Reflections on the AMA Disease Decision – Part 1

July 3rd, 2013 by MorganDowney Leave a reply »

I think I have been responding to questions about whether or not obesity should be defined as a disease since the American Obesity Association’s (AOA) first Obesity and Public Policy Forum in 1999. It came up again with the petition filed by AOA with the Social Security Administration to have persons with severe obesity continued eligibility (with other criteria) for Social Security Disability in 2000.

At AOA, we drew attention to the policy of the Centers for Medicare and Medicaid Services (then called the Health Care Financing Administration) stating that obesity was not a disease in testimony March, 2000.

But it was really AOA’s effort to have obesity treatments treated as eligible for the medical deduction on income taxes under the Internal Revenue Code which brought national attention to the issue, including an interview on the Today Show with Katie Couric on November 11, 2003. After that, there were a host of call-in radio shows and interviews. “Obesity as a Disease” was a kind of Rorschach Test of Americans’ views about obesity. So, let me give you my take on the most common objections to the AMA decision.

Calling obesity a disease will increase stigma.” I got this several times in the early 2000s and recently on the HuffPost Live interview. Not to be too glib, but how much worse can it get? The fact is stigma has been attached to obesity since ancient times. Today, we know it begins at very young ages. ( See Latner and Stunkard, 2003, “Getting Worse: The Stigmatization of Obese Children.)Those who stigmatize persons with obesity don’t need to read about the AMA’s decision to get their prejudice. Nor will calling it a disease be likely to change their attitude. Where stigmatization may change, and for the better, is inside the health care community where stigmatization is widespread and largely unrecognized. This decision by the AMA is, hopefully, going to spur the medical community to reconsider its prejudice and bias. See statement of ASMBS. AMA House of Delegates Member for the American Society of Bariatric Physicians Ethan Lazarus said, “Classifying obesity as a disease will reduce weight bias. It means that medical students and residents will receive training in what obesity is and in the best treatment approaches. It means that the medical community will have incentive to research and develop new and better prevention and treatment strategies. But most importantly, it communicates to individuals affected by obesity that this is a chronic disease, not a problem of personal responsibility.”

For an account of what a medical student with obesity goes through, read this short but painful essay from Dr. Madjan, Memoirs of an Obese Physician.

Abigail C. Saguy does caution in TIME that classifying children with obesity as diseased, may result in their parents being accused of neglect or abuse, a la David Ludwig’s argument but that was taking place before the AMA’s resolution.

Obese People will drop Personal Responsibility. They won’t try to lose weight, saying, ‘I have a disease.’” Well, this deserves some parsing. If persons with obesity give up trying to lose weight, it isn’t for lack of trying. Surveys indicate that about half of all adult Americans are trying to lose weight every year. Overweight and obese Americans try harder. Most are trying to eat less and exercise more. Most fail. This comes as no surprise to researchers and clinicians who see an abundance of poor advice to consumers. In my opinion, in discussions about obesity, “personal responsibility” is the end of the conversation. In other diseases (or conditions, if you like) it is part of the conversation. In obesity, it is the conversation stopper.

If your dentist tells you ‘you have periodontal disease’, do you stop brushing your teeth or flossing? If you are told ‘you have a sexually transmitted disease’, do you go out on the town without protection? If you have been told ‘you have dangerously high cholesterol’, do you rush to the steak house? Well, maybe some do. But by and large, we have to assume that most patients are reasonable people and when told that they have a serious condition, they respond, well, like a reasonable person. After a heart attack, Bill Clinton goes on the Dean Ornish diet. Concerned about his weight (and maybe his Presidential prospects) Chris Christie has lap-band surgery. So, why do many people assume persons with obesity will act irrationally? Well, the short answer is bias. They assume persons with obesity are irrational and out of control. In other words, most of the objections based on the loss of ‘personal responsibility’ disguise stigmatization. They assume that persons with obesity will act irrationally and selfishly, even if they are talking about 1/3 of the adult population.

The AMA and physicians are declaring obesity a disease for the money. There are these new drugs out there and they can’t wait to write the prescriptions.” The AMA has had their chance with fen-phen, Meridia, Xenical, Alli, etc. Fact is, as documented on this site, most primary care physicians have a woeful record in understanding and treating their patients with obesity. They are not trained in obesity, they don’t understand the basic human physiology of weight regulation and they do not know how to counsel their patients. They have sat on the sidelines of this epidemic and have been comfortable being there. (To be fair, a lot of their patients do not raise their weight issues with their physicians either.) As one young physician told me years ago, “I didn’t go to medical school to treat fat people.”

Further, they have seen many of their colleagues wrapped up in the fen-phen litigation and want no part of that. The current drugs (and, I believe, future obesity drugs approved by the FDA) are not allowed to be dispensed out of physician offices. So they can’t make money out of direct dispensing. This is what fueled the phen-fen mills of the late 1990s. Physician counseling of patients will probably be billed as under “E&M” or “Evaluation and Management” codes which typically are reimbursed a lesser amount than procedures.  If physicians make any money on it (and it won’t be much) they will have earned it. The Pay-for-Performance trend in health insurance reimbursement may also cool physician interest in getting involved in obesity counseling.

“The AMA decision is ok but it’s not about (fill in the blank)!” This usually comes from folks not in clinical care of actual patients, i.e. they are concerned about community prevention efforts, the built environment, blaming the food industry, Western culture, etc. They feel left out of the discussion. They begrudge the focus on treating individuals and try to shift the conversation to where the spotlight shines on their area of concern. Know what? It’s a big world. Don’t begrudge the people who are trying to help individuals with their personal issues.

“The AMA overruled the finding of their expert committee that obesity is not a disease.” The report of the Committee on Science and Public Health was deeply flawed. First, it found that it could not define “disease”.  (See report (scroll down to page 19). The TOS Obesity is a Disease Writing Group actually got into this discussion in our evidence paper. Can you imagine what kind of criticism the AMA would have received if they said they could define ‘disease’?  Second, CSPH said it could not define “obesity” because the most common measurement too, the Body Mass Index, is flawed. Readers of this site will know that argument.  But the definition of obesity is “excess adipose tissue.” The BMI is only one of several measurement tools. Others include DEXA, bioimpedance, skinfold thickness test, waist-hip ratio, etc. Unfortunately, the Food and Drug Administration has made it into a clinical tool, not an epidemiological tool, as it was intended. There is a great deal of research underway to improve the BMI or create a better clinical instrument, such as the Edmonton Obesity Staging System or the Body Adiposity Index.

But many diseases have weak measurements. What about autism spectrum disorders? Alzheimer’s disease can only be diagnosed on autopsy. Most neurological, mental or substance disorders are very subjective but that does not stop us from classifying them as diseases.

“Obesity can’t be a disease since it can easily be prevented.” What we have here is a very common leap from the question, “Is obesity a disease?” to prevention or treatment issues.   The fact is that, no matter how weak the definitions of “disease” are, obesity meets all of them. (See my article in American Heart Journal). While I respect the arguments about the ambiguity of the definition of “disease,” I have to observe that it seems that no one gets very concerned about it until the subject of obesity comes up. Only then, do the Defenders of the Purity of the Definition of Disease arise to declare obesity “INELIGIBLE!”  In any event, if one stays just with the extant, secular definitions of disease, as commonly used, I think one has to admit that obesity meets commonly used terminology.

To address this specific objection, there are a number of diseases which are preventable. Not all diseases are caused by infections or toxins.  Probably the most prominent are sexually transmitted diseases, including HIV/AIDs. Others include, for example, scurvy, beriberi, rickets, pellagra are diseases caused by vitamins deficiencies. Does this mean that they are not diseases? If polio, smallpox and tuberculosis are eradicated, do they lose the ‘disease’ designation? Melanoma (skin cancer) can be prevented by relatively simple measures, e.g. sun screen, wearing hats, long sleeve shirts, etc. But we don’t stop calling melanoma a disease.

If obesity is a major risk factor for type 2 diabetes and cardiovascular disease, and obesity is not a disease because it can be prevented, does it not follow that obesity-induced type 2 diabetes and cardiovascular disease are not diseases either?

Most the comments taking this approach assume that obesity is easily preventable. Is it? A recent review by AHRQ shows that current prevention strategies have little or no evidence of effectiveness. A 2011 AHRQ review found that behavioral intervention for weight loss averaged loss of about 3 kg or 6.6 pounds, far below the excess weight most adult Americans are carrying.

Insurance companies roll over and start paying for obesity treatments?” Well, maybe. Insurers still exclude certain diseases and treatments. They will certainly be looking for evidence of safety and effectiveness, particularly for the newer drugs, in broader distribution. There is certainly some momentum for greater coverage. However, obesity treatments are not considered “essential health benefits” under the Affordable Care Act. So greater insurance coverage here may be limited

Realistically, the AMA decision is not the parting of the Red Sea. For all the years that the evidence of the scope and virulence of the obesity epidemic has been developing, the AMA has largely sat on the sidelines. Don’t forget, they have not changed their policy that persons with severe obesity who cannot work should not be eligible for disability support. The AMA has mumbled about obesity as a lifestyle factor, condition, or risk factor. Now, it has put down a marker for the medical community: ‘Obesity is a disease. These are our patients. Get to work.’ With this decision, the House of Medicine, aka “the Mothership”, has moved obesity from the back door to the front window. Good for them. Good for us.

 

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