Sherry Pagoto, a psychologist and associate professor of medicine at the University of Massachusetts Medical School, gives her take on a recent decision by delegates for the American Medical Society to recognize obesity as a disease.
Last week, following the lead of the World Health Organization and the National Institutes of Health, the American Medical Association declared obesity a “disease.” The AMA cited the plethora of evidence linking obesity to chronic disease including the number one cause of mortality in the United States, cardiovascular disease. They describe the move as an effort to urge physicians and insurers to recognize the need for obesity treatment ranging from lifestyle interventions to surgery.
While the definition of “disease” continues to be debated, the AMA’s call to action is much needed given that access to non-surgical preventive care is virtually non-existent. Rates of physician counseling for obesity have declined as rates of obesity have risen, meaning physicians are doing less, not more, over time to combat the risks that obesity imparts on patients. Also concerning is that behavioral counseling, shown in large randomized trials to significantly reduce the risk of type 2 diabetes, is not a reimbursable health care service.
How might labeling obesity a “disease” change the way we treat patients? Physicians may be more inclined to put obesity on their radar, counsel patients, and refer them to effective programs, but this can only happen with concomitant changes in reimbursement policy.
The challenge for physicians has been twofold: 1) They lack the time and skills to effectively treat obesity in the context of a primary care visit, and 2) there are no reimbursable services to which they can refer patients.
The move by the AMA may push the Centers for Medicare & Medicaid Services, the organization that sets the tone for health care reimbursement, toward better coverage for obesity treatment. The federal agency’s policy is now extremely narrow.
In December 2011, it decided to pay primary care physicians to provide behavioral counseling for obesity, but again, physicians lack the skills and time to deliver this care. Lifestyle interventions involve six to 12 months of dietary counseling, exercise, and behavioral modification, skills that are in the wheelhouses of dietitians, exercise physiologists, and behavioral health professionals who were conspicuously left out of the federal policy.
To be reimbursed for counseling, this group of professionals can only see patients who have a “disease,” such as diabetes, cardiovascular disease, an eating disorder, or depression. As the reimbursement policy stands, a serious condition must develop before obese patients can be treated by the professionals who are trained to treat them.
Preventive care, by definition, should be available prior to the development of a condition, not after. These professionals also bill at much lower rates than physicians, and in a time of spiraling health care costs, preventive services that leverage the entire health care team are needed.
A negative side effect of the AMA decision is that the word “disease” is often misinterpreted as meaning that a person has no control over the condition. On the other hand, critics say that obesity should not be called a “disease” because it is a result of lifestyle choices which people should be able to easily control.
Both of these suppositions reflect a poor understanding of human behavior. Behavior is not out of our control, but it is not always easy to control either. Our genetics and environment heavily influence our behavior. For example, a host of genetically-driven neurobiological variations influence appetite and even our experience of a food as palatable.
This means that some people have intense appetites, some less so. Some people have an intense affinity for sweets and fats, others less so. Humans vary in these factors just as they vary in every other physical characteristic.
In terms of environment, the increasing availability of super-palatable foods over the last three to four decades strongly impacts how much we eat, which is likely why rates of obesity are climbing since our genes haven’t changed in this time frame. The food environment is more challenging to contend with for some than others, depending on the hand one is dealt in terms of those neurobiological variations in appetite. Further complicating matters are a host of psychological and physical factors that influence appetite including sleep deprivation, stress, and depression.
The assumption that any lifestyle choice should be just as easy for one person as it is for another (i.e., “If I can maintain my weight, everyone should be able to!”) is egocentric, because it assumes our brains and environments are identical which is not true for any two people on the planet.
To offset the fallout from misconceptions about what obesity as “disease” really means, providers should counsel patients with a richer explanation of behavior and empathize with them on how hard it is to combat environmental forces, while empowering them with effective strategies. Counseling should help patients reconstruct their environments to reduce the presence of palatable foods so that ultimately healthier choices become easier to make. This differs from the traditional advice of “eat less and move more,” which ignores the very processes that make this advice so difficult to follow.
In the end, the AMA’s decision was a necessary call to action given the need for preventive care. The debate over what the word “disease” means likely will continue, however the real task at hand is to prevent obesity from leading to chronic life-threatening conditions and reduce the spiraling health care costs fueled by a food environment that increasingly threatens our collective health.