There is a certain irony in the nearly immediate juxtaposition of the rare introduction of a new FDA-approved drug for weight loss (Belviq) to the marketplace and the recognition of obesity as a “disease” by the American Medical Association (AMA). Drugs need diseases, diseases need drugs.
Think of Obesity as Drowning
And that’s part of what has me completely worried. The notion that obesity is a disease will inevitably invite a reliance on pharmacotherapy and surgery to fix what is best addressed through improvements in the use of our feet and forks and in our Farm Bill.
There is, of course, some potential upside to the recognition of obesity as a disease. Diseases get respect in our society, unlike syndromes, which are all-too-readily blamed on the quirks of any given patient and other conditions attributed to aspects of character. Historically, obesity has been in that latter category, inviting castigation of willpower and personal responsibility and invocation of gluttony, sloth, or the combination of all. Respecting obesity as a disease is much easier.
And as a disease, obesity will warrant more consistent attention by health professionals, including doctors. This, in turn, may motivate more doctors to learn how to address this challenge constructively and compassionately.
But overall, I see more liabilities than benefits in designating obesity a disease. For starters, there is the simple fact that obesity per se isn’t a disease. Some people are healthy at almost any given BMI. BMI correlates with disease, certainly, but far from perfectly.
The urge to label obesity a disease, and embrace the liabilities attached to doing so, seems to be a price the medical profession is willing to pay to legitimize the condition. But none would contest the medical legitimacy of drowning. If you drown, assuming you are found in time, you will receive urgent medical care, no matter your ability to pay for it. If you have insurance, your insurance will certainly pay for that care.
But drowning is not a disease. Perfectly healthy bodies can drown. Drowning is a result of a human body spending too much time under water, to which it is poorly adapted.
Our bodies, physiologies, and genes are much the same as they ever were. Certainly these have not changed much in the decades over which obesity went from rare to pandemic. What has changed is the environment.
We are awash in highly processed, hyper-palatable, glow-in-the-dark foods. We are afloat in constant currents of aggressive food marketing. We are deluged with ever more labor-saving technological advances, while opportunities for daily physical activity dry up.
We are drowning in calories. And that’s how, in my opinion, we should make obesity medically legitimate, namely as a form of drowning, not as a disease.
With drowning, we don’t rely on advances from pharmaceutical companies. No one is expecting a drug to ‘fix’ our capacity to drown. Our capacity to drown is part of the normal physiology of terrestrial species.
Our capacity to get fat is also part of normal physiology. Obesity begins with the accumulation of body fat, and that, in turn, begins with the conversion of a surplus of daily calories into an energy reserve. That’s exactly what a healthy body is supposed to do with today’s surplus calories: Store them against the advent of a rainy (i.e. hungry) day tomorrow. The problem that leads to obesity is that the surplus of calories extends to every day, and tomorrow never comes.
Thinking of obesity as a form of drowning offers valuable analogies for treatment. We don’t wait for people to drown and devote our focus to resuscitation. We do everything we can to prevent drowning in the first place. We put fences around pools, station lifeguards at the beaches, get our kids to swimming lessons at the first opportunity, and keep a close eye on one another. People still do drown, and so we need medical intervention as well. But that is a last resort, far less ideal than prevention, and applied far less commonly. There is an exact, corresponding array of approaches to obesity prevention and control.
The most important reasons for rampant obesity are dysfunction not within our bodies but at the level of the body politic. Long before labeling obesity a disease, the AMA lent the full measure of its support to the Hippocratic Oath and medicine’s prime directive: First, do no harm. Obesity is much more like drowning than a disease. Calling it a disease has, in my opinion, the potential to do harm. And so it is that I vote: No.
David L. Katz, MD, MPH, FACPM, FACP is the founding director of Yale University’s Prevention Research Center. He is a board certified specialist in both Internal Medicine and Preventive Medicine/Public Health. He is the director and founder of the Integrative Medicine Center at Griffin Hospital in Derby, CT. For more information visit http://www.davidkatzmd.com and http://www.turnthetidefoundation.org
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