According to the American Medical Association (AMA), 78 million American adults and 12 million children have a new disease. On June 18, the AMA voted to recognize obesity as a medical condition at the association’s annual meeting in Chicago.
What does this controversial decision mean for broader public health efforts to combat obesity, and what does it mean for overweight people? In an effort to answer these questions, health experts and advocates are sharply debating what it means to have a disease, how obesity is measured, and how to best address the stigma obese people often suffer.
One important question the AMA’s vote on obesity raises is: what is a disease? When you think of being sick, you might think of trips to the hospital or medicine bottles, but you probably don’t think of being fat. Neither do many experts. In fact, some health professionals have made fun of the AMA’s decision. For instance, Richard Gunderman, vice-chair of the radiology department at Indiana University, sarcastically asked: “When we meet obese people, should we cast them a knowing glance of concern and ask how they are doing? Should we send flowers and ‘get well soon’ cards to obese family members and friends?”
Yet the AMA is not the first authoritative health organization to describe obesity as a disease. Nearly two decades ago, a committee of the Institute of Medicine described obesity as an “often disabling disease” in a 1995 report. A 1997 interim report written for the World Health Organization (WHO) recognized obesity as a disease. In 2000, the final WHO technical report that resulted similarly called obesity a serious and chronic disease. By using the word disease, these reports sought to highlight the urgent need to address obesity, which the WHO described as “a growing threat to health in countries all over the world.”
Is calling obesity a disease the best way to call attention to this public health problem? The Oxford English Dictionary defines the word disease as “a condition of the body, or of some part or organ of the body, in which its functions are disturbed or deranged.” A 2001 article in the International Journal of Obesity questioned whether obesity met this definition. The authors, Stanley Heshka and David B. Allison noted that many fat people do not suffer any difficulty functioning in their lives, and that sometimes excess fat is the only sign or symptom of obesity. In other words, the definition of obesity does not necessarily indicate that a person has any other health problem.
One of Heshka and Allison’s arguments against calling obesity a disease was that “being a risk factor for other diseases is not an accepted definition of disease.” Yet experts aren’t even always sure about when obesity is a risk factor for other diseases. While researchers have documented associations between obesity and heart attack, stroke, and many other diseases, some research has found that people considered overweight actually live longer than people considered to be of normal weight. Researchers continue to debate the meaning of these findings and when and how obesity truly poses health risks.
Much of the disease definition debate relates to how we measure obesity. The AMA defines obesity using body mass index, or BMI, which is calculated using a person’s weight and height. BMI is a highly controversial measure. The creator of this measure, professor Ancel Keyes, intended BMI to be used in studies of large groups of people, not for diagnosing individuals with a health condition. Indeed, the Centers for Disease Control and Prevention’s website clearly states that “BMI is not a diagnostic tool.” Simply having a high BMI is not enough information to indicate whether or not a person’s weight poses a health risk. BMI is a category of weight, but not necessarily a category of individual health.
If the way we measure obesity is not an appropriate tool for diagnosing a disease, and if obese people can be otherwise healthy, why call obesity a disease? Some doctors and advocates contend that the AMA’s decision could help patients and providers by improving insurance reimbursement for obesity-related treatments. As advocate Morgan Downey told the New York Times, “Companies marketing the products will be able to take this to physicians and point to it and say, ‘Look, the mother ship has now recognized obesity as a disease.’”
Yet the AMA’s own Council on Science and Public Health warned that classifying obesity as a disease could increase “patient and provider reliance on (presumably costly) pharmacological and surgical treatments to achieve a specific body weight.” In addition to potentially encouraging costlier treatments, focusing on achieving a specific body weight or BMI measurement may not be the best way to measure or promote individual health.
Fat-trimming Policies and Stigma
The AMA’s decision does not carry any legal authority to require insurers to pay for obesity treatments. But Dr. Jaime Ponce, president of the American Society for Metabolic and Bariatric Surgery, told NBC News that the AMA’s decision “sends a powerful message that access to evidence-based treatments across the spectrum of the disease are medically necessary” and that obesity “should be treated in similar fashion to treatments for Type 2 diabetes, heart disease or high blood pressure.”
Supporters also argue that the AMA’s decision will reduce prejudice against fat people by framing obesity as a medical condition, as opposed to a lack of willpower. In a letter to the New York Times, Dr. Fatima Cody Stanford described the decision as a “step away from patient blame and toward patient-centered solutions.”
Opponents, however, argue that stigma against fat people will increase due to the suggestion they are abnormal and diseased. Sociologist Abigail Saguy argued that calling obesity a disease “may reinforce blame by raising the stakes.” Linda Bacon, author of Health at Every Size, told the Orlando Sentinel, “The AMA just determined that some people are sick based on how they look.” Bacon argues that BMI “defines someone’s physical appearance, not their health.”
The essence of Bacon’s arguments is that the AMA’s decision focuses on the appearance of health, rather than health itself. The AMA’s decision uses a potentially inaccurate measure of individual health status and gives people with a high BMI a new and potentially stigmatizing label of disease. In so doing, is the AMA’s vote and the subsequent debate distracting from broader strategies to promote healthy lifestyles?
Promoting Health For All
Medical and public health professionals could instead focus their support to population-level policies that would increase the availability of more nutritious foods and opportunities to exercise. Many Americans recognize the importance of access to healthier options and would support such policies. In January 2013, the Associated Press and National Opinion Research Center published the results of their public opinion survey on perceptions of obesity in the United States. They found “strong support for government policies that would add more physical activity time in schools, provide information about healthy choices, and incentives to the food industry to produce healthier options.”
Furthermore, policies that promote a healthier environment might be more cost-effective than attempting to treat 78 million obese adults as having a disease. According to one New England Journal of Medicine article, “People’s behavior is influenced by their physical and social environment. It can be far less expensive to alter an environmental element to which many people are exposed than to interact with each person directly.” For example, building a new sidewalk that would enable many people to walk twenty minutes a day could ultimately prove less expensive than trying to develop individual exercise programs for thousands of people.
In 2001, Heshka and Allison argued that “it seems neither logically necessary nor tactically essential to have obesity labeled a disease in order for it to be taken seriously.” Other approaches, such as promoting environments that increase access to nutritious foods and physical activity, can benefit people of all sizes and shapes, whatever their BMI.
Edited by Dana March.