The American Medical Association Has Decided Obesity Is A "Disease," Even Though That Doesn't Really Mean Much

What follows is a slightly tidied-up version of my internal monologue upon reading about this in the news.

Jun 19, 2013 at 3:00pm | Leave a comment

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OBESITY VECTOR -- DO NOT APPROACH

 
 
“Recognizing obesity as a disease will help change the way the medical community tackles this complex issue that affects approximately one in three Americans,” Dr. Patrice Harris, a member of the association’s board, said in a statement.
 
Thanks, Dr. Harris! OK, so let’s unpack this one suitcase at a time.
 
What does it mean to recognize something as a disease?
 
It turns out, not much. As the NYT article above points out, there is no single medical definition of what "counts" as a disease. Surprising but true! Merriam-Webster calls a disease “a condition of the living animal or plant body or of one of its parts that impairs normal functioning and is typically manifested by distinguishing signs and symptoms” but that’s kind of broad when you get down to trying to pinpoint what IS disease and what isn't. 
 
Is a deviated septum a disease? Lactose intolerance? Mental illness? If I burn my dominant hand really badly, am I now “diseased”? Or just injured? What’s the difference between injury and disease? Because by the dictionary definition above they could be the same thing in a lot of cases. A “condition” could be BASICALLY ANYTHING, after all. Hell, by this reckoning, pregnancy could be a disease.
 
This is probably why medical authorities have never uniformly agreed on a single definition. Of course, on a social and cultural level, we don’t think of pregnancy, or many other conditions that might “impair normal functioning,” as diseases. We think of diseases as sicknesses. Bad stuff. Gross stuff, sometimes. Unpleasantness. The word has profound social connotations in public discourse. Not so much in medicine, which deals in disease as a matter of course.
 
All of that said, the AMA’s declaration of obesity as a new disease is mostly symbolic, as they have no legal control over how obesity is understood or treated in the medical field as a whole. So really, their recognition doesn’t mean much.
 
Hey wait though, couldn’t classifying obesity as a disease cut back on social stigma by mitigating the whole personal-responsibility, people-only-get-fat-because-they-eat-too-much conventional wisdom that continues to be so popular?
 
Yes and no. This is, weirdly, the AMA’s plan -- to help de-stigmatize obesity among doctors as always being fully within an individual’s control. Because sometimes it’s not. (If for no other reason, this event is worth noting because it led to this sentence being printed in the New York Times: “Some doctors say that people do not have full control over their weight.” WHOA, STOP THE PRESSES. NO WAIT, DON’T STOP THEM. KEEP THEM GOING.)
 
The AMA hopes that doctors who would ordinarily assume that their fat patients were just uncontrollably stuffing themselves with cake every night might be motivated, instead, to think of said patients as suffering from a disease that can be treated. And that insurance companies might then be more likely to pay for those treatments. Which can be expensive.
 
Critics of this move, however, will argue that medicalizing and pathologizing obesity will likely INCREASE stigma, not lessen it. Many people with chronic illnesses -- especially people who are not elderly but comparatively young to be suffering from long-term conditions -- will tell you that it can be rough to deal with a lack of patience or understanding from people in social (or professional) contexts. Just because you can explain pain or exhaustion or other symptoms by saying you have fibromyalgia or multiple sclerosis does not mean everybody you tell this to will immediately become sympathetic. 
 
Indeed, sometimes people will straight-up avoid you after such a revelation. Or they will assume you can’t do your job, or that you are too depressing to hang out with, or whatever. 
 
So people might not want to be associated with disease because the social and cultural connotations would just be swapping one form of social stigma for another? Isn’t that sort of disablist?
 
Some of the resistance is probably rooted in folks not wanting to be identified as disabled or sick because on some level, they think these things are icky and bad, yes. And we absolutely should also be working toward erasing the social stigma associated with ANY chronic illness or disability. But I also think that the fat resistance to being lumped in with these ideas is not necessarily coming from a negative place. 
 
There are plenty of people who are both fat and chronically ill, or otherwise disabled. Some have issues connected to their size, and some have conditions that are totally unrelated to weight. Being fat and disabled is its own intersectional experience, as anyone who is these things will tell you. 
 
But the fuller reality of obesity is that not all fat people inevitably and universally suffer impaired physical function directly caused by their weight. And to assume that they do is both inaccurate and lazy. SOME do, sure. But some fat people are active and healthy even by objective medical standards and numbers -- I mean, aside from simply being fat. 
 
So it’s tough to suggest that obesity is uniformly one disease when it affects different people in such radically different ways. 
 
It’s also difficult to reframe obesity a disease when there are no reliable methods of diagnosing it. Indeed, the AMA’s move is so controversial that in making this declaration that obesity is a disease, the AMA is going against the conclusions of its own public health council, which spent a year assessing the prospect of disease-ifying obesity and whether doing so would help public health outcomes:
 
The council said that obesity should not be considered a disease mainly because the measure usually used to define obesity, the body mass index, is simplistic and flawed.
 
Some people with a B.M.I. above the level that usually defines obesity are perfectly healthy while others below it can have dangerous levels of body fat and metabolic problems associated with obesity.
Since obesity does not affect everyone the same way, not everyone is going to be interested in being “cured,” and not everyone is going to need extensive (and expensive) treatments for their weight. So what do we gain by calling it a disease?
 
Wait, is this about selling weight loss drugs?
 
Possibly. Or, at least, it is likely to be partly about developing weight loss drugs.
 
I am not by any means suggesting some kind of AMA/drug industry conspiracy in which the two are in cahoots to turn a profit. However, there is precedent for medical authorities promoting the research and use of prescription weight loss drugs for the purpose of increasing the research and use of MORE prescription weight loss drugs. 
 
For example: in 2011, a drug called Contrave was up for FDA approval. The FDA advisory panel that looked at Contrave recommended it for approval in spite of the fact that it produced only modest clinical results, AND in spite of evidence that it may cause some unfortunate cardiac effects, stating outright that they were doing so because NOT approving the drug would “kill development of these medications.” 
 
You read that right: the FDA advisory panel recommended a drug be approved not because it works and is safe, but because rejecting it might result in fewer new drugs being developed, as drug companies might be unwilling to pour time and money into creating drugs with little reason to hope of ever reaching the marketplace. (This is even more troubling given that Meridia had been pulled from the market in 2010, after 13 years of being prescribed for weight loss, because of concern over its links with increased risk of cardiovascular events and strokes.)
 
In the end the FDA disagreed with this logic and rejected Contrave, telling the drug’s manufacturer to do more research, the news of which resulted in a rash of articles that rather dramatically declared the obesity drug field to be DEAD FOREVER, callously slain by the FDA’s unreasonable safety standards.
 
Obviously, they were wrong, since two new weight loss drugs -- Qsymia and Belviq -- were approved by the FDA last year, and have just become available by prescription this month, the first new drugs to enter the market in over a decade. (Although Contrave is still being developed, she continues to be a bridesmaid, never an FDA bride.)
 
Qysmia is a combination of two drugs that have been used for weight loss before; in trials, depending on dosage, its average users lost between 6.7 to 8.9 percent of their weight. For reference, that means a 250-pound person taking the medication, along with the necessary “lifestyle changes” to diet and activity level, could expect to lose somewhere between 16 to 22 pounds. The cost? About $150 for a 30-day supply.
 
Belviq is less impressive, with its lifestyle-changin’ participants losing an average of 3 to 3.7 percent of their weight. In a 250-pound person, that’s about 7 to 9 pounds. However, by the end of the second year, most patients had gained 25 percent of that loss back, which sort of makes you wonder how helpful this drug can really be, and whether it's worth the $200 per month price tag.
 
What’s extra interesting about these two drugs is that the FDA states that patients should expect to take them for the rest of their lives, which is a sharp divergence from the popular notion that weight loss drugs are a thing people take only as long as they want to lose weight. It is also definitely in keeping with a cultural shift toward thinking of obesity as a chronic disease. 
 
This is happy news for drug companies, as a drug that needs to be taken for a lifetime is a very profitable drug indeed, and therefore this may inspire said drug companies to put more effort into developing more drugs. Thus, it’s likely that the AMA’s move is an attempt to contribute to this cultural shift in how we think about and treat obesity, and at least partly about inspiring further interest and research into weight loss drugs.
 
Unfortunately, it will probably also result in a lot of people paying for a lot of treatments they don’t really need. For all of our cultural hand-wringing about how much fat people are allegedly costing health insurance companies, the AMA sure doesn’t seem bothered by potentially causing an explosion of unnecessary prescriptions (and surgeries!) among the one-third of Americans who are suddenly now “diseased.”
 
One last thing: can I call in fat to work now?
 
Oh man, that’d be great, wouldn’t it? “Sorry, can’t come in today, too fat.” I think you're still out of luck on this, though.
 
Naturally, a Twitter hashtag -- #Iamnotadisease -- has sprung up to speak out against the AMA’s decision, and the cultural stigma associated with fatness in general, because simply being fat and facing the assumptions and judgment of strangers every day is itself pretty sick-making, a lot of the time. 
 
For all the possible medical and pharmaceutical repercussions, let’s not forget that identifying obesity as a disease has an impact on actual individuals, many of whom are not impressed with the idea that what they thought was their body is now instead being formally recognized as a big walking illness. And understandably so -- while some folks might be relieved to have the AMA’s backing in thinking of their weight as a sickness, it seems unfair to force that perspective on everyone, regardless of widely diverse personal experiences. 
 
Although I would prefer to believe in the American Medical Association’s good intentions, this choice just doesn’t make sense. It is unlikely to change our public health -- as determined by the AMA’s own council on the subject -- and it certainly isn’t going to radically alter the overwhelming personal-responsibility-laden cultural associations with fatness, as people will still judge fat folks for knowingly afflicting themselves with a so-called disease. All it will do is further support the existing stigma against obesity, a stigma that is not helpful to the people it affects and is often flat-out harmful.
 
Oh, and it will sell a lot more expensive and only mildly effective weight loss drugs. Which may well be the point.