Why Obesity IS a Disease and How This Helps, Not Harms

Forgive me for sitting on the sidelines for a week and watching the news from the bleachers. What I’m going to talk about is not the event, but the aftershocks.

Last week, the American Medical Association officially classified Obesity as a “disease state with multiple pathophysiological aspects requiring a range of interventions”, a hotly debated change that follows in the footsteps of the American Association of Clinical Endocrinologists (2012) and The Obesity Society (2008), and highly supported by the American College of Cardiology and the American Heart Association. It wasn’t a shoo-in: the AMA Committee appointed to the task recommended AGAINST the disease classification, but the AMA House of Delegates –  the providers – overruled that recommendation and passed the motion with a large  (no pun intended) majority (276-181: 60.4% to 39.6%).

The professionals arguing against the classification fell back on the same old sorry party line – there are no specific conditions associated with obesity, and that it is a risk factor for other diseases but nothing more.

The AMA made a kind and accurate comparison to other lifestyle-related diseases: “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.” Or diet and hypertension, or alcohol and cirrhosis, or sex and HIV, or drugs and Hepatitis C, or motorcycle accidents and brain injury among others. We are imperfect beings and we seek physical experience, sometimes to excess and to our detriment.

When they declared obesity a disease, you may have heard me doing my happy dance in my office where I practice Functional Medicine and Integrative Psychiatry, and treat obesity daily. Finally, I thought, recognition that obesity is NOT simple thermodynamics of calories in = calories burned. If it was that simple, everyone who ever lost weight would still be thin.

Not Everyone is Happy with the New Classification

I was stunned at the subsequent backlash that occurred, especially since all of the scientific evidence over the last decade points toward obesity as a progressive metabolic, endocrine, toxic, nutritional, psychiatric and inflammatory disease that sabotages weight loss efforts, no matter what the diet. Why would you NOT want obesity classified as a disease?

On Twitter, hashtag “#IAMNOTADISEASE took over with a vengeance.  People worried about the new obesity disease classification as (1) being more stigmatizing than being fat in a supposedly thin society, (2) overmedicalizing obesity because not everyone who is obese is unhealthy, (3) catering to the pharmaceutical and device industry, (4) being inaccurate because there is debate about Body Mass Index as an inaccurate and fallible measure of obesity and (5) promoting racial discrimination based on the epidemiology of obesity.

Let me try and answer their concerns:

Re: Stigmatization: People were offended and suspicious, especially the community of fat advocates. Apparently the word “disease” is worse than the word “fat”. I’m not sure how an already stigmatized condition can be further stigmatized, but I understand how an oppressed group may be overly sensitive to any slight or comment that seems derogatory.

Re: Overmedicalizing: Sigh. I understand that part of fat advocacy has been the Health At Every Size (HAES) campaign, which includes healthy eating and movement and a healthy balanced lifestyle, all of which I support and work with my patients daily to achieve. At any size. However the scientific physiological data just doesn’t support long-term “healthy obesity” on a micro or macroscopic level. Fat cells are metabolically active, and too many of them are eventually harmful. Years of morbid obesity will eventually erode joints, and take its toll on organ systems. Maybe the advocates need to change the term to “healthy obesity at this moment, but maybe not in 20 or 30 or 40 years”.

Re: Industry Profit: Yes. Assuming the pharmaceutical and device industries, and the supplement industry, and the medical and nutritional and even organic food industries will benefit is a given. They all always find a way. But the argument about the pharmaceutical industry making money off fat people is just simply a cost shift from the multi-billion dollar supplement and fitness industry that victimizes the gullible and the desperate among us.

Re: Disagreement within the medical and scientific community: There will always be disagreement within the medical community on disease and treatment – that is the definition of evolution. In a brilliant Aeon magazine essay The Obesity Era, science writer David Berreby said this, “One possible response, of course, is to decide that no obesity policy is possible, because ‘science is undecided’. But this is a moron’s answer: science is never completely decided; it is always in a state of change and self-questioning, and it offers no final answers.”

Re: Racial Discrimination: Absolutely, I give a nod that poverty is indeed associated with obesity in the United States, and a caution to not overinterpret or universalize epidemiologic data. In other countries, it is the middle and upper classes that are associated with obesity (such as India). I’m hoping that underserved populations will be able to see professionals about their weight, and have it covered, instead of not being able to afford a diet program or a gym. In my real dreams, there are urban community gardens, and decent produce and quality protein and fresh fruit in the food deserts, and safe areas to exercise or walk. The causal paradox of hunger and cheap food and obesity are not being ignored by classifying obesity as a disease. To the contrary, this reclassification calls attention to ALL causes of obesity – physiological, psychological, social, environmental, genetic, hormonal, economic.

What really struck me was that people who were upset about the obesity disease classification said “I AM NOT A DISEASE”, not “I don’t HAVE a disease”.  Yet they don’t say I AM ASTHMA. The AMA didn’t say “you are a disease”. Those of you who have read my blogs before know that I am a fervent proponent of turning the word “diabetic” back into an adjective where it belongs, not a noun. You are NOT a diabetic. You HAVE diabetes. You are NOT a disease.

So what is this about?

Maybe, just maybe, calling obesity a disease implies it is hopeless.

So let’s look at the actual AMA proclamation and how it is helpful, not hopeless.

Is Obesity Really a Disease?

The AMA says these are the “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”.

Re Impaired physiologic functioning: “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”.

Re 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.”

Re Associated Harm or Morbidity: “The physical increase in fat mass associated with obesity is directly related to comorbidities including type 2 diabetes, cardiovascular disease, some cancers, osteoporosis, polycystic ovary syndrome.”

In my opinion, the AMA made the case for obesity as a disease. It gets even worse scientifically. In a groundbreaking study published in PLOS ONE 6/26/2013, OVERWEIGHT may be a disease also. In a study of 200,000 people affected by a common genetic variant, even a ONE UNIT increase in BMI is associated with a 20 per cent increased risk of developing heart failure. Further, the study also confirms that obesity leads to higher insulin values, higher blood pressure, worse cholesterol values, increased inflammation markers, and increased risk of diabetes.”

How Does Classifying Obesity as a Disease Help Patients and Providers?

How does a disease classification help providers and patients give and receive treatment and help?

1) Insurance Coverage. In my world, a diagnosis of Morbid Obesity is not yet reimbursable. I find myself having to scratch out an explanation of an eating disorder or anxiety or irritable bowel syndrome to cover the time and appointments that are needed for someone to completely change their lifestyle. In addition, prescription medications that are sometimes helpful will be covered, as will surgeries for people who need drastic measures to prevent end-stage disease before they develop those diseases. Patients with obesity will be able to see the dietitian or nutritionist, unlike the present where those appointments are not covered unless you already have diabetes, and then, only once a year. Losing weight requires a great deal of support – people should be able to see their professionals as often as needed. And maybe, in an ideal world, physical therapy will be expanded to include physical fitness.

2) Reducing Weight Bias among Health Care Providers. One fact to consider is that currently many, if not most, physicians and medical students and nurses and other health care providers are biased against obese patients. Interestingly, health care professionals also freely admit they have no skill or training or knowledge in how to treat these patients’ obesity other than treating the associated late-stage diseases. We providers don’t like it when we have no idea what to do for someone. A formal disease classification opens the medical school curriculum floodgates with research, algorithms, evidence, and support.

3) Politics, Policy, and Funding The AMA decision does not have legal clout, but becomes a crucial guideline when setting medical policy and health regulations, and determining funding priorities. Honestly? I dislike the politicians legislating medical care as much as anyone, but at this point, I dislike lip service for obesity more. Fund us, and let us go to work.

How does Obesity as a Disease Benefit the Integrative Practitioner?

Functional Medicine combines the best of medical science with the newest of medical science, what some people consider “holistic”. I am just as likely to order labs, write a prescription for medication as I am to recommend a vitamin or herb, but the bulk of the healing occurs with lifestyle changes – one small change at a time – with lasting huge effects.  You can’t stop eating cheeseburgers and ice cream because you have an essential fatty acid deficiency and your brain is screaming for them. But once they are replenished in your body, using the correct ratio of fatty acids and a reputable brand which does not contain mostly junk fish oil, the cravings disappear. Not a thought, not a wish, not a command in your mind. Gone.

The more we learn, the more we have to offer. For some of the data, we’re currently working off of minimal research and findings, with a great deal of mainstream opposition. Remember the position of acupuncture 25 years ago? Now…acupuncture is totally mainstream, and covered by many insurers. We are in the early years with alternative obesity treatment. There is a dearth of substantial credible data, and we are relying mostly on observational or exploratory data or small studies lacking statistical power. And yet we know from those patients, one at a time, who have responded, that many alternative treatments have potential in the treatment of obesity.

Weight loss coach Steve Nicander, who lost 400 pounds through lifestyle changes, and promotes an holistic weight loss program, “Healthful Hope”, expresses this beautifully. Says Steve, “I may have lost a massive amount of weight, but in my mind I will always consider myself to be obese and have that potential to be again. What I think this will do is allow for better treatment methods starting with our chronic childhood obesity problem allowing them to feel more comfortable discussing it with their health care providers. I hope the best and biggest change coming from this new awareness is improved training in medical schools in dealing with this epidemic, where education is at a bare minimum. Holistic approaches and non-invasive measures, as you know, can still reverse the weight and cure the underlying diseases.”

Nothing works for everyone, most treatments work on someone.  Everyone needs to clean up their diet and increase their movement, but, as we now know, that may not be enough for people. Lately, I’m lying on my new pulsed electromagnetic stimulation device and running the obesity program to see if I lose weight with the same lifestyle (which is pretty organic but a little underexercised and overworked). So far down 7 pounds, is this for real? At the same time, I’m happy to share the latest animal data on green coffee beans which demonstrates absolutely no prevention of weight gain. I feel like I’m pitching blindfolded. It’s not enough. I need more, you need more, and just like the commercial with those adorable kids… I WANT MORE. The door just creaked open.

This blog was first published on the American Holistic Medical Association blog

Functional Medicine and Integrative/Bariatric Psychiatrist Sara Stein MD can be reached on her blog at obesefromtheheart.com/the-blog or in her office at Stein Wellness in Woodmere Ohio.

WebMD’s Health Care Social Media Disaster – Read the Fine Print!

Occasionally, my vocation of treating obesity and my avocation of health care social media intersect.

This is one of those moments. This is the story of a health care social media betrayal in which obese children and e-patients are the victims. Nobody died, except medical ethics, good judgment, and trust in doctors. This is WebMD’s Health Care Social Media Disaster.

Big Cereal Comes to DC 5

Recently, WebMD published an “advertorial” from Kellogg’s: "Mums, kids & breakfast: The truth about sugar“ with a brief disclaimer, “This content is from our sponsor. The sponsor has sole editorial control.” The kind of disclaimer a casual visitor might easily overlook. Here are excerpts from the article, meant to convince you that sugary breakfast cereals are nutritious, and that sugar consumption is a healthy option for your children.

Myth #1 :Sugar is always responsible for tooth decay

The truth: Breakfast cereals eaten with milk, even pre-sweetened varieties, do not increase the risk of tooth decay.

Myth #2 : Sugar is bad for you

The truth: A panel of world health experts recently reviewed the scientific evidence and concluded that a high sugar intake is not related to the development of heart disease, diabetes, high blood pressure or cancer.

Myth #3: Some sugars are more nutritious than others

The truth: All sugars provide approximately 4 calories per gram. And despite popular belief, no type of sugar is more nutritious than any other.

Myth #4: Children should eat a lot less sugar than adults

The truth: Children do have different needs to adults, so they have different Guideline Daily Amounts (GDAs) for sugar. But not as different as you might think.

Because they are active and growing, children are not vastly different to the “average person” used on the front of the pack. In fact, for sugar, it is very similar indeed.

Guideline Daily Amounts (GDAs) for sugar: Average person – 90g; Children – 85g

Advertisers can claim pretty much anything as long as they can manipulate data. No surprise Big Food is fighting back on the attack on the nutrient value of processed food. The problem is not the advertisers. The problem is WebMD and the trust we want e-patients to have on the internet.

The main tenet of health care social media is to advise e-patients, also known as empowered patients, to seek out reliable and credible medical information, most often on major medical websites, including WebMD. We “soc med” docs are working hard to direct the 88% of patients getting healthcare information off the internet* to these sites. Our good faith and theirs. When a major medical site allows this level of misinformation in advertising, the average person is at serious risk.

Here are the tweets ….

@Appetite4Profit What happens when a medical site sells out to Big Food? Kellogg & WebMD report sugar’s good for you!

@AplusPaz Cigarettes are good for kids too, the nicotine kills bacteria within their stomach.

@MagWrites I guess that now really makes them cereal killers

@YoniFreedhoff Kellogg’s states 360 calories of sugar daily = good 4 kids. That’s 20-30% daily cals!

Obesity expert Dr. Yoni Freedhoff pondered the judgment of advertising authority in his blog, Weighty Matters, “I wonder who the WebMD genius was who decided giving sponsors sole editorial control over content was a good idea?”

I’m figuring it was the person who ate the sugared breakfast cereal, and was cognitively impaired for the rest of the day.

 

(This blog was originally published under the title “Sponsored content on health sites can mislead patients” on KevinMD.com 8-22-2011)

(Photo courtesy of Ted Eytan MD, http://tedeytan.com)