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In Practice

A weighty issue with multiple viewpoints

Adapted from the In Practice blog on Boston.com.

A few years ago, while I was teaching in the hospital, a medical student presented the case of a man with coronary artery disease, diabetes, hypertension, and hyperlipidemia. When we entered the man’s room I was surprised that the student had omitted the fact that the man weighed well over 400 pounds.

No one argues that diabetes and blocked coronary arteries are diseases. And nobody argues that obesity, at least in part, causes these diseases — or that losing weight helps improve or even reverse them. But the question of whether obesity itself is a disease has been controversial.

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The American Medical Association, the nation’s leading organization of physicians, has just announced its stand on the question: Obesity is a disease.

Some might wonder why the issue is controversial at all. I think it has to do with our ambivalence about conditions that have a behavioral component. In the last few years the question of whether certain behaviors are diseases or disorders — drug use and alcoholism, as well as hoarding, gambling, and Internet overuse (which the American Psychiatric Association now lists as disorders or potential disorders) — has come up repeatedly.

We like to think we can control our behaviors, and everyone knows someone who — by effort and willpower — has given up certain self-destructive behaviors. No doubt, many will see the AMA’s designation of obesity as a disease as an absolving of personal responsibility.

But the causes of obesity are complex, and include genetics, stress, the food supply, medications, and other factors. One could argue that if self-discipline alone cured obesity, millions who exhibit this quality in other aspects of their lives wouldn’t have a problem with weight.

Another objection to classifying obesity as a disease will be that it’s so common. Do one-third of adults and one-fifth of children in America have a disease? By 2020, when, as is projected, 75 percent or more of us are obese, will most of us be “sick?” Does the word “disease” have any meaning if it affects a majority of people?

The AMA has no specific authority to designate obesity as a disease, but it’s decided to use its considerable influence to effect a cultural shift. The hope is that if obesity is thought of as a disease, insurance companies will be more supportive of obese people, researchers will pursue the problem more aggressively, public health efforts to curb obesity will be strengthened, and clinicians will be better trained to address obesity with patients.

A study last year showed that only about half of primary care doctors felt competent to deal with patients’ obesity. Among doctors who were obese themselves, the percentage was much lower.

The blog is at www.boston.com/inpractice
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