Obesity's "New" Disease Status Spurs Debate

Published in July 2013 Issue             

The American Medical Association’s (A.M.A.) official recognition of obesity as a disease started another national conversation about obesity and its treatment. This time, medical and surgical experts, were joined by financial analysts, advocacy groups, opinion columnists, major media organizations from all over the world, debating the virtues of the A.M.A.'s watershed decision.

John Morton, MD, ASMBS Secretary-Treasurer, called the declaration by the national’s largest physician organization a “tipping point” noting that “the scientific consensus that has been built around the disease of obesity and its treatment cannot be ignored.”  This was included in the ASMBS official statement on the matter. Further support was expressed in a joint statement by The Obesity Society (TOS), American Society of Bariatric Physicians (ASBP) and American Association of Clinical Endocrinologists (AACE).

“The A.M.A.’s acknowledgment facilitates more dialogue around the need to provide patients with coverage of safe and proven treatments, including surgery, which will influence policy and drive greater access to care and greater understanding of the disease of obesity.”

On CBS This Morning, Lou Aronne, MD, director of the Comprehensive Weight Control Program at New York Presbyterian Hospital, similarly expected the organization’s decision to “have a tremendous impact on legislation in Washington [and] with insurance companies.”

A.M.A. President Ardis Dee Hoven, stated, “The purpose of the policy is to advance obesity treatment and prevention. It issues a call for a paradigm shift in the way the medical community tackles this complicated issue.”

But the costs of obesity definitely factored into the discussion. In a CNBC.com story, one commentator speculated, “We know that there are higher costs associated with people who are obese or morbidly obese. The question is, by covering treatment of obesity, would we influence and change that prevalence enough to more than offset the additional costs associated with treatment?”

It was noted by numerous reports that that obesity maybe simply too “common” to be designated a medical condition, with one-third of adults and one-fifth of children in America having the disease. Many financial commentators said because of these staggering numbers, in the short term, expansion of treatment coverage "could dent the profits of insurance companies," despite the potential cost savings resulting from improvement or resolution of  obesity-related conditions.

The New York Times published a letter to the editor, submitted by the Delaware, Alaska, Louisiana and Wisconsin senators who, the day after the A.M.A. announced its decision, proposed the “Treat and Reduce Obesity Act” to Congress. The bill is aimed at curbing costs for patients with obesity by requiring Medicare to cover treatments such as prescription drugs for weight management, and make it easier to receive weight loss counseling.In the letter, the senators said the A.M.A’s decision should “promote access to prevention, treatment and comprehensive coverage determinations,” adding that coverage for the costs of obesity treatments would open the door to expanded research in patient care that would “foster a healthier population and lead to significant health cost savings.”

CBS News and CNBC.com turned to the impact of the classification of obesity on bariatric surgery. CBS News reported “procedures like the lap-band or gastric bypass surgeries are courses of treatment that may now be included in insurance coverage.”

Jaime Ponce, MD, ASMBS President, commented in a CNBC.com story: “Many private insurers, employers and state health plans specifically exclude the treatment of obesity and severe obesity from their coverage policies. Recognition of obesity as a disease by the A.M.A. sends a powerful message that access to evidence-based treatments across the spectrum of the disease are medically necessary, and should be treated in similar fashion to treatments for Type 2 diabetes, heart disease or high blood pressure.”

Though the reporting of the A.M.A.'s reclassification of obesity as a disease received largely favorable coverage, there were naysayers, who said people could expect higher insurance premiums. A posting in the public comment section of the CNBC.com article said:

“…why should I have to subsidize their premiums while I also pay for my monthly gym membership and healthy food… it’s called self control and self responsibility… something our country is lacking thanks to our hand out POUTUS and Congress…”

Many insurers were quick to downplay the influence the A.M.A.'s decision would have on them, saying it was unlikely it would force coverage changes. Julie Kessel, a senior medical director for coverage policy at Cigna Corporation, says CIGNA already recognizes obesity as a chronic medical condition, and on FOX Business explained that “if a patient goes to a primary-care physician for a regular check-up, and is identified as having obesity, that doctor will order tests to assess the persons’ risk as a result of obesity.”

In that same story, Carey Vinson, vice president of quality and medical performance management at Highmark Health Services, said, “I think the standards are not going to change for right now. The AMA pronouncement isn’t going to affect coverage decisions – allowing weight loss surgery for those who are on the lower end of the obesity scale, for example. What will is conclusive medical research, gathered and disseminated over time.”

Boston Globe columnist Alex Beam speculated on the A.M.A.’s motivation, saying he believes the decision “is really about money.” He said with the A.M.A. hoping to expand coverage of obesity-related services, “newly minted diet pills such as Vivus, Inc.’s Qsymia acquire a sudden legitimacy.” He further contends the disease designation “is a potential windfall for the dubious field of bariatric surgery,” which he characterizes as “a subcategory of plastic surgery” that has experienced “explosive growth” in recent years. In his column, Beam said, “you could practically hear the corks popping over at the American Society of Metabolic and Bariatric Surgery,” noting that the new recognition will create “pressure” on Medicare and private insurers to extend coverage of surgery to people with a BMI of 30. Beam references Dr. Morton's statement about the decision being "a tipping point"  He concludes his column though with the statement:  “There is no magic bullet — no medicine — for obesity…The way out of obesity is to eat less and better and to move
your body.”

The issue of “responsibility” was a largely debated topic among opinion columnists in the weeks following the breaking news. Who is accountable in the fight against obesity? Doctors? Individuals? Policy Makers? All of the above? In The Huffington Post, David Katz, MD, director of the Yale Prevention Research Center, stated that he believes the “medicalization of obesity” is “concerning,” writing in a blog post, “If we look more to clinics and less to culture for definitive remedies, it will do net harm,” claiming, “the notion that obesity is a disease will inevitably invite a reliance on pharmacotherapy and surgery.” He believes this will result in people “failing to consider the power we each have over our own medical destiny,” meaning we as a society will “skip right past concerns about access to produce” focusing more on access to drugs, for example.

Opinion columnists for The Globe, TIME Magazine, Forbes and many other news outlets also offered their views on the topic of responsibility. A columnist for The Globe commented that the reason naming obesity a disease is so controversial is because it “has to do with our ambivalence about conditions that have a behavioral component. In the last few years the question of whether certain behaviors are diseases or disorders — drug use and alcoholism, as well as hoarding, gambling, and Internet overuse (which the American Psychiatric Association now lists as disorders or potential disorders) — has come up repeatedly,” and “many will see the AMA’s designation of obesity as a disease as an absolving of
personal responsibility.”

Noted Personal Health columnist Jane Brody from The New York Times provides some balance writing, “The A.M.A. has said in effect that it is medicine’s responsibility to provide the knowledge and tools needed to curb this runaway epidemic.” She adds that “the designation may change how aggressively doctors treat obesity, foster the development of new therapies, and lead to better coverage by insurers.”

On TIME.com a reader in favor of the A.M.A’s decision commented:

“Classifying it [obesity] as a disease removes the burden of failure and the lack of confidence that develops over years of trying and never succeeding. Now the medical community, at least, says ‘Let's try to fix this together and figure out something that will work’ rather than others saying ‘Just do it. You're a bad person because you're not losing weight.’”

But the National Association to Advance Fat Acceptance (NAAFA) countered, “Declaring us diseased without regard to our actual health is not likely to improve our health. My fear: how is this going to impact my relationship with my physician? Declaring obesity a disease will only strengthen the cycle of stigmatization, discrimination and greed?” NAAFA, following the news of the A.M.A.’s reclassification, simply posted on its Twitter account, “Shame on
the AMA!!!”

In an opinion piece in U.S. News & World Report, the Obesity Action Coalition's advocacy chair, Ted Kyle, said he believes, “An unclear definition of obesity has certainly led to some confusion across the board. Those affected do not simply look different from others; there is much more happening beneath the appearance of a larger body type…. Calling obesity what it is, ‘a disease,’ can help direct more resources to needed research, prevention
and treatment.”

So, ‘did the A.M.A. make the right decision?’ – that’s what MedPage Today asked in an online survey of it readers. Largely divided, 51.8 percent agreed with the decision, and 48.2 percent disagreed. However, despite a slight majority voting in favor of the reclassification, comments revealed that many still harbored harsh thoughts about people with obesity, even if they agreed obesity is a disease.

One anonymous member of the public offered his hopes for the future in light of the A.M.A’s designation posting on The Boston Globe’s webpage:

“Whether you believe obesity is a disease, a mental disorder or just poor self control is rather irrelevant at this point. The end result is the same; an epidemic of overweight adults and children that impacts all of us through lower economic productivity and higher health care costs. The AMA’s decision, in my opinion, was driven by the grave realization that current strategies to control obesity are failing badly and we have a national crisis that is only going to get worse,” adding he hopes the decision with “lead to more effective
treatment strategies.”