Obesity as a Disease

In the Washington Post, Esther J. Cepeda asks what to me seems to be an odd question about obesity:

Is obesity truly a disease that requires medical treatment and prevention, as the American Medical Association recently proclaimed? Or is it still more accurately a “condition” with too many variables and factors to shoehorn into a neat category?

Perhaps by "condition" Cepeda means "symptom"? Which would potentially put obesity in the same category as pneumonia - the cause may be a bacterial or viral infection, but you can start treating the pneumonia before you know the exact cause? Or is it because obesity has a behavioral health element, and the comment represents resistance to treating conditions with a significant psychological element as diseases? The author opines that it does not matter, "if a label with more gravitas is what it’ll take for obesity to be taken seriously, then let’s go with it", but at heart it does matter because if the public perception remains "Obesity results from a lack of willpower - if you have the strength to push away from the table it's nobody's fault but your own", the label the medical community uses has little relevance save perhaps as to determining whether and when treatment should be covered by insurance.

The author makes some good points about nutrition - most doctors know little about it, and too few doctors given any appreciable amount of counseling or information to their patients about weight.

In 1998, the National Institutes of Health recommended that health care professionals advise obese patients to lose weight. In 2011, research published in the Archives of Internal Medicine found that of participants in government health surveys, one-third of obese patients and 55 percent of overweight patients said a doctor had never told them they were overweight.

I know of doctors who believe that they fulfill the first duty by telling patients, "You should lose weight," which usually has all of the impact and relevance as, "You should stop smoking," or "You should exercise more." Making the statement isn't enough. As for the rest, yes, there are significant numbers of people in our society who are in deep denial about how they appear to other people, but I don't believe for a moment that the typical obese person is not aware that he or she carries more than a few extra pounds. For a typical obese person, being told "You're overweight" would be roughly as insightful as telling them, "Hey - you still have a pulse."

Something else to recall is that a big part of how we, as a society, perceive "overweight" has to do with societal standards of beauty, not whether or not a person has achieved a healthy weight. A copy of the Enquirer I saw yesterday at the supermarket checkout stand had a typical tabloid cover about which celebrities - as is usually the case, all women - had gained weight, and which had lost weight to the point of being skeletal, never mind that the celebrities that are "too skinny" may be starving themselves down to the size that allows them to obtain employment. Margaret Cho's account of how she was pressured to lose (too much) weight for her TV show is a couple of decades old, but remains illustrative.

Meanwhile, if you're inclined to pretend that "You should lose weight" is an easy answer, take a look at people you know - overweight, normal, skinny - and contemplate how many of them, in the absence of an illness or surgical procedure, experience or sustain a significant change in their weight. You may know somebody who lost weight and slowly (or quickly) gained it back, you may know somebody who put on weight during (for example) a pregnancy and didn't lose the weight afterward, you may see weight change associated with a physiological change (e.g., menopause), but most people remain relatively constant. From that short list, of those who lost weight and sustained that loss, take a look at how many of them gained the weight during adulthood (e.g., after a pregnancy) and were returning to baseline as opposed to having been overweight throughout their entire lives. Now contemplate the billions of dollars spent each year on diet plans, diet pills, diet supplements, and the like and ask yourself, "If that many people know that they are overweight and want to lose weight, why isn't it happening?"

It's easy enough to ridicule the diet industry as pitching easy answers. What the typical diet book or plan is really pitching, I think, is the notion that you can lose weight without being uncomfortable. The tried and true formula for losing weight is "eat less and exercise more", but people don't really want to hear that. It's not easy to do, and its not easy to sustain. Nebulous comments about "changing your lifestyle"... to include eating less and exercising more... are similarly unhelpful. I am of the opinion that the advice should be tailored to the patient, and should be concrete and case specific. Also, "eat less and exercise more" is not particularly useful advice to somebody whose level of activity will make it difficult for them to lose weight even if they're on an extremely low-calorie diet, or if their weight or other health conditions prevent them from engaging in significant physical activity.

The author suggests that part of the problem lies in "self-esteem",

Perhaps even worse: neither the medical community nor the patient population has figured out sensible, neutral ways to even approach the topic of obesity in the context of the doctor-patient relationship. Part of this can be blamed on Americans’ need to put self-esteem ahead of health, and some also rests on physicians’ bias and poor people skills.

A national survey published in a fall 2011 edition of the journal Pediatrics found that parents feel blamed and respond badly to words such as “fat,” “obese” and “extremely obese.” Parents said they’d feel more motivated if a doctor said their child had an “unhealthy weight,” a “weight problem,” or a “high BMI” (Body Mass Index).

And... we're back to the notion that most overweight people don't know that they're overweight, and that parents of overweight children don't understand that their children are overweight. Again, there are some people who live in a state of denial, but most people - adults and children - are acutely aware of their weight problems. If they're not, society is full of people who will happily draw it to their attention. If patients are more likely to respond when doctors approach the issue with a degree of sensitivity, odds are that's because of their history of acute awareness of their weight and involves the predictable human response to negative judgment on something they're ashamed of or that already caused them to experience a history of judgmental, perhaps abusive comments.

I hope that labeling obesity as a disease helps encourage a response to obesity that is focused less on surgical intervention and more on behavioral health, exercise and nutrition. I do know somebody who, after struggling with eating disorders, has stabilized for a couple of years at a healthy weight - but only after intensive psychological and nutritional counseling. To get that type of treatment you pretty much need to be starving yourself to the point that you need to be hospitalized - even if, prior to that particular manifestation of your psychological condition, you were previously "clinically obese".

Part of me thinks the entire focus is incorrect. The concept of BMI is predicated upon a somewhat average individual, and it becomes a useless measure when applied to bodybuilders. Why do we draw from that the notion that bodybuilders are the exception. We know that we can make poeple of any weight healthier by helping them engage in additional physical activity. I would not argue that we should refrain from offering nutritional advice, but during the broad range in which weight is primarily a cosmetic issue as opposed to an imminent health issue I think we should focus on trying to find people develop types and levels of physical activity that fit with their lifestyles, and which can help them avoid additional weight gain while improving their physical health and muscle tone - providing appropriate education about how the initial effect of exercise can be to increase appetite, and also to modestly increase weight as the person starts to add muscle mass. Put the focus on health, not weight.

Finger-Pointing Won't Change the Obesity Rate

ABC News hypes the "obesity epidemic", announcing "America Keeps Getting Fatter". But the story they're not sharing is that, as the developed world's diet becomes more "American", other nations are also becoming fatter. And once we reach a certain threshold of obesity, specific regions pretty much stop getting fatter. What we're really seeing is that, thanks to changes in diet and lifestyle, the baseline for how many people are obese or non-obese is shifting.

Should we be concerned that the waistline of the world keeps on expanding, and that things tend to settle with a bit more than a third of the adult population classified as obese? Yes, we should. There are health consequences to obesity, particularly if associated with low muscle mass and an inactive lifestyle, that are valid concerns both in terms of quality of life and cost to society. (For what it's worth, the same is true for people who are underweight, but we don't consider being "too thin" to be a sign of moral weakness.)

But here's the thing: When you see a trend that's not just nationwide, but is increasingly international in its nature, you gain next to nothing by focusing on individual lifestyle and choices. The fact is we live in a culture that is loaded (larded) with calorie-dense foods. The fact is that some of the most calorie-dense foods are among the cheapest. The fact is that it profits the food conglomerates that engineer and market those foods to convince us to eat more. The fact is that, even with information about calories and weight, most people will not make the long-term lifestyle changes necessary to lose a substantial amount of weight and maintain that loss. The fact is that the overwhelming majority of people who do lose a significant amount of weight ultimately regain it. The most likely means by which an obese person will lose a significant amount of weight and maintain the loss is surgical - bariatric surgery, banding and the like. The fact is that there is refined sugar in pretty much anything you buy at the grocery store that has even a small amount of processing, even if you are left scratching your head wondering, "Why does that have to be sweetened?"

At a certain level, yes, "Eat less and exercise more" works for everybody. But once you recognize that blaming and shaming are not effective (and can be counter-productive), education has little impact, and that most of those who attempt to lose weight will end up concluding that "that approach doesn't work for me" or "this is too hard." No, I'm not suggesting, "Throw up your hands and give up," but the type of changes that might work will take more than simply telling people that they need to lose weight or move around more than they do. We could take a look at how we, as a society, subsidize the means to be inactive and to eat a low-cost, calorie dense, high-fat diet. We could recognize that physical activity is good for kids and should be a routine part of the school day.