Monday, September 14, 2015

Is obesity a disease, a disability, both, or neither?

In 2013, the American Medical Association recognized obesity as a disease. Dr. Peter Ubel, writing in his blog on the Forbes website, thought this was a bad idea. He feared that calling obesity a disease will result in people having less motivation to lose weight and cited a study which found that people who were told that obesity is a disease tended to be less concerned about their weight and when offered a sandwich for a hypothetical lunch, chose less healthy food.

Although he gave good reasons why obesity should not be considered a disease, he favored retaining the disease label because it would help reduce the stigma attached to obesity and build public support for programs to conquer obesity. I am not sure about that.

Back in December, the BBC reported that the European Court of Justice heard the case of a 352 lb Danish childcare worker who was fired from his job because he couldn't bend down to tie children's shoelaces. He denied the allegation.

The European Court "ruled that if the obesity of the worker 'hinders the full and effective participation of that person in professional life on an equal basis with other workers,' then obesity can fall within the concept of 'disability.'" Danish courts need to hear the case and decide if the worker is truly disabled. The ruling affects all other countries in the European Union.

The Editorial Board of the Chicago Tribune commented on the issue in a piece entitled "the dangers of treating obesity as a disability." It mentioned a Texas case in which a court said a company that dismissed a 600 lb materials handler could not do so because they had not tried to "find ways to help him perform his duties."

The Tribune article pointed out that one-third of Americans are obese with 15 million (7% of the population) classified as morbidly obese. The board felt that this was a potentially very costly expansion of the Americans with Disabilities Act, which they say was intended to help those who were disabled not by individual decisions, but rather were "victims of fate." It did not address the fact that many are disabled from smoking-related emphysema. Are they victims of fate or poor choices?

A recent editorial [full-text here] in the American Journal of Medicine took it up another notch. The author, Dr. Robert M. Doroghazi blamed obesity on eating more calories than one burns—a hypothesis held by many. Regarding the war on obesity, he said, "We will not make progress until we tell obese patients they eat too much, and it is their personal responsibility to eat less." Too harsh?

Disease, disability, both, or neither? What's your opinion?


Blacksails said...

Its an addiction, the same as alcohol or heroin.

High mortality and morbidity, disabling and destructive

Skeptical Scalpel said...

Thanks for commenting. I disagree. If alcohol is so addicting, why don't more people who drink it become addicted? Similarly, lots of people eat, but not everyone is obese. On the other hand, heroin use seems lead to a much higher percentage of users becoming addicted.

JEN said...

Ooohhhh this is tough. As a person that lost 80 lbs (gained by a combination of PCOS, insulin resistance, college and too much fast food), I look back and realize that I could have made much better choices. I did exercise a LOT though. The PCOS certainly was a factor and once that was treated it was much, much easier to lose weight.

I think is a combination of poor choices, ignorance of nutrition, and not enough movement. So it is an addiction that becomes a disability???

Anonymous said...

Dr. Robert M. Doroghazi hits the nail on the head! Our country has become too politically correct and afraid to ruffle feathers when it comes to this issue. It doesn't help that many physicians are just as ignorant about nutrition and fitness as the average "Joe", since they lack coursework in these topics.

Don't even get me started on the fat acceptance "movement" (oh, the irony of calling it a movement!). Shows like "My Big Fat Fabulous Life" only glorify obesity.

Anonymous said...

Just as some people can abuse alcohol, drinking mas much or more than the true alcoholic, but feeling no craving to drink again once they go cold turkey, there are some people who overeat but can stop and not be tempted to go back to excessive eating, and there are true compulsive overeaters. Like alcoholics, they can recover, but face a unique challenge, as compared to other addictions. Food is the only substance that one has to indulge in several times a day to survive- other substances CAN be excluded totally.

So some who suffer from obesity do, indeed, have a disease, but to advance them to the category of "disabled" seems overreaching, just as would classifying the heroin addict or alcoholic as disabled. If we go this far, anyone with any chronic disease will be able to reach to claim disabled status.

William Reichert said...

Disability is a kind of insurance. Obesity disability should be an option workers can purchase as a rider on ordinary disability. Each year your premium will be adjusted depending on your weight. If you feel no need for the converge you don't need to buy it. If you don't buy it and get disabled due to,obesity you don't receive disability. It' only fair.

Sevoflurane said...

It's a frustrating topic. In my opinion, it is an illness, like hypertension, like COPD, like diabetes. Unlike those diseases, there is so much stigma attached to a person's weight that it is almost impossible to have a frank discussion about problems obesity brings. As an anesthesia resident, if I tell people, you have had a heart attack, and still suffer from angina, that is why you are at higher risk of A B C when we put you to sleep for this surgery, and we are going to do our best to optimize you before hand, it would be completely reasonable for me to do so. But, as soon as I say, you are obese, therefore you are at higher risk of A B C when we put you to sleep for this surgery, it suddenly becomes an attack on them as a person, and I'm being judgemental and spiteful for commenting on their weight. Even though, my staff and I will have similarly lengthy conversation we have about a person's heart problem as we would about their weight, somehow telling an obese person about our concerns is going to hurt their feelings.

Muhammad Faateh said...

In my opinion obesity is a disease but a disability only if it seriously impeds the day to day life of a person. I think that the emphasis should not be on the appropriate classification of obesity, instead it should focus on the fact that 90%+ obesity is due to poor food choices and a sedentary lifestyle and is reversible. One third of a country that is obese automatically makes it national health priority.
Also I think that glorifying obesity through TV shows and telling people that it's okay to be fat is ridiculous. If you categorize food as an addiction, then by that standards how mindless would it be to tell people that it's okay to abuse drugs. BTW this is a coming from a morbidly obese person.

Skeptical Scalpel said...

Thanks everyone for your comments. It is a controversial subject about which people have strong views. I don't think these questions will be solved in comments on my blog. It is interesting to consider all of the different viewpoints.

artiger said...

Disease, disability, comorbidity, addiction, glamour opportunity, whatever we want to call it, it has a major impact on health care. In surgical fields we have the 22 modifier for cases that have circumstances that make the case much more difficult. With the way things are going, I think a separate modifier for obesity should be created.

That might sound like a cruel joke on my part, but it was written with serious intent.

William Reichert said...

A few years ago, I was called to see the CEO of my hospital because
a patient complained he was sent to another outside facility to have his MRI done. He was sent because our table for MRI was built only to bear the weight of a 500 pound man. He felt insulted by this information and thought that I has insulted him.

Vamsi Aribindi said...

I wrote a blog post on this topic a little while ago, with some tangential but relevant thoughts to this question:

Vamsi Aribindi

Anonymous said...

William Reichert I hope that that CEO is no longer a CEO. Either that or he was calling you in for a laugh.

William Reichert said...

No, he was dead serious. He was a moron.

Moose said...

Along with your blog I read the blogs of obesity specialists and other medical professionals with an interest in obesity. Obesity specialists realize things that most other doctors do not - that obesity is not a simple thing. The idea that weight comes just from over-eating is a gross oversimplification - a study, first done in the 1970s and since repeated, shows that for most people, overeating causes some weight gain but then metabolism shifts to stop the gain. When calorie intake is normalized, people from families with fat people tend to keep the weight on, while those from thin families tend to automatically take the weight off, without restrictive dieting.

So far, obesity researchers have identified a swath of issues that can contribute to weight gain, retention, and difficulties in weight management. These include hormonal triggers (notably, but not only, sex hormones and cortisol), gut bacteria, genetics (iirc they've just discovered the 9th gene that may play a part in obesity), disease, medications, and more. There's been arguments for years over whether there's a virus at work as well.

My belief is that obesity is neither illness nor a simple "lack of willpower," or the lack of personal responsibility -- those are easy answers and a way to blame the victim. Instead I think it is a syndrome - a mesh of the right mix of circumstances that come together and create a storm.

So why the so-called "obesity epidemic"? There's a correlation between the rise in obesity and the low-fat diet craze, and while correlations are never causations, think of this: Take a large percentage of people who all have the genetics for obesity and glucose intolerance, but it has never been a problem before because they ate normal, balanced, natural foods. Tell them that they have to go on a high-carb diet,because fat is bad. The over-abundance of carbs aggravates insulin resistance, which in turn promotes weight gain, which in turn causes doctors to shame their patients for being fat, which then causes a huge wave in diet programs and products, none of which actually "cure" the problem and may make it worse.

These people have kids and raise their kids to believe that eating fat is bad and feed them a high-carb diet, and the cycle continues.

This isn't an advocacy of low- or high- whatever diets. I am against restrictive dieting, which meta-studies have shown just do not work. I subscribe to the Health At Every Size movement, which encourages all people (no matter their weight) to eat balanced, healthier meals and exercise regularly, since exercise is THE best key to long-term health.

And, I have to say, as for the fat acceptance movement -- fat acceptance is the radical idea that fat people shouldn't hate themselves (which is also part of HAES, because people who like themselves are more likely to want to take care of themselves, eat healthier, and exercise more), and the even more heretical idea that fat people should not be bullied or shamed. Fat acceptance no more "glorifies" obesity than GLBT acceptances "glorifies" being gay.

Moose said...

For Sevoflurane - I recommend taking a look at the Rudd Center for Obesity and Food Politics. They have a whole section on how medical professionals can approach obesity-related issues without weight stigma.

Sometimes changing to something like, "I need to tell you that heavier people can run the risk of XYZ" can sound less confrontational than "You are obese, and..." (This is the conflict-management method of using an "I" statement instead of a "You" statement. "You" statements can sound confrontational, even when technically correct.)

Skeptical Scalpel said...

Thanks for the thoughtful comments. Vamsi, nice post. Thanks for the link. William great story.

Moose, lots to think about. I would disagree that obesity is correlated with low fat diets. There may be an association, meaning that the increase in obesity occurred in the same time frame as the rise in obesity. But there's no proof of cause and effect.

frankbill said...

Many low fat foods have more sugar in them. A lot is written about diet sodas being a cause of one eating more.

RobertL39 said...

NICE job, Moose. Thanks for the input and clarifications. Your overview of the relevant science was very helpful.

Moose said...

No, there's no proof of cause and effect, and I'm the first to scream "Correlation is not causation!". But the influence of a high carb diet on insulin resistant people is pretty well documented, as is the relationship between insulin resistance and obesity (a vicious cycle, to be sure).

While I've seen studies done on -healthy- people about high carb vs low carb diets, I've not seen any on the long term effects of a high-carb diet on insulin resistant, "pre-diabetic" people.

It's times like this I wish I could go back to school and get the degrees needed to make these studies happen. :)

Anonymous said...

The problem is that someone short would be obese and "disabled" at maybe 60 lbs overweight. A tall person with large bones wouldn't be that way until double that. The way we live has a whole lot to do with obesity. I'm not sure if you can call it a disability or a disease. I think what would be better was the medical community & insurances paying for surgery, nutrition counseling (not the garbage we have now), and then figuring out what we can do to stop things like the recent articles saying a good % of kids eat fast food every day.

William Reichert said...

If you eat 100 extra calories a day or 36400 in a year you would (,everything else equal), gain about 4000gm of fat in a year.
(Assuming the extra calories we're all converted to fat. Fat :1gm=9 cal.( 36400/9= 4040gm fat
4 kg times 2.2= 9.6 or almost 10 pounds.
SO we can see that a very slight increase in intake can , over a long time, add significant weight. Or in the reverse if you decrease your intake by 100 cal day ( everything else equal) you would lose 10 pounds in a year or 50 pounds in 5 years.We can quibble over confounding factors but the basic mathematical concept applies
on some level.
The point of this is that no long term study of restrictive diets can be
carried out without strict measurement of food intake. This can only be done in an institutionalized setting. and it has not been done and probably never will be done.
However, the effectiveness of restrictive diets was demonstrated
conclusively ( if I may be so evil as to suggest) by the Germans
in WW2 in their concentration camps.This is obvious.
Dieting is a form of starvation.As such, safe dieting must be done by very slight reduction in food intake ( or slight increase in exercise) and to be effective this must be done over a long period of time.
Most people do not have the ability, the patience nor the desire to quantify and restrict their food intake precisely for a long period of time. But this is what it takes.This is why all diets fail. And this is why diet fads appear from time to time but obesity persists.

frankbill said...

William Reichert

There is most likely more to the story and the obese patient and the MRI table. Over all obese patients are treated different then non obese patients. Both obese and non obese patients can have the disease and SX but the non obese patient will get Dx and the obese patient will be told it is his weight the is the cause of his SX.

I am one of the obese patients being told that it is my weight that is the cause of shortness and the brain fog I have all the time. Even though both Sx started like someone turned a switch on in me. and with no change in weight for many years until after Sx started.

So we that go without a Dx after many visits to many Dr tend to get upset when we think we are just being sent to somewhere else.

Anonymous said...


My vote is that obesity is not a disability.

Even though being obese may prevent a person from doing certain things which may be work related, by the same logic I could say I'm disabled because my muscles have a mitochondria deficiency and I am not able to lift weights like Arnold Schwarzenegger.

In both scenarios it comes down to life choices, and has nothing to do with being dealt a bad hand (like being disabled by ALS, cancer, trauma, etc.).

In support of my argument, we have Type II Diabetes classified as a disability, which often is the result of obesity. Obesity is the risk factor for a real and actual disability (of the pancreas), but is not a disability or disease itself.

Skeptical Scalpel said...

Anon, You make some good points. Hard to disagree.

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