Is Obesity a Disease?

The American Medical Association Goes Against Recommendations And Says, "Yes."

In a controversial move, The American Medical Association (AMA) officially declared obesity a disease. In doing so, the AMA disregarded findings by the Council on Science and Public Health, which had closely studied the issue over the last year. The AMA asserts that this new classification might encourage physicians to pay more attention to the “condition,” and entice more insurers to pay for treatments.

This decision, made by the nation’s largest physician group, could have far reaching consequences. Many doctors, mental health professionals, and advocates enthusiastically predict that the AMA's decision might draw even more focus and attention to obesity. However, many fear it might not be positive attention or focus; rather it might be more "obesity panic." Although many within the medical community strongly believe that obesity has a direct correlation with poor health, legitimate questions from critics around the validity of this new obesity definition have already developed. Current research suggests that people living in larger bodies may actually live longer than people who live in "clinically normal body weight" bodies. This research should give pause to wonder if the AMA’s perceptions (misconceptions?) about the negative effects of large body size are more deeply entwined with cultural attitudes rather than fact.

How did the AMA determine that obesity should be named a disease? There is an assortment of definitions for what it means to have a disease in the medical community, including Dictionary.com: a disordered or incorrectly functioning organ, part, structure, or system of the body resulting from the effect of genetic or developmental errors, infection, poisons, nutritional deficiency or imbalance, toxicity, or unfavorable environmental factors; illness; sickness; ailment. The AMA’s definition of obesity as a disease relies on a measurement of BMI (body mass index), which is simplistic, antiquated, and flawed.

BMI is a mathematical calculation taken from the person's weight divided by his or her height squared. (Weight in pounds/height in inches x height in inches)x703). The whole concept of BMI was first introduced by a Belgian mathematician, Lambert Adolphe Quetelet in about 1830. Quetelet was not a physician and had no medical background. Instead, he sought to conceptualize the "average man" and scientifically map the normal physical characteristics of man in order to assist the government in allocating resources….in 1830! Unbelievably, however, society at large, particularly physicians and insurance companies, promote and exclusively rely upon this 183 year-old calculation. Furthermore, in June of 1998, millions of Americans became “fat” overnight as the federal government adopted a change in BMI standards. http://edition.cnn.com/HEALTH/9806/17/weight.guidelines/

For Obesity as a Disease:
• Those in favor of this definition of obesity argue that this new label will reduce the stigma of obesity, which stems from the widespread perception that it is simply the result of eating too much or exercising too little. If obesity is a disease, than less blame will be placed on those “suffering” from the illness.

• The definition fits some medical criteria of a disease, such as impairing body function.

Against Obesity as a Disease:
• There are no specific symptoms associated with obesity.

• BMI is a flawed and outdated measurement. People with identical BMI can have remarkably different levels of body fat, physical fitness, and health statuses. For example, if you are an athlete or participate in a high level of physical fitness, your BMI might indicate that you are "overweight" or "obese" simply because of a higher muscle mass.

• “Medicalizing” obesity by declaring it a disease would define one-third of Americans as being ill, therefore increasing dollars spent on treatment rather than lifestyle change.

• “Given the existing limitations of B.M.I. to diagnose obesity in clinical practice, it is unclear that recognizing obesity as a disease, as opposed to a ‘condition’ or ‘disorder,’ will result in improved health outcomes,” the Council on Science and Public Health stated.

• Weight bias and stigma against those who are “overweight” or “obese” are likely to increase with this new label of “diseased.”

When examining the topic of obesity, it is important to discuss those who are both obese and suffering from Binge Eating Disorder (BED). BED is the most common eating disorder in the United States, affecting all ages, races, levels of income and education. According to CEO & Founder of Binge Eating Disorder Association (BEDA) Chevese Turner, 15-20% of the obese population can be diagnosed with BED. In order to prevent further damage, this illness must be identified, recognized, and understood among health care providers. Simply suggesting a diet or behavioral weight loss for a patient with BED “will not be productive in the long term and set people up for more self-perceived failure, self-loathing, and weight cycling (internalized weight stigma),” explains Turner.

With a strong focus on dieting and weight loss as the "solution" for obesity, the stigma attached to those who cannot successfully maintain a “normal” weight will only escalate. Weight stigma permeates our culture, including within the medical community. Research shows this causes many larger bodied patients to feel reluctant or embarrassed to seek out healthcare. Further, weight bias creates a lower standard of care. Research also shows that as doctor visits have grown increasingly focused on weight and BMI, and solutions to address those two “problems.” The result is that broken bones go undiagnosed, symptoms of depression get diagnosed as asthma, and weight-loss is the resulting prescribed solution. In a country where two out of three adults and one out of three children are overweight or obese, weight bias affects millions, at a steadily increasing rate. The Yale Rudd Center defines weight bias as “serious and pervasive, leading to negative emotional, social, economic, and physical health consequences for overweight and obese.”

Suggesting weight loss, dieting, and weight loss surgery as the answer (for obesity or BED) will only provide limited and short-term results. According to ASDAH (the Association for Size Diversity and Helath), restrictive dieting is an ineffective long-term prescription for “obesity,” as up to 95% of dieters regain the weight they lost, and sometimes more, within three years. In the words of professor, researcher, author, and Health at Every Size expert Linda Bacon, “research demonstrates that most people, regardless of willpower or diet or exercise, regain the weight they lose. In fact, research shows that dieting is a strong predictor of weight gain!”

Furthermore, ASDAH anticipates that if this decision becomes widely adopted by doctors and policy makers, levels of weight stigma, bariatric surgery, dangerous weight loss drugs, and disordered eating will increase, while health levels decrease overall.

So, what’s the solution? Advocating on behalf of those suffering with BED, Turner contemplates the value of this new definition of obesity. “We must look at this in a risk/benefit assessment,” she explains. “Do we recommend the pursuit of something that has a high failure rate (diets/behavioral weight loss), or do we help these individuals pursue an approach to life that values health over size, and enables them to have a high quality of life (free from self-loathing and feelings of failure)?”

How will the “obesity epidemic” resolve? Only time will tell.
For further reading, see: NY Times article dated June 18, 2013.

Wellness Programs in the Workplace: What's So "Well" About Them?

Originally posted on Eating Disorders Blogs

I recently was a participant in a CVS sponsored Webinar entitled, “Navigating Wellness Communication to Avoid Legal Liability & Pitfalls.” I was a little shocked, but not totally surprised, that the information provided in the webinar was essentially a "how-to" for employers to persuade their employees to participate in Wellness Programs, all the while circumventing rules that protect their employee's rights and privacy.

What is a Wellness Program? The U.S. Department of Labor (DOL) defines a Wellness Program as an opportunity to improve the health of Americans and to help reduce health care spending, while Wellness Proposals (one of the nation’s leading corporate wellness and employee wellness consulting companies) defines it as “…excellent for waistlines and your organization’s bottom line.” Even the Affordable Care Act has facilitated the implementation of Wellness Programs by allowing employers to expand on incentives that entice employees into participation.

Employee wellness programs have been around for decades but they have increasingly become a huge trend among employers, in part because of the incentives for employers. Wellness programs were originally designed to implement strategies in an effort to reduce injuries, health care costs, and long-term disability. Advocates for wellness programs have the point of view that when employees participate in a wellness program, they have fun, increased moral, reduced sick days, and decreased employee turnover. On the surface, that sounds like a good plan for all employers to invest in, right?

But if we look at this from a different point of view -the view of Health Advocates- we recognize the bottom line of Wellness Programs, which is: insurers and employers reducing costs by requiring "healthy" behaviors in employees. Again, this potentially might sound like a good idea. However, there is more to consider than the 'appearance' of Wellness Programs designed to help you get "healthy."

One type of Wellness Program we hear about all too often is the "Weight Loss Competition" or "ABC Company's Biggest Loser Challenge!" in which employees compete against their co-workers to lose weight, and the 'winner' subsequently receives an award for the most pounds lost. Many people think this sounds like a good idea, especially if they are of the thinking that "fat is bad." As health advocates, we do not think, "good" when we hear of this type of Wellness Program because we know that there is an enormous void of empirical evidence to support the myth that weight, or weight-loss, somehow signifies "wellness." We also consider the fact that creating an environment of competition based on weight and numbers often leads to feelings of shame and isolation, which is never a good thing to encourage.

While wellness programs boast of well-intentioned goals, the DOL has recognized the inherent flaws and the need to protect consumers against possible health-contingent wellness programs, discrimination, and violation of privacy. The DOL recently released their rules for Wellness Programs. The rules were developed to protect consumers from unfair practice and include:

• Programs must be reasonably designed to promote health or prevent disease. To be considered reasonably designed to promote health or prevent disease, a program would have to offer a different, reasonable means of qualifying for the reward to any individual who does not meet the standard based on the measurement, test or screening. Programs must have a reasonable chance of improving health or preventing disease and not be overly burdensome for individuals.

• Programs must be reasonably designed to be available to all similarly situated individuals. Reasonable alternative means of qualifying for the reward would have to be offered to individuals whose medical conditions make it unreasonably difficult, or for whom it is medically inadvisable, to meet the specified health-related standard.

• Individuals must be given notice of the opportunity to qualify for the same reward through other means. These proposed rules provide new sample language intended to be simpler for individuals to understand and to increase the likelihood that those who qualify for a different means of obtaining a reward will contact the plan or issuer to request it.

The CVS webinar I mentioned earlier spoke directly about these rules, and detailed how employers could create Wellness Programs without being subject to the rules mentioned above. It is the belief of many corporations that Wellness Programs can save hundreds of thousands of dollars in health care costs, thus the drive to find a way around the rules put in place to protect their employees. What is "well" about that?

Readers who have been approached about Wellness Programs may have wondered, "Can my employer really ask me to do this?" While Wellness Programs were once designed to use only “carrots” (incentives such as gift cards and gym membership discounts), many Programs have evolved to using “sticks” (such as penalties or fees for not participating or meeting a specific 'health' standard). While there are limits that your company can impose on you through their Wellness Programs, it is not uncommon for employers to demand far beyond what is considered legal or ethical. For instance, Whole Foods offers significant insurance discounts based upon the arbitrary measurement of BMI. Although those with a BMI over 30 would not qualify for the program at all, Whole Foods CEO John Mackey explains this incentive as "empowering and fun for employees who enjoy a challenge."

What can you do to protect yourself? Be aware of what Wellness Programs cannot legally require:

HIPAA rules distinguish between incentives or “carrots” based on participation in a program and incentives based on achieving certain health standards, or “sticks.” Your employer cannot manipulate rewards into penalties, for things such as quitting smoking or BMI (Body Mass Index). “If the reward is tied to achieving a health standard but there’s no alternative standard available to people who can’t reasonably be expected to meet that standard, it would violate HIPAA,” says Michelle Mello, a professor of law and public health in the Department of Health Policy and Management.

PepsiCo charges employees $50 a month when they smoke or have medical issues that may trigger weight gain. HIPPA violation? Unfortunately, this type of violation is not uncommon. According to a survey by Towers Watson and the National Business Group on Health, U.S. companies adding financial incentives and penalties to control workers’ health-care management rose 50 percent from 2009 to 2011. Furthermore, 38 percent of employers surveyed said that they plan to punish people who miss targets linked to cholesterol levels or body-mass index.
http://www.businessweek.com/news/2012-02-13/pepsico-unions-seek-nlrb-help-to-fight-50-tax-on-fat-smoking.html