Is obesity a disease?

July 13th, 2016 No comments »

Readers interested in the debate over whether obesity is a disease or not should visit Dr. Arya Sharma’s blog. He has addressed numerous arguments for and against categorizing obesity as a disease. He also has a video addressing how to lose 50 pounds and explaining adaptive or metabolic thermogenesis at https://youtu.be/o9hRhsaopz4.  See also.

Where is Your New Year’s Resolution? Or, Where did I put my Adaptive Thermogenesis?

January 17th, 2014 No comments »

It’s mid-January: do you know where your New Year resolution went? You know the one about losing weight.

So maybe you are losing the weight you put on over the holidays? Maybe you are underway with a good weight loss program? Maybe you have already given up? No matter what your status, there is something you should know:

The human body is programmed to defend its weight and, when it senses weight loss, it starts cutting down its energy expenditure…big time!

Let’s talk about energy expenditure or “EE”. About 65-70% of calories burned each day are used to keep the routine body functions going, e.g. pumping blood, working the lungs, kidneys and liver. About 10% are used up in thermogenesis or the digestion of food. The rest, about 20%, is spent by the muscles in physical activity.

As far back as 1987, researchers compared the daily resting metabolic rate (RMR) of obese women who had lost weight and were no longer obese with women who were  never obese. The researchers found that the post-obese women had metabolic rates approximately 15% lower than the never-obese group and they ate less.

So, metabolism in persons who have lost weight and those who are lean may not be the same.

Exercise and the heat value of food are skewed against those with obesity. In one experiment, 10 lean women and 10 women with moderate obesity were measured during periods of eating and exercise. Eating before exercise increased the exercise metabolic rate in lean women by 11% but only by 4% in women with obesity. The thermic effect of food was 2.54 times greater during exercise than at rest for the lean group, but only 1.01 greater for the women with obesity.

In a now classic 1995 paper by Jules Hirsch, Rudy Leibel and Michael Rosenbaum at Columbia University found that when a body loses weight, it adjusts by reducing its energy expenditure. This effect is so strong that an obese person who went from 250 lbs to 200 lbs would have to consume about 30% less than a 200 lbs person who had not lost weight just to maintain the same weight. This extra-reduction in food intake would have to continue indefinitely if the person were to maintain their weight loss.

This process, called by researchers “Adaptive Thermogenesis” can persist after active dieting for up to a year in one study.  In an experiment involving subjects with severe obesity who were on a program of diet restriction and vigorous physical activity, researchers saw dramatic weight loss (over 30%) but a slowing of the resting metabolic rate (RMR) “out of proportion to the decrease in body mass, demonstrating a substantial metabolic adaption.”

Some researchers considered adaptive thermogenesis a major factor in the plateauing one sees in dieters, the increase in hunger and the eventual regain of lost weight. In one study of short-term severe diet and exercise subjects, the ‘metabolic compensation’ was seen as a major contributor to the less-than-expected weight loss. Individuals will have different adaptions to weight loss. In some cases, the effect can be significant. Tremblay et al state, “Indeed, as it is difficult to prescribe food intake that imposes an energy deficit exceeding 700-800 kcal per day to obese individuals, the decrease in energy expenditure in response to weight loss can entirely compensate for this prescribed deficit.”

Others are less sure. They seem to accept adaptive thermogenesis but see measurement problems and questions as to its utility in weight management.

The point is that our bodies contain a defensive mechanism against the disease of obesity. Until we realize that our strategies for prevention and treatment are like a novice chess player going up against a Grand Master. The point is: obesity is a lot tougher than our simplistic policy prescriptions assume.

The quandary of obesity has been expressed by Tremblay Chaput and Doucet in their article “Obesity: a disease or a biological adaption? An Update,“ Additionally, substantial body fat loss can complicate appetite control, decrease energy expenditure to a greater extent than predicted, increase the proneness to hypoglycaemia (low blood sugar) and its related risk towards depressive symptoms, increase the plasma and tissue levels of persistent organic pollutants that promote hormone disruption and metabolic complications, all of which are adaptations that can increase the risk of weight regain. In contrast, body fat gain generally provides the opposite adaptations, emphasizing that obesity may realistically be perceived as an a priori biological adaptation for most individuals. Accordingly, prevention and treatment strategies for obesity should ideally target the main drivers or root causes of body fat gain in order to be able to improve the health of the population.”

 

D is For Disease, Death and Disability

July 8th, 2013 No comments »

Supposed you woke up and the TV news and newspapers revealed that scientists had discovered a global threat affecting all races, both genders, reducing lifespans and causing millions of cases of disabilities, likely to cost billions of dollars a year. There was no clear cause and no treatment which seemed available, except, in some cases, surgically removing part of the GI track seemed to work…for a while.

What would you say? “Who cares”? “It’s their own fault”? “How much is this going to cost me?”  Perhaps, you would call your Congressional representative and Senator and demand a crash research program to find a cure? Or you could quibble for, say, forty years or so, over who is to blame and whether this “threat” is a condition, syndrome, risk factor or (God forbid!) a disease? Well, the latter is pretty much what we have been doing about obesity. Three new papers show the impact of obesity on mortality, disability and disability-related health care costs, reminding us of the toll this disease takes on the human body.

First, regarding mortality, a great number of studies have been published and the public is still confused. Now, Chang and colleagues, have published a paper in which they are able to predict life years lost associated with obesity-related diseases for non-smoking US adults. They found that obesity-related comorbidities are associated with large decreases in life years and increases in mortality rates. Years of life lost is more marked for younger than older adults, for blacks more than whites, for males than females and for more obese than less obese. Their study confirmed that being obese or underweight increased the risk of mortality. Furthermore, an obesity-related disease, such as coronary heart disease, hypertension, diabetes and stroke, increased the chances of dying and decreased life years by 0.2 to 11.7 years, depending on gender, race, BMI and age.  Obesity-related diseases were expected to shorten lifespan of people in their 20s by more than 5 years, while people in their 60s were predicted to lose just under one year of life. See, Chang SH, Pollack LM, Colditz, Life Years Lost Associated with Obesity-Related Diseases for U.S. Non-Smoking Adults.

Obesity-related diseases are also only partially understood. Type 2 diabetes and heart disease are commonly associated with obesity but there are a host of other conditions which are less well-known and appreciated. Among these are the disabling conditions associated with obesity. Brian S. Armour, et al, have looked at disability prevalence among persons who are obese. Of the 25.4% of US adults who are obese (53.4 million), 41.7% reported a disability in contrast to 26.7% of those at a healthy weight and 28.5% of those who were overweight. Movement difficulty was the most common type of basic action difficulty, affecting 32.5% of the adults with obesity. Of course, movement difficulties can hinder physical activity for weight loss.

Work limitations affected 16.6% of the adults with obesity. Visual difficulty was the common sensory difficulty at 11.5%, probably attributable to type 2 diabetes.  20.5% of adults with obesity reported complex activity limitation, compared to 12% of those at a healthy weight. All estimates for disability were significantly higher for people who were obese compared to those with a healthy weight. The prevalence of cognitive difficulty, contrary to Hank Cardello’s implications, was low at 3.6% for persons with obesity. However, persons at a healthy weight had higher cognitive difficulty than those who are overweight, 2.9% v. 2.4%. Armour BS, Courtney—Long EA, Campbell VA, Wethington HR, Disability Prevalence among health weight, overweight, and obese adults. Obesity, 2013 Apr.21 (4); 852-5.

Wayne L. Anderson, Joshua M. Weiner and colleagues widen the picture of persons who are obese with disabilities in terms of health care costs. Their new study estimates the additional average health care expenditures for overweight and obese adults with and without disabilities. They found that people with disabilities who were obese had almost three times the additional average costs of obesity compared to people without disabilities, $2,459 v. $889. Prescription drug costs were 3 times higher and outpatient expenditures were 74% higher. People with disabilities in the 45-64 year age group had the highest obesity expenditures. Overweight people with and without disabilities had lower expenditures than normal-weight people with and without disabilities. The authors note, “A substantial portion of people with disabilities are obese. People with disabilities are at higher risk of obesity because some conditions such as arthritis and diabetes are characterized by high levels of functional impairment. Arthritis can readily limit mobility, which may result in substantial weight gain over time. For diabetes, weight gain can be a byproduct of insulin use if patients do not effectively manage their weight. The coexistence of disability, obesity, and serious chronic conditions may result in very high health care expenditures.” Anderson WL, Wiener JM, Khatutsky G, Armour, BS Obesity and People with Disabilities: The Implications for Health Care Expenditures. Obesity, 2013 June 26, (epub ahead of print).

So, obesity is a driver of mortality and morbidity but is not a disease? Eh?

 

Reflections on the AMA Disease Decision – Part 1

July 3rd, 2013 No comments »

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.

 

Huffington Post Live Discussion of AMA Decision

June 20th, 2013 No comments »


Here is the link to the HuffPost Live Discussion:

http://live.huffingtonpost.com/r/segment/ama-recognizes-obesity-as-a-disease/51c1cd312b8c2a0a3100028d

Enjoy.

AMA Considers Recognizing Obesity as a Disease

June 17th, 2013 No comments »

At their annual meeting this week, the American Medical Association’s governing body, the House of Delegates,  will consider a resolution recognizing obesity as a disease. As they say, we wait with baited breath.

In 2009, the AMA declared that obesity should not be a condition qualifying for disability status. (See post, How the AMA Got It Wrong, Sept. 27, 2009)

In 2012, the American Association for Clinical Endocrinology recognized obesity as a disease. The Obesity Society did so in 2008. This is the white paper of supporting evidence. See also my paper in 2001: Obesity as a disease entity

The Social Security Administration recognized obesity as a disease in 1999. The Internal Revenue Service determined that costs for the treatment of obesity were medical costs eligible for the medical deduction on individual income taxes in 2002. In 2004, the Centers for Medicare and Medicaid Services effectively recognized obesity as a disease by removing language to the contrary from their coverage manual.

 

Is Melanoma A Disease?

October 29th, 2011 No comments »

What kind of question is that? This week the American Academy of Dermatology and the CDC came out with several papers on the incidence and prevention of skin cancer. The papers cover ultra-violet exposure to children and adolescents, mortality rates, racial and ethnic variations, education in schools and screening. Journal of the American Academy of Dermatology – Supplements 

So, here’s the picture on skin cancer. It is increasing across the country. It leads to higher mortality. It has a strong genetic component: light skin predisposes individuals to skin cancer. It is highly preventable by taking protective step against skin exposure. But many people do not take the  preventive steps. Hey, sounds a lot like obesity doesn’t it? Epidemic level of incidence, genetic predisposition, high environmental exposure, lack of personal protective behavior. So why do people get so excited when obesity is considered a disease but not when skin cancer is discussed? (For an example of the reaction, see the comments to Dr. Scott Kahan’s blog on Huffington Post Scott Kahan, M.D.: Why Obesity Is a Disease.)

Clearly, melanoma is a disease. So, too is obesity. The difference is our knee-jerk reaction to want to blame persons with obesity for their condition while cutting other people a lot of slack for contributing to their diseases. Until we get over this attitude, progress on preventing and treating obesity will remain limited.

AACE Recognizes Obesity as A Disease

July 30th, 2011 No comments »

The American Association of Clinical Endocrinologists (AACE) has recognized obesity as a disease in its own right. See their statement at AACE Declares Obesity as a Disease State | American Association of Clinical Endocrinologists