Petitio Principi

The Obesity Society recently commissioned a panel from its members* to write a white paper arguing that obesity should be a disease. Their paper was just published in the June issue of the Society’s journal, Obesity. It offers an indispensable opportunity to test our own logical reasoning and to get a glimpse of their's.

As they wrote: “The panel strongly endorsed the position that there can be no higher authority than reason.” In explaining why they chose to address this issue, they said:

We hope that by providing an answer to the question of whether obesity should be considered a disease — an answer that is based on sound reasoning and represents the collective wisdom of this leading professional society — we may catalyze society at large to come to a consensus view on this point. In turn, we hope that reaching such a consensus may enable efforts to ameliorate the problems of obesity to move forward more effectively.

They said that their panel struggled with the complexities of the issue, not “because of any disagreements about facts regarding obesity, but... the definition of disease.” As they wrote, “there was absolutely no disagreement on the following fundamental points, which we voice loudly and clearly:”

· Obesity is a complex condition with many causal contributors, including genetic ones and many environmental factors that are largely beyond individuals’ abilities to choose or control.

· Obesity causes much suffering.

· Obesity causally leads to many aspects of ill health, to functional impairment and reduced quality of life, to serious disease, and to greater mortality...

· Obese persons are subject to severe societal discrimination...

[By this logic, or course, poverty could be a disease... Black or ethnic minority a disease... Old age a disease... Homosexuality a disease... Ugliness a disease... Low intellect or literacy a disease.]

They argued for the “utilitarian approach” in determining whether something is a disease, rather than the scientific or forensic approaches, saying that:

It seems that conditions that produce adverse health outcomes come to be considered diseases as the result of a social process when it is assessed to be beneficial to the greater good that they be so judged. Such decisions about likely benefit to the greater good are utilitarian judgments that may take empirical input but must also assume certain values... the utilitarian argument in favor of labeling obesity a disease is not that this benefits some small special-interest group such as obesity researchers or treatment providers. Rather, the argument is that the disease label might have broad effects for a large portion of society, for the greater good...

[A] utilitarian argument is not fallacious when it concerns the benefit of courses of action as opposed to the truth of propositions. For this reason the utilitarian argument can address the question “should obesity be declared a disease?” as opposed to “is obesity a disease?”

In other words, this isn’t about scientific truth, but a social label purportedly for the good of society. In making their case, they addressed three main objections to declaring obesity a disease, repeatedly applying circular reasoning that worked from the belief that obesity is a disease, and using the very myths of obesity that they themselves promote.

· Viewing obesity as a disease, they said, might lessen condemnation of fat people for having 'unhealthy' lifestyles and being unable to maintain a ‘normal’ weight. A disease label would bring in the genetic, behavioral and environmental influences that show they can’t help themselves. “On the other hand, labeling obesity a disease may further stigmatize some...who would now be marked as having a disease whose existence is visually detectable.” The panel rejected these concerns, however, saying it “does not seem a good justification for refraining from categorizing obesity as a disease.”

· Viewing obesity as a disease, they said, might also be used as an excuse for individuals to stop trying to manage their weight. While some were concerned about this possibility, the panel believed that increasing the perception of obesity as a disease that results in premature death, sickness and disability would result in people taking their weight more seriously and more aggressively work to lose weight.

· Viewing obesity as a disease, rather than a risk factor, they said, “is more problematic.” [For whom, they didn’t say.] “This view is well supported by numerous association and observational studies and backed, in many but not all cases, by probable mechanisms of action.” But calling it a disease, they argued, is a matter of emphasis. Risk factors can include lots of things that might increase the chance of developing a disease, they said, but “diseases receive substantially more research funding than risk factors. Treatment of diseases is more often covered by health insurance than is the amelioration of risk factors... Risk factors are assigned to preventive healthcare, which historically receives fewer resources than disease treatment.”

Because they believe that fatness causes such suffering and is so horrible, increasing resources to alleviate obesity the thing to do “because we care about the welfare and health of all people.”

The went on the describe the effects of an official obesity disease declaration. While they had claimed this wasn’t about benefiting special interests, it's difficult to conclude anything different from the evidence they presented.

Childhood obesity polices. It would have a positive effect on supporting programs promoting “active lifestyles and healthy eating” to prevent childhood obesity, they said. “It is even possible that it might give such programs greater urgency.”

Employer wellness programs. They acknowledged that a disease declaration could require employers to offer obesity treatments, including medications and surgical procedures, which would ultimately increase costs for employers and some might raise insurance premiums or be increasingly less likely to hire fat people. But, they said, legislation to prevent weight discrimination could get around this obstacle and make it illegal to tie incentives to weight or BMI. It could also enable obesity treatments to be protected and on a level playing field with other aspects of corporate wellness programs, they said. “On balance, the panel felt that the greater urgency conveyed by the disease label and the prevention programs that this might spur would substantially outweigh any detrimental effects on the implementation of such programs.”

Treatment. Categorization of obesity as a disease by the federal government and the medical establishment could have profound effects on treatment. It would ensure that the costs of medical obesity treatment and drugs for obesity-related conditions would be covered by government programs and private insurance, they said. This would mean “more physicians would be likely to engage patients in treatment protocols. The FDA would come under more pressure to approve obesity drugs, and physicians would be more likely to use obesity drugs in treatment.” The FDA would also alter its approval process to give less importance to metabolic biomarkers and more to the loss of fat cells themselves and, they claimed, the harmful substances they secrete.

Medical education. If obesity is declared a disease, the panel wrote, medical education would give greater attention to it and “medical treatment options, especially drug treatment, likely would become more aggressive. Medical treatment and obesity surgery would be given more attention by physicians, health administrators, insurance companies, and employers...”

Insurance coverage. As a disease, it is likely that insurers would feel greater pressure to remove the exclusion of obesity in their coverages, the panel wrote. While it could raise premiums for fat people and limitations on coverage as having pre-existing conditions, “it is difficult to see a negative effect [for their Society stakeholders] in terms of health insurance reimbursement.”

Weight loss market. While the definition of ‘obesity’ to date has been a BMI of 30 or greater to distinguish it from overweight, if obesity is declared a disease, it “might be used to persuade the FDA to change its definition of obesity or to expand the current definition using a BMI with a lower cutoff.”

“Credibility of obesity field and experts.” The panel claimed that “obesity deconstructionists” offer two main arguments: that the ill effects have been exaggerated and that those behind obesity disease mongering have financial conflicts of interest. “Because of this, we believe it is important that obesity experts not cloak their utilitarian views on obesity as a disease as purely objective scientific determinations because doing so is disingenuous and likely to increase mistrust.” [Did you follow that and what they just admitted??] They went on to say that if obesity was officially declared a disease, the net effect would be positive because it would be taken more seriously and legitimately as a field and “result in an increase in practitioners willing to engage in obesity treatment and in a greater trust of those practitioners.” The “net effect on the credibility of obesity experts and practitioners,” they said, “is likely to be positive.”

Just before their conclusion, they added a proviso about their use of the utilitarian argument. Utilities change over time, they said, as new information becomes available and cultural values shift. As they exampled, homosexuality was once seen as a disease, but isn’t any more. Therefore, they said, “we must act on the utilities before us today” and take advantage of them, while being alert to the fact that public perceptions change and of the need “to modify our acts in the future.” The utilitarian approach is also highly subjective, they said. “There is no denying that there is subjectivity in values that in turn leads to subjectivity in utilities,” they wrote. So they couldn’t prove their value stance. They also “fully acknowledged” that there might be negative effects of their actions, but said this only implied the need to monitor, “not that we should not take action in the absence of perfect knowledge.”

“Because there are few data and precedents, we must enter these waters with humility about to our ability to forecast the future,” thus, they said:

The panel concluded that considering obesity a disease is likely to have far more positive than negative consequences and to benefit the greater good by soliciting more resources into prevention, treatment, and research of obesity; encouraging more high-quality caring professionals to view treating the obese patient as a vocation worthy of effort and respect; and reducing the stigma and discrimination heaped on many obese persons. Thus, although one cannot scientifically prove either that obesity is a disease or that it is not a disease, a utilitarian approach supports the position that obesity should be declared a disease.

No, you are not going crazy. That was every bit as surreal and illogical as as it seemed. A scientific, evidence-based approach towards health would have reached a very different conclusion.

*The authors made a full disclosure, writing:

The Obesity Society and members of the writing group have accepted funds from multiple food, pharmaceutical, and other companies with interests in obesity.