In June of 2013, the American Medical Association (AMA) officially recognized obesity as a disease. This announcement was met with loud opinions on both sides of this issue. From one side, we heard it is about time and now we can start treating obesity as the serious medical condition it is. From the other side, we heard that labeling obesity as a disease only offers an excuse for those without the willpower to eat less and exercise more. I have had discussions about the legitimacy of obesity as a disease at cocktail parties, my children’s school, baseball games, dance recitals and, most often, in the ivory towers of academia. And everyone has a strong opinion! I am pretty sure there was no such ruckus when hypertension was acknowledged as a serious medical condition, which is ironic given the great similarities between hypertension and obesity. They both have a strong familial component (genetic), generally get worse with age, are strong risk factors for cardiovascular disease (CVD), are associated with diabetes, and most importantly can very successfully be treated with aggressive lifestyle changes but rarely are. I doubt there are many people with hypertension who are accused of being hypertensive because they are lazy and cannot push away from the table. The topic of obesity is a strange amalgamation of societal values, physical environment, psychology, sociology, pathophysiology, culture, economics, and the media. There is no other health condition which is on the cover of nearly every magazine at the super market checkout lines. Psoriasis, gout, or angina, do not sell magazines or books, but celebrities eating high protein diets do! It is estimated that over $60 billion dollars a year are spent on weight loss products in the U.S. and unfortunately most of these offerings are not grounded in science which adds further challenge to successfully preventing and treating obesity. We must change where most Americans, including our health care providers, get their physical activity and weight management advice. Likely to the surprise of many, I am in complete agreement with AMA’s stance on obesity. My reason for changing my very vocal argument against labeling obesity is actually quite simple. Working from the basic assumption that we are in this profession to do the most good for the most people, I believe that the AMA recognizing obesity as a disease has the potential to positively impact hundreds of millions of people. We can debate indefinitely if sugar, fat, inactivity, vending machines, viruses, air conditioners, or various other scapegoats are the cause of the obesity epidemic. What is not debatable is that helping individuals lose weight through exercise, diet, medications, and/or surgery can have tremendous health benefits. There is no better example than diabetes which has risen in prevalence in parallel with the rise in obesity but can be successfully prevented, and sometimes reversed, by physical activity and weight loss. Given that approximately 1 in 3 American adults are now obese we cannot wait until a winner of the weight debates is declared. We have to do something about obesity now! But until medical providers are reimbursed for weight management services there will be hundreds of millions that do not get the help they need. As the dollar continues to get squeezed in the primary care clinics, we cannot expect health care providers to treat a condition that they do not get reimbursed for. It makes no sense. Would you donate 20% to 40% of your time to your employer for free? The AMA recognizing obesity as a disease is critical to helping get much needed physical activity, diet and weight loss options reimbursed in the clinical setting. I expect this to have a domino effect which will include better weight management training for providers, better weight loss treatments being developed, and eventually expansion of reimbursement to other related areas such as physical activity promotion. In my view three things need to change to maximize the potential impact of the AMA recognizing obesity as a disease:
- Dramatically Improve Physical Activity and Weight Loss Education for Health Care Providers
During my medical school training, we received a few rudimentary dietary lectures and an exercise lecture where a young cardiologist told our class, “Remember, whether you exercise or not, you are still going to die one day.” We must do better than that. A lot better. We need to incorporate state of the art physical activity and weight management training at all levels of health care education. To assure that people actually listen, we need to include physical activity and weight management questions on the Boards. It would not be difficult to create a standardized physical activity and weight management curriculum that could be incorporated into medical, nursing, and other health care providers’ schools immediately. In fact many groups have been working on such as curriculum. For practicing health care providers we need to assure that continuing medical education includes high quality physical activity and weight management advice. To do this right, it will likely require both distance based and lecture based components. We cannot continue to have the primary source of health care providers’ weight management knowledge be popular books or magazines.
- Expand Coverage
It is one thing to declare obesity as a disease, it is quite another to get legitimate treatments reimbursed and do so in a way that is not overly burdensome for overworked health care providers. We need to assure that we adequately reimburse for behavioral skills building that promotes dietary improvements and increases in physical activity. We need to view weight loss medications and surgeries as a means to improve clinical risk factors through weight loss, not as an elective cosmetic intervention. There now is extensive data demonstrating that physical activity, even without weight loss, has tremendous health benefits for individuals of all weight, and that weight loss, regardless of interventions, can lower blood pressure, improve lipids, and reduce the risk of diabetes. In many instances the clinical improvement in risk factors with substantial weight loss (and increased PA) is larger than would be expected from blood pressure or blood sugar medications alone.
- Improve Treatments
In the last two decades, we have seen great improvement and understanding across all levels of weight management treatment. We continue to strengthen, refine, and disseminate behavioral programs that promote physical activity, improve diet quality, and reduce caloric intake. The YMCA Diabetes Prevention Program is an excellent example of this. Today there are two new weight loss medications on the market and a third is likely to be available this year. All three of the medications reduce caloric intake, produce significant weight loss and most importantly, greatly improve CVD and diabetes risk factors. We continue to get a better understanding of the role of surgery in weight management and it appears that surgery has particularl benefit in those with diabetes. We need to continue to refine our ability to match the right treatment to the right patient as well as explore the importance of behavioral strategies paired with medication or surgery. I have in the past made the argument that sedentary lifestyle (or low fitness) is just as important, if not more important, than obesity on health. I still believe it, but I have given up on this position being widely accepted anytime soon. That said, I am not willing to throw the baby out with the bath water. Getting physical activity programs reimbursed, as part of obesity treatment would be a tremendous motivation for health care providers to become actively engaged in dialog with patients. In summary, while I encourage continued debate and research on the causes and relative importance of the obesity epidemic, I also applaud the AMA recognizing obesity as a disease as it is time to take action. The AMA acknowledging obesity as a disease will open the door for coverage of obesity and effective treatments, which is long overdue. While we still have much to learn, we have gained tremendous knowledge about the use of behavioral strategies, medications, and surgery to combat obesity. It is time to move these treatments from the fringes of medicine to the center of the clinic as hundreds of millions of Americans stand to benefit.