A Month ago (June, 2013) the
American Medical Association voted to reclassify obesity as a disease. This was
met with some very good critique from Fat Activists (here, here, and here among others) and brief flurry of media attention - largely consisting of opinion waiving about obesity, fat
people, and the future of health care in our nation-state. The usual suspects were trotted out,
interrogated, and in the end the matter was but back to bed with the usual
sentiments regarding the need for more personal responsibility and education
for those poor (or disgusting, depending upon the subtly of the audience) fat
folks. It was, it would seem, Much Ado
About Nothing. After all, as most news
outlets informed us, the AMA has no legal standing and the move is a largely
symbolic and/or semantic one.
This is where a lot of news
outlets - and scientists - got it wrong.
The AMA may not have legal power, but they certainly have epistemic
authority. This move might be semantic
and symbolic, but that hardly means it is without consequence. This move by the AMA has very real impacts
upon fat individuals, upon the science investigating "obesity" and
upon our ideas about disease.
When starting this blog post I
pulled up a bunch of dictionary definitions of "disease" I think I
like this one the most:
1. A pathological condition of a part, organ, or
system of an organism resulting from various causes, such as infection, genetic
defect, or environmental stress, and characterized by an identifiable group of
signs or symptoms.
2. A condition or tendency, as of society, regarded
as abnormal and harmful.
3. Obsolete Lack of ease; trouble.
Though I will attend to the first two options throughout the
Blog post, in the end I think we will find that #3, the archaic or Obsolete
definition is perhaps the most salient one: Trouble.
Defining Disease
With all the hullabaloo you might think that the AMA is the
first professional association or medical authority to classify obesity as a
disease. You would be wrong. Medicare classified obesity as a disease
(and therefore eligible for benefits coverage) way back in 2004. In a lot of ways the AMA is late to the
game. You might also be wondering,
"what was obesity before June of 2013??" After all, we have been fighting a war against an "obesity
epidemic" - how do you have an epidemic without a disease? And when you went to the doctor and they
explained the BMI to you and informed you that you were obese, that seemed like
a diagnosis, didn't it? It even appears
on the billing forms with an official number and everything. It seems like we have been treating obesity
like a disease for quite some time now, but prior to Tuesdays ruling the AMA
considered obesity to be a "'complex
disorder' (Policy 7 H-150.953), 'urgent chronic condition' (Policy D-440.971),
'epidemic' (Policy D-440.952), and 'major health concern' and 'major public
health problem' (Policy H-440.902).[1]" The council tasked with evaluating and
making a recommendation about the classification of obesity as a disease (and
incidentally recommended against the reclassification) noted that
"disease" has no set definition.
They note that no definition of disease exists which if implemented
would positively render all currently labeled diseases, as disease; "Indeed, the medical community’s definitions of disease
have been heavily influenced by contexts of time, place, and culture as much as
scientific understanding of disease processes.[2]"
Thus, part of the difficulty
in deciding if obesity is a disease is that we don't really agree on what a
disease is. The Committee on Science And Public Health (CSAPH) Rep 3-A-13 report
cited an earlier report's table of definitions[3]
- which amount to the conglomeration of several dictionary definitions of
disease. So the AMA did the same thing
that I did for this post, or any college student writing a term paper might
do. They pulled open a bunch of
dictionaries and tried to find some consensus. In the end what made obesity a
disease wasn't whether it fit a definition of disease (though that in itself is
an interesting query) or whether the subcommittee found evidence in the medical
literature to support the classification of obesity as a disease -- No, rather
like the stripping of Pluto's planetary status, Obesity became a disease by
vote.
In fact a great deal of
scientific knowledge becomes scientific fact through the democratic process of
voting. Voting is what made
homosexuality a disease, and then a disease if it upset you to be homosexual (DSM IV), and then
not a disease at all (DSM IV-TR) in the span of a few decades. The world of classification is not the cut
and dry pursuit of independent "fact" that we like to think of it
being. Now, that doesn't mean that there isn't truth or fact to be accessed, it
just means that the epistemological process isn't always linear and it is often
influenced by time, place, and culture much more than layman discussions of
science account for. In fact there is no reason to think that what we think of
as a certain disease entity today, and what we label as being the same
disease entity in the past - they may not be
the same entity at all (For a far more eloquent discussion see Ludwick
Fleck). What is more important is that
they certainly were not thought of, interacted with or treated in the same way
in the past, and this changed how they were researched, conceived of and what
explanations and treatments were accepted.
So the designation of obesity as a disease, or condition, or
lifestyle is a semantic move. BUT that semantic move has a lot of baggage and
meaning attached to it. It also has very real impact upon how that entity (obesity) is thought about. We could take
the AMA to task for the definition they used, or the applicability of that
definition but I suspect this has been done elsewhere. I know that other sources have discussed whether or not this decision will be good for fat patients (incidentally the AMA committee based their recommendation to not change the classification upon the assertion that such a change would NOT improve health outcomes), and whether or not the classification is valid - but I have not seen a source that gets to the epistemic impact of this move. So it is far more interesting at this
junction to attend to the fall-out of the AMA decision.
Fuzzy meets fuzzy - Defining
obesity
One of the primary reasons the
AMA's own council on Science and Public Health recommended against classifying
obesity as a disease was a lack of satisfactory definition of obesity: "Without a single, clear, authoritative, and widely
accepted definition of disease, it is difficult to determine conclusively
whether or not obesity is a medical disease state. Similarly, a sensitive and
clinically practical diagnostic indicator of obesity remains
elusive." We know that the use of
BMI alone leads to erroneous classifications of obesity (Tom Cruise is obese
using BMI). However, it is not just a
matter of weeding the fatties from the muscle bound - there is much more to an
adequate definition of obesity.
What is obesity anyway? If obesity is a disease, what is the disease
agent? Is it fat - does that mean we
all have some of the disease in us? Is
it too much fat? How much fat is too much fat?
What do we use to determine what makes a certain amount of adipose
tissue too much adipose tissue? Do we use population distribution? ... How many
deviations from the mean are we allowed to go?
Does that mean that as the population gets fatter, the level of
acceptable fat moves with the population?
Should we use Social standards?
Should it be based on the point when fat begins to affect your
health? But then we would need to know
how it affects your health, what the mechanism is, when it affects your health
- that sort of thing that we actually don't have a lot of information on. We could base it on statistical evidence, so
the point at which excess fat becomes correlated to negative health outcomes
(though we would need to pick a threshold and have a way to measure fat that is
accepted and standardized).
The difficulty, and what makes
obesity research fruitful to investigate, is that defining obesity as a disease
is where the fuzzy meets the fuzzy; the fuzzy ways we define disease and
health, meets the fuzzy ways we define obesity. In certain ways obesity as a disease reveals the circular logic
that comes from substituting common sense for data.
- According to the AMA obesity is a disease because it is associated with negative health outcomes.
- BUT the category of obesity exists to designate levels of adipose tissue that are healthy from those that are unhealthy (by virtue of negative health outcomes).*
- The categories are arbitrarily chosen, and quite wide
- BUT the existence of increased mortality at the high end of the obese category supports the idea that obesity is associated with negative health outcomes.
- Therefore, obesity is a disease.
* Except, that the
methods of categorizing obesity are actually pretty bad at distinguishing who
has too much adipose tissue and who doesn't. They are also bad at accounting for why some people who exist in
the category of "obese" fail to have negative outcomes, while others
who do not fall into the category of "obese" do have negative health
outcomes (and the often the same negative health outcomes like Type II diabetes
and metabolic difficulties).
Hmm...that does seem problematic,
doesn't it?
Impacts:
So, beyond the problems of validity this move poses, what does this rhetorical turn
of events do? Why should we care?
Well, first of all it makes it so
that No fat body can be healthy.
This is a big deal. When we
thought about obesity as a condition or a risk factor there left some room to
think about fat bodies as potentially healthy bodies. If excess adipose tissue in and of itself constitutes disease
then no fat body can ever be healthy.
Now the idea of the fat body as
always becoming (and never stable) is an idea that is pushed around a lot in
fat studies. The fat body is always
becoming something - and usually it is becoming one of two things: 1) thin or 2) dead. There is a certain narrative to the way
that we talk about fat bodies. There is
a constant state of potentiality - you as the fat body are always the
"before" picture. If you are
a virtuous fat body you are pursuing the end goal of becoming thin. You are
actively attempting weight loss (though scientifically speaking your likelihood
of success is quite slim). If you are
not actively pursuing weight loss than you are left as a fat body that is
rhetorically painted as diseased and doomed.
You are dying. This AMA decision extends this logic to the realm of scientific
fact production. By making obesity
itself a disease, the health or ill-health of the fat body is taken off the
table. You are fat therefore you are
sick, end of story. So even if you are
fat but otherwise in perfect health - good BP, good lipids, no joint
complaints, good sugar, exercise regularly, eat your vegetables, don't smoke,
don't drink - it doesn't matter because you still have a disease. Now this is very reflective of the attitudes
that many physicians (particularly Bariatric physicians have) about
obesity. The fat body even when not
presenting symptoms is just in a state of pre-sickness. When presented with the case of a fat person
who is in good health the response is often that the person is "just not
showing symptoms yet." This vote
reflects that attitude about fatness - without new data, without addressing the
literature that indicates one can be fat and healthy. The definition has become the justification for the disease. This vote attempts to effectively end the
HAES(r) discussion.
This is why we should care about
this ruling. This move by the AMA, in
defiance of their own committee's recommendation, substitutes common sense
for evidence. That is something
that no one should be comfortable with.
Whether you are a Fat Acceptance advocate or you identify with the idea
that fat is patient's rights issue - even if you are a obesity researcher that
believes to the tips of their boots that fat is unhealthy this still shouldn't
sit right with you. This is not
evidence-based medicine and it shuts down productive avenues of investigation
and inquiry.
The move to classify obesity as a
disease comes to soon. We don't
understand enough about obesity to call it a disease. We can't agree on what obesity is, better yet what causes
it. Is obesity a symptom, or disease
entity on its own? How does obesity
cause all the myriad diseases it is supposed to influence? How can obesity be a symptom for certain
other diseases, an outcome of health choices and behaviors and a disease all by
itself? By classifying obesity as a
disease before we answer these and other important questions related to fat
that we have just finally started to ask the AMA has filled in the facts we
don't have - and that is going to affect how obesity is studied and treated
from here on out.
Just look at the effect that the
2004 Medicare decision had - it bolstered the obesity epidemic paradigm and set
in a particular way of seeing fat and obesity.
Just as we start to unravel some of that set viewpoint this decision
again forces a particular way of viewing fatness that will shape research and
funding in the future. Think about
obesity research as a message that we only have some of the words from (a two
word phrase from a game of hangman for instance). This move fills in the first part of the sentence and assumes that
it is correct (without knowing it is), and now researchers will investigate the
rest of the sentence based on that assumption.
This solidifies obesity as a
disease entity in and of itself - that creates a bandwagon for researchers -
just as the obesity epidemic did. This
is a way of thinking that is intelligible to scientists and can be accessed to
access funding (or in this case insurance reimbursement) but that means that
only those strategies which address this way of thinking will be considered and
proliferated. To make this move without
foundation is very dangerous. It will
effect everything from funding, to policy to hypothesis formation for thousands
of practitioners for years to come.
Lastly, this is move that is yet
another transition from what we do to what we are. Michel Foucault argued that there was a
shift around sexuality, from what we do to who we are. With this shift comes a great deal of
baggage and problems. This shift in the
way we think about obesity medicalizes a bodily state. Fat goes from something we have, to
something we are, to a state of automatic ill health. This is highly concerning and highly problematic. The medicalization of the fat body is not
new, it doesn't start with the AMA, but this move does compound that
status.
This AMA move was supposed to be
about easing the burden for fat people.
As the NY Times notes, some at the AMA hoped this change would
"reduce the stigma of obesity that stems from the widespread perception that
it is simply the result of eating too much or exercising too little[4]." However, historically classifying something
as a disease or as biologically based doesn't absolve the individual of the
burdens of stigma. At best the question
of culpability remains (as it has with addiction or LGBT status) and at worst
the condition is compounded by the stigma of disease. We already see strains of this in conversations about whether or
not Fat can be "caught" from friends and neighbors.
In the end we are left with what
we started with - Trouble.
