By Oliver Watson & Mikkel Brok-Kristensen
Although a concern for healthcare systems for several decades, 2013 was a watershed year for obesity. Its recognition as a disease by the American Medical Association provides an opportunity to move beyond dead-end debates around personal responsibility and create renewed focus on what healthcare systems can do to treat this burgeoning epidemic. In this article we explore the implications and opportunities that this reclassification presents.
Change is needed, but does it matter that we label obesity a disease?
Today obesity is one of the biggest health concerns facing the modern world. Over a third of Americans and a quarter of Brits are obese, and the implications are dramatic. So far initiatives focused on prevention and treatment are struggling to shrink our collective waistlines – though a few initiatives are showing some success[i]. So it is worth hoping that the AMA decision to reclassify obesity as a disease will lead to changes. In fact, according to members of the AMA board, it was the hope that reclassification would be a catalyst for change, rather than a definite and overwhelming scientific agreement, that was a key factor in the AMA’s decision. Nevertheless, whether the face of obesity treatment will change significantly anytime soon is questionable.
Moving from blaming to helping
That some of us are overweight or obese is nothing new, and a historical perspective will tell you that excessive weight has long been regarded as a symbol of status and wealth – albeit a symbol that has moved in and out of fashion. However, as medical understanding around body weight and a number of related medical problems has increased, obesity has become a health care concern as well as an aesthetic one.
But for a long time, the debate around obesity has largely centred upon who is to blame. Reduced to its core, this debate has been built upon two opposing perspectives:
The first perspective frames obesity as a problem belonging to individuals. In this traditional conception, obesity is often portrayed as a lifestyle choice, and responsibility is placed squarely at the feet of those affected by the condition.[ii] This has been, and in many countries remains to be, the most prevalent perspective.
The second perspective blames systemic forces for expanding waistlines. Proponents of this view point to social and economic pressures in the environment that influence or even override individuals’ agency, by determining the set of choices that are available, and nudging them towards less healthy ones.
The individualistic framing of obesity dominated the debate for a many years and has led to an expectation on obese individuals to solve their ‘weight problem’ themselves, and a consequent denial of responsibility by the state and the market. However, this view has been challenged over the past two decades. As systemic framing has gained traction, obesity has been reconceived as an issue of public health, calling forth a range of preventative public measures to eliminate its environmental causes. Many of these measures target the ‘toxic food environment’, working to reduce the abundance of cheap, high-calorie, low-nutrition food, and improve the provision of healthier options. This point is vividly illustrated by the mapping exercise from the US Department of Agriculture, which reveals the expanse of “food deserts” spread across the US (areas where people live more than a mile away from a grocery store)[iii]. Public health measures which target obesity are an increasingly well-established part of government policy: the US 2012 legislative session saw the proposal of over 450 obesity-related bills, which “underscored a common theme – an interest in helping to create supportive environments where healthy choices are easier choices.”[iv] [v]
Although broad environmental changes may reduce the prevalence of obesity in the long term, more is needed to improve the health of those who are already affected by obesity today. A variety of individual obesity intervention strategies are available, ranging from diet and nutritional products sold in supermarkets; intensive behavioural counselling to encourage better lifestyles; and, medical procedures such as bariatric surgeries. But given the prevalence of obesity, few obese people are seeing the benefits of these interventions. A recent trend-watching bulletin observed that, “while obesity prevention has gained traction in recent years, obesity interventions remain few and far between.”[vi]
Pharmaceutical treatments have existed, but the promise of effortless weight loss, which is how these treatments are often perceived, is deeply unsettling to a lot of people. The desire to lose weight without breaking a sweat has become condemned as a kind of chronic disorder of its own, yet another symptom of the sloth that made people ‘fat’ in the first place. In light of this, the pervasive term ‘magic pill’ is suggestive of the uncharitable attitude that many take towards this quest for a quick fix. [vii] [viii] [ix]
But when we factor in the cultural dimensions to obesity, this desire for a pharmacological solution becomes more understandable. Obesity is also an inherently cultural phenomenon. It is rooted in a complex web of customs, attitudes and ways of life that, though not immutable, are difficult for any individual to bypass without turning their back on who they are. From culinary traditions which define the staples of our diets to less tangible attitudes to eating such as notions around masculinity and ‘a healthy appetite’ – obesity is intertwined with nationality, ethnicity, social class and gender. Though these cultural factors can be influenced by education and public health policy, changing something so ingrained as culture takes sustained time and effort. So until these more systemic measures begin to have an effect, those who are obese today need support on an individual level and it is often the promise of a pill that is most alluring.
Redefining obesity as a disease creates the space for a more pragmatic approach to treatment
Many expect that classifying obesity as a disease will finally banish the tendency for health care systems and policy makers to focus on blaming the obese rather than supporting them. As diseases are afflictions generally considered beyond our control, there will be a greater acceptance of interventions that move beyond merely emphasizing individual responsibility and simple behavioural changes centred upon eating less/exercising more. Nonetheless, it is important to stress that broader social actions combined with, rather than instead of, individual actions are likely to be most effective in treating obesity.
As we see it, the two most critical challenges we now face are the efficacy of our interventions and their cultural acceptance as appropriate solutions to obesity. To some extent, these problems intersect, since boosting efficacy would influence acceptance. But acceptance cannot be reduced to efficacy: however effective treatments become, they will still face cultural resistance if they conflict with prevailing conceptions of obesity and weight loss.
The Institute of Medicine (US) recently detailed a set of “Guiding Principles” for public health measures, one of which stressed the need for a “synergy of multiple strategies” in any coordinated effort to prevent obesity. When seeking efficacious interventions for obese people it seems as if the same approach will be beneficial. The modest success of pharmacotherapy and behavioural counselling (each achieving a reduction in bodyweight of around 5%) should come as no surprise: behavioural counselling targets the behavioural factors that contribute to obesity, and pharmacotherapy targets the condition’s physiological causes. Yet neither intervention targets both behavioural and physiological factors. If combined as a single solution, the efficacy of these interventions could be improved. For instance, pharmacotherapy that delivers weight loss could provide a much-needed motivational catalyst for behavioural counselling, kick starting the notoriously difficult process of lifestyle change. Meanwhile, behavioural counselling could improve on the long-term efficacy of pharmacotherapy, helping patients to maintain their weight loss beyond the limited timescale of a prescription.
This kind of synergy could also improve the cultural acceptance of pharmacotherapy – by enabling them to embrace personal responsibility as a value but also accepting their role in giving people that initial support to begin losing weight. Moreover, it could also produce multiplier effects by increasing the effectiveness of complimentary policy measures that increase access to healthier foods and/or decrease access to high calorie food. In short, the notion of the magic weight loss pill becomes replaced by a comprehensive approach to obesity in which the pill plays a critical supportive function. Lessons and parallels can be drawn from efforts to reduce smoking.
Learning from smoking cessation: The case of Nicotine replacement therapies
Nicotine replacement therapies (NRTs) are the smoker’s pharmacotherapy – suppressing the appetite for cigarettes. But they are no ‘magic pill’ for addiction. Rather, they work by helping to enable and sustain the behavioural changes that are required for smoking cessation: with the physiological appetite at bay, smokers can take on the psychosocial forces that sustain their habit. Research has shown that smokers using a combination of behavioural support (counselling, group activities, exercise) and NRT can increase their chances of quitting considerably.[x] One especially successful manufacturer of NRTs explicitly positions its offerings as a crutch to willpower: each packet bears the slogan “helps overcome your urge to smoke” [emphasis added]. NRTs have found a ‘sweet spot’ where efficacy and acceptance are maximised. They are included in an increasing number of health insurance plans, and several states have even guaranteed their provision.
Time for pharmacotherapy to weigh in
Like obesity, smoking was once considered a lifestyle choice in which notions of ‘treatment’ were overshadowed by arguments of personal responsibility and willpower. Today these notions have been successively marginalised by a greater concern over smoking’s negative effect on individual health and the extra cost to health care providers (and society) for smoking related illnesses. This shift in understanding has subsequently led to a range of efforts such as cigarette taxes, marketing restrictions and public smoking bans that, together with the availability of NRTs, have helped reduce rates of smoking in the US from around 45% in 1965 to 18% today[xi].
Can pharmacotherapy follow the example of nicotine replacement therapies and become that crucial physiological crutch that many people need in their journey towards healthier waistlines? The AMA’s decision would certainly indicate that the time is ripe, but it is clear that only if new therapies are combined with other efforts will we see significantly shrinking waistlines.
[i] Childhood obesity has been a particular focal point for public health measures, and the considerable efforts undertaken in this domain appear to be showing the first signs of success: a report published by the Robert Wood Johnson Foundation in September 2012 announced that childhood obesity rates had fallen in a range of key areas across the USA, including Philadelphia, New York, Mississippi and California, a result which the author attributed to broad environmental changes which encourage healthy eating and physical exercise. (Health Policy Snapshot: Childhood Obesity, Robert Wood Johnson (2012)
[ii] Saguy, A.C. & Riley, K.W. (2005), “Weighing Both Sides: Morality, Mortality, and Framing Contests over Obesity”, Journal of Health Politics, Policy and Law
[iv] Kahan, S. (2012), United States of Obesity, Huffington Post
[v] Admittedly, only a small fraction of obesity-related bills are passed, as illustrated by the recent failure of Mayor Bloomberg’s ban on large servings of soda to pass through New York’s state courtrooms. But it is often the detail of legislation which fuels objections: Bloomberg’s ban was largely overruled due to concerns about uneven enforcement and loopholes. In principle, public health measures are widely accepted as an appropriate response to the obesity crisis.
[vi] STOP Obesity Alliance Quarterly, Q4 2012
[vii] According to Helen Darling, CEO of the USA’s National Business Group on Health, the notion of the ‘magic pill’ is especially at odds with the ethics of large employers, who are “deeply committed to the concept of personal responsibility for a healthy lifestyle.”( http://www.managedcaremag.com/archives/1209/1209.obesity.html)
[viii] On top of these ideological concerns, there are also worries about the consequences of sponsoring treatments that make personal responsibility seem unnecessary. A UK government report in 2009 expressed apprehension at the prospect of “a ‘magic pill’ form of treatment”, due to the risk of “undermining the importance of individual responsibilities and healthy lifestyles” (“Tackling Obesities: Future Choices – Project Report”, Government Office for Science (UK)
[ix] American large employers share a similar concern: “There is a worry that instead of changing their lifestyle, people will come to rely on medical interventions.” (http://www.managedcaremag.com/archives/1209/1209.obesity.html)
[x] Stead LF, (2012) “Combined pharmacotherapy and behavioural interventions for smoking cessation.” Cochrane Library (http://www.cfah.org/hbns/2012/review-confirms-value-of-combined-approach-to-quitting-smoking#.UjrJwUIyBFI) and NY Times “Nicotine and Tabacco In-Depth Report” (http://health.nytimes.com/health/guides/disease/nicotine-withdrawal/in-depth-report.html)
[xi] 50 years of progress cuts smoking rates in half — but can we ever get to zero? http://www.nbcnews.com/health/50-years-progress-cuts-smoking-rates-half-can-we-ever-2D11899207