Is Obesity a Disease?

Sunday, July 07, 2013
Lebanon — For most of her life, Karen Dennis has struggled to control her weight.

In grade school, Dennis was the “fat kid in class,” she said. The Lyme native never learned to ski, for fear of falling and not being able to get up. As she got older, health problems began to emerge.

“It has affected my whole life,” said Dennis, 57, of West Lebanon. “It’s caused me hypertension. It’s caused me depression.”

Like so many others who are overweight, she tried an array of diets that never led to lasting change. She would shed pounds and gain them back. A nurse at Dartmouth-Hitchcock, Dennis was well aware of the health risks of carrying extra fat on her frame. But no matter what she tried, the weight never seemed to come off.

By any measure, Dennis was obese.

Dennis felt powerless. Then, in 2009, she was diagnosed with Type 2 diabetes. The medications she was prescribed caused her additional health problems. Something needed to change. By 2011, weighing 247 pounds, Dennis began exploring bariatric surgery, which reduces the size of a person’s stomach with a goal of helping her lose excess weight.

It was while getting screened as a candidate for surgery that doctors told Dennis she had a metabolic disorder.

“It was so good to finally have validated that it wasn’t me,” she said. “It wasn’t a character flaw of mine. It was genetic.”

Obesity has long been considered a condition caused by lifestyle, driven by overeating and lack of exercise. But in recent years there has been a gradual shift among many health care professionals in the way they think about the issue.

Last month, the American Medical Association changed its position on obesity, officially recognizing it as a disease rather than a condition.

The decision to call it a disease is largely a semantic one — the AMA has no legal authority over how health care providers or insurers treat obesity — but health care professionals say it still could be influential in removing the stigma associated with being overweight and continue the gradual evolution in how problem is approached.

“Seventy-two million Americans are obese and another 24 (million) really hit the criteria for morbid obesity,” said Bill Laycock, director of the bariatric surgery program at Dartmouth-Hitchcock Medical Center. “Just the impact on their health, life expectancy, that’s a disease.”

The AMA’s decision is not without controversy. Many health professionals, fitness experts and even obese people themselves are skeptical of calling obesity a disease. No one is born obese; they eat their way there. Critics worry that calling it a disease could absolve people of taking personal responsibility for their physical condition and cause them to throw their hands up in the air and not address it.

“When you call something a disease, that means it’s out of your hands,” said Ben Dearman, owner of KDR Fitness in Lebanon. “Obesity, it’s a lifestyle condition. It’s not just something you woke up and discover, ‘Hey, I’m obese now.’ ”

The debate is unlikely to be settled for some time, but may influence the ways in which society thinks of obesity, how patients and doctors choose to address it, and also how we pay to treat a problem that in the United States many consider an epidemic.

Disease vs. Condition

Figuring out how to think of obesity is complicated by the fact that there is no singular definition for it. A common standard of obesity is the body mass index, or BMI, which is a rather simple calculation based on a person’s weight and height. And by this measure — or pretty much any standard, really — it is clear that America has a weight problem.

More than a third of all U.S. adults are obese, according to the Centers for Disease Control and Prevention, and obesity has been linked directly to some of the leading causes of preventable death, including heart disease, stroke and type 2 diabetes.

Obesity rates are not as high in the Twin States, but they are still cause for serious concern. More than a quarter of Vermont and New Hampshire residents were considered obese in 2011. The proportion of each state’s population that is obese is expected to double by 2030 if the current trend continues, according to the Robert Wood Johnson Foundation.

The problem is not only worrisome from a health perspective; it is also driving the cost of care higher.

In 2008, medical costs associated with obesity were estimated at $147 billion, according to the CDC, with medical costs for obese people averaging $1,429 more than those of normal weight.

Allison Breen is among the 25 percent of Vermonters who are considered obese. The 32-year-old Quechee resident has struggled with her weight since childhood. She thinks there were a variety of factors involved, including stress from her parents’ divorce and growing up in an environment in Wisconsin where healthy eating was not a priority.

Not everyone in her family had weight problems. Her brother and half-sister were both thin. Meanwhile, she and another half-sister were large.

She does not think of obesity as something other than the result of a series of poor lifestyle choices.

“I do not think it’s a disease,” she said. “And this is coming from 27 years of being overweight.”

John Grainger agrees. As fitness director at the Upper Valley Aquatic Center, Grainger’s job involves helping people transition to a healthier lifestyle. The assumption that fitness programs make is that obesity is a reversible condition addressed through better diet and increased activity rather than medical intervention.

“I think it’s something that is developed over years of making bad choices and developing bad habits,” Grainger said. “People can reverse it.”

Lifestyle factors have no doubt led us to this point, Laycock said. At the end of the day, obesity is due to eating more calories than a person burns. Environmental factors influence a person’s weight, and there may be some genetics involved. But just because a person’s eating and exercise decisions brought them to this point doesn’t disqualify obesity from being a disease, he said.

Cirrhosis of the liver is a disease that can be caused by a person’s decision to drink excessive amounts of alcohol, Laycock said. Obesity can be thought of much the same way.

“How you get there is clear,” he said. “But once you’re there, the impact to almost every body system is extremely well-documented, and the implications are severe.”

Treating Obesity

A consequence of thinking about obesity as a disease is that it may change the ways in which overweight people try to deal with it. “Disease” seems to warrant medical intervention.

Similar to Dennis, Breen has tried a number of diets, none of which have led to lasting results. In 2008, she lost 60 pounds on a low carbohydrate diet, and then gained it all back. At one point, she considered bariatric surgery and began the screening process at DHMC. She ultimately decided against it.

“I didn’t do it because … if (the problem) was a mental issue, I’d gain the weight back afterward,” Breen said.

Breen is now enrolled in a program at KDR Fitness in Lebanon. Over the past four months, she has lost around 1 percent of her body weight each month. She has changed her eating habits. But she has been frustrated at times with her rate of progress.

“People look at me and think I should be losing pounds like Biggest Loser fast,” she said, referring to the reality television show in which contestants compete for weight loss.

But Breen said she believes she is making permanent, lasting changes, and for that she is willing to be patient. Her goal is not so much for lowering the numbers on the scale alone, but for more general physical fitness.

She wants to avoid the trap many of her friends have fallen into, which is trying crash diets, shedding pounds quickly and then gaining them all back.

This is a problem with almost all weight-loss diets, said Laycock. A lot of them help people lose weight, but rarely does anyone keep it off long term.

He sees it with almost every one of the 150 patients who seek bariatric surgery at DHMC every year.

In the pre-surgery evaluation phase, patients are required to detail what diets they have tried before, what weight loss they have had and finally what weight they gained afterward. Whatever pounds the patient lost on the diet usually were put back on, “and with a vengeance,” he said.

“At the end of the day, that’s the problem,” Laycock said. “And if you just say to someone, ‘You should just try harder,’ it doesn’t work. And these people are dying. There’s about a thousand people a day that die of obesity in the United States. It’s threatening to wipe out all the medical advancements we’ve made so far in the last century.”

Surgery isn’t a cure either. Just because doctors can shrink a person’s stomach is no guarantee that the patient will make the lasting changes necessary to maintain a healthier weight.

At DHMC, 95 percent of bariatric surgery patients lose at least a third of their excess body fat within one to two years after the procedure, and 71 percent lose at least half.

There are plenty of patients who gain it back, Laycock said. More than 50 percent, however, keep the weight off. A component of DHMC’s bariatric surgery program includes patient education about nutrition, exercise and annual follow-up visits to monitor a patient’s progress.

“We tell people that if you don’t think you can tolerate coming for (post-operation) follow up, you shouldn’t come in for surgery,” Laycock said.

The long-term success rates of surgery, as well as the cost benefits for the nation’s health care system, continue to be studied. But Laycock said he believes it’s the best option currently for helping people overcome severe obesity and the array of related medical problems.

“You have to balance all of the results from surgery against the alternative,” he said. “What’s the alternative? The personal trainer can say, well, I can whip you into shape. Most of (the patients) can’t afford that, for one thing. And two, as soon as you stop, it’ll likely fail.”

Paying for the Problem

As promising as bariatric surgery might seem, however, the cost benefits remain in dispute.

A study published this year in the journal JAMA Surgery found that it did not lower patients’ costs over the six years after they underwent the procedure.

The average cost for someone paying out-of-pocket for bariatric surgery at DHMC was around $23,000, according to hospital spokesman Michael Barwell. That does not include annual follow-up visits or subsequent care.

The cost is about half that for people with private insurance, because insurers negotiate with hospitals for lower rates. Still, most insurance plans cover surgery for only the most severe cases of obesity. Instead, companies have chosen to invest in wellness and prevention programs to fight obesity.

“To address this effectively, it really requires the individual to be involved,” said Leigh Tofferi, spokesman for Blue Cross Blue Shield of Vermont, which insures 180,000 people in the state.

Last year, Blue Cross Blue Shield of Vermont covered 63 bariatric surgeries, Tofferi said. Its obesity prevention efforts in the state were more widespread, however, including education initiatives through schools and employers, financial incentives to employees who participated in various wellness programs and through community events promoting physical fitness.

Health plans across the country have been aggressively promoting wellness programs for many years, said Susan Pisano, vice president of communications for America’s Health Insurance Plans, an industry trade group. The strategy insurers have taken toward reducing obesity rates is not going to be affected by the AMA’s decision to classify it as a disease.

“The issue is whether you call it a disease or whether you call it a risk factor or you call it a condition, what’s going to drive coverage is evidence that a treatment is safe and effective,” she said. “So what you call it in that respect isn’t going to influence coverage.”

Pediatrician Lou DiNicola said he would like to see insurers do more to cover obesity as a medical disease. DiNicola, a pediatrician at Gifford Medical Center since 1976, said he sees children whose primary problem is that they are overweight. But he cannot bill insurers for that alone.

“I cannot put down obesity as the only reason I’m seeing them,” he said. “Insurers will not pay, in general, for a primary diagnosis of obesity. I can’t even start if it’s just obesity.”

Whether insurers pay for bariatric surgery, or medication or even a gym membership still does not address the argument that health professionals make about the long-term steps needed to address America’s obesity epidemic.

Dennis’ surgery in 2011 was only the beginning of getting herself to a healthy weight. Two and a half years later, she remains 70 pounds lighter than she was before she had her stomach reduced by two-thirds its original size. The weight has stayed off, she said, because of the lifestyle changes she made.

She has committed to eating healthier, “colorful” foods. She controls her portion sizes. Before surgery, she would eat a foot-long submarine sandwich. Now, she eats a three-inch sandwich. She ran her first 5K road race in March and plans to run another next month.

These are changes that she is trying to make on a permanent basis. She wants to be a role model for her patients, her two daughters and her grandchildren.

Whatever the medical community decides to call obesity — disease or condition — she knows she doesn’t want to experience it again.

“I am amazed now with how active I am with this,” she said. “Seventy pounds heavier, I could not be chasing a 20-month old (grandchild) around like I do now.”

Chris Fleisher can be reached at 603-727-3229 or cfleisher@vnews.com.