Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Tuesday, June 23, 2009

Obesity is NOT a Disease

I've had enough!! It's time for another lesson in basic terminology. Words like "disease," "risk factor" and "epidemic" mean specific things, not just whatever someone happens to want them to mean at any given moment. Pronouncements from government and even from organized medicine about the "obesity epidemic" are meaningless. Let me tell you why.

Obesity is a risk factor for diabetes, high blood pressure, and a host of other medical conditions.

Now listen up, because I'm only going to scream at the top of my lungs until the blood vessels in my eyes burst say this once:
HAVING A RISK FACTOR FOR A CONDITION
IS NOT THE SAME
AS HAVING THE CONDITION.
Really. It's not. A family history of colon cancer is not the same as colon cancer. Smoking isn't the same as chronic lung disease. Alcoholism isn't the same as cirrhosis of the liver. A blistering sunburn isn't the same as skin cancer. And obesity is NOT THE SAME as having diabetes and high blood pressure.

In fact, obesity is different from all the other risk factors above, in that all "obesity", defined as a body mass index over 30, is so not created equal.

Here's what I tell my patients:
  1. If your blood pressure is normal, and
  2. If your cholesterol is normal, and
  3. If your blood sugar is normal, and
  4. If you don't smoke, and
  5. If you are active (defined as 30 minutes daily of walking too fast to talk), then
I DON'T CARE WHAT YOU WEIGH.

As it happens, it's actually pretty tough to be really morbidly obese and have all the above points apply to you. Then again, look at Sumo wrestlers. Still, if you don't actually have any of the conditions for which obesity puts you at risk, AND if you continue to get monitored for those conditions on a regular basis, what's the big deal? Answer: it isn't.

So for everyone who wants to charge for health insurance on a BMI sliding scale, get your head out of your ass and start looking at what really matters: the presence of actual medical conditions like diabetes, hypertension, and so forth. Metabolic syndrome? Osteoarthritis of the knees? Weight loss is absolutely the treatment of choice; no argument there. But quit blaming every complaint on someone's weight if the BMI happens to be over 30.

From the standpoint of public health policy, absolutely encourage walking and exercise, a varied, healthful diet low in processed foods and high in fruits, vegetables and whole grains, and discourage smoking. But quit wasting time and resources railing against the "obesity epidemic", a meaningless term that detracts from real medical issues.

26 Comments:

At Tue Jun 23, 10:47:00 AM, Blogger AnneBethMN said...

standing ovation in MN

 
At Tue Jun 23, 11:00:00 AM, Blogger Rogue Medic said...

Now, what are we going to do about this epidemic of logical analysis?

Proponents of populist prevention plans might choke on their breakfast upon reading your words. The death toll due to this epidemic of logical analysis is potentially huge.

Your writing needs to be quarantined. This isn't censorship, it's for the health of the political machine.

 
At Tue Jun 23, 11:05:00 AM, Anonymous Cheryl Fuller, Ph.D. said...

THANK YOU!!!!

I have been watching the Senate Health Committee mark-up on the health care bill and screaming at the television over this kind of madness. Harkin was especially egregious about it today.

Oh, and it's poor people who need these prevention programs because you know, they are just too ignorant to take good care of themselves.

 
At Tue Jun 23, 12:45:00 PM, Blogger Beach Bum said...

BMI is such a blunt instrument. According to BMI, I am overweight. But I am absolutlely NOT overweight. Body composition is important. Great post!

 
At Tue Jun 23, 12:46:00 PM, Blogger HugeMD said...

Bravo. I'm proof-positive you can get down to just regular-old morbidly obese from super morbidly obese and meet your criteria! Not that I wouldn't like to drop a few more pounds.

Actually, I'm going to drop about 160 real quick once I get a right lawyer, but that's another issue... Sorry, kind of bitter at the moment and couldn't resist. Thought about deleting it, but then figured what the hell. At least I decided against rubbing poison ivy in all his underwear...

 
At Tue Jun 23, 12:51:00 PM, Blogger #1 Dinosaur said...

HugeMD: Been there, done that. Email me if you want to talk.

 
At Tue Jun 23, 02:15:00 PM, Anonymous Anonymous said...

Oh Dr. D, how I wish you were my PCP...
whoops, didn't mean to rhyme, but there ya go...

 
At Tue Jun 23, 02:23:00 PM, Blogger Virginia Doc said...

Your logic doesn't quite flow. Diseases can also be risk factors for disease. Rheumatoid arthritis is a risk factor for heart disease. Cirrhosis is a risk factor for cancer. And your suggestion that alcoholism is not a disease because it is not the same as cirrhosis is a bit scary, coming from a primary care physician and all. Alcoholism is most certainly a disease. Most alcoholics do not die from cirrhosis. They die behind the wheel, or from suicide, or pneumonia, etc.

In other words, do you tell your patients that if they don't drive drunk, aren't suicidal, rarely fall down, and don't beat their spouse, you don't care how much they drink?

I'm a bit worried...

 
At Tue Jun 23, 02:57:00 PM, Blogger Rogue Medic said...

Virginia Doc,

The post was making comment about the obesity as a disease meme.

The post did not say that this is the way to counsel alcoholics, nor did it suggest that. You have taken an analogy and substituted the analogy for the substance. This can be fun with synecdoche, but it is not anything more than that. The analogy may not work in all cases, but that does not mean that the argument is false.

Should I be worried about you teaching your patients faulty logic?

 
At Tue Jun 23, 03:02:00 PM, Blogger #1 Dinosaur said...

No, Virginia, I never said alcoholism wasn't a disease; I just said it wasn't the same as cirrhosis.

Diseases can cetainly be risk factors for other diseases, but not all risk factors are diseases themselves.

Actually, what I said was that HAVING the risk factor was not the same as HAVING the disease. Thus the treatment for alcoholism is not the same as the treatment for cirrhosis (well, aside from not drinking), the treatment for sunburn isn't the same as the treatment for skin cancer, etc. Sometimes that works to our disadvantage in trying to modify those risk factors. Not every smoker gets lung cancer, as they enjoy pointing out to us with such glee.

All I'm talking about in this post is obesity, and that is entirely possible to be "obese" (objectively, per BMI) and be completely healthy. I mean to imply no more and no less.

 
At Tue Jun 23, 03:03:00 PM, Blogger Virginia Doc said...

Rogue Medic,
Dino gave no argument _except_ his analogies. So if the analogies do not hold up, how is the argument to hold up?
As for teaching my patients, I aim to eliminate risk factors _and_ disease. Obesity is a disease, like it or not: the adverse metabolic effects are present even if they are not (yet) manifested in more recognizable things such as HTN, DM, etc. To tell people you are not worried about something as significant as their obesity is, to use an analogy, a lot like saying you are not worried about their high-functioning alcoholism or their smoking because their BP and lungs are (so far) just fine.

 
At Tue Jun 23, 03:07:00 PM, Blogger Virginia Doc said...

@ #1 Dinosaur,

I would argue it is not possible to be obese and be perfectly healthy. Of course, obesity affects each individual differently, but obesity has deleterious metabolic effects in everybody, to some degree or another. Not all of these are recognized, and not all manifest in outright metabolic syndrome or frank T2DM, but they are there nonetheless.

I agree with you that BMI is hardly a be-all-end-all that it is made out to be. But I think it is a bit reckless to tell a patient you don't care what they weigh--even if their other risk factors are in check.

 
At Tue Jun 23, 03:16:00 PM, Blogger #1 Dinosaur said...

Dear Virginia,

I beg to differ. I submit that our understanding of metabolism is incomplete, and that applying your rubric to all individuals with a BMI over 30 (a very blunt instrument indeed, as pointed out above, but it's the most commonly utilized measure) will result in a great deal of wasted time and resources.

When the BP, A1c, and LDL cholesterol are all normal in an active, non-smoking patient with no family history of diabetes, hypertension or heart disease, that patient is healthy. Granted he or she is also very unlikely to be morbidly obese, so perhaps we can find some middle ground simply by redefining what BMI levels we should be talking about.

 
At Tue Jun 23, 07:11:00 PM, Anonymous Paul OFlaherty said...

Thank you, thank you, thank you! I've been ranting about this myself for years. Great to hear someone else say it in public :)

 
At Tue Jun 23, 07:11:00 PM, Blogger The Hatchling said...

Virginia Doc-

You have yet to define obesity which is where you lose the argument. Dino defined it as BMI >30 and you're thinking big fat people in general. Just look at all our athletes or children who BMI is a terrible measure of body composition or measure of obesity (compared to weight percentiles for children).

I think you'll be pressed to find anyone who says that thinks that obesity is the same thing as BMI >30 but as long as politicians set policies because its an 'easy weigh to measure'.

 
At Tue Jun 23, 09:09:00 PM, Anonymous red rabbit said...

I explain this "you have high blood pressure, but this is a risk factor and not a disease" thing approximately daily. People are made to obsess about these things, and whereas I agree awareness is great, obsession is a disease.

So, hear hear Dino.

And again, Viriginia, for your sick obese patients (BMI > 30 and other issues like your arthritis etc) yes, absolutely, weight loss is a great thing. But as Dino points out, not everything is known about metabolism, and recent research points to a subset of the obese for whom there is little to no evidence for harm, and indeed potential small benefits.

So, before you attack my judgement, this is not my standard line, it is something I keep in mind when assessing my patient's general health. Trying to be fair, and not blame everything on one orifice.

 
At Tue Jun 23, 10:00:00 PM, Blogger Rogue Medic said...

Virginia Doc,

Dino gave no argument _except_ his analogies.


You might want to go back and reread the post. It isn't a review article on obesity. There is a brief discussion of the definition of obesity as a BMI over 30. This is a definition that is used because it is convenient, not because it has any diagnostic relevance.

The Governor of California used to have a BMI that was larger than his waist size. Was he obese? No. While that is not a typical case, the criteria listed in the post are also mentioned as not typical patients.

That is the whole point. This is a criticism of a mindless measurement. This is an encouragement for physicians to discuss things with their patients, not to just label them according to BMI.


So if the analogies do not hold up, how is the argument to hold up?


In all cases. Please do not rewrite my comments. I may need an editor, but I will choose an editor who does not mangle my already problematic prose.

Perhaps you should acquaint yourself with the meaning of analogy, before you start to tell others what it means.

A lot of the comments here indicate that both the analogy and the argument worked.


As for teaching my patients, I aim to eliminate risk factors _and_ disease. Obesity is a disease, like it or not: the adverse metabolic effects are present even if they are not (yet) manifested in more recognizable things such as HTN, DM, etc. To tell people you are not worried about something as significant as their obesity is, to use an analogy, a lot like saying you are not worried about their high-functioning alcoholism or their smoking because their BP and lungs are (so far) just fine.


No. This is not about toasting alcoholism or lighting cigarettes for smokers. This is about addressing the specific condition of each patient.

It is about recognizing the limitations of a definition made to be used by a machine, rather than an educated professional.

Someone who is exercising 30 minutes a day to the point of being short of breath is doing something good for their health. I suspect that you look at more than the patient's BMI, no matter how much your comments defend the BMI = Gold Standard.

If you are stating that you do look at more than the patient's BMI. maybe you agree with this post more than you realize. Look at the specific criteria that were listed.

 
At Wed Jun 24, 10:58:00 AM, Blogger Midwife with a Knife said...

Hooray!!! I would also like to add that weight loss isn't as simple as many people would point out. A lot of people say calories in < calories out = wt loss, which is true, however, it isn't that easy to balance that.

I've been obese forever, but I'm halfway to a blackbelt in taekwondo, I jog daily, my blood pressure is normal (although nearly hypertensive on chronic prednisone), my glucose and a1c are normal. The only thing about me that isn't normal is my appearance in a bikini. After ranting to my doc that I was so sad that 2 years of chronic prednisone had resulted in approximately 30 lbs of wt gain, her response was very sympathetic and much like what you said. (And also suggested a new gastroenterologist, 'casue I'm not as great a candidate for long term prednisone use because of that).

Anyway, sorry, you just hit a nerve. It's tough to be a fat doc what with all of the people thinking that fat=undisciplined and that fat=sick. Ironically, my only major medical problem is not related to obesity. And there are a lot of docs who think that fat=bad patient. Sometimes I just want to cry and say, "I'm sorry I'm fat, but I'm really trying....please forgive me for that and take good care of me anyway...".

Um.. sorry.. you hit a bit of a nerve there.

 
At Wed Jun 24, 11:34:00 AM, Blogger #1 Dinosaur said...

MWAK: No need to apologize. I hears ya.

VA Doc: What if it turns out that the actual risk factor isn't obesity itself, but rather inactivity? Certainly the two conditions often go together; often enough for obesity to seem like a valid proxy for it when studied. But mounting evidence appears to say otherwise.

If this is the case, then you're doing your slender but inactive patients a disservice by giving them a clean bill of health, while wasting your time with the healthy, active "obese" ones trying to convince them they have a disease.

Food for thought (not fattening, either).

 
At Wed Jun 24, 03:09:00 PM, Blogger Virginia Doc said...

#1 Dino,
I hear what you are saying, but there is plenty of evidence that obesity alone leads to bad outcomes. A Pubmed search will net you a half dozen good studies showing improved metabolic profiles in people who undergo bariatric surgery--despite being on excercise regimens prior to surgery. I encourage all my patients to exercise, but the evidence is too strong for me to say weight does not matter--or that it is just a marker. To say that it can be overlooked if all else is fine does not make sense to me. It is unlikely all else will remain fine if weight loss is not achieved. That said, you are quite right that we agree that the BMI is hardly the be-all-end-all some make it out to be. And truth be told, I don't calculate it on my patients. I follow abdominal circumference--that is where the evidence really is.

Rogue Medic, this is not a personal argument. Don't make it one. Take some deep breaths--it'll be good for you.

And regarding the multiple mentions of "why is 30 defined as obese": it is because that is the BMI where increased mortality is seen.

 
At Wed Jun 24, 09:47:00 PM, Blogger dona dicarlo said...

wait long enough and the risk factors WILL MANIFEST..into diseases..


I have seen it many many times...in my practice yeah a few people skip away and don't die.

You have to have some form of measurement that is science.

LONG TIME RN

 
At Fri Jun 26, 05:36:00 AM, Blogger Rogue Medic said...

Virginia Doc,

That said, you are quite right that we agree that the BMI is hardly the be-all-end-all some make it out to be. And truth be told, I don't calculate it on my patients. I follow abdominal circumference--that is where the evidence really is.


And that is what the point was.

Here you are lecturing about how nobody should criticize the use of a BMI of 30. That criticism of the BMI of 30 is equivalent to buying drinks for alcoholics.

Lo.

Behold.

Virginia Doc does not use the BMI of 30.

Have you resuscitated Lewis Carrol to write this?

What was the point of your non-disagreement? Are you entering law school and need to practice arguing both sides of an argument?

PS I'm breathing just fine, thank you for the concern.

 
At Fri Jun 26, 08:41:00 AM, Blogger Virginia Doc said...

Rogue Medic,
My point is that obesity matters, and matters independently.

You really need to learn that arguments can be conducted with being personal. You seem like a very angry person. No need to be vicious just because somebody disagrees with you.

 
At Mon Jun 29, 09:17:00 AM, Anonymous Marsha @ Green Mountain at Fox Run said...

Just want to add my kudos for a great blog post. For overall health and well-being, we're much better off focusing on lifestyle, not a number on a scale. The long history of focusing on that number in this country just goes to prove it doesn't work, even for those for whom a higher number does suggest that something is awry.

 
At Mon Jun 29, 09:19:00 AM, Blogger Yoni Freedhoff said...

Interesting discussion and Dino, I like your blog.

Given that I'm a doc with a focused practice on nutrition and weight you might be surprised that I agree with Dino - to a point.

Like Dino I regularly see patients who are medically "obese" yet metabolically and co-morbidly healthy.

Good for them.

I've also seen smokers live to ripe old ages without COPD or lung cancer, heavy drinkers hold down steady jobs and healthy relationships and friends who still don't buckle their seatbelts when driving (and generally them I tell they're morons).

Just because you have a risk factor does not guarantee you'll develop that for which you're at increased risk.

Of course thinking back through the patients off the top of my head I can't think of a 60+ year old in my practice with a BMI of over 35 and no associated co-morbidities.....

But I digress.

So obesity isn't a disease in the classic sense of the word. I'd argue though that obesity is in fact a disease - a disease of the environment. 100 years ago obesity was a rarity. Were genes different? Were people less hedonistic? No. The world was different.

Of course it's all semantics anyhow.

I'm sure both Dino and Virginia agree that as a general rule, a general rule that as weight rises becomes more a certainty, weight carries with it tremendous risk and probably it's worth treating. Consequently when I see passionate arguments against the notion of labeling it a disease I do worry whether they may deflate efforts at prevention (though to date those efforts sure aren't much to brag about)

For a scholarly article on whether or not obesity is a disease feel free to click here (to save you the click - they decided the answer was no).

 
At Tue Jul 07, 02:44:00 PM, Blogger K2 said...

I just found your blog and this post...thank you.

 

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