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Obesity, a Fledgling Disease, Needs Physician Support

 |  By jcantlupe@healthleadersmedia.com  
   August 01, 2013

If physicians don't start having serious dialogues with their overweight patients, the American Medical Association's recent classification of obesity as a disease won't mean much at all.

So, America is heavyset. It's husky, unslender, and thin-challenged.

What's in a name? As more Americans are tipping the scales toward obesity, the American Medical Association says that another name is linked to obesity and that name is: disease.

Delegates at the AMA's annual meeting last month voted to recognize obesity as a disease, elevating it from its previous status as just another health concern. Proponents hope the move will prompt reimbursement changes that may allow physicians to take more time to discuss obesity with patients and advise them to change their diets.

But not everyone agrees with the shift, and some are wondering whether the AMA is missing the point because of the complexities of obesity. Critics also note that one of the AMA's key committees even recommended against declaring obesity a disease because of different definitions being used for body mass.

Michael Nusbaum, MD, medical director of the Obesity Treatment Centers of New Jersey, doesn't think so. How ironic, he says, that the Patient Protection and Affordable Care Act doesn't treat obesity as a disease. By omitting it from essential benefits, tens of millions of Americans "are disenfranchised from the healthcare system," he told me.

He says the Centers for Medicare & Medicaid Services and insurance plans should "wake up and admit it's a disease; it needs to be treated like a disease and covered like a disease."

Yet Andrew Weil, MD, a best-selling author on health and eating, disagrees, saying on his Web site, "I do not consider obesity a disease." Instead, he sees it as "a condition that may increase risk of certain diseases. It is possible to be obese and healthy – if one eats a balanced diet, gets regular physical activity, attends to other aspects of lifestyle that influence health and makes use of appropriate preventive medical services," Weil writes. He declined an email request for comment.

Controversy notwithstanding, with its latest move, the AMA hopes put pressure on insurers to cover the diagnosis of obesity.

The Centers for Disease Control and Prevention estimates that more than 65% of adults over age 20 are overweight. At least 30 million Americans have diabetes, also linked to obesity. For obese patients, there also is an increased risk of heart disease, stroke, high blood pressure, high cholesterol, kidney, and gallbladder disease. Moreover, 17% of children are considered obese.

"We know the health consequences and financial burden of obesity on our country is devastating," says AMA board member Patrice A. Harris, MD. "As physicians who are on the front line treating this disease, we seek to elevate this issue and get people to pay attention to the seriousness of the situation, which was one motivating factor in adopting the new policy."

Since the AMA's decision, it has "sparked a public conversation about obesity and its health consequences," Harris adds.

"This classification changes the way physicians and the medical community will talk about obesity with their patients," she adds. "For instances, physicians previously had conversations with their patients about treating obesity's health implications, but this designation helps physicians to talk about obesity in and of itself."

Among the obstacles are different views of what constitutes obesity, especially in terms of body mass index. While the AMA believes a body mass index of 30 or greater should be considered obese, CMS holds to a different number, 35.

There have been major disagreements within the AMA itself, with the organization's Council on Science and Public Health voting against obesity being defined as a disease, in part because of various measures trying to define it.

"While recognizing the important public health implications of the obesity epidemic, the council was reluctant to identify obesity as a disease," Harris says. "Rather, they opted to reaffirm some important AMA obesity policies." The AMA's House of Delegates acknowledged the Council on Science and Public Health's position, she adds.

During the debate on the resolution, "physicians in the (House of Delegates) considered all the information in front of them, including the council report and testimony presented by various physicians, state and specialty societies," Harris says. "The council supports the view that the most important task moving forward is for the nation to do a better job of addressing the obesity epidemic."

After the AMA declared obesity as a disease, legislation was introduced in the U.S Senate and House of Representatives that would require Medicare to cover more obesity treatment costs. The proposed Treat and Reduce Obesity Act, focuses on payments for prescription drugs for weight management and allows providers to be financed to offer intensive behavioral counseling for obese patients.

Whether CMS will declare obesity a disease remains to be seen. The AMA "cannot predict what, if anything, CMS will do in response to the adoption of this AMA policy," Harris says. "While the AMA is not the authority that dictates insurance coverage of procedures and treatments, this policy could potentially encourage the government and other third-party payers to increase their coverage of obesity-related services."

Paul Teitelbaum, a healthcare expert and managing director with Mesirow Financial's investment banking group in Chicago, told me the AMA's action is significant because there will be "an increase in investment and strategic" decisions directed toward medical device innovation for obesity treatment.

All this is certainly well and good. But discussions between patients and physicians may be the most helpful tool for treating obesity. And so far, many physicians haven't done an effective job in treating obese patients.

For one thing, many doctors don't tell patients they have a weight problem that needs to be addressed. An Archives of Internal Medicine study found that only one-third of 5,500 patients who were obese and 55% of overweight participants were told by a doctor about their weight issues.  Moreover, only 30 to 40% of family practitioners compute their patients' body mass index on a regular basis, according to the American Academy of Family Physicians.

At the same time, studies show some doctors have biases toward obese patients. A 2009 Journal of General Internal Medicine study showed that 40 Baltimore area physicians and 238 of their patients found that doctors have a lower respect for patients with higher BMI.

That's no way to help patients.

Harris of the AMA is convinced, however, that characterizing obesity as a disease will spur much-needed changes in treatment of the condition.

"Recognizing obesity as a disease will encourage patients and physicians to have candid conversations about their weight, and also about other key health indicators like blood pressure, blood sugar, and cholesterol levels," she says.

"This will help to facilitate a dialogue between patients and physicians to determine which behavioral, medicinal or surgical options may be right for each patient," she adds.

If physicians don't have that "dialogue" with patients, the AMA's characterization of obesity as a disease won't mean much, and will be pretty much forgotten, especially if funding for treatment of obesity isn't improved.

Joe Cantlupe is a senior editor with HealthLeaders Media Online.
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