COMMENTARY

Obesity: It's a Risk! It's a Symptom! It's a Disease!

Sandra Adamson Fryhofer, MD

Disclosures

July 16, 2013

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Hello, I'm Dr. Sandra Fryhofer. Welcome to Medicine Matters. The topic: the obesity name change. Is it a disease? A condition? Or a disease risk factor? The American Medical Association (AMA) House of Delegates has spoken: It is a disease.[1] Here's why it matters.

Obesity is a major public health problem in this country. Two thirds of adults are overweight, and one third are obese. Being obese increases the risk for other diseases: high blood pressure, heart disease, type 2 diabetes, osteoarthritis, sleep apnea, and even some cancers. But is obesity a condition, a disorder, a disease risk factor, or a standalone disease? The arguments for and against calling it a disease were put before the AMA House of Delegates at its June 2013 meeting. The reasoning behind how to classify obesity is both complex and controversial. And to put it mildly, there are differing opinions about whether or not classifying obesity as a disease would improve health outcomes.

First, here's the downside of calling obesity a disease. Some worry that this would medicalize obesity and intensify reliance on drugs and surgical treatments rather than relying on diet and exercise to attain a healthy weight. Another concern is that calling obesity a disease could alienate some obese individuals, especially if the emphasis is on achieving ideal weight rather than focusing on healthy eating and increasing physical activity. Some argue that how much and what you eat is a personal choice. Others point out that there is no effective well-established treatment.

Here's the pro side. Calling obesity a disease could mean greater investments by the government and the private sector: more research into causes, triggers, and treatments, including more US Food and Drug Administration (FDA)-approved drugs for treatment. Another benefit of making obesity a disease is that it could make it harder for third-party payers to deny coverage.

After much discussion, and both sides being heard, the final decision came down to a vote on the AMA house floor: The majority ruled that obesity is a disease state with multiple pathophysiologic aspects requiring a range of interventions to advance obesity treatment and prevention. This sentiment of obesity as a multimetabolic and hormonal disease state was championed by the American Association of Clinical Endocrinologists, the American College of Cardiology, the Endocrine Society, and the American Society for Reproductive Medicine. It was also backed by the American Academy of Pediatrics, the American Academy of Family Physicians, and the American Society of Bariatric Physicians.

OK, so obesity is now a disease. But no matter what you call it, we need a better way to measure it. Body mass index (BMI) has many limitations. It was originally designed as a research tool: a rough population-level indicator. It's not a great way of measuring body fatness. Some people with a BMI in the so called "normal" range can have too much body fat, as well as metabolic problems. Some with BMIs over 30 kg/m2 -- the so-called obese range -- have plenty of muscle and no excess fat . Some with high BMIs are normal metabolically and also have normal blood pressure and cholesterol levels.

There's also the obesity paradox to consider: the collection of studies suggesting that BMIs in the overweight or obese range may have protective effects on mortality risk. (In fact, some studies have shown that "a little extra body fat" may be protective.[2,3,4,5,6] It can provide "extra padding" in case of falls. This caloric reserve may provide nutritional backup in the healing process. Some recent studies looking at conditions from diabetes and stroke to acute coronary syndrome suggest that those carrying excess pounds may have better outcomes than their normal-weight neighbors.[4,6])

Help is on the way. The National Heart, Lung, and Blood Institute is working on new guidelines on overweight and obesity in adults. Hopefully, these will be released soon and will shed new light on the best way to measure and determine which patients are afflicted with obesity -- now classified as a disease. According to BMI measurements, one third of all US adults have it. That means one third of our adult population and 17% of our children are diseased. This is serious business. Let's hope this obesity name change can help make a difference.

For Medicine Matters, I'm Dr. Sandra Fryhofer.

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