Wednesday, July 10, 2013
Obesity, Disease, and Sustainability
But this business of classifying obesity as a disease makes me a little nervous.
In case you haven't heard, the AMA recently declared obesity, widely defined as having a BMI (body mass index) of 30 or above, as a disease. That means that the actual condition of obesity is considered a sickness, if you will, instead of just the conditions -- like diabetes, coronary heart disease, joint pain, etc. -- that can result wholly or partially from it.
Better commentators than I am have identified some of the obvious problems with this. For one, BMI is a wildly inaccurate measure of health. Since it is a number derived from your height and weight only, it has a tendency to produce some pretty bad results at either end of the curve. Professional athletes with lots of heavy-for-their-size muscles tend to be declared obese, while fashion models starving themselves into anorexia might be declared simply "underweight." Even if you eliminate these populations, there are perfectly healthy people whose bodies are simply tuned to carry more weight on them than others. If you doubt me, you should visit any dance studio I've ever been in. I'm in pretty good physical shape, and I regularly meet dancers who have a good 50 pounds or more on me (often without my height) who can keep up a technically perfect Viennese Waltz (note for non-dancers: read that as "fast, spinning sprint of a dance") for round after round, while I'm winded in the corner.
(Digression #1: One of my major concerns is that our society is more likely to consider overweight a problem than underweight. It is very, very true that we have an obesity "epidemic" in this country, and marginal overweight probably causes more health problems than marginal underweight. But I also think that we are far more likely to criticize someone with a BMI of 26 -- one point into "overweight," than we are a BMI of 17.5 -- one point into "underweight." The first person will be asked, "how could you let your body get this way," while the second will more likely be told, "you look great, but you could use a sandwich." The pressure to measure ourselves by numbers is a contributing problem to the health issues we have. How can you stay inspired to keep taking care of your body if the feedback you get is overwhelmingly negative?)
I understand why some parts of the medical community are happy to have obesity be named a disease. After all, if you are a primary care physician (and if you are, you are indeed a hero), you have maybe 15-20 minutes per patient visit, and it is hard to get insurance coverage and ultimately payment to counsel said patient about lifestyle choices that impact obesity. Recognizing it as a disease would mean making this time for counseling and any resulting therapies something that the physician is less likely to have to do on a near-pro-bono basis. And the last thing I want physicians to do is not be able to run their businesses and make a good living. They are too important to us for that.
(Digression #2: We are pressuring our primary care physicians way too much. It is no wonder we project a shortage in that profession happening very soon. My primary care doc is fabulous, but, knock wood, I'm a generally healthy person, so I see him once or twice a year. It is hard for him, conscientious as he is, to amass a lot of background information about my life that would let him make good suggestions to me. I would love to have the option to schedule 30 or 60 minutes where we just chat with no attempt to solve an underlying problem -- just talk about my lifestyle and my hobbies and my family and my worries and anything else that might impact my health. Then, I'd like to walk out of that appointment and write a check for the value of that time to his practice. I would be happy to pay out of pocket to give my doc information that could help him do his job better in a no-stress situation for us both.)
I'm over-simplifying here, but overall, our medical establishment is far more likely to pay for a prescription than a suggestion to visit the farmer's market. And that's really the problem here. Once you classify something as a disease and attach a handy-dandy numerical measure to it, the system starts rewarding an over-reliance on a single measurement. Look at blood pressure. Normal is 120/80. Most primary care docs I know see this as a general target, not an absolute, but I have definitely talked to over-zealous physicians who would start to suggest prescriptions for 125/85 and pat you on the back for 115/75. (Again, this is not all physicians, so if you are one and feel your hackles rising while reading, I seriously doubt if you are doing this. I do a lot of medical writing, and I hear this kind of thing once in a while, so I know it is out there. But I don't think it is representative of the profession as a whole.)
(Digression #3: And where the money is, Big Pharma will follow. Again, I have spoken to far more ultra-conscientious pharmacists and drug researchers that money-grubbing ones, but we are building a system that will reward the development of and the prescribing of drugs, because that's where insurance reimbursement will be. I'm pretty sure that none of this will result in your health insurance reimbursing you for buying a bunch of carrots at the farmers' market or for paying your gym membership.)
And this is where I'm afraid we are headed with obesity, only our numerical measure is an inaccurate one. So, more insurance coverage and ultimately more money for prescriptions and for surgeries and other therapeutic measures that all have their place. But you can bet that money isn't going to go into addressing systemic issues, like whether there are enough bike paths and bike racks, why there are food deserts in this country, what impact HFCS and glyphosate (an herbicide used widely in preparations like Roundup) has on the human metabolism, and the like. And it almost certainly won't be used consistently to differentiate the person who is healthy and obese from the many whose lifestyle has led first to obesity and eventually to life-shortening conditions.
So I'm not sure what to do to fix this, other than to say that identifying another disease to code in medical billing probably won't solve the problem and is probably unsustainable. Obesity is a definite problem in this country, and it needs to be addressed. Luckily, there is a lot that you, the individual, can do to impact your overall health and, consequently, your chances of developing obesity or remaining obese in an unhealthy way. I'm just not sure whether more policy and procedure is the way to solve this problem.
(Next post will be my own tips for a healthier lifestyle, worth every penny I paid for my non-existent medical degree!)
Your thoughts? (Keep it respectful -- remember, different viewpoints are valuable and my anxiety level needs to stay low!)
Posted by Jennifer Lorenzetti at 9:28 AM