Obesity is a disease, recognize it as such

In 1962, renowned physiologist Edwin Astwood, MD, PhD, wrote: “Obesity is a disorder which, like venereal disease, is attributed to the patient. The discovery that the treatment doesn’t work is attributed to a lack of courage. At that time, about 13% of American adults were suffering from obesity (defined as a BMI> 30). Unfortunately, despite the best efforts of health professionals and others, the prevalence of obesity is now over 42%.

More unfortunately, Astwood’s statement remains essentially correct. Two major causes of this pervasive misconception are society’s unwillingness to accept obesity as a disease process, coupled with tolerance to blatant and subtle fat biases on many levels, even in the face of an overwhelming body of scientific evidence. on the contrary. The consequences are delays in preventing obesity, treatment to prevent co-morbidities, and passing cost-effective legislation to support treatment.

This raises an important question: what if society starts to recognize obesity as a disease?

Disease Qualifications

The 2005 American Medical Association (AMA) Scientific Affairs Committee stated that a disease should reflect an alteration in the normal functioning of certain aspects of the body, characteristic symptoms and damage or morbidity. Obesity is clearly the result of a failure of homeostatic energy systems and exhibits a distinct phenotype and comorbidities that account for over $ 200 billion per year in health costs alone, with a projected annual cost of 390 to 520. billion dollars by 2030. All of WADA’s criteria are met and we believe obesity is a serious disease.

Why is it so easy to gain weight and so difficult to lose it?

The increasing prevalence of obesity and the difficulty in achieving and maintaining weight loss reflect the interactions of environmental influences (eg, higher calorie and highly processed foods) with multiple genetic variants at risk for obesity. This complex interaction largely reflects an evolutionary environment favoring the selection of genes that allowed our parents to store additional calories in the form of fat in the face of frequent undernutrition.

There is a remarkable physiological “coupling” of calorie intake and production to our usual weights. Average weight gain from onset to middle age in the United States is approximately 1 kg / year (approximately 4,000 net additional kcal) despite ingestion of over 1 million kcal / year. Unfortunately, during or after weight loss there is a disproportionate increase in willingness to eat and a decrease in energy expenditure, creating “the perfect storm” for weight gain and explaining the general lack of long term success. of non-surgical weight loss.

Consequences of fat bias

The AMA officially identified obesity as a disease in 2013. Despite this, about 35% of people participating in weight reduction programs do not view obesity as a disease, and 40% of the American public still perceive it. obesity as a “personal problem of poor choice”. “

The failure to recognize obesity as a pathological process is more evident in the stigmatization of those who do not meet society’s body shape standards. The fat bias has been around for centuries. The difference is that excess fat was seen as the consequence of karmic retribution for moral failure in Buddhist cultures and the sin of gluttony in the Judeo-Christian tradition. Now, fat shaming is a damaging belief that the fault is not in our stars or our cells, but only in ourselves.

Worldwide, fat shaming is reported by over 50% of people trying to lose weight and is perpetuated by the news and entertainment media, healthcare professionals and the general public. Diffuse fat bias promotes self-directed fat bias, low self-esteem, and feelings of hopelessness in obese people. The view that obesity and the inability to maintain weight loss is due to unwillingness associated with unhealthy lifestyles is reinforced by the flawed assumption that people without obesity are therefore more in control. self-esteem and engage in better lifestyle choices. The shame of fat is perpetuated by weight loss plans that promise you can “lose weight forever” simply by correcting your unhealthy (implied) lifestyle.

Fat bias worsens health regardless of body weight and actually interferes with treatment (contrary to recent media comment). Stigma-induced stress has been associated with more meals and less gym attendance. The effect is evident throughout life. It was shown over 60 years ago that children between the ages of 10 and 11 found images of an obese child less likable than children of “normal” weight, in a wheelchair, with crutches and a splint. for the legs, a missing hand or a facial. disfigurement. Similar results have since been reported in preschool children.

The psychological stress of the social stigma imposed on obese children can be just as damaging as medical co-morbidities, leading to significant body dissatisfaction, social anxiety, loneliness and somatic symptoms. These negative images can be so strong that stunted growth and delayed puberty have been reported in children due to self-imposed calorie restriction resulting from fear of developing obesity. The consequences are cumulative, and more weight-related teasing in childhood is associated with less successful weight maintenance in adulthood.

While the explicit shame of overweight or obese people can be increasingly dismissed, the prevalence of weight bias is not changing quickly enough. In a survey of nearly 90,000 adults, the Obesity Action Coalition found increased social discomfort and rejection among obese people.

Recognizing obesity as a disease is important

What difference would it make for a patient who wants to lose weight and keep it off if everyone recognized obesity as a disease and gave it the same consideration as people with other chronic conditions?

Widespread acceptance of obesity as a disease would be beneficial in many ways, some going beyond shaming fat reduction. If Congress realizes it is denying Americans coverage for a disease whose treatment could lower health care costs, it could authorize the Stop Subsidizing Childhood Obesity Act of 2012, the bipartisan Treat and Reduce Obesity Act of 2012, the SWEET act of 2014, or the bipartite ENRICH Act of 2015 to move to a vote instead of languishing in subcommittees out of deference to Big Food.

Of course, there is progress. The overall prevalence of fat bias is slowly decreasing. There are several promising new drug therapies. The NIH’s current focus on precision medicine and nutrition is a big step towards increasing our ability to take advantage of current and future treatment options to promote weight loss and prevent recovery. The mandate for healthcare professionals and others to use the mother tongue – when a person is identified as a person suffering from obesity or diabetes rather than an obese patient or a diabetic patient – is a another big step towards separating the person from the stereotype from his or her somatotype.

Yet the term “obesity” remains taboo and is rarely spoken in front of patients or by politicians. It affects 40% of eligible voters and there are ethnic / racial and income disparities. For example, Africans, Latin Americans and Native Americans are disproportionately affected and are also subject to disparities in treatment. Americans earning less than $ 25,000 are 40% more likely to be obese than those earning over $ 75,000. Obesity is responsible for over 300,000 deaths per year among US citizens. There are huge health and financial benefits in recognizing and accepting that obesity is a disease process that begins long before associated comorbidities such as diabetes or cardiovascular disease are detected.

Almost 60 years ago, Astwood also wrote: “Corpulence in America is seen with drug addiction as something nasty, and I won’t be surprised if soon we have a ban against it in the name of national security.” . In 2013, Benjamin Carson, MD, Secretary of Housing and Urban Development in the Trump administration, called morbidly obese people “food addicts.” A recent CDC publication is titled “Obesity Impacts National Security.” How long will it take before all of Astwood’s predictions come true and half the country is held criminally responsible for being too fat? Meanwhile, we magnify billionaires because they briefly became weightless in space, but stigmatize 100 million Americans because they weigh no less.

Michael Rosenbaum, MD, is professor of pediatrics and medicine at Columbia University Irving Medical Center who has spent more than 35 years studying obesity. George Bray, MD, is a University Professor Emeritus and former Head of the Division of Clinical Obesity and Metabolism at Pennington Biomedical Research Center at Louisiana State University, whose obesity research spans 60 years and started in Edwin Astwood’s lab.