Is Obesity a Disease?
Background:
The United States is the second most obese industrialized country in the world. [52]A 2013 report stated that 31.8% of
Americans were obese, compared to 14% in the mid-1970s. [54] [52] Obesity accounts for 10% of deaths and healthcare
spending in the United States. [2]
Proponents contend that obesity is a disease because it meets the definition of disease; it decreases life expectancy and
impairs the normal functioning of the body; and it can be caused by genetic factors.
Opponents contend that obesity is not a disease because it is a preventable risk factor for other diseases; is the result of
eating too much; and is caused by exercising too little.
How Obesity Is Measured
People are usually identified as obese, which is defined as "having an excessive amount of body fat,” based on their Body
Mass Index (BMI). [14] BMI is calculated by taking a person's weight divided by the square of his or her height (kg/m2).
The "normal" BMI range is between 18.5 and 24.9, while "overweight” is 25-29.9 and "obese” is 30 and above. For
example, a person who is 5'5" tall and 180 lbs. (BMI of 30) and a person who is 6'0" tall and 221 lbs. (BMI of 30) are
considered obese by the BMI measurement. Some people, such as muscle-heavy athletes, may have "overweight” or
"obese” BMIs but may not have excess body fat. [1]
Obesity as an "Epidemic”
The Centers for Disease Control and Prevention (CDC) reported an "epidemic" of 72 million obese people in the United
States in 2005-2006 [21] According to a 2011-2012 study published in JAMA, 34.9% of American adults and 17% of youth
are obese. [13]The study indicated there were no significant changes in obesity rates from 2003-2004 to 20112012. [13] According to the CDC, "Non-Hispanic blacks have the highest age-adjusted rates of obesity (47.8%) followed by
Hispanics (42.5%), non-Hispanic whites (32.6%), and non-Hispanic Asians (10.8%).”[12] Obesity is highest in adults who
are 40-59 years old (39.5%). [12]
In the mid-1970s the obesity rate for the United States was about 14%. [54] 1994 is the first year with CDC data for all
states and shows all states at obesity rates of 19% or lower. [12] By 1997, three states were in the 20-24% range: Indiana,
Kentucky, and Missouri.[12] In 2001, Missouri became the first state to have an obesity rate between 25-29%. [12] By 2005,
14 states were in the 25-29% range while three states breached the 30% and higher rate (Louisiana, Missouri, and West
Virginia). [12] By 2010, no state reported an obesity rate under 19%. [12]
Obesity rates continued to increase in the United States each year since 2008, growing from 25.5% in 2008 to 27.1% in
2013. [32] 11 states had obesity rates over 30% in 2013: Alaska (30.1%), Arkansas (32.3%), Delaware (34.3%), Kentucky
(30.6%), Louisiana (32.7%), Mississippi (35.4%), Ohio (30.9%), Oklahoma (30.5%), South Carolina (31.4%), Tennessee
(31.3%), and West Virginia (34.4%).[32] Montana had the lowest obesity rate at 19.6%. [32] The poll data show that the 10
most obese states had the highest rates of high blood pressure (35.8%), high cholesterol (28.2%), depression (20.7%),
diabetes (14.3%), cancer (7.8%), and heart attacks (5.0%). [32] The data also show that the 10 least obese states reported
higher rates of healthy eating, eating five or more servings of fruits and vegetables at least four days a week, and
exercising for 30 minutes or more on at least three days a week. [32]
A 2009 study published in PLOS Medicine found obesity was the cause of 1 in 10 deaths in the United States. [2]Obesity
was the third-leading cause of death in men and women, after high blood pressure and smoking. [2] Obesity and obesityrelated health conditions cost an estimated 10% of annual medical spending in the United States, totaling $147 billion in
2008. [22]
The United Nations’ "The State of Food and Agriculture 2013” report found that Mexico was the most obese populous
country with 32.8% of Mexicans falling into the obese category compared to 31.8% of Americans in the second-place
United States. [51] [52] The Republic of Nauru had the highest obesity percentage (71.1%) but, with a population of 9,488 in
July 2014, was not considered a "populous country” by the study. [52] [53]
According to the World Health Organization (WHO) 2013 Fact Sheet "Obesity and Overweight,” obesity rates worldwide
have almost doubled since 1980, accounting for over 200 million men and almost 300 million women. [11] Combined,
overweight and obesity cause at least 2.8 million deaths annually and are the fifth leading risk for death globally. [11] 65%
of the global population lives in countries where being overweight or obese causes more deaths than being underweight,
making 2012 the first time overweight and obesity caused more deaths than malnutrition. [11]
Obesity and obesity-related health conditions cost almost ten percent of annual medical spending in the United States,
totaling $147 billion in 2008. [22] In Apr. 2014 Duke Global Health Institute and Duke-NUS Graduate Medical School
researchers found the lifetime medical costs for obese 10-year-olds alone will be $14 billion. [51]
Public Opinion and Medical Perspectives on Obesity
The FDA, the American Medical Association (AMA), the National Institutes of Health (NIH), American Heart Association,
American College of Cardiology, and the Obesity Society have stated that obesity is a disease. [27] [10] [47] The WHO
called obesity a "chronic disease" in 2000. [29] The IRS announced a policy in 2002 stating that "obesity is medically
accepted to be a disease in its own right" and allows Americans who are medically diagnosed as obese to claim tax
deductions for doctor prescribed treatments.[20] In Sep. 1998 the National Institutes of Health's National Heart, Lung, and
Blood Institute wrote, "Obesity is a complex multifactorial chronic disease." [28] The American College of
Gastroenterology, in 2008, stated that obesity is a "chronic, debilitating and potentially fatal disease." [30] In 2013 the
American Academy of Family Physicians (AAFP) stated, "Overweight and obesity are chronic diseases with behavioral
origins that can be traced back to childhood.”[8]
In the health care bill H.R. 3962, "Affordable Health Care for America Act” approved by the House of Representatives on
Oct. 29, 2009 (but later abandoned in favor of the Patient Protection and Affordable Care Act; also called the PPACA or
Obamacare), being overweight or obese was not classified as a disease but as a "behavioral risk factor" along with
alcohol and drug use, tobacco, poor nutrition, physical inactivity, untreated mental health problems, and risky sexual
behavior. [25]
The American Academy of Pediatrics (AAP), American College of Physicians (ACP), Centers for Medicare and Medicaid
Services (CMS), and American Nurses Association (ANA) do not have policy statements stating whether or not obesity is
a disease, as of Apr. 18, 2014.
PRO / CON Reasons:
PRO Reasons
1.
Obesity meets the definition of disease. The American Medical Association's 2013 "Council on
Science and Public Health Report" identified three criteria to define disease: 1. "an impairment of the normal
functioning of some aspect of the body;" 2. "characteristic signs and symptoms;" and 3. "harm or
morbidity." [19] Obesity causes impairment, has characteristic signs and symptoms, and increases harm and
morbidity. Scott Kahan, MD, MPH, Director of the National Center for Weight and Wellsness and Preventative
Medicine Physician at Johns Hopkins University, stated obesity "satisfies all the definitions and criteria of what a
disease and medical condition is... The one difference is that people who have obesity have to wear their disease
on the outside." [26]
2.
Obesity, like other diseases, impairs the normal functioning of the body. People who are
obese have excess adipose (or fat) tissue that causes the overproduction of leptin (a molecule that regulates food
intake and energy expenditure) and other food intake and energy mediators in the body, which leads to abnormal
regulation of food intake and energy expenditure. [35] Obesity can impair normal mobility and range of motion in
knees and hips, and obese patients make up 33% of all joint replacement operations. [48]Obesity is also linked to
reproductive impairment, contributing to sexual dysfunction in both sexes, infertility and risk of miscarriage in
women, and lower sperm counts in men. [48]
3.
Obesity decreases a person's life expectancy and can cause death, like other
diseases. Obesity in adults can lead to three years' loss of life. Extreme obesity can shorten a person's life
span by 10 years. [4] The Surgeon General reports an estimated 300,000 deaths per year may be attributed to
obesity. [36] People who are obese have a 50-100% increased risk of death from all causes. [36]
4.
Obesity can be a genetic disorder such as sickle-cell anemia and Tay-Sachs, which are
classified as diseases. Studies have shown that obesity can be inherited like height. [5] [6] Genetic
disposition plays a large role in determining if a person will be obese. [5] [6] A May 2014 study published in
theJournal of Molecular Psychology linked higher rates of obesity to the "fat mass and obesity association" (FTO)
gene. [56] The FTO gene reportedly lowers activity in the part of the brain that "controls impulses and the response
to the taste and texture of food," so people with the gene are more likely to eat more fatty foods and eat more
impulsively as they age. [56] A 1990 study published in the New England Journal of Medicine on body mass in
twins not raised in the same home concluded, "genetic influences on body-mass index are substantial, whereas
the childhood environment has little or no influence." [38] In addition to genetic predisposition, almost 10% of
morbidly obese people have defects in the genes that regulate food intake, metabolism, and weight. [37]
5.
Government entities and major medical groups recognize obesity as a disease. The Food
and Drug Administration (FDA), the American Heart Association, the American College of Cardiology, and the
Obesity Society, the National Heart, Lung, and Blood Institute (NHLBI), and the American College of
Gastroenterology (ACG) have identified obesity as a disease. [50] [46] [47] Even the Internal Revenue Service (IRS)
recognizes obesity as a disease so weight loss expenses may be counted as a medical deduction from
taxes. [49] On June 18, 2013, the American Medical Association recognized obesity as "a disease requiring a
range of medical interventions to advance obesity treatment and prevention." [39]
6.
Physicians from as early as the 17th century have referenced obesity as a
disease. English physician Thomas Sydenham (1624-1689) wrote, "Corpulency [obesity] may be ranked
amongst the diseases arising from original imperfections in the functions of some of the organs." [9] William Wadd,
a 19th century British surgeon and medical author, wrote, "when in excess--amounting to what may be termed
OBESITY--[fat] is not only in itself a disease, but may be the cause of many fatal effects, particularly in acute
disorders." [9] In the Feb. 12, 1825 issue of The Medical Advisor and Guide to Health and Long Life, Robert
Thomas, a 19th century doctor, wrote "Corpulence, when it arrives at a certain height, becomes an absolute
disease." [34]
CON Reasons
1.
Obesity is a preventable risk factor for other diseases and conditions, and is not a
disease itself. Like smoking is a preventable risk factor for lung cancer and drinking is a preventable risk
factor for alcoholism, obesity is a preventable risk factor for coronary heart disease, stroke, high blood pressure,
type 2 diabetes, cancers (like endometrial, breast, and colon), high cholesterol, high levels of triglycerides, liver
and gallbladder disease, incontinence, increased surgical risk, sleep apnea, respiratory problems (like asthma),
osteoarthritis, infertility and other reproductive complications, complications during pregnancy and birth defects,
and mental health conditions. [42] [36] Women who gain 20 pounds or more between age 20 and midlife double
their risk of postmenopausal breast cancer. [36]For every 2 pound weight increase, the risk of developing arthritis
rises 9-13%. [36]
2.
Obesity is a side effect, not a disease.Obesity can be caused by hypothyroidism, Cushing's syndrome,
Prader-Willi syndrome, polycystic ovary syndrome, arthritis, increased insulin levels (from carbohydrate-heavy
diets or diabetes treatments) and depression. [17] [55] Certain drugs like antidepressants, anti-seizure medications,
diabetes medications, anti-psychotic medications, antihistamines, anticonvulsants, steroids, beta blockers, and
contraceptives can cause obesity. [17] [16] Obesity can also be caused by lack of sleep (or sleep debt), ingesting
endocrine disrupters (such as BPA, DDT, and phthalates), consuming high-fructose corn syrup, a lack of
temperature variation (due to air conditioners and heaters), and quitting smoking. [16] [15]
3.
Many obese people live long, healthy lives.A 2013 Lancet article noted that as many as one third of
obese people are "healthy obese," meaning that despite being significantly overweight they have normal
cholesterol and blood pressure levels, and no sign of diabetes. [41] Obese people tend to go to the doctor more
and have regular checks for other risk factors and diseases. [40] Many people with a BMI (Body Mass Index; a
measure of body fat based on height and weight) in the obesity range are not physically impaired and live normal
lives. BMI does not take into account the overall health of the individual and can identify fit, muscular people as
obese because muscle weighs more than fat. [40] [41]
4.
Obesity is the result of eating too much. The suggested daily caloric intake for 31-50-year-olds is
1,800 calories for women and 2,200 calories for men. [7]In 2009-2010, 30-39-year-old women consumed an
average 1,831 calories (which is 1.7% over the recommendation) while men of the same age consumed an
average 2,736 calories per day (which is 22% over the recommendation). [3] The average American restaurant
meal portion size is four times as large as portions in the 1950s and 96% of entrees at chain restaurants exceed
dietary guidelines for fat, sodium, and saturated fat, with some almost exceeding daily intakes in one meal. [44]
[45] The body is doing what it has evolved to do by converting excess calories into fat cells. The CDC
recommends reducing consumption of sugar drinks (like sodas) and high-energy-dense foods to prevent and
reduce obesity. [42] The Mayo Clinic states, "Having a diet that's high in calories, eating fast food, skipping
breakfast, eating most of your calories at night, drinking high-calorie beverages and eating oversized portions all
contribute to weight gain." [43]
5.
Obesity is the result of sedentary lifestyles.Compared to 40 years ago, people today spend more
time commuting, sitting in front of a computer, watching television, playing video games, and generally exercising
less. [10] In 1960 50% of jobs required moderate physical activity compared to just 20% of jobs in 2011; the other
80% in 2011 required little or no physical activity. [18]This shift represents 120-140 fewer calories burned per day,
which closely aligns with the nation's overall weight gain trends. [18] Men expended 142 fewer calories daily and
weighed 32.8 pounds more in 2003-2006 than in 1960-1962, while women expended 124 fewer calories daily and
weighed 25.13 pounds more in 2003-2006 than in 1960-1962. [18]
RESEARCH
PROS:
SOURCE 1
Pamela M. Peeke, MD, MPH, FACP, President of the Peeke Performance Center for Healthy Living and Clinical Assistant
Professor of Medicine at the University of Maryland, in a June 2013 statement to a Prevention Magazine article titled "Is
Obesity a Disease? PreventionExperts Weigh In," available at www.prevention.com
"Does obesity fit the strict definition of a disease? According to Mosby's Dictionary of Medicine, Nursing, & Health
Professions, a disease is: 1. a condition of abnormal vital function involving any structure, part, or system of an organism;
2. a specific illness or disorder characterized by a recognizable set of signs and symptoms attributable to heredity,
infection, diet, or environment. Answer? It fits.
Moreover, as a physician who, like my medical brethren, has had to resort to creative diagnostic coding to work with
people in the field of weight management, I'm hoping that now, with a disease designation, these people will be able to
have insurance to help defer some of the costs associated with obesity. This is particularly true of those who, on paper
and exam, do not yet have the metabolic syndrome, but are clearly obese and seeking help.
Further, it is important that the medical community as well as the public and insurers drop their stereotypic perceptions of
those who are obese, and elevate the obese condition to that of other disease conditions along with respect for those who
are suffering."
June 2013 - Pamela M. Peeke, MD, MPH, FACP
SOURCE 2
The American Medical Association (AMA) in a May 16, 2013 policy change, available at www.ama-assn.org
"Whereas, Our American Medical Association's Council on Science and Public Health Report 4, A-05, has identified the
following common criteria in defining a disease: 1) an impairment of the normal functioning of some aspect of the body; 2)
characteristic signs or symptoms; and 3) harm or morbidity...
RESOLVED, That our American Medical Association recognize obesity as a disease state with multiple
pathophysiological aspects requiring a range of interventions to advance obesity treatment and prevention."
May 16, 2013 - American Medical Association (AMA)
SOURCE 3
Tasneem "Taz" Bhatia, MD, CEO, Medical Director and Founder of the Atlanta Center for Holistic and
Integrative Medicine, in a June 2013 statement to a Prevention Magazine article titled "Is Obesity a
Disease? PreventionExperts Weigh In," available at www.prevention.com
"Obesity, like alcoholism, depression, and anxiety, is a disease. There are definite medical patterns:
hormone imbalances, neurotransmitter deficiencies and nutritional exhaustion that all contribute to
obesity. Many of my patients that are obese have underlying medical issues that need to be
addressed.
I agree that there are behavior patterns that contribute to obesity, but these same behavior patterns
are rooted in other biological factors. Stress, the standard American diet and the industrialization of
food have all been blamed in the obesity epidemic. While all of these factors contribute to being
obese, they also create critical biological imbalances that people cannot overcome, or do not have
the tools or knowledge to understand how to change.
Diets and exercise regimens often fail simply because the underlying medical pathology has not been
addressed. My approach is to evaluate a patient fully, including family history, exhaustive hormone
evaluation, nutrient status, and life inventory to understand where to begin in treating this disease.
There is no quick weight loss for the obese."
June 2013 - Tasneem "Taz" Bhatia, MD
SOURCE 4
The American Obesity Association (AOA), now known as The Obesity Society (TOS), provided on the
AOA's "Obesity Is a Chronic Disease" page (accessed Jan. 8, 2010):
"The American Obesity Association (AOA) believes that obesity is a disease. We want obesity
understood by the health care community and patients as a serious disease of epidemic proportions.
First, let's define our terms. Dictionaries agree: obesity is excess body fat. It is not defined as a
behavior. However, many people use the term obesity as short-hand for overeating or lack of
exercise. But that is not its definition.
Consider this: most people can distinguish between smoking and lung cancer. One is a behavior and
one is a disease. Or problem drinking of alcohol and liver disease. One is a behavior and one is a
disease. Sunbathing without protection is a behavior; skin cancer is a disease.
Second, obesity - the excess accumulation of body fat - fits all the definitions of 'disease.' How is
'disease' defined? Most dictionaries, general as well as medical, define a disease as an interruption,
cessation or disorder of a bodily function, organ or system. Obesity certainly fits this definition."
Jan. 8, 2010 - American Obesity Association (AOA)
SOURCE 5
José F. Caro, MD, Vice President of Global Diabetes Care at Eli Lilly, wrote in his McGraw-Hill's
AccessScience Encyclopedia of Science & Technology article "Obesity Pathophysiology" (accessed
Jan. 13, 2010):
"[O]besity is one of the most frequent and serious metabolic diseases. Furthermore, strategies for
long-term reduction of body weight are largely ineffective. More than 90% of people who lose weight
eventually regain it.
[H]uman obesity belongs to a large group called complex diseases. Included in this group are type II
diabetes, hypertension, and ischemic heart diseases (characterized by deficient supply of blood to
cardiac muscle). The inheritance of these diseases is different from the classic mendelian mode of
transmission of monogenic diseases (related to or controlled by one gene). The phenotype of
complex diseases reflects the multifactorial effect of all contributing genes (polygenic) and all
environmental factors."
Jan. 13, 2010 - José F. Caro, MD
CONS:
SOURCE 1
David L. Katz, MD, MPH, FACPM, FACP, Founding Director of the Yale Prevention Research Center at the Yale
University School of Medicine and Editor-in-Chief ofChildhood Obesity, in an Apr. 22, 2014 interview with Yale Daily
News, "Obesity 'Disease' Discourages Prevention, Katz Argues," available at www.yaledailynews.com
"I often compare obesity to drowning. Would we consider it a disease if a person were drowning? When someone is
drowning, it's not a problem with their body: Humans cannot be in the water for an arbitrary amount of time, so the
problem is a mismatch between the body and the body's environment.
I think drowning and obesity share many important characteristics. Both are about an interaction between a perfectly
healthy body and the challenge of an environment in which they are maladapted. In both cases, you're exposed to
something that's initially a good thing, but you're exposed to too much of it for too long. In the case of water, you need it,
but too much of it for too long and you drown. In the case of food, if you eat too much of it for too long, then you get fat.
In both cases, absolutely everybody is vulnerable, but people are vulnerable to varying degrees. If we're put underwater,
eventually all of us will drown, but some of us are able to hold our breath longer than others. I think that's true about
obesity: About 80 percent of the adult population of the United States is either overweight or obese. That indicates that
essentially, we're all vulnerable, but we're not all vulnerable to the same degree.”
Apr. 22, 2014 - David L. Katz, MD, MPH, FACPM, FACP
SOURCE 2
Keith Ablow, MD, psychiatrist, in a June 20, 2013 article, "Dr. Keith Ablow: Obesity Is Not a Disease and Neither Is Alcoholism," available at www.foxnews.com
"The American Medical Association (AMA) has decided to classify obesity as a disease. This decision
is another example of inventing illnesses - a favorite pastime of the American Psychiatric Association
(APA) - and another step towards eroding people's autonomy and making them passive participants
in their health. It is also an example of how the medical establishment is laying the groundwork to bill
Medicare and Medicaid for every bad choice anyone makes, ever.
With the exception of when obesity is caused by a known pathology, such as hypothyroidism (which,
while making weight loss more difficult, would certainly not completely prevent it), it is largely caused
by poor decisions—like binging on food or eating lots of candy, ice cream or Cheetos...
Last time I checked, there was no known gene that would make people veer off into the McDonald's
drive-through lane or direct them to choose whole milk over 1 percent milk. No known gene can
make you raid the refrigerator at midnight. No known gene can make you drive past six gyms on your
way to work and stop at none of them…
The AMA, in classifying obesity as a disease, furthers the dependency, disempowerment and
entitlement culture that is eroding scientific truth and personal autonomy in America."
June 20, 2013 - Keith Ablow, MD
SOURCE 3
Richard B. Gunderman, MD, PhD, Professor of Radiology, Pediatrics, Medical Evaluation,
Philosophy, Liberal Arts, and Philanthropy, and Vice Chair of Radiology at Indiana University, in a
June 24, 2013 Atlantic article, "Is Obesity Really a Disease?," available at www.theatlantic.com
"When we meet obese people, should we cast them a knowing glance of concern and ask how they
are doing? Should we send flowers and 'get well soon' cards to obese family members and friends?...
If obesity truly is a disease, then over 78 million adults and 12 million children in America just
got classified as sick... Everyone has friends and acquaintances who now qualify as diseased.
Yet many sensible people, from physicians to philosophers, know that declaring obesity a disease is
a mistake. Simply put, obesity is not a disease. To be sure, it is a risk factor for some diseases. But it
would be as false to say that everyone who is obese is sick as to say that every normal-weight person
is well."
June 24, 2013 - Richard B. Gunderman, MD, PhD
SOURCE 4
Max Pemberton, MD, Psychiatrist in the National Health Service (NHS) and Journalist, in an Oct. 12,
2013 Spectatorarticle, "Obesity Is Not a Disease," available at www.spectator.co.uk
"Doctors should be required to tell patients a blunt truth: if you're fat, eat less, exercise more, or both.
And if you keep guzzling the tasty treats, you will die earlier. It's not a disease, it's a mindset — and
that means it can be changed. We doctors need to be a little less understanding, a little more
judgmental, and realise [sic] that our oath — 'do no harm' — must come before our desire to save the
feelings of our patients. The truth can be the hardest drug to administer."
Oct. 12, 2013 - Max Pemberton, MD
SOURCE 5
Andrew Weil, MD, Director of the Arizona Center for Integrative Medicine at the University of Arizona,
in a June 2013 statement to a Prevention Magazine article titled "Is Obesity a
Disease? Prevention Experts Weigh In," available at www.prevention.com
"I do not consider obesity a disease. It is a condition, which may be associated with increased risk of
certain diseases. It is possible to be obese and healthy, if one eats a balanced diet, gets regular
physical activity, attends to other aspects of lifestyle that influence health, and makes use of
appropriate preventive medical services."
June 2013 - Andrew Weil, MD