Did Naming Obesity a Disease Improve the Outlook for People Living with It?

| March 1, 2022

by Theodore K. Kyle, RPh, MBA, and Joseph F. Nadglowski, JR., BS 

Mr. Kyle is with ConscienHealth in Pittsburgh, Pennsylvania. Mr. Nadglowski is with the Obesity Action Coalition in Tampa, Florida.

Funding: No funding was provided for this article.

Disclosures: Theodore K. Kyle reports professional fees from Gelesis, Novo Nordisk, and Nutrisystem. Joseph Nadglowski, Jr. is an employee of the Obesity Action Coalition.

Bariatric Times. 2022;19(3):13.

Abstract

Looking back on nearly a decade since the American Medical Association (AMA) determined that obesity is a complex, chronic disease, we see incomplete progress. People have better options for obesity care and the availability of it is somewhat better. However, persistent bias and the need for more and better options tells us that the problem is far from solved. Much work remains to be done before we can begin to reduce the harm that obesity causes to health.

Keywords: weight bias, obesity treatment, access to care, pediatrics, bariatric surgery, pharmacotherapy, innovation, health insurance, advocacy, chronic diseases

Nearly a decade has passed since the American Medical Association (AMA)— haltingly—decided to put a name on obesity. Obesity is a complex, chronic disease, declared the organization at its annual meeting in 2013. At the time, AMA board member Patrice Harris explained the benefits this decision would bring: “Recognizing obesity as a disease will help change the way the medical community tackles this complex issue that affects approximately 1 in 3 Americans.”1

So, how is that working out? Nearly a decade later, how much have things changed?

Visible Progress

The truth is that a lot has changed since 2013.For one thing, dealing with obesity as a medical problem has become much more common. Before 2013, that would have been exceedingly rare. But since 2013, the specialty of obesity medicine has flourished and become the fastest growing medical specialty in America. More than 5,000 physicians are now board certified in obesity medicine, and each year the specialty is growing by roughly a thousand more. It adds up to better odds of getting medical care for this condition, instead of getting blamed and shamed for it.

Recognition for the medical value of bariatric surgery has grown, too. In 2013, surgery for an adolescent with severe obesity was regarded as something far outside the mainstream of medical care. Today, the American Academy of Pediatrics recommends it.2 To be sure, utilization is low and slow, but the change in attitudes is nothing short of remarkable. What’s more, the value of surgery for getting Type 2 diabetes into remission has evolved from being a marginal idea to becoming an accepted fact. According to the American Diabetes Association, it is part of the standard of care, as they explain, “Metabolic surgery strongly improves glycemic control and often leads to remission of diabetes, improved quality of life, improved cardiovascular outcomes, and reduced mortality.”3

There is an undeniable and growing regard for the lived experience with obesity. A decade ago, people living with obesity were dismissed, stigmatized, and marginalized. This tendency was so strong that a brilliant candidate for surgeon general was openly discounted because of her visible adiposity.4 Such blatant bias is no longer acceptable today, although implicit bias is certainly still quite common.

Finally, the progress and investment in research and development for better obesity care is breathtaking. In 2013, virtually all of the effort to address obesity was going into ineffective options aimed at a single goal, nudging people to eat less and move more. Pharmaceutical research had largely abandoned obesity as a therapeutic target. Today, the competition to develop new and better therapies has grown exponentially. Novo Nordisk has paved the way with two blockbusters for obesity treatment. One, semaglutide, has been hailed as a breakthrough.5 Bariatric surgery remains the most reliably, durably effective treatment for obesity, but semaglutide offers another good option. 

In fact, pharmacotherapy has a growing role as an option for preventing or reversing relapse after bariatric surgery. A recent systematic review concludes, “The use of glucagon-like peptide-1 (GLP-1) analogues in addition to surgery promises good results concerning weight loss and improvements of comorbidities and can be used in patients with unsatisfactory results after bariatric surgery.”6

Miles to Go

Despite all this progress, significant problems stand in the way of routine care for obesity that is consistent with standards of care for any other chronic disease. Most people who live with obesity do not have equitable access to effective care. The reasons for this are many. To begin with, many health systems take advantage of the false, but common, presumption that obesity is primarily a disease of unhealthy behaviors. Such thinking holds that the most effective treatment is to simply change those behaviors. This presumption suggests that behavior change is ultimately the responsibility of the patient alone.7

This is particularly evident in coverage by health plans for obesity care. Though coverage for obesity care has slowly improved over the last decade,8 barriers based on the behavior-change narrative persist all too often. These include requirements for dieting, documenting specific behavior change efforts, and similar arbitrary hurdles. They serve to limit access to evidence-based obesity care by making patients have to “earn the right” to obesity treatment beyond behavioral change strategies. For what other disease do health systems routinely deny effective care?

False narratives about the futility of obesity treatment also persist because many healthcare providers rely exclusively on behavioral strategies. By themselves in real-world settings, such strategies do not work well for most patients. Because the eat less, move more approach is not adequate for many people, many providers and gatekeepers presume that obesity treatment is futile.

Even with progress in options for science-based obesity care, people living with obesity do not have an ideal set of options for managing this chronic disease. Not even bariatric surgery can work for every patient. The trade-offs between safety, convenience, and real-world effectiveness are simply not acceptable for many people, so they do not opt to pursue medical treatment of obesity, or, despite their best efforts and even with care from skilled providers, they do not get satisfying results.

Persistent Bias

But perhaps the biggest problem that blocks progress in overcoming obesity is persistent and even growing implicit weight bias. Researchers from Project Explicit have documented declines over the last decade in both explicit and implicit bias regarding sexuality, race, and skin color. For age, disability, and weight, explicit bias is also declining. But for weight alone, they found increasing levels of implicit bias.9 This persistent bias directly harms people living with obesity, often more immediately than the longer-term physiological harm that obesity itself causes. 

Persistent and growing weight bias is harming people in many ways.10 Of course, the psychological harm and stress that it causes is significant, but it also leads patients to avoid seeking medical care because of the reasonable expectation that they will encounter humiliation in a medical setting from professionals who should be helping them. Thus, the experience of weight bias produces worse health outcomes and less medical care for persons living with obesity. 

Incomplete Progress

Looking back on nearly a decade since the AMA determined that obesity is a complex, chronic disease, we see incomplete progress. People have better options for obesity care and the availability of it is somewhat better. However, persistent bias and the need for more and better options tells us that the problem is far from solved. Much work remains to be done before we can begin to reduce the harm that obesity causes to health.

References

  1. Pollack A. AMA recognizes obesity as a disease. The New York Times. 18 Jun 2013. https://www.nytimes.com/2013/06/19/business/ama-recognizes-obesity-as-a-disease.html. Accessed 21 Feb 2022.
  2. Armstrong SC, Bolling CF, Michalsky MP, et al. Pediatric metabolic and bariatric surgery: evidence, barriers, and best practices. Pediatrics. 2019;144(6):e20193223.
  3. American Diabetes Association. Standards of medical care in diabetes—2022 abridged for primary care providers. Clin Diabetes. 2022;40(1):10–38.
  4. James SD. Critics slam overweight surgeon general pick, Regina Benjamin. ABC News. 20 Jul 2009. https://abcnews.go.com/Health/regina-bejamin-surgeon-general-nominee-overweight/story?id=8129947. Accessed 22 Feb 2022.
  5. Busko M. FDA approves “game changer” drug for weight loss. 7 Jun 2021. https://www.webmd.com/diet/obesity/news/20210607/fda-approves-game-changer-drug-for-weight-loss. Accessed 22 Feb 2022.
  6. Schneider R, Kraljević M, Peterli R, et al. GLP-1 analogues as a complementary therapy in patients after metabolic surgery: a systematic review and qualitative synthesis. Obes Surg. 2020;30(9):3561–3569.
  7. Singleton MM. Obesity is America’s self-inflicted preexisting condition. 23 Jan 2020. https://www.kevinmd.com/blog/2020/01/obesity-is-americas-self-inflicted-preexisting-condition.html. Accessed 22 Feb 2022.
  8. Stop Obesity Alliance. Obesity Treatment Coverage. https://stop.publichealth.gwu.edu/coverage. Accessed 23 Feb 2022.
  9. Charlesworth TES, Banaji MR. Patterns of implicit and explicit attitudes: i. long-term change and stability from 2007 to 2016. Psychol Sci. 2019;30(2):174–192.
  10. Tomiyama AJ, Carr D, Granberg EM, et al. How and why weight stigma drives the obesity ‘epidemic’ and harms health. BMC Med. 2018;16(1):123. 

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