A fairly terrible article appeared recently in the New York Times. The article, which I’ll not be linking to lest I give them traffic I don’t think they deserve, asked the question “should obesity be considered a disease.”
Now, I would be thrilled if the authors were asking questions like – “how can [weight in pounds] x 703 divided by [height in inches]2 be a diagnosis for a disease? Or, if that does constitute a disease diagnosis, how will we be treating Tom Cruise, Mel Gibson, people of above average height (since a squared equation in a three dimensional world skews toward “diagnosing” tall people as obese) and a good chunk of the NFL? Or how about, “How can a body size constitute a disease diagnosis when people of that size have extremely varied health outcomes and when studies show that health outcomes are changed by behavior regardless of body size?” Or, “How can we diagnose a group of people with a disease just because their physical appearance is correlated (without causal relation) with a higher incidence of diseases?” Or, “Why did the AMA ignore the recommendation of their Council on Science and Public Health who they themselves commissioned to study this question for a year, and who recommended that obesity should NOT be categorized as a disease?”
But no, alas they aren’t asking those questions. They are predictably worried that a disease diagnosis might convince the big fat fatties not to try to lose weight. “Suggesting that one’s weight is a fixed state — like a long-term disease — made attempts at weight management seem futile, and thus undermined the importance that obese individuals placed on health-focused dieting and concern for weight.”
I think they do raise an important point, but not in the way they think. To say that weight loss attempts are futile would suggest that people end up at the same weight. While that is the experience of some, many people who make intentional weight loss attempts actually gain back more weight than they lost. So if obesity is a “disease” and weight loss is the “treatment,” than we are prescribing something that results in the exact opposite of the intended effect for the majority of patients, with no proof that even the small majority who succeed will be healthier for it.
Here’s where someone will jump in and say that this is because people “go back to their old eating habits.” First of all, let’s get real with the fact that intentional weight loss (whether you call it a lifestyle change, or a diet, or something else) is about feeding our body less fuel than it needs, in the hope that it will consume itself and become smaller, with the additional separate hope that greater health will come along for the ride. I think there is good research that shows that the body has a number of reactions to this that are created with the express purpose of regaining and maintaining weight, even if the dieter maintains their habits. I also think that in this case we have to realize that “going back to their old eating habits” actually means no longer feeding the body less fuel that it needs to complete its daily tasks. I think that the research shows that almost everyone can lose weight in the short term, and almost everyone gains it back in the long term, with a majority of people gaining back more than they lost. I think that the diet industry has done an excellent (and profitable!) job of taking credit for the first part of a biological response and blaming their clients for the second part.
But even if we employ enough willful suspension of disbelief to suggest that it’s true that it’s the dieter’s fault that they gain back the weight, the “treatment” for the “disease” of obesity still fails to meet the guidelines for ethical medicine – if almost everyone with a disease who attempts an intervention is unsuccessful (with the majority actually making their disease worse) then medical science needs a new intervention regardless of the reason. For example, if a protocol of prescriptions is so complicated that only a tiny fraction of people is able to engage in it successfully, and the majority of people actually exacerbate their disease state by trying to follow it, then the proper course is to look for new interventions, not blame the patients and just keep prescribing it knowing that it will make the disease worse for the majority of patients.
In the meantime, if the doctor isn’t telling the patients that their “prescription” is likely to have the exact opposite of the intended effect, then they are not meeting their ethical requirements for informed consent. Since the earliest studies on weight loss, there has not been a single study in which more than a tiny fraction of participants have succeeded at long term weight loss. Not a single study. There is also not a single study of successful long term dieters showing that their dieting lead to better health (in fact, a study by Mann and Tomiyama showed that there wasn’t a strong connection at all.) So, even if we buy the idea that obesity is a disease and that making obese people smaller will make them healthier, we still run smack into the fact that we don’t actually know how to get that done and that the thing that we’ve been prescribing for decades actually has the opposite of the intended effect the majority of the time.
So even if we think that being obese is, in and of itself, a disease state (and I don’t think that it is), knowing that the majority of weight loss interventions end by making the subjects fatter than when they started, would lead to the conclusion that the NYT authors’ concerns are completely unfounded and, actually the BEST that we can hope for is that classifying obesity as a disease leads to obese people not taking part in weight loss interventions. Not because those weight loss interventions are futile, but because they are actually far worse.
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