Framing Obesity Beyond Disease: The Unintended Consequences of Not Casting a Wider Net

“Obesity spans a spectrum of health states, from an asymptomatic predisease risk factor—where excess adiposity (however defined) has yet to manifest overt signs or symptoms—to advanced disease stages complicated by downstream comorbid conditions, including diabetes, heart disease, and cancer. Obesity causes health effects and poses risks on a continuum; greater excess adiposity leads to higher health risk. In this way, obesity is analogous to many cardiometabolic risk factors, such as elevated blood pressure, dyslipidemia, and hyperglycemia. The location of adipose tissue also matters for some metabolic effects, whereas for others (for example, obesity’s mechanical effects), total adipose tissue affects functional health. Thus, a binary threshold will by definition be artificial and will, as Bajaj and colleagues highlight, inevitably result in health inequities. Moreover, as Cuevas and Willett suggest, this inequity may result whether the marker used is body mass index, waist circumference, or direct measures of adiposity.

[..] We now know that obesity is a product of the interplay of genetic, biological, psychosocial, environmental, cultural, and behavioral factors. The dominance of any of these, however, varies not only across populations and individuals but perhaps even over time within individuals. At a given stage on the continuum, the trajectory of health risk may vary on the basis of an individual’s genetic–clinical–psychosocial–cultural–environmental–behavioral context. Thus, assessing risk purely on the basis of biological or clinical markers will likely fall short.

[..] Obesity fits the chronic disease paradigm. Casting it as a disease medicalizes the condition, frames it in familiar clinical language, raises its public health profile, and reassigns responsibility for its management as one shared by clinicians, patients, and the health care system. However, there is no universally accepted definition of the term “disease.” Exclusively medicalizing obesity risks causing many to place the focus solely on biological causes and medical or pharmacologic solutions when, in reality, obesity is a “normal” response to an “abnormal” and “disordered” environment for some. The disease construct may oversimplify this complicated condition and undermine public health and policy efforts to address socioenvironmental contributors, including our food environment. It gives our legislatures and the free market a pass on their culpability and may obscure other important clinical and nonclinical contributors.

Ironically, framing obesity as a disease to justify coverage for treatment reinforces weight bias. It conflates the need to label a condition a disease with health care reimbursement and raises the stakes for developing accurate diagnostic criteria. The International Statistical Classification of Diseases and Related Health Problems (ICD) includes many conditions with reimbursable codes that are not diseases. By exclusively linking obesity as a disease to reimbursement, it sends the message that only those who manifest disease from excess adiposity warrant treatment—and, by inference, those on the continuum who have not yet manifested disease do not warrant treatment. This latter determination should be driven by science and objective guiding principles for reimbursement and not by the current discriminatory paradigm that applies a different standard for treatment coverage when it comes to obesity. Health payers do not withhold pharmacologic or behavioral treatment from people with high blood pressure or high lipid levels before manifestations of disease are evident. [..]

The new highly effective weight loss agents have cosmetic and social benefits and are in high demand and ripe for misuse. This, together with the high prevalence of obesity and the high cost of these therapies, leaves health payers and clinicians rationing treatment. Rather than focusing on whether one’s adiposity conforms to an expert panel’s definition of “disease,” we should address how to best stage obesity risk with sufficient accuracy and fairness and reach a consensus on how to prioritize and match treatments to individual patients.

To facilitate allocation of limited health care resources, efforts to develop accurate risk stratification tools to properly stage obesity risk are critical and should consider more comprehensive but accessible clinical, demographic, psychosocial, environmental, and behavioral variables that account for the heterogeneity in obesity’s causes and effects. We also need more precise phenotyping of obesity in therapeutic clinical trials and dynamic decision analysis and cost-effectiveness models that tell us not only whether a therapy or intervention is effective and cost-effective at a given price point but also at what lower price point and for what subset of patients with obesity each intervention would become cost-effective. Whatever standard we use to allocate obesity treatment, it should be the same standard used for any other chronic health condition. [..]

It’s time we treat obesity as the serious health threat that it is. We were able to galvanize private, public, and health care stakeholders to address the COVID-19 pandemic in short order. Is it not time we address this other pandemic?”

Full editorial, CC Wee, Annals of Internal Medicine, 2024.7.23