hopefully to aid in reimbursement from insurance companies for the treatment of obesity -- and, to take it a step further, to promote payment for the 2 new obesity drugs that it just so happens recently came to market. Follow the money, folks.
I am sorry, but it is not hard for primary care physicians to recognize obesity. We see it every day. We don't ignore it. We attack it head on.
That said, obesity comes in different shapes and sizes. The strict definition of obesity being a BMI greater than 30 kg/m2 does not always define the actual patient. I have several athletes who have BMIs of 30 kg/m2 or more who are in fabulous shape and health. I would not consider them diseased (and I have a hard time labeling them as obese). I do not think that calling it a disease is going to make the average doctor change the way they look at the patient in front of them.
It comes down to money. Obesitologists (does this specialty exist yet?) must have lobbied the AMA for the statement. Well, make that the bariatric surgeons. Talk about a specialty explosion. The hospital I work for has a "bariatric product line," and I am sure that they are applauding this label change.
And then there are the new drugs. Industry policy does not allow us to take pens or note pads or T-shirts or golf balls from any pharmaceutical reps. With the Sunshine Law, we need to declare every bottle of water or bag of chips a rep gives us for lunch. Despite this, I find it too coincidental that Qsymia® and Belviq® were both released shortly before this change in how the AMA looks at obesity. Follow the money.
Do I agree with the change? Do I think that obesity should be considered a disease? Not really. I don't think that smoking is a disease. I don't think that laziness is a disease. I don't think that poor hygiene is a disease, so I need to be consistent and say that obesity is not a disease.
Honestly, I don't think that it really matters. I do not think that it will change how doctors look at obese persons. I don't think that it will motivate doctors to treat more aggressively (or take better care of themselves, for that matter), and I do not think that insurance companies will be any more likely to pay more when they are looking for ways to pay us less. It will, however create a lot of material for Jay Leno and other late-night comics for their monologues and for us to debate in Roundtables.
If It's a Disease, It's a Social One
Robert W. Morrow, MD (Family Physician)
Obesity is a disease -- a social disease. Much as we don't stop an epidemic of chlamydia or human papillomavirus by treating individual cases, we need to address root causes if we as health professionals wish to effect any change.
Happily, the medicalization of obesity has not progressed among people in general, especially on the pharmaceutical front, as reported in the business section of the New York Times on June 18, 2013.[4] That article reports that no "diet" medication has achieved important sales figures. I presume the AMA pronouncement seeks improvement of those sales figures.
Not to put too fine a point on what we all recognize, obesity is a condition that warrants attention. We know many things about obesity and its relationship to diabetes, atherosclerosis, diet, exercise, social class, physical mobility, and so on. We even know that if simple mechanical treadmills or pedal devices are installed under work desks that people at those desks lose weight.
But the attention warranted is social, with an individual encouraged by their health professional to participate in those social reframings. Such reframing involves superficially easy changes in the caloric density of foods and the quantities eaten, matched with increased physical activity.
Hold my Nobel Prize -- those changes are complex, of course. But it is embarrassing for me to go to a country such as France, where I look rotund, and a relief when I return to the good old US of fat A, where I look below the mean (for an old man). Modernity does not require being fat.
The social changes that we need involve intersectorial collaboration and interventions. Now there's a word! "Intersectorial" refers to the integration of the efforts of different social sectors, such as clinical, public health, agricultural, marketing, governmental, educational, manufacturing, city planning, and so on. But don't hold your breath for the AMA to declare the need for an intersectorial campaign to address obesity.
But do hold the pills, please.
What's Next? Will Being Old Equal Being Sick?
Mark E. Williams, MD (Internal Medicine and Geriatrics)
I hate to jump into the middle of this, because I am not up to speed on the AMA pronouncement. But in general terms, it seems to perpetuate a long list of "medicalization" of common human predicaments. As a geriatrician, I expect that the development of gray hair or the aging process itself to be the next condition considered as a disease.
Clearly, morbid obesity is a special case, but to me, obesity is not a disease. What is the definition of the disease "obesity," and what defines a "cure?" And I wonder about the intent of this new labeling. Is it to draw attention to major risk factors, such as sedentary lifestyle or poverty, or is the intention to justify markets for antiobesity remedies, such as medications or bariatric surgery?
So Many Diagnoses. What's One More?
Charles P. Vega, MD (Family Physician)
I support the establishment of obesity as a diagnosis, although with some mixed emotions. The realpolitik of the acceptance of obesity as a disease is clear. With over one third of the US adult population classified as obese, and what we know about the health dangers of obesity, we are long overdue to mount a serious campaign against fatness. The problem is intractable and requires both broad and personalized interventions that are based on science.
The most effective means to reduce the scope of obesity is to prevent it. We need to ensure that young people have access to healthy lifestyle choices. Cases of overweight need to be addressed directly and concretely by health professionals, regardless of patient age. None of this happens without support from public officials and third-party payers, and that is where the recognition of obesity as a disease is most important. It helps to free up funding for prevention, research, and treatment. The AMA's action will not vanquish obesity, but it may change the battle lines.
At the same time, I am overwhelmed by the sheer number of diseases one individual might experience and still walk in to see me in my office. The International Classification of Diseases, tenth edition (ICD-10), has now captured the popular imagination because of its absurdity.[5] Personally, my favorite diagnosis code is E845: launching pad accident. Runners-up include E884.9: fall from a haystack, and E906.8: pecked on head by bird.
It would be nice if we could make strides against obesity without contributing to the burgeoning list of diseases. But we are victims of our own cleverness: New research methods have greatly expanded our ability to understand pathophysiology and subtle differences between not just normal and abnormal, but distinctions found in the same disease state. Expect that list of potential diagnoses to grow exponentially.
So what's one more? Thank you, AMA, for moving us in the right direction.
I pasted the article. Just needs a Medscape account which is free.