This article first appeared in the St. Louis Beacon, July 1, 2013: When an obese patient walks into a doctor's office, the physician isn't likely to talk about weight unless it's the reason for the visit. That attitude might change now that the American Medical Association has classified obesity as a disease. Among other things, this means doctors are more likely to engage patients in a discussions about their weight, while insurers will be more likely to cover weight-loss treatment.
But not everyone, some of whom are struggling with weight problems, believes obesity should be elevated to disease status. Take Joy Weese Moll. On days when she used to feel a little stressed and needed time alone, Moll would grab a big bag of potato chips and eat them in the car or while reading a book. She now concedes that this was a bad habit. That realization led her to face up to her weight problem by exercising and reading 70 books, sans the chips, to match the 70 pounds she has lost.
A former librarian and now a book blogger, Moll says losing the weight was harder than it needed to be because advertising “is saying to us it’s OK to eat 24/7.” Even so, she’s not ready to embrace the American Medical Association’s new position that obesity is a disease. “I suspect that’s more useful than thinking of obesity as a character defect,” says Moll, 51, “but I’m not very supportive of the notion that we should be solving this problem with pills and surgeries.”
It’s an argument that isn’t new to Dr. Mario Morales, medical director of the SSM Weight-Loss Institute at DePaul Health Center. While acknowledging such concerns, he praises the AMA’s position as a game-changer, generating more research to understand obesity better as well as new medical and nonmedical techniques for addressing it.
In addition, health coverage for various types of diabetes treatments is likely to become available as a result of the AMA’s action.
He expects these will make life easier for those coping with obesity and its harmful health consequences, including diabetes, heart disease, high blood pressure, and kidney failure. Some medical experts argue that classifying obesity as a disease is inappropriate because not all individuals who are severely overweight experience those other consequences.
Everyone seems to agree, however, that obesity is a major problem in Missouri and across the nation. A study in 2010 showed that the overall rate of obesity in Missouri had risen to more than 29 percent of the population and that rate was 38.4 percent among blacks across the state.
Morales says the AMA’s position will mean more intense research to address issues such as why bodies and minds react differently to food. “One individual might have a sandwich or an apple and they are satisfied. But there are other individuals whose hunger hormones are not satisfied by an apple or a sandwich.”
He says that choice is far more complex than a personal decision of consuming “three more sandwiches because I want to.” Additional studies can help sort out how much such choices are based on environmental factors and how much stems from genetics, Morales says.
To the extent that environmental influences are factors, Morales was asked whether, instead of medical interventions, it might make sense to educate people about food choices and make fresh fruits and vegetables more accessible in neighborhoods where people might lack automobiles or convenient public transportation.
“Absolutely,” he says. “For action to be taken, there needs to be scientific proof, more objective data. I think the decision by the AMA is going to lead to that.”
He notes that the AMA’s decision to define obesity as a disease has been embraced by many associations of medical specialists, including cardiologists and endocrinologists.
“Why? Because they see patients affected by diabetes and heart disease and they go back and look at the epidemiology, the root causes, and it’s obesity,” Morales says.
The institute focuses on both surgical and non-surgical responses to obesity. Patients undergo a number of examinations to determine their health issues, and their history of dieting and other weight-loss efforts. They are also seen at least once by a psychologist or psychiatrist to figure out what psychological issues might be affecting their failure to lose weight.
“We try to fill in the holes,” Morales says, then “fashion a regiment that is going to help them.” Three of the most common surgical procedures for obesity, all aimed at reducing food intake, are: a gastric band placed around the stomach; a sleeve gastrectomy, which reshapes the stomach; or a gastric bypass, which reshapes the stomach and rearranges the intestinal tract.
Of the three, Morales says the sleeve is the newest and most widely used. “It’s less invasive, meaning the surgery isn’t complicated. I think that is a real selling point to a patient. And the results are very, very good” in terms of positive effects on patients who might also suffer from diabetes, high blood pressure or heart disease. He says many patients are pleased by the surgery and often wonder why they didn’t do it sooner.
“I do appreciate that patients should be held accountable, and we try to hold them accountable after surgery.” he says. “But I don’t agree that we shouldn’t be doing surgery. We have to do something. If a patient shows up in the ER in a diabetic coma because they’ve had too many sweets to eat, you are not going to leave them out there. Patients should be offered a range of options. Surgery should be one of the options.”
Others have called attention to what appears to be a public bias against the obese when it comes to viewing their condition as a disease requiring medical intervention. One common response is that people are fat because they want to be and can solve the problem by regulating their food intake and exercise. Yet, some proponents of obesity-as-a-disease note, the public tends not to blame heart patients, for example, for their health problems even if their condition is due in part to lack of exercise, smoking and clogging their arteries with food that’s bad for them.
In spite of the AMA’s position, Moll, who has lost 70 pounds and is “fighting to keep it off,” thinks plenty could be done beyond medicine to help overweight people lead healthier lives.
She says a wiser approach is to “fight to reduce the marketing” of sugar-laden beverages and food high in calories and low in nutrition. In addition she thinks there needs to be more “education about the addictiveness of those products and the ways that food companies try to hook us on them.”
Maria Martinez-BonDurant, 49, an analyst at Citibank, has a different view of obesity. Unlike Moll, she thinks a case could be made in support of the AMA’s recognition of obesity as a disease.
“Diet plays a role with our health,” she says. "Many people already have health issues because of their diets. In those cases, I believe obesity should be treated as a disease.”
Her personal approach to weight control includes at least 30 minutes of physical fitness activity each day. With its parks, sturdy sidewalks, a bike trail and access to a school track, Martinez-BonDurant’s neighborhood in west county doesn’t present obstacles to getting plenty of exercise.
The neighborhood also includes easy access to major food stores. But Martinez-BonDurant believes access doesn’t necessarily mean consumers will make better food choices. “The sugary foods and the processed foods are cheaper. So if you are on a tight budget you would probably lean more toward those items versus organic foods and fresh fruits and vegetables."
She says she is motivated to exercise mainly as a result of observing how obesity has caused illnesses such as diabetes in others.
“I am being proactive to prevent health issues because of eating habits,” she says. “I don’t have those other health concerns, such as diabetes and high blood pressure.”
That’s not to say her approach would work for everyone, she says. “It’s important to stress that it (obesity) is not only a physical problem, but it’s also a mental problem. I don’t think people who are overweight want to be that way.”
It makes sense for the AMA to classify obesity as a disease, she says, since some people might have “an addiction to food” and “their eating habits are at the point that they can’t change without medical attention.”
Her comments come close to the thinking of Morales and other weight-loss experts, some of whom warn that obesity is widespread and growing. They are concerned that the public doesn’t seem to appreciate the scope of the problem in Missouri where nearly 1 in every 3 adults is overweight. That, to Morales, makes a good case for new strategies, including treating the issue as a disease.
“We walk around parts of the city and the state and we see large individuals and we’ve become desensitized to how big they really are,” Morales says. “People don’t realize that there are a lot of 500-pound people walking around.”
Fit City
The St. Louis Beacon is embarking on a year-long initiative on obesity. Our focus is on north St. Louis where the rates of obesity, diabetes and cardiovascular disease are disproportionately high. We are holding neighborhood conversations and programs to address the problem. Through a grant from the Missouri Foundation for Health and the Public Insight Network, the Beacon will report on research on obesity, the success and failures of programs to reduce obesity — as well as the stories of local individuals.
