Is Obesity a Disease?

Is obesity a disease? This is a question I ask myself regularly and have many internal debates in my efforts to answer.

On the one hand, I want the health consequences of obesity to be taken seriously. In the spirit of The Obesity Society's "I Treat Obesity Seriously" campaign, I want people needing treatment to have access to it. I want people to have access to evidence-based, sound treatments, with plenty of options between the extremes of "just eat less" and bariatric surgery.

On the other hand, obesity is currently defined as a size. As Dr. Sharma told us at this week's Your Weight Matters Convention, anatomical descriptions of obesity don't tell us anything. By using definitions--even if they can be calculated with numbers--that ultimately rely on visual cues, I worry we further stigmatize people who have obesity.

In order to think of something as a disease--and treat it seriously, we (1) need a definition that demonstrates health impact, (2) we need ways to screen and identify individuals with a disease, and (3) we need treatments to offer them.

The CDC, and pretty much everyone else, defines obesity based on BMI. Of course, BMI doesn't distinguish fat from muscle, subcutaneous fat from visceral fat, healthy people from unhealthy. There have been some good attempts to "score" obesity in terms of health, including the Edmonton Obesity Staging System. They are huge improvements, but we don't have enough evidence to define obesity using them alone. Does my BMI-defined obesity remain "obesity" because I think Prevacid is the best drug ever invented, or do I need to have actual GERD? Is a tight airplane seat enough functional limitation, or does it have to reach the point I buy velcro shoes?

For that matter, how we are we going to implement and screen any sort of health-based measure like this? Do I have to have a high BMI? I could have high percent body fat and a low BMI. What about all of the people who have a low BMI and conditions associated with obesity? If we use size as the fundamental requirement for defining obesity, how do we get past the stigma of the current societal perceptions of size? BMI is used because it's so easy to calculate. Really identifying when a high BMI is problematic requires more effort--a fasting lipid panel, for example, along with many other assessments.

One of our greatest challenges is that there are too few treatments for obesity. Intensive lifestyle interventions can work, but they don't always, and they aren't readily accessible to everyone. There are a few new drugs, but pharmaceutical treatment continues to struggle to overcome the black mark of Phen-Fen. Obesity treatment research is painfully hampered by the perception that obesity is the fault of the person with the obesity. The unremarkable success of current treatments has led to a focus on prevention, assuming treatment will never work. But we don't know that treatments won't work--we just haven't found them yet. What if we stopped trying to find cancer treatments because early efforts were not successful?

The "obesity epidemic" is not something that we can solve overnight. Prevention is a key element, but until we regularly use health-focused definitions, recognize the complex factors underlying obesity, and develop effective treatments, we will never succeed. Paraphrasing Ted Kyle, we are "writing off an entire generation, perhaps two generations." And we are doing this because of our unwillingness to accept that the failure is actually our own. We researchers, clinicians, and policymakers have failed people who have obesity because it's easier to say "people just need self-control" than "we have done a terrible job defining this disease and developing treatments."

Passing the blame is simply unfair. We will only ever be able to "Treat Obesity Seriously" when we take responsibility for developing serious health-focused definitions, step away from body size stigma, and focus our energy on real, effective treatments.

The Researcher's Promise

I've had one of those days where I'm questioning whether researchers should even be allowed to present their findings to the general public.

It started with the report on the increase in autism rates. I don't want to minimize the devastating effects of autism on families. But it reaches a point that it defies credulity. A jump from 1 in 88 to 1 in 68? In two years? And with a nearly fourfold variation between the lowest and highest states? (Alabama and New Jersey. Can you think of some differences between Alabama and New Jersey to explain that?)

Another study reported that a third of school-age kids have borderline or high cholesterol. These were kids between 9-11, a time we know cholesterol increases naturally--and is probably a necessary increase. And we have no clue how or if this affects them as adults. (By the way, this was just a meeting abstract, not a peer-reviewed paper.)

And, of course, there's the study showing that toddler obesity plummeted, one with significant issues I've already written about. Another writer posted about it recently, raising a different set of (equally valid) problems. An interesting tidbit there was that the author of that piece was not giving media interviews. (And I'm trying to not be bitter that no one cared when I made my arguments a month ago!)

As a researcher, I've had to learn to understand the media, and learn to understand how to present my findings. I'm sure I've stumbled. But this is something we, as researchers, absolutely HAVE to learn--how to explain what we've found. And we have to be absolutely sure what we are presenting is accurate, not just statistically, but in how it gets presented.

Why is this so important? These three studies tell me 1) autism is increasing at a rate that will eventually make it the scourge of the US, 2) a third of kids need intensive cholesterol interventions, and 3) obesity is all better. None of these things are true. Autism prevalence is still a mystery tied up in diagnosis rates and societal norms for "disorder". The only kids who really have cholesterol problems are a small group with genetic hypercholesterolemia--the rest are probably just growing. Obesity, or whatever we want to call this increase in body size, is pretty much unchanged.

Our studies, when promoted in the media, are the foundation of public discourse. They determine the policies that get developed, the programs that get funded, how the public perceives health problems. Carefully putting information in the public domain is our responsibility. We work so hard to do good work and get it into the journals. But that is only the first step. Of course we don't have complete control over the media--but too many of us denigrate journalists as not understanding researchers. That's not true at all, in my experience. We, the researchers, seem to not understand the rest of the world.

I think we need a researcher's promise (with some inspiration from the Girl Scouts).

"On my honor, I promise to always try to ensure my work serves the people of this world, to take an active role in translating the message to non-researchers, and to generously offer my knowledge and time in making research have only a positive impact."

I'm willing to consider edits on that promise!

Be Wary of the Headlines: Has Toddler Obesity "Plummeted"?

Yesterday, a study was published showing the prevalence of obesity in children and adults over the last decade.

The headline that was commonly seen was "Toddler Obesity Plummets". This insinuates that the main story out of this study is that we are winning the "battle against obesity".

Let's look at two things: What the study says about toddler obesity and what it says overall.

First, the study did indeed find that toddler/preschool (ages 2-5) obesity in 2011-2012 is much lower than it was in 2003-2004. However, what it also showed is that the drop happened right after--in 2005-2006. In fact, if you look at the authors' previous work, you can see that it was much lower in 2001-2002. For some reason, 2003-2004 was anomaly in NHANES, or in obesity rates. The rates went from ~10% to ~14% to immediately back down to about ~10%.

To say that toddler obesity has plummeted in the last decade in disingenuous at best. It has only decreased when making the very specific comparison of one two-year cycle. The trend over the last decade is not significant. The authors do acknowledge the importance of the comparison, but do not discuss the very important difference in 2003-2004.

Second, although obesity in young children dominated the headlines, the paper actually examined children and adults at all ages. The real story of this paper, in my opinion? Nothing has changed. It hasn't changed for young children or teenagers, for young adults or older adults.

Don't let a shocking headline distract you.

A New Approach to Data?

We all know that new technologies are changing how we do research. One of the most interesting was first introduced to me several years ago by a student of mine, who was particularly interested in how social media spread information about health-related issues. The first goal was to see how accurate the information was, but I think it's becoming more and more obvious that social media can be used to identify things more quickly than traditional research methods.

A post by kottke shows a fascinating result of using Google to identify disease breakouts. This picture is the interesting point:

The Orange is US data, Blue is Google-based data.

The tracking of certain Google search terms is very, very close to CDC data. What appears to be happening, though, is that Google identifies the trends a couple of weeks before CDC data.

Potentially more interesting, though, is what this could mean for other types of disease outbreaks. The US has a good system for tracking certain infectious diseases, particularly flu. But what about for diseases or problems that are newly emerging? Can we use Google, or other social media, to identify problems before we even know there is a problem we should be looking for?

We haven't even begun to understand how we can make use of all of the data that are being generated by millions of individuals across the world. This is the true "new frontier" of research.