June 26, 2013

Is Obesity a Disease?

By Mark Sisson

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You’ve probably heard that the American Medical Association recently classified obesity as an official disease. I’m still mulling the whole deal over, and I’m not quite sure what to think about the decision. First, what exactly is a disease?

A disease is defined thusly:

1. A disorder of structure or function in a human, animal, or plant, esp. one that produces specific signs or symptoms or that affects a specific location and is not simply a direct result of physical injury.
2. A particular quality, habit, or disposition regarded as adversely affecting a person or group of people.

By those literal definitions, obesity could be considered a disease. It’s caused or characterized by disordered diets, disordered hormonal responses to food, and disordered energy intake/absorption/expenditure ratios. Furthermore, obesity can lead to other, worse diseases, like heart disease, diabetes, and cancer. It’s also a “quality” (a preponderance of body fat) that adversely affects a person (increases the risk of other metabolic diseases, increases impact on joints, impairs physical ability, etc.).

But I’m not sure if obesity is actually a disease in the sense that most people imagine it, nor am I sure it should be called that. When people hear words, they don’t consult the dictionary to determine their meaning and mount a response. Unless it’s for language class, they care not for denotations, but rather connotations – commonly held cultural or emotional responses to words or phrases. This tendency of ours is not by choice. It’s simply how language works in the real, immediate world made up of actual thinking, feeling humans. So, what are a few connotations aroused by the word “disease” and how might they affect an obese person’s response to such a “diagnosis”?

Diseases are:

Immutable – A disease “stays with you.” Everyone knows that. It’s here to stay, and nothing’s going to change that unless you’re taking some serious pharmaceuticals or surgical interventions. You, a layperson, couldn’t hope to get over a disease all by yourself. Why try?

Deadly – You get over sicknesses, which are just minor annoyances. But diseases kill. This will either light the fire of god underneath you or fill you with despair.

Out of your hands – Disease strikes. It acts upon you, and you have no say in the matter.

Diseases require:

Medical intervention – You can’t beat this by yourself. A medical professional – an “expert” – needs to intervene and save you.

Pharmaceuticals – You’re probably gonna need a pill or three to get over or manage this, costs be damned.

In other words, for many people, having a “disease” may remove their sense of urgency and give them the idea that they need someone else to fix their problem. They can’t fight it, so why even try? Though other people may be motivated to “cure” their disease, they’ll likely do so through “official” routes, i.e. doctors, prescriptions, and dietitians. You could get the odd professional who has actually delved into nutritional science and won’t tell you to cut out the butter and eat more whole grains, but I wouldn’t bet on it. Either way, the obese end up frustrated with the ineffectiveness of the prescribed plans or resigned to their condition. And probably still obese.

That’s too bad. Obesity is preventable. It is avoidable. And, once “afflicted” with the “disease,” the obese can cure it simply – but not necessarily easily – through lifestyle modification.

I’m torn, though. While obesity is largely up to the individual, I see no reason to make obesity a moral failure worthy of social stigmatism, and calling it a disease may help in that regard. We individuals have gotten bad advice – advice that we’re supposed to draw upon to make health decisions – from the experts to whom we bend the knee. We’re told to “eat less” and “move more,” we’re reminded about “diet and exercise” (without any useful details, as if everyone already knows what’s healthy), that you just need to flex your willpower muscle, that fat people who stay fat just “want” to be fat, that eating animal fat and red meat will make us fat and give us cancer. I assume the same advice would be given to the medicalized obese to similar (non)effect.

Now, obesity is solely a problem of the body. This could be cool if they end up exploring the physiological origins of obesity with tons of research money, but I strongly suspect it will only lead to further ignorance regarding the external origins of obesity, like corn subsidies, lobbying from the processed food industry, the emergence of dwarf wheat, the pushing of the USDA food pyramid (what, you think the AMA’s gonna stop pushing their ideal dietary recommendations?), the preponderance of industrial seed oils and the subsequent condemnation of animal fat, the evolutionary mismatch between our genes and the modern environment, chronic stress, sleep disturbances, and all the other circumstances over which we have little to no control but which have immense consequences on our weight. Until the medical community accepts – or at least acknowledges as worthy of study – these factors, I fail to see how calling obesity a disease will do the obese any actual good.

I do see how it might cause some issues, though:

Now, the overweight kid in school isn’t just fat; he’s sick and fat. That will do wonders for self-esteem.

Now, instead of checking out a free Primal blog for helpful advice, the overweight single mother might assume she has to fork over the money for a physician-sanctioned registered dietitian. Ineffective advice that comes with a co-pay (if you’re lucky enough to have health insurance)? Awesome!

Now, the obese man won’t even think about looking into lifestyle modifications. He’ll just add the next big anti-obesity drug to his daily cocktail, right between the statins and the beta blockers.

I also worry about the legal fallout from this decision. Are people writing those free Primal (or any diet) blogs full of advice on losing weight now subject to governmental regulation because they’re dispensing medical advice regarding an officially recognized disease? A similar thing already happened to Steve Cooksey, who committed the egregious sin of dispensing nutritional advice to people with another recognized disease: type 2 diabetes.

I also question the motivations of the people ultimately responsible for the decision. As Dr. Davis wrote last week, the Obesity Action Coalition, a non-profit, spearheaded the initiative in order to “change the way the medical community tackles this complex issue that affects approximately one in three Americans.” Sounds nice, doesn’t it? Until you learn that the OAC board is made up of bariatric surgeons and the coalition is funded by pharmaceutical companies with big stakes in weight loss drugs and surgical supply manufacturers with big stakes in weight loss surgery. In other words, the very people who stand to make a ton of money from medicalizing obesity are responsible for medicalizing obesity. I don’t doubt that they care, on some level, about people’s health, but their motivations appear to be clouded by other interests, and that makes me wary.

As I said before, I’m torn. I don’t think obese people should be blamed or made to feel like moral failures. Even if it were true that all obesity is caused solely by personal irresponsibility, saying “you’re fat because you’re lazy and eat too much” simply does not help people lose weight. They “know” that; it’s the implicit message all around us. But I doubt this is the right way forward.

We need a balance, not a diagnosis. On one side is “obesity as a disease,” with patients assuming it’s out of their control and a medical intervention is necessary. On the other side is “obesity as personal failing,” with the obese feeling a deep sense of shame and hopelessness, especially when their willpower fails to deliver them to the promised land. But you and I and everyone reading this know that it’s a lot greyer than either position. We know that the real story is a tad more complicated.

What do you think, folks? Is obesity a disease? What impact will this decision have on obesity in this country?

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