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Tue 11 Nov, 2003 09:08 am
Quote:Is Obesity A Disease?
Insurance, Drug Access May Hinge on Answer
By Rob Stein
Washington Post Staff Writer
Monday, November 10, 2003; Page A01
The rising number of Americans who are seriously overweight has triggered intense debate among scientists, advocacy groups, federal agencies, insurance companies and drug makers about whether obesity should be declared a "disease," a move that could open up insurance coverage to millions who need treatment for weight problems and could speed the approval of new diet drugs.
Proponents argue that new scientific understanding has clearly established that obesity is a discrete medical condition that independently affects health. Officially classifying obesity as a disease would have a profound impact by helping to destigmatize the condition, much as the classification of alcoholism as a disease made it easier for many alcoholics to get treatment, experts say. But equally important, the move would immediately remove key economic and regulatory hurdles to prevention and treatment, they say.
Opponents contend that obesity is more akin to high cholesterol or cigarette smoking -- a risk factor that predisposes someone to illness but is not an ailment in itself, such as lung cancer or heart disease. Labeling it a bona fide disease would divert scarce resources, distract public health efforts from the most effective countermeasures and unnecessarily medicalize the condition, they say.
Nevertheless, the move to classify obesity as a disease appears to be accelerating. The Internal Revenue Service ruled last year that, for tax purposes, obesity is a disease, allowing Americans for the first time to claim a deduction for some health expenses related to obesity, just as they can for those related to heart disease, cancer, diabetes and other illnesses.
The federal agency in charge of Medicaid and Medicare is conducting a review to determine whether it, too, should consider obesity a disease. That would mean that for the first time the poor, elderly and infirm would be covered for some weight-control therapies without first having another illness diagnosed, such as diabetes. That decision would pressure private insurers to follow suit, and they are resisting the move.
Like thousands of others, Lori Asburry, 36, of Waldorf, Md., has been trying to get her insurance company to pay for a program she hopes will help her shed some of the 100 extra pounds she has been trying to lose.
"I think that insurance companies absolutely ought to cover this," Asburry said. "Some insurance companies now will pay for weight-loss surgery, which is a dramatic procedure. Yet they're not covering something that will have the same positive effects but in the end would end up saving them money."
At the same time, the Food and Drug Administration is reviewing how it judges new weight-loss drugs. As part of that review, the agency will consider whether it should evaluate diet drugs more like it assesses treatments for such illnesses as diabetes and cardiovascular disease, which could help get new medications on the market more quickly by making it easier to get them approved.
Together, these actions could result in a major shift in how the nation deals with what had long been considered a cosmetic or psychological problem, not a major public health crisis.
"For ages, obesity has been regarded as a personal moral failing -- a behavioral issue that's easily fixed by people who have sufficient willpower to do so," said Morgan Downey, executive director of the American Obesity Association, a Washington-based advocacy group that has been lobbying for obesity to be reclassified. "The modern scientific understanding of obesity is that it is a complex disease in its own right."
That understanding has led many major medical authorities, including the National Institutes of Health and the World Health Organization, to conclude that obesity should be considered a distinct disease entity.
"There's no question that obesity is a disease," said Arthur Frank, medical director of George Washington University's Weight Management Program. "Obesity is a disease where there's a disregulation of eating -- just like diabetes is a disease where the system of controlling blood sugar is not functioning properly."
But not everyone agrees. Although obesity can increase the risk of a host of health problems, skeptics argue, so do smoking and high cholesterol, which are not considered diseases. Not everyone who is obese or overweight develops problems requiring treatment.
"You can be overweight and healthy if you are active," said Tim Church, medical director of the Cooper Institute in Dallas, a nonprofit research center focused on exercise. "In fact, an overweight individual who exercises is healthier than a normal-weight individual who is sedentary. You could say that if obesity is a disease, then not enough exercise is a disease or not eating right is a disease."
Then there is the fact that being overweight can actually have some health benefits, said Paul Ernsberger, an associate professor of nutrition at Case Western Reserve University School of Medicine in Cleveland.
"When something is a disease it doesn't have beneficial or neutral effects. There's a decreased incidence of osteoporosis in older people who are overweight. Where some cancers are increased, there are others that are decreased. So calling it a disease is misleading," said Ernsberger, a scientific adviser to the National Association to Advance Fat Acceptance.
Nonetheless, the IRS, under pressure from the American Obesity Association, declared obesity a disease in April 2002. That allows taxpayers to deduct the cost of weight-loss treatments prescribed by a doctor, including such programs as Weight Watchers that insurance does not cover. Previously, such costs could be deducted only if prescribed by a doctor to treat another condition, such as hypertension.
But most health insurance programs, including the federal Medicaid and Medicare programs, do not cover such costs. As a result, people often cannot be reimbursed for diet programs, nutritional counseling or drugs unless they have a condition that is considered a disease, such as diabetes or heart disease. Parents of overweight or obese children similarly cannot get treatment that may prevent them from developing health problems later in life.
Eugene V. Martin, 67, of the District has not been able to get his insurance company to pay for one of the few available prescription weight-loss drugs.
"Both the medical profession and the insurance industry seem to treat obesity with such disdain and abhorrence instead of assistance and support," he said. "It certainly isn't rational, and I think goes back to the general sense that we're fat because we simply can't control ourselves."
The insurance industry, however, argues that it is more appropriate for employers to pay for such services through employee assistance programs, and many already do. In addition, the effectiveness of many weight loss programs, on which Americans spend almost $40 billion a year, remains far from clear.
"There is a growing sense that perhaps Americans are too heavy, but I think there's also an awareness that there's not a single solution to address the problem," said Larry Akey, a spokesman for the Health Insurance Association of America. "It's really going to require a whole host of responses, and not simply, 'Let's have the insurance companies pay for it.' There is a line that sometimes get blurred between legitimate health care expenditures and lifestyle or behavioral changes."
Nevertheless, the agency that runs the federal Medicare and Medicaid programs is studying whether to classify obesity as a disease, and, if so, what types of treatment have been demonstrated to be effective. The Agency for Health Care Research and Quality delivered a report outlining the evidence on both sides of the debate in September, and a decision is expected any time.
"We certainly recognize and agree that obesity is a significant problem. The question is whether losing weight, which people can do without ever seeing a provider, is something a health care system ought to pay for," said Steve Phurrough, director of the coverage and analysis group at the Centers for Medicare and Medicaid, which will make the decision.
If obesity is classified as a disease, then the question will become precisely what types of treatment should be covered, he said.
"For example, if it's demonstrated that exercise is beneficial for obesity, there could be an argument that Medicare ought to buy a Gold's Gym membership," Phurrough said. "Another issue is diet counseling. One of the difficulties is that I'm not sure there's a lot of medical evidence that going to see a dietitian actually helps people lose weight."
Meanwhile, FDA officials met with drug companies and the American Obesity Association in April and will gather again, perhaps as soon as this month, to discuss whether obesity drugs should continue to be held to tougher safety and efficacy standards than those for diseases such as diabetes.
"There is a fair bit of consensus in the field that the FDA has been somewhat hostile to obesity products and don't treat it like cancer and other major diseases," said Downey, of the Obesity Association.
The growing recognition that obesity is a major public health problem has prompted the FDA to begin a review that is likely to result in revised guidelines for testing diet drugs, FDA Commissioner Mark McClellan said.
"There's certainly a careful evaluation going on right now to make sure we're using the most efficient and effective approach for reviewing weight-loss therapies," he said. "This is an important enough problem . . . that we want to make sure our regulatory process is up to date as possible. We really need those treatments."
Advocates hope that taken together these moves could push more people to seek help for obesity by making it less of a personal failing and more of a medical condition.
"There are a lot of people who believe obesity is a simple failure of willpower," said Richard L. Atkinson Jr. of the University of Wisconsin at Madison, president of the American Obesity Association. "In my mind, there's no doubt whatsoever that obesity is a disease. If diabetes is a disease, if heart disease is a disease, then obesity is a disease."
I think obesity is more of a cultural disease than anything. Somehow I just can't bring myself to believe that all obese people (some certainly, but not all) would be obese if the fast food was not so cheap and readily available, if they had to walk a little instead of driving everywhere, etc. Plus lack of education on healthy living adds to the problem. You'd be amazed what some patients suffering obesity consider a 'light snack'. Why, I only had omelette from 6 eggs and a hamburger.. No clue this food might be bad in any way. arrrrgh.
What is obesity?
Obesity is a long-term (chronic), complex disease in which having too much body fat (adipose tissue) increases your risk for developing other health problems. Obesity generally is measured by body mass index (BMI). A BMI of 30 or more is considered obese in adults.
If your BMI is between 25 and 30, you are overweight. See the topic Healthy Weight for information on maintaining a healthy weight.
What causes obesity?
Obesity is a result of many factors. Although it was once thought that a lack of will power?-eating too much?-and a lack of physical activity caused obesity, it is now recognized that family influence, genetics (including your basal metabolic rate, or BMR), and cultural and psychological factors all contribute to becoming obese.
To fit the medical definition of obesity, your extra weight must come from having too much body fat. Not everyone with a BMI over 30 is obese. For example, athletes may have a BMI over 30, but because their weight is due to muscle, not fat, they are not considered obese.
The main factor in obesity is an energy imbalance. People gain weight when they take in more energy (measured in calories) from food than they use through their BMR and physical activity. The excess energy is stored as fat.
What health problems does obesity put me at risk for?
If you are obese, you are more likely to develop type 2 diabetes, high blood pressure, heart disease or stroke, high cholesterol, breathing problems, sleep apnea, cancer, gallstones, arthritis, blood vessel problems, skin infections and rashes, sex hormone problems (including a decreased ability to have children), gout, heartburn, gastroesophageal reflux disease (GERD), liver problems, colon or kidney cancer, and endometrial cancer. If you lose weight, your risk for these conditions is reduced.
Often overlooked are the psychological and cultural problems associated with being obese. Stereotypes of obese people?-such as that they are lazy?-and the emphasis our society places on thinness may result in low self-esteem, a poor body image, depression, and eating disorders. Stereotypes also may make it more difficult for an obese person to find a job or to progress in one.
Although a high BMI does indicate an overall greater risk of health problems, the distribution of body fat is also important. If fat accumulates mostly around the abdomen (central obesity, sometimes called apple-shaped), you are more likely to develop heart disease, stroke, high blood pressure, and/or type 2 diabetes than people who are lean or people with fat around the hips (peripheral obesity, gynecoid or gluteofemoral obesity, or pear-shaped). The apple shape is more common in men, while the pear shape is more common in women.
How will my doctor diagnose obesity?
Your doctor will take your medical and family history and do a physical examination. He or she will use your BMI to determine whether you are obese. Your doctor may measure your waist or determine your waist-to-hip ratio (WHR) to determine how excess fat is distributed on your body. This helps determine your risk for other health problems.
If your weight or family history suggests you have an increased risk for developing health problems, your doctor may want to do more tests to check for those problems. The most common tests are blood tests to check for type 2 diabetes, thyroid problems, and excess cholesterol or triglycerides (fats) in your blood.
How is obesity treated?
Because obesity is a chronic disease, it requires long-term management. The focus is often on reducing the risk for developing health problems as much as on losing weight.
The U.S. National Heart, Lung, and Blood Institute (NHLBI) recommends that treatment be based on the degree of obesity and overall health risk status. If you are obese, you should try to initially lose about 10% of your current weight, at a rate of 1 lb (0.45 kg) to 2 lb (0.91 kg) per week using diet, physical activity, and self-monitoring. Approved weight-loss medication may be used, and in extreme cases surgery is used to reduce the size of the stomach.
Treatment also covers the psychological and social components of obesity. Stress management and counseling may be helpful. Getting family support and creating community contacts help you deal with the stereotypes and other social issues that are associated with obesity.
What does being obese mean to my lifestyle?
How obesity affects you depends on a number of factors, including your age, gender, fat distribution, and how physically active you are. For example, if you are an obese younger woman who gets regular physical activity, you may be at less risk for other health problems than an older man who is not physically active.
Being obese may make it more difficult to get out and socialize with others. The stereotypes of obese people may contribute to low self-esteem and emotional problems. However, you should make every effort to lead an active life. If you are surrounded by caring people, you may not be affected by the emotional and social negatives toward obesity.
Body mass index (BMI)
Body mass index (BMI) provides a way to estimate whether you weigh an appropriate amount for your height. Your BMI is based on your height (in inches or meters) and weight (in pounds or kilograms).
To calculate your exact BMI, use one of the following equations:
If you know your weight in pounds and your height in inches: BMI = (pounds x 700)/(inches squared)
If you know your weight in kilograms and your height in meters: BMI = kilograms/(meters squared)
Desirable BMIs for adults are between 19 and 24.
Obesity is a genetic predisposition, exacerbated by fast foods, snacking and lack of exersize.
I can't wait till scientists find stupidity is also a disease. I mean, imagine the ramifications. We will live in a completely blameless society.
ceili, stupidity is already quite common in all spheres of this society. equal opportunity for the stupid. they even get elected to the leading positions.
Common yes, but as of yet, as far as I am aware, it is not an official disease. It'll happen I'm sure and then we are all off the hook.
I'm sure it will be. Our Centers for Disease Control considers failure to use seat belts and motorcycle helmuts to be diseases.
Ceili wrote:Obesity is a genetic predisposition, exacerbated by fast foods, snacking and lack of exersize.
I can't wait till scientists find stupidity is also a disease. I mean, imagine the ramifications. We will live in a completely blameless society.
I think it's just more convenient for people to explain the deplorable existences of fatty fats by thinking them to simply be gluttonous instead of trying to comprehend the complex host of factors that might contribute to the end result.
More often than not I think gluttons are only the marginally overweight people. I.E. There are bigger factors at play for the people who are significantly overweight.
I think you're right, wenchilina. For a normal person to maintain the weight of the grossly obese, they would have to be eating constantly. This simply not happening.
Maybe my first thought was a bit flip.
Ceili wrote:Common yes, but as of yet, as far as I am aware, it is not an official disease. It'll happen I'm sure and then we are all off the hook.
Actually, I think it will be labelled as a disorder ;-)
It certainly couldn't be because people may enjoy food.
Obesity is certainly not "normal".
An obese animal in the wild would not be able to move fast enough--either as predator or prey--to survive.
Obese people cost insurance companies and taxpayers billions of dollars every year.
Obesity may not be a disease but it is certainly a "dis-ease" that damages both the individual and society. It is certainly a problem looking for a solution.
I think that SOME obesity is genetically aided. . . I don't believe that there are people who HAVE to be obese. We all have a hand (literally) in what goes into our body, how much exercise we get, what we choose to eat and how we choose to live.
I agree with Noddy. Obesity has many of the same consequences as a disease, and it affects society in the same way. But an actual disease? Maybe not. . .
It's a common mistake to think that everyone in the world thinks and has bodies that function like oneself.
Ooh, don't get me wrong. . . I've had problems with weight all my life, as has nearly everyone in my family. But I have to admit that I have not always been vigilent about what I eat and how I eat it, exercise and so forth. . . I have the worst metabolism in the world, a slow heart beat, and all that other great weight-loss-hindering stuff. . . and I've had to work hard, HARD , to get back down to a healthy weight. So I know what it's like. . . but I do believe obesity is something that can be ameliorated, if not "cured". . .
Tell that to someone with a case of glandulars.
As far as your own situation to maintain "healthy weight" .. I maintain that simply because something is valued or devalued as attractive / fit unattractive / obese in today's society does not mean that its reasons for being deemed that are entirely valid.
No, I agree. . . I dislike the fact that one has to be perfect in our society to be attractive. . . especially since I believe well over half of Americans are overweight. But the health concerns that go along with obesity are alarming, and it's the health concerns that I believe others are citing as an expense to tax payers and insurance companies.
Being attractive isn't the issue. . . being dangerously unhealthy, however, is.
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