Jarris, Paul E. MD, MBA
Association of State and Territorial Health Officials, Arlington, Virginia.
Correspondence: Paul E. Jarris, MD, MBA, Association of State and Territorial Health Officials, 2231 Crystal Dr, Ste 450, Arlington, VA ( firstname.lastname@example.org).
The author declares no conflicts of interest.
The American Medical Association (AMA) recently classified obesity as a disease. This critical decision has the potential to create important opportunities for improving the health of the nation and further create yet another opportunity for public health and clinical medicine to leverage their combined strengths to decrease obesity and its sequelae.
The AMA resolution compared obesity with tobacco:
Whereas, The suggestion that obesity is not a disease but rather a consequence of a chosen lifestyle exemplified by overeating and/or inactivity is equivalent to suggesting that lung cancer is not a disease because it was brought about by individual choice to smoke cigarettes....1
This comparison is not arbitrary, for tobacco prevention and control has, for more than 30 years, served as an outstanding example of public health and clinical medicine seizing opportunities to combine population-based policy approaches with individualized medical and public health interventions to prevent initiation among nonsmokers and facilitate cessation among established smokers. Publicly funded tobacco cessation quitlines, now in every US state, the District of Columbia, Guam, and Puerto Rico, are powerful examples of an evidence-based public health intervention that depends on rigorous collaboration between federal and state public health entities, academic and medical research institutions, and clinical medicine. Going beyond cessation, quitlines have come to play an important and integral part in a much larger public health framework for disease prevention and control. This powerful alignment, along with a number of other policy and programmatic forces, such as raising tobacco prices and clean indoor air laws, has resulted in a 50% decrease in tobacco use in the past 30 years.
In June 2013, the AMA House of Delegates adopted Resolution 420, which states that the AMA “recognize(s) obesity as a disease state with multiple pathophysiological aspects requiring a range of interventions to advance obesity treatment and prevention.”1 Similar policies have been considered and defeated by the delegates in the past.2 In fact, the organization's Council on Science and Public Health issued a report for consideration at this meeting titled “Is Obesity a Disease?”3 The council's report, which was also adopted, concluded,
It is unclear that recognizing obesity as a disease, as opposed to a “condition” or “disorder,” will result in improved health outcomes. The disease label is likely to improve health outcomes for some individuals, but may worsen outcomes for others.3
In recommending adoption of Resolution 420, the organization's public health reference committee concluded, “The ramifications of obesity warrant a paradigm shift in the way the medical community tackles this complicated issue.”4
Obesity is the latest example of a disease with significant public health impact that we can address more effectively by working together rather than choosing to wage separate, parallel battles. The AMA policy presents many potential opportunities, including the possibility that insurance coverage for counseling and treatment will be required (with corresponding laws limiting discrimination in hiring based on body weight). Payment to providers who address obesity and weight loss would reduce the financial barriers to appropriate counseling and treatment.5 The policy may also reduce stigma among providers, in professional and educational settings, and in interpersonal relationships with patients.5 Patients who view obesity as a disease may overcome feelings of guilt about their “choices” and “willpower” and seek care. It may also lead to increased funding for research on clinical and community obesity prevention and treatment. These opportunities will reach their potential only if public health and clinical practice work in concert.
If we, as public health practitioners and leaders, work closely with health care providers and insurers, we can align efforts—leverage the prevention focus of public health and the traditional counseling and treatment focus of clinical medicine—to tackle the problem. We can engage clinical partners to support public health prevention efforts, such as promoting environmental change, including improving access to healthy, affordable foods and communities that promote safe physical activity, to increase the likely success of clinical approaches. If an obese patient benefits only from treatment confined to the physician's office and then returns to an obesogenic environment, the prognosis is not very promising. A 15-minute visit cannot overcome life in an environment in which healthy choices are not available and affordable.
In 2008, less than 30% of physician office visits of adult patients who were obese included counseling or education related to weight reduction, nutrition, or physical activity.6 More than half of obese patients have never been told by a physician that they need to lose weight.7 Perhaps, this will improve when the provider views obesity as a disease rather than a choice and is reimbursed for time and effort counseling and providing care when indicated.
People listen to their providers. If doctors and nurses say that obesity is a real problem, that it is not just a matter of poor individual choices, and that individuals can participate in weight loss programs that actually work, and those same clinicians publicly support policy-oriented obesity prevention efforts to increase the availability and accessibility of fresh fruits, vegetables, and physical activity opportunities in neighborhoods where these are lacking, this alignment of public health and clinical medicine will result in real progress.
Indeed, we have already made real progress in the burgeoning partnership between public health and clinical medicine in the prevention of obesity demonstrated by tools that allow health care providers to effectively address obesity during clinical encounters. The National Physical Activity Guidelines8 and the Dietary Guidelines for Americans9 are useful for professionals in this work and resources such as Be Active Your Way10 and MyPlate11 provide easy-to-understand information to the individual. Parallel to the US Public Health Service's Clinical Practice Guideline,12Treating Tobacco Use and Dependence, 2008 Update, recommendation that the 5As (Ask, Advise, Assess, Assist, and Arrange) be implemented for every patient who uses tobacco at every clinic visit, physicians must be encouraged to do the same for obesity by assessing body mass index and providing advice to lose weight and assistance with doing so. If a patient is overweight or obese, the physician can assess the patient's readiness to change, advise the patient to lose weight, assist the patient with setting a date to act, and arrange for the patient to receive nutritional counseling (eg, a provider referral to community program or resource).
The AMA policy if implemented by insurers should lead to the services of a dietician or a community program being covered. Like a tobacco quitline that clinicians can refer smokers to, additional community supports and resources are needed for patients who are leaving doctors' offices with a directive to manage their weight in order to improve their health. If appropriate, the clinician could also prescribe medication. If the patient were at a healthy weight, the clinician would provide anticipatory guidance on maintaining healthy weight and can recommend evidence-based programs that support a healthy lifestyle.
More innovation and research are needed to determine effective evidence-based interventions for both clinicians and public health practitioners. Will the 5As work for obesity counseling? Can telephonic and online support be developed to support weight reduction and physical activity as it does for tobacco cessation? Which community interventions, such as menu labeling, portion control, or school and workplace healthy foods policies, are most effective? Is there a role for raising costs of unhealthy foods as in tobacco control? And, importantly, how does our society view these interventions—as an infringement on personal choice and liberty or as necessary steps to stem the tide of an epidemic? Despite all of these questions, one thing is clear. Innovation must drive research and then research must, in turn, drive further innovation in a continuous quality improvement cycle. In the face of this epidemic, we cannot be paralyzed by the notion that we can do nothing because evidence does not yet exist. Evidence does not appear through spontaneous generation—it is driven by innovation and experimentation.
Some are concerned that the classification of obesity as a disease has the potential to medicalize obesity and shift the focus toward surgery and pharmaceuticals and away from lifestyle/behavior, environmental, and policy changes. With expanded insurance coverage and revenue motive, aggressive medication and surgical treatment could be sold beyond true medical indications as an alternative to healthy lifestyles in healthy environments.13 Just as public health must study and develop an evidence base, clinical medicine must do the same. When is medication or surgery indicated in addition to diet and activity modification? Another possibility is that having a disease could cause patients to feel disempowered and seek medications and surgical procedures.13 This is yet another reason why the comprehensive approach using all the full range of public health and clinical tools in addressing obesity is so critical. If public health and clinical medicine work together in a comprehensive, collaborative, and strategic way that leverages many of the lessons learned by our great success in tobacco prevention and control, we have the potential to replicate success and turn the obesity epidemic around.
5. Allison DB, Downey M, Atkinson RL, et al. Obesity as a disease: a white paper on evidence and arguments commissioned by the Council of the Obesity Society. Obesity. 2008; 16:1161–1177.
6. Kraschnewski JL, Sciamanna CN, Stuckey HL, Chuang CH. A silent response to the obesity epidemic: decline in US physician weight counseling. Med Care. 2013; 51:(2):186–192.
7. Galuska DA, Will JC, Serdula MK, Ford ES. Are health care professionals advising obese patients to lose weight? JAMA. 1999; 282:1576–1578.