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The Unease Over Classifying Obesity As A Disease


I'm Michel Martin and this is TELL ME MORE from NPR News. Later in the program, we'll speak with singer and actress, Macy Gray. She has a new album out, she's on tour and we'll talk about some of her movie roles. That's coming up.

But first, we want to talk again about what could be a major change in how we talk about and treat obesity in this country. Recently, the American Medical Association, which is this country's largest physicians group, voted to classify obesity as a disease. Now this comes at a time when one in three American adults could be officially classified as obese, according to the Centers for Disease Control. So we wanted to talk more about how this could change how we talk about and treat this.

When we asked doctors and other healthcare professionals to weigh in on Twitter and Facebook - and we heard from hundreds of people across the country, so now have three people joining us. Dr. Patrice Harris is a member of the board of the American Medical Association. She's also the director of Public Health in Fulton County, Georgia. Dr. Neil Minkoff is a medical consultant at Fountainhead HealthCare in Boston. He formerly practiced as an internist. He's also a regular contributor to our barbershop roundtable. And Dr. William Stratbucker is a physician who specializes in obesity, in Grand Rapids, Michigan. Thank you all so much for speaking with us.

PATRICE HARRIS: Thank you for having us.

NEIL MINKOFF: Well, thanks for having us.


MARTIN: Dr. Harris, I'm going to start with you. I don't want to revisit the whole - all the details of how the AMA came to this decision. But I did want to just note that the AMA's own Council on Science and Public Health advised against this because their argument was that the body mass index is just too imprecise of a measurement.

That there are plenty of people with a body mass index above the standard, who can be classified as healthy and there are people who with a body mass index below it, that can be unhealthy. So can you just briefly tell us what you think of the decision and why did the AMA decide to go forward with this?

HARRIS: Well, first of all, I want to say the AMA is a big tent organization where there's a diversity in thought of opinion. But after - at the end of the day, after the debate, the house did vote to recognize obesity as a disease.

And you're right, the BMI is an imperfect measure. But we want to say that weight goals are just a start. So the conversation is just not around BMI or obesity, but the conversation is also around what are your blood pressure goals, and what are your blood sugar goals, and what are your cholesterol goals.

So the BMI is just one measure. It's really about looking at all of these things but the ability to now talk about obesity as a disease entity in and of itself, before it progresses to some of the complications like diabetes, high blood pressure and cardiovascular disease.

MARTIN: Do you think this is helpful to you as a physician? Is this helpful to you in talking to patients and talking about the issue from a public health perspective?

HARRIS: I think it adds another tool in the toolbox for patients and physicians. And, as you said, I am a public health physician and so any time we are able to impact a disease entity on a more preventative level, it's a good thing.

MARTIN: Dr. Stratbucker, what about you? You see obese patients daily, especially a lot of children. And we note that obesity now affects 17 percent of all children and adolescents in the U.S. That's triple the rate from just a generation ago. Do you find this designation helpful or hurtful?

STRATBUCKER: Definitely helpful. I agree, as a pediatrician, I am treating this daily, and working with families. And just as Dr. Harris said, you know, the BMI is something we use, it's another tool but it is imprecise. But the fact of the matter is there's plenty of children and families who are struggling with this multifaceted problem.

And they're not - these are not the kids at the borderline of body mass index classification, and as my students and residents will tell you, I'm a fan of semantics. I think that the designation as a disease I think gives this problem, that families feel and deal with, the designation it deserves so that we can have the attention put on it by physicians and payers, insurance companies and others.

MARTIN: Why do you need the designation though to talk about this?

STRATBUCKER: Well, it's not necessarily to talk to families about it, we're going to go right ahead and keep treating people. But the conversations and the feedback that you hear when this comes up is that, well, no, you know, this isn't something you go to the doctor for, this is something you put the sandwich down and get on the treadmill. And those types of comments really drive me crazy as a medical professional specializing in trying help families overcome the fundamental - some of the fundamental problems they have.

For example, children who are - their mothers were gestational diabetics or insulin-dependent diabetics. Before they were even born they were set up to be overfed and to develop obesity as a disease. It's no different than some other famous diseases like cancer. We've developed really rigorous treatments, but it didn't happen overnight.

MARTIN: Dr. Neil Minkoff, what do you think?

MINKOFF: Well, I think my, I have two concerns about the semantics of classifying obesity as a disease. Well, maybe three.

One is I'm not really sure, to our patient population, it matters a tremendous amount if something is a disease versus a condition or a disorder, and some of that gets to the semantics point.

The second is that to be a disease it would be helpful if, like most diseases, there were a specific definition for what the diagnosis is. And that comes back to BMI and how it's going to be augmented with other standardized measurements that could be used, so there's one standardized definition of obesity if it's going to be a disease.

And the third would be, you know, I think that one of the things that we see in population management of chronic health conditions is a rush to over-medicine, over-treat. And that my concern is that some people will gravitate to this as a disease and be less than likely to engage in lifestyle modification.

And I think that's true not just here but in tons of chronic conditions, whether it's hyper cholesterol or high blood pressure or other things that are risk factors towards diabetes or heart disease, where treating the disease is often counterproductive in terms of treating the lifestyle.

MARTIN: Well, but Dr. Neil, why is that any different from lung cancer, for example. I mean, you can have - lifestyle factors, certainly, can contribute in many cases. Although we all know people who have contracted lung cancer who never smoked a day in their lives. But for a lot of people, it is a risk factor - but you still have to treat disease. So how is this different?

MINKOFF: Well, that's - I mean, I think we're conflating two different things. I think that what your better analogy would be, obesity to smoking, therefore as a risk factor to type-2 diabetes or to coronary disease, as smoking is a risk factor for lung cancer. And there are lots of people who get coronary disease who have little, few - I think something like 40 percent of heart attacks happen in people with very few risk factors. And we know lots of people who develop coronary disease and acute MIs from other problems, which would be some sort of heart rhythm issue or something.

So the - I think the analogy would be to smoking and in that case, while there is an addictive component to smoking, the disease is nicotine addiction and smoking is a behavior. And what I'm not understanding here is the differentiating between the disease and the behavior states that can be part of it.

MARTIN: Let me talk more about some of the comments that we received from social media. Dr. Harris, I'll go back to you. This is one from Carin Nielsen, she's a family practitioner in Petoskey, Michigan. She says I am - I'm quoting here - I'm amazed at how many people come in to my office with obesity, high cholesterol, and pre-diabetes that say to me, how come my doctor never talked to me about this?

So Dr. Harris, you know, what about that? Does - shouldn't doctors be talking to people about this without the designation? Or - what does the designation do that helps open the door to those conversations?

HARRIS: Well, you're right and certainly I believe that doctors have been talking to some degree with their patients and I'm sure this varies among the medical profession. But this has been an epidemic for some time and a worry, and I just believe it will just turn the conversation. Lots of times you have to wait until - or doctors may be talking about, well, obesity is going lead to X, Y, and Z, diabetes, high blood pressure.

Now we can just talk about obesity in and of itself. Again, and it's not in a vacuum, it shouldn't be in a vacuum, but doctors will be able to talk about the weight but also talk about the other issues. And potentially, again, as I said earlier, prevent those issues.

The other thing I want to mention is, it is a multi-factorial condition and so it really is about what goes on in the physician's office. But it also is about what goes on outside the physician's office, looking at those social determinants of health.

So I think what this designation does is raise the level of conversation about this so we can look at what goes on within the patient-physician relationship, as well as what goes on in communities and what communities can do to address this issue.

MARTIN: Well, to that end, Dr. Stratbucker, let me raise this - we got this comment from Mary Phipher (ph), she's a nurse practitioner from Missouri. She works in a family planning clinic. And she, like Dr. Minkoff, is concerned about this whole question of whether it becomes harder to talk about personal responsibility. She says, and I'm quoting here again- I'm quoting her accurately - she says, I give them the, you don't want to be the 40-year-old person in the cripple cart at Walmart, do you? Most say no, but some just give me the drop dead stare.

And her concern is that it makes it harder for people to say, well - for her to press people on their lifestyle questions because then they say, well - she feels it becomes a thing of, well, it's a disease - there's nothing I can do, it's not my responsibility. What do you say to that?

MINKOFF: In general, yeah, I'm going to disagree with that. I think that, you know, to Dr. Harris' comments, I think the onus here - part of the onus here - is on the physician to bring the topic up. I went in to a practice of pediatrics about 12, 13 years ago, and came out of medical school, residency, practice, and hadn't really learned much at all about having this conversation with families and kids, and adults and the parents.

So I think that there's plenty of studies now that show that physicians practicing today don't know how to have the conversation, and part of that gets back to training. We need to train better, we need to get people up to speed on that this is a very treatable disease, that the, you know, it's multi-factorial.

There's a lot of things that the family may have as far as risk factors that help develop this, but it's very treatable. It's not necessarily treatable with surgery and medicine - we treat with a multidisciplinary team where we have a dietitian, and a social worker, an exercise specialist, and a psychologist working on the mental health aspects.

So there's a lot of things that come up and I think that, in general, the resources are there and we need motivated families and patients to take advantage of them, and to be serious about it because it doesn't take the families and patients off the hook either.

MARTIN: Neil - Dr. Neil, can we try another metaphor? Which is - what about...

MINKOFF: It's your show, Michel.

MARTIN: Yeah, let's try it. What about - I'm thinking about substance abuse. Is this a similar factor, like substance abuse where there has been a very long debate in this country around, you know, moral factors, lifestyle factors.

I mean, lots of people still see this as a moral failing, as opposed to - and yet there's a whole body of thought that says, no, this is a disease and addiction is a disease and should be treated as such and though about - remove the moralism from of it. That's a lot more productive.

MINKOFF: Yeah, I mean, I think that's a reasonable metaphor and I think it's a reasonable way of looking at it. I mean, there certainly are genetic or other predispositions to addiction and there certainly - which is also certainly multi-factorial and has a lot to do with family and the community as well. So, I mean, it's something I feel more comfortable with.

I don't think that I was trying to say that obesity was a moral failing, as much as I was concerned about it falling into the trap of other chronic diseases where many patients are happy to try to let the medication do the work for them. And every PCP has a ton of anecdotes about patients who, you know, report to them, well, why should I modify my diet, I'm taking my cholesterol medication and it seems to be working fine.

So I think it's more concern about - we're talking about primary care doctors engaging their patients in a conversation that's inherently difficult to have, that's fraught with a lot of emotional overtones, and it's something that they haven't been trained for. My concern is that the term disease doesn't necessarily answer those questions.

MARTIN: Dr. Stratbucker or Dr. Harris, I want to hear from you with in the time we have left. What do you think should happen now? Dr. Stratbucker, do you want to start, what should happen now?

STRATBUCKER: Well, I think, you know, just like your show, focusing on this, I think is one of the good outcomes of this designation.

I think the fact that there's more conversations going on about how to treat this, where are the resources, what are the - what's the resource going to be like behind this disease, and trying to categorize people into different - into different places where they have - some people do have, you know, need to step up with their motivation and worry about their lifestyle. Other people have significant factors contributing to the development of obesity and excessive weight gain - things like asthma that goes undiagnosed or undertreated.

People who have mental health concerns, things like sexual abuse that happens at an early age and never gets properly treated and ends up being an eating disorder. There's developmental delay in kids and adults, and those people are particularly troubling for their families to tackle, and sometimes they go to using food to control their behavior.

Those types of things we need to find out what's behind this and start to really dig in to the differences within patients who have obesity and I think that's where we're headed. It's not just one type of problem.

MARTIN: Dr. Harris, can I ask you about the question of stigma? Because one of the things that you hear from - first of all, I don't think there's really any question that there's still - there's a lot of stigma attached to being - to having excess weight. I mean, you know, people seem to feel that they can make jokes about people who are large size and the way that they might not - you know, lots of other groups.

Does this help or hurt this question? 'Cause, you know, you also hear patients saying they don't want to go to the doctor to talk about these issues 'cause they don't want to be made to feel worse than they already do. So what do you think? We have about a couple of minutes left.

HARRIS: Yes, in my opinion this can help, and I'm a psychologist by training and it reminds me of years ago when we thought that mental illnesses were moral failures or perhaps even demonic possessions.

And once we were able to understand more and more about the physiological causes of mental disorders, folks are - there's less stigma surrounding mental illness. And that's not a one-for-one analogy and not a perfect analogy. But I think that this has the opportunity to reduce the stigma, have people talk about it, and again, focus on all of the solutions which include the behavioral, the diet and exercise.

But some people will be appropriate for medical treatments and some people will be appropriate for surgical treatment. So it's about, again, having all of the tools in the toolbox. And then we hope that this spurs further research and further conversations in communities.

MARTIN: What kind of research would you like to see?

HARRIS: So I wouldn't mind seeing research about what's the best way to train physicians to talk about this or any new therapies that come on board. The AMA right now is working on our improving health outcomes initiative and we're working with the YMCA and other community partners.

And we didn't even have a chance today to talk about the health disparities. So just as we continue to look at this issue, you know, the more information - knowledge is power, the more we have, the better the health outcomes will be.

MARTIN: Well, thank you all so much for talking about this at these very early stages of conversation. We hope we'll speak again about this very important issue. Dr. Patrice Harris is a member of the board of the American Medical Association. We caught up with her in Fulton County, Georgia. Dr. Neil Minkoff is a medical consultant at Fountainhead HealthCare in Boston. He's a frequent member of our barbershop roundtable. He was with us from member station WGBH, in Boston. Dr. William Stratbucker is a physician who specializes in obesity, particularly with children. He was with us from member station WGVU in Grand Rapids, Michigan. Thank you all so much for speaking with us.

STRATBUCKER: Thanks so much for having me.

HARRIS: Well, thank you.

MINKOFF: Thank you. Transcript provided by NPR, Copyright NPR.