Last month at its annual meeting in Chicago, the American Medical Association (AMA) declared that obesity was a disease. This was a relief to many people who had argued for years that obesity was a condition often requiring medical intervention, and not simply the result of too little willpower and too many calories. Even so, there remains plenty of disagreement over whether obesity should be regarded as a disease or not.
While some who support the “disease” classification rightly point out that there is a genetic element to obesity that appears to contribute to a sort of dysfunction associated with disease, others see the picture differently. As The New York Times reports, some who oppose classifying obesity as a disease argue that “there are no specific symptoms associated with it and that it is more a risk factor for other conditions than a disease in its own right.” Both sides, however, agree on many things, including the dangers of obesity.
What is obesity?
While some sources simplify the answer to this question by suggesting an obese person is a certain number of pounds heavier than his or her ideal weight, obesity is based on a person’s body mass index (or BMI). A BMI of 18.5 to 24.9 is considered ideal or “normal,” regardless of gender. A BMI between 25 and 29.9 indicates a person is overweight. A BMI of 30 or higher is said to indicate obesity.
Estimates of the number of obese Americans average nearly one third, or about 100 million Americans. Level 1 obesity is indicated by a BMI between 30 and 34.9. Level 2 obesity is indicated by a BMI between 35 and 39.9. A BMI of 40 or higher indicates Level 3 obesity.
It is often noted that body mass index alone—while a good general indicator of obesity—does not always give an accurate picture of an individual’s health. As the Times reports, “Some people with a BMI 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.” While this is true, the Centers for Disease Control and Prevention (CDC) has linked obesity to a variety of serious health conditions including:
- Coronary heart disease
- Type 2 diabetes
- Endometrial, breast, and colon cancer
- High total cholesterol or high levels of triglycerides
- Liver and gallbladder disease
- Sleep apnea and respiratory problems
Obesity is associated with other serious health conditions including kidney, colorectal, and esophageal cancer. And, while it is true that a body mass index of 30 or more does not necessarily indicate ill health of any sort, CalorieLab.com reports that the Centers for Disease Control and Prevention “found that individuals with a BMI of 30 or above had an 18 percent higher death risk and that value becomes greater as weight increases.” Estimates of the annual cost of obesity in America often exceed $200 billion, or about $600 per American. This includes both direct costs associated with prevention, diagnosis, and treatment and indirect costs, which cover losses (such as loss of workplace productivity) tied to obesity.
As far as individuals’ costs are concerned, Marc Ambinder reported a few years ago in The Atlantic that “obese Americans spend about 42 percent more than healthy-weight people on medical care each year.”
Obesity strikes Americans of all ages
Adult obesity is a major concern partly because of the strain it puts on healthcare resources and economic productivity, but some observers believe childhood obesity is an even more serious problem that is likely to have major repercussions in the future. While the percentage of obese children in the United States is lower than the percentage of obese adults, the gap is narrowing and it is feared that many currently obese children will develop complications related to obesity at an earlier age than previous generations of obese Americans did.
Treatment of obesity for younger and middle-aged Americans is often hindered by the lingering view that the condition is the result of choices and not inherent physical causes.
According to nutrition coach John Berardi, Ph.D., in The Huffington Post, obesity treatment in the United States is hindered by an “obvious lack of training preventing most physicians from being able to treat obesity.” Berardi suggests the AMA’s classification of obesity as a disease may not be particularly significant because few doctors have the training to treat obesity as more than the result of unhealthy choices.
Even the advice many doctors give obese patients—to eat right and exercise—rings hollow, according to Berardi, because while in medical school the majority of doctors had “less than two weeks’ curriculum in nutrition prescription, and no direct coursework in exercise prescription.”
Further hindering doctors’ ability to understand the needs of obese patients, Berardi says, is the brief time patients normally spend with their doctors during visits. According to Berardi, research suggests the average doctor visit nowadays is about eight minutes long, which Berardi says is “barely enough time for a presentation of symptoms and a subsequent referral or prescription.”Elderly people who are obese face these same challenges and more.
Complicating obesity treatment for older Americans is the importance of weighing the possible benefits of treatment against possible complications that might arise from treatment. For example, the National Institutes of Health (NIH) and other leading institutions have long advised that any weight loss program for seniors should not result in reduced intake of important nutrients and minerals.
Bone health is a particular concern for many older people, and any diet reducing calcium intake may do more harm than good to an older person. Medicare’s approach to obesity seems to take the big picture into account.
Although Medicare services are limited as far as obesity coverage is concerned, the Times reports that in 2004, nine years before the AMA’s declaration, Medicare removed language saying Medicare was not a disease from its manual. Medicare obesity services have improved significantly since then, particularly with the 2011 introduction of Medicare preventive services aimed at obesity.
Obesity screening and behavioral therapy services are available to Medicare recipients with a BMI of 30 or more. Medicare-covered counseling has helped many people with obesity enjoy improved health—and this service is available at no cost to people who qualify. Unfortunately, Medicare does not normally pay for other treatments related to obesity unless weight loss or other obesity-related treatment is necessary for treating another condition. For example, successful treatment of diabetes often requires some form of treatment relating to weight loss or control of weight.
As Arbinder points out in The Atlantic, “Type 2 diabetes is one of the leading drivers of rising costs for Medicare patients, and 60 percent of cases result directly from weight gain.” As a result, procedures designed to control weight may be covered by Medicare if weight loss is seen as a necessary component of treating diabetes. Normally, inability to lose weight over time in other ways (such as by dieting) has to be documented, but if a doctor is convinced that a procedure such as gastric bypass surgery is necessary in order to reduce the weight of an obese patient with a serious condition such as diabetes or cardiovascular disease, there is an excellent chance that Medicare will cover the procedure.
Unfortunately, out-of-pocket costs deter some people from receiving even Medicare-approved treatments and procedures that can combat obesity and greatly improve their health. Other people who stand to benefit from procedures to combat obesity find that Medicare supplement plans are an excellent tool for helping them receive all the care their doctors recommend with few or no out-of-pocket costs to worry about.
What might be the effects of the AMA declaration?
Some possible effects are that:
Obesity treatment methods may change significantly.
If obesity is recognized by the medical community as a disease in its own right, doctors are likely to receive better training in methods of treating it. Dan Goldberg of Newark’s Star-Ledger reports that Kenneth Storch, director of Atlantic Health’s metabolic program at Overlook Medical Center in Summit, New Jersey, “said doctors were prone to treat symptoms of obesity such as high blood pressure, high cholesterol, diabetes or sleep apnea rather than treating the underlying cause — obesity.” Goldberg continues: “This new designation could encourage doctors to take a more proactive role with medications or surgeries, as opposed to only recommending diet and exercise.” Many others agree with the assessment that recognizing obesity as a disease will result in many new approaches to treating it.
Some people may focus on a medical solution for obesity while ignoring the importance of good dietary habits and good physical habits.
Regardless of whether a particular case of obesity is more directly related to genetics or environmental factors and choices, the importance of a sound diet and adequate exercise should not be forgotten. There is some fear that designating obesity as a disease will encourage some people to forget about exercise and proper diet and look to medication as a solution.
Even if there are genetic factors contributing to obesity, the CDC advises that “genes do not always predict future health. Genes and behavior may both be needed for a person to be overweight. In some cases multiple genes may increase one’s susceptibility for obesity and require outside factors, such as abundant food supply or little physical activity.”
Obesity may be recognized as grounds for certain legally-mandated protections and accommodations.
For example, some observers expect the Americans with Disabilities Act of 1990 to mandate major accommodations for obese Americans in the future. Many Americans are unaware that the Social Security Administration currently recognizes obesity as a potential cause of, or contributor to, disability. While obesity is not currently listed as an impairment qualifying for Social Security Disability Insurance (SSDI) benefits, if the effects of obesity are equivalent to the effects of an impairment on the list, or if obesity combined with an impairment on the list prevents an individual from making a living, that person may qualify for SSDI benefits.
It is believed that, if obesity is recognized as a disease and, at its extreme, a potentially disabling condition, major accommodations will have to be introduced to ensure obese persons are able to carry out every aspect of their jobs and their daily lives without undue difficulty. Restaurant booths and airplane seats may have to become more spacious, work duties may have to require only minimal movement, alternatives to climbing stairs may have to be introduced or installed, and so on. Otherwise, some observers expect lawsuits in the United States to reach an all-time high.
Obesity and health insurance
According to NBC, the AMA says, “Employers may be required to cover obesity treatments for their employees and may be less able to discriminate on the basis of body weight.” Given the likely cost of obesity treatments, however, it seems likely that some companies will look for ways to get around such a requirement.
As CalorieLab.com reports, some companies “have begun tying health insurance premiums to people’s health. Employees often have to go through medical and biometric testing as part of their health insurance open-enrollment process. Individuals with high values for cholesterol, glucose and blood pressure, or with chronic conditions like diabetes, are often told they will have to pay higher premiums unless they actively try to address their medical condition.”
Another approach, tested by University of Michigan and Stanford University researchers, involves offering premium reductions to obese people who agree to engage in a level of physical activity designed to keep them relatively healthy. According to the lead author of the study, the vast majority of people, eager to save money on their premiums, lived up to the agreement.
As for Medicare, it is unclear how premiums may be affected if obesity is widely regarded as a disease. However, the likely scenario that Medicare Part D prescription drug plans would pay for obesity drugs—as is not the case now—would probably save many Medicare recipients with obesity a great deal of money on their healthcare. And, regardless of what gaps would remain in Medicare coverage as it relates to obesity, Medicare supplement insurance would be the logical solution for people wanting comprehensive coverage, fixed premiums that would never rise as a result of new diagnoses or complications, and minimal or no out-of-pocket costs for Medicare-covered services.
The AMA’s Influence
While the American Medical Association’s declaration that obesity is a disease has no official standing of any sort, and is not likely to result in any laws being changed overnight, the AMA’s influence on healthcare debates shouldn’t be underestimated. At the very least, the AMA has done a service by bringing this debate to the forefront and making more Americans sensitive to some of the challenges people with obesity face. And, though it remains to be seen where this debate will go from here, both sides are in agreement that obesity, whether primarily a disease or not, is a major cause of concern across all age groups and across the country.
Where do you stand in this debate? In your view, is obesity a disease?
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