Two decades ago, no U.S. state had an obesity rate above 15% and the condition was barely on the nation's radar screen. Today, the majority of states are dealing with obesity rates of at least 25%, according to the Campaign to End Obesity, and a study reported in the January 2012 Journal of Health Economics concluded that obesity and obesity-related conditions account for more than 20% of the nation's health care spending. In light of these data, it's no surprise that the Centers for Disease Control and Prevention has declared obesity an epidemic.
Figure. Photo by Lau...Image Tools
To address this burgeoning problem, the American Medical Association (AMA) voted at its annual meeting in June (with heavy lobbying from, among others, the American Association of Clinical Endocrinologists, the American College of Surgeons, and the Texas Medical Association) to “recognize obesity as a disease state with multiple pathophysiological aspects requiring a range of interventions to advance obesity treatment and prevention.”
In one fell swoop, the AMA declared that at least one-quarter of America's adults had a disease. And it did so despite the fact that the AMA committee that had been studying the issue for a year, the Council on Science and Public Health (CSAPH), had advised against the designation. (To read the CSAPH's arguments for and against the designation, see http://bit.ly/11Xh4Ip.) The committee wrote that it was “premature to classify obesity as a disease,” arguing that, “If obesity is to be considered a disease, a better measure of obesity than [body mass index (BMI)] is needed to diagnose individuals in clinical practice.”
BMI isn't a measure of fat, nor can it reveal what kind of fat—visceral or subcutaneous—causes a person's overweight. A significant number of people with BMIs of 30 and above, the value typically used as the threshold for obesity, are healthy, whereas many people with lower BMIs have high levels of body fat and the metabolic problems associated with it.
THE PROS OF CALLING OBESITY A DISEASE
The AMA has no legal authority in this matter. However, the association does have influence, and the designation puts pressure on health care providers, policymakers, insurance companies, pharmaceutical manufacturers, and advocacy organizations to put even more resources into raising awareness of and solving the nation's weight problem. And because it explicitly references the multiple aspects of the condition, the designation may be the official nudge that's been needed to get all the stakeholders on the same page regarding treatment and prevention. That nudge, in conjunction with Medicare's decision to reimburse for obesity surgery, the Internal Revenue Service's decision to allow tax deductions for obesity treatment, and the insurance coverage that will come with the Patient Protection and Affordable Care Act's insurance exchanges, should increase access to office visits, treatment, and care, especially for the problems that come with obesity.
One phrase in the AMA resolution, “requiring a range of interventions,” should focus much-needed attention on the major causes of obesity, behavior and lifestyle choices that often take root in childhood. “You can't address [obesity] if you don't acknowledge and deal with the behaviors causing it,” said Bonnie Gance-Cleveland, PhD, RN-BC, PNP, FAAN, a professor in the Division of Women, Children, and Family Health at the University of Colorado Denver, who's been studying childhood obesity for almost two decades.
In addition, because the insurance industry listens attentively when the AMA speaks and the designation implicitly acknowledges the roles that lifestyle, behaviors, and mental health play in obesity, the designation should also lead to better reimbursement for the counseling and psychotherapy that can change behavior. “Changing the way people live and act is difficult, but the real challenge is to get them to make the changes long term,” said Kimberlee A. Gretebeck, PhD, MSN, RN, an assistant professor at the University of Wisconsin–Madison School of Nursing, whose research focuses on prevention and behavioral interventions.
“For kids and young adults,” she said, “change is prevention. For older adults, it's the key to long-term management of their condition.”
The designation is also a wake-up call, especially for primary care physicians and NPs, to talk with their overweight patients about their weight. But, noted Gance-Cleveland, constructive discussion—the kind that leads to action—will occur only if health care providers “have the training they need around how to introduce the topic and provide the counseling and treatment in a nonoffensive, nonjudgmental way.”
The designation may also generate support for a campaign to eradicate obesity, something along the lines of the one that has driven tobacco use into the ground. That campaign tackled the environmental influences—especially the teen-focused advertising that promoted smoking—with public health initiatives, school-based programs, and community education strategies showing what lighting up could lead to. “Who better,” said Gance-Cleveland, “to lead that kind of approach than nurses?”
The designation might also spur more communities to improve their infrastructures, with bike lanes, community gardens, community exercise programs, or wellness fairs, for example, that can make getting to and maintaining a healthy weight easier. “Health care professionals can do everything possible with surgery and diet plans,” said Gretebeck, but if patients go right back into a bad environment, “they're going to have lapses and relapses and collapses… and just give up.”
Finally, the increased visibility the AMA's designation is giving obesity may increase funding for the kind of research that's needed to prevent it.
… AND THE CONS
Proponents of the change argue that labeling obesity a medical condition has the potential to reduce the stigma that comes with a disease that's typically ascribed to a failure of willpower, but research on obesity suggests that calling it a “medical problem” may actually stigmatize it more than it already is, which could decrease a patient's self-esteem, increase pessimism about one's ability to change behavior, and reduce one's motivation to do so, especially if the prejudice lies within the health care community (see Puhl and Heuer in the May 2009 issue of Obesity). Part of the problem, explained Gretebeck, is that “when people think they can't do something about their situation [because it's a medical condition], they can't.”
The AMA designation creates what is essentially a medical, or pathology-focused, model that suggests a need for a slew of treatment options, including prevention strategies. But if the health care community's response to the designation is merely to plow more money into medical treatments, surgery, and pills, it will simply magnify the role physicians already play now. And, said Randall R. Bovbjerg, JD, a senior fellow in health policy at the Urban Institute, “They aren't making a lot of progress doing what they are doing now because obesity is due to lifestyle and behavior.”
In the end, if the designation causes the stakeholders not just to recognize the limits of the medical model but also to see a role for themselves in addressing the obesity epidemic, and if that results in more money being funneled into public health, community, and group programs that help people address their health issues, it's going to make a huge difference in the battle against the bulge—not to mention for the health care professions. As Bovbjerg points out: “It's going to create a whole lot of new business for primary care physicians and nonphysicians, including nurses, social workers, therapists, counselors, and community health people who have developed proven programs—like what they are doing at local YMCAs—for weight loss and maintenance.”—Eileen Beal
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