In 2016, three out of every ten inhabitants on the planet, equivalent to more than 2.2 billion people, were overweight, and more than 796 million were obese, according to data.of the World Health Organization (WHO). Such a scope turns accumulated excess fat into something much more serious than a local problem – not to mention aesthetic – and the UN body dedicated to public health policies calls it a “global epidemic of the 21st century”. Obesity is the letter to trigger numerous and dangerous health problems, such as type 2 diabetes, metabolic syndrome, heart disease, strokes, various types of cancer and respiratory disorders. There’s no question of its impact as a risk factor, but should it be treated like a disease? Would that drive a medical solution to the problem?
These are questions that have the medical community engaged in intense debate. No one doubts that behind the discussion, which was recently aired in an article published in the British Medical Journal, there is a powerful gentleman, healthcare spending. But it is not the only factor in the debate.
A controversial investment
For Clotilde Vázquez, head of the Endocrinology and Nutrition Department of the Jiménez Díaz Foundation and researcher of the CIBER of Obesity at the Carlos III Health Institute, the controversy of considering obesity as a disease is due to factors of health economics. “As in diabetes, that the person does his part is as important as considering obesity as a disease and the need to treat it. Obesity is an abnormal form of interaction with the environment, and that depends on the complex overlapping of various mechanisms . If it is as a disease, we are obliged to subsidize care and drugs and techniques for treatment , “he explains.
According to a study published in the Spanish Journal of Cardiology, by researchers at the Hospital del Mar Institute for Medical Research and the Hospital del Mar, in Barcelona, care for people with overweight, obesity and morbid obesity generates an extra cost for the National System of Health that is around 2,000 million euros. “Although in Spain it is considered as a disease, and as a risk factor for many other diseases, the response of the health system is poor, and despite good epidemiological studies on the prevalence of obesity, prevention measures are clearly lacking community and state scale “, emphasizes the endocrinologist.
Regarding the objective of health spending, a key point is to market drugs that benefit body weight, indicates Camilo Silva Froján, member of the Center for Biomedical Research in the Pathophysiology of Obesity and Nutrition and specialist in Endocrinology and Nutrition of the Clinic University of Navarra. For Silva, considering obesity as a disease would imply improving patients’ access to treatments: “The arrival of new, safer and more effective drugs could generate a lot of frustration if the patient does not access them. The expectation is very positive in the results of studies preliminary with developing drugs, but the economic crisis forces to control the sanitary cost. In Spain the access of the patients to the dietary treatments must improve a lot -a quality nutritional education- , surgical and pharmacological. There are treatments that significantly improve the weight and health of obese patients, but they are not funded. ”
The dietician-nutritionist at the Vallcarca-Sant Gervasi Primary Care Center in Barcelona Àlex Pérez remembers that a person is obese when their body mass index (their weight in kilograms divided by the square of their height, in meters) is above 30. “Years ago, waist circumference was also taken into account in its diagnosis (if it is greater than 88 centimeters in women and 102 in men). But body composition (fat, muscle, bones, viscera … is not taken into account … ), since in the usual clinical practice precise and reliable devices are not available , nor many times, “ laments Pérez, for whom it is a mistake that when pathologizing obesity, political or economic interests weigh on health and social interests.
Less social stigma, but also responsibility
A positive effect of considering obesity as a disease, according to its supporters, would be to lessen the prejudices and stigmas that weigh on the obese person. “Like all diseases, it has causes, complications, epidemiology, and treatment. It can be treated through changes in lifestyle, endoscopic procedures, drugs, or surgery. It can have a mild, moderate, or severe impact on health, and it can vary throughout of life, sometimes even unpredictably. Hearing that weight loss depends only on willpower is unfortunate. Normalizing a disease status for obesity would improve things, as long as the patient no longer considers himself the steward of his health, “ says Silva.
For the critical voices of the debate, obesity represents the body’s expression of an excessive diet and, in general, of an inactive lifestyle. “It is not due to organic failure, nor to an accident, nor is it the product of a bacterial, fungal, or viral infection, but rather to living in a hyperalimated environment where a primary instinct is continually driven to be satisfied,” says nutritionist Àlex Pérez. And he warns of the counterproductive effects of considering obesity as a disease: “Over-medicalizing a health problem that requires corrective measures in lifestyle leads one to think that diseases are entities that act externally, which leads us not to take responsibility beyond taking a pill “,
Although excess fat accumulated may be the sign of some diseases such as Cushing’s syndrome , the doctor Juan Gervás, author of the blog Sano y salvo (and free of unnecessary medical interventions) , believes that in most cases obesity it is not a disease. “Nor is famine. Whether it is considered a disease depends on a social consensus.The broadening of the field of diseases is a medical abuse, and moderation should be used when defining disease, risk factor and health. The debate responds to spurious interests of doctors, obesity clinics, academics, researchers and scientific disseminators of nutrition, which over-abound and dogmatize non-stop. Many people will suffer when they become sick and such exclusion will not be compensated with any benefit, and would legitimize aggressive treatments that often lack scientific basis. This is a repeated history of obesity, with dozens of medications withdrawn for serious problems of adverse effects, “warns the doctor.
There is another way of looking at it. Vindicating obesity as a disease is framed, according to the psychotherapist Xavier Sanmartín , in making visible problems that until now have not been exposed and that generate a great mobilization to raise social awareness, such as functional diversity, carnism or the use of plastics. “Making a problem visible aims to hold us accountable for taking action along the lines of change. Obese people have suffered social stigmatizationand they are very sensitive to criticism from those who feel entitled to tell them what is in their best interest. The danger they can sense is that if obesity is considered a disease, other people may feel entitled to invade their privacy by telling them how they should live and what they have to do. Here an identity reaction would reject help in an attempt to restore self-determination to one’s choice. The debate should revolve around the responsibility of the patient for his illnesses. There are social movements that seek to empower the patient towards a greater awareness of their disease and towards greater involvement in treatment, “says Sanmartín.
A consequence of inequality
The debate over whether obesity should gain disease status is complex, and fraught with nuances. For example, those that emerge due to the fact that different types of obesity can be distinguished; for Sanmartín, placing all obesities at the same level, both by grade and by etiology, would be a mistake. “Obesity due to biological causes (for hypothyroidism, for example), social factors (a consequence of poverty, education …) or behavior (the cross on the back of the emotional dining room) is not the same. The intervention has that considering biological, cultural, psychological factors … is therefore a multifactorial problem that requires a multidisciplinary approach.Social action to face risk factors for obesity such as poverty are also medical competence, as prevention, “says the psychotherapist.
And it is that obesity is not an exclusively health problem or that it should be solved only with medical interventions, as recognized by the endocrinologist Camilo Silva. The environment plays a determining role, and its influence is very difficult to deactivate (when it is possible to do so). “Obesity is a medical problem that is increasing morbidity and mortality in our society. Being such a widespread problem, it has a strong social dimension, which has its peculiar characteristics. One of them is the association of obesity with a lower purchasing power due, among other things, to the abundance of cheap but very caloric foods. ”
People who live in lower-middle socioeconomic strata take less care of their health in general than in the upper-middle strata, especially in large concentrations of the population, says nutritionist Pérez. “There has been talk of ‘ food deserts’ , urban or peri-urban areas in which getting fresh and healthy food without having to travel and drive many kilometers is almost impossible. In these cases, the majority use of ultra-processed food is almost the only option. It is necessary that the economic and productive agents, the health professionals and the urban planners reconsider the politicians so that their decisions go beyond their partisan interests, “he stresses.
In developed countries, the most important thing is to see obesity as a political and not a medical problem, emphasizes Dr. Gérvas. “The atlas of obesity is the atlas of poverty. Poverty , and the inequity that causes it, is associated with obesity and type 2 diabetes. Clinical interventions are doomed to failure. Over the years, patients, in general, they regain the lost weight. The practical thing is to go to the social determinants, to public health, to the conditions in which people live. The WHO should say that obesity is the symptom of inequality, and develop policies against inequity and inequality.In addition, it should promote the approach from public health. Furthermore, in the health sector there is a clear ‘anti-obesity’ stigma with serious repercussions on women’s health. Obesity, more than a problem that puts health at risk, is a problem that puts dignity and human rights at risk, “concludes Gérvas.