What’s next now that the AMA has declared obesity a disease?
■ The AMA’s classification is expected to influence changes in treatment, coverage, research and health policy.
By Christine S. Moyer — Posted July 1, 2013
Chicago Within a day of the American Medical Association declaring it a disease, obesity also captured attention on Capitol Hill.
Lawmakers introduced bipartisan bills in the Senate and House to lower health care costs and prevent chronic diseases by addressing the nation’s obesity epidemic.
Although the timing was coincidental, observers say the declaration by the AMA House of Delegates meeting in June probably will have a significant impact in adding momentum to policy, research and treatment approaches to obesity — including a new dimension in exam room conversations between doctors and patients.
Although the AMA is not the first medical organization to classify obesity as a disease — the National Institutes of Health did so in 1998 — its role as the nation’s leading physician organization means its policies often carry more clout with industry, insurers and lawmakers than do statements by other groups, according to some health leaders.
“The American Medical Association, I would argue, is the most important medical association in the country,” said Marlene B. Schwartz, PhD, acting director for the Rudd Center for Food Policy and Obesity at Yale University in New Haven, Conn. “For the AMA to take a position on this will have an influence on health care in the United States.”
The declaration already is sparking discussions among medical organizations about the biologic, environmental and genetic factors contributing to unhealthy weight. Such conversations are important, because obesity long has been attributed to poor behavior, which fueled stigma against the disease, health experts say.
“Many of us believe that this is going to propel a critical mass effect so that we will see a lot of action,” said Jeffrey I. Mechanick, MD, president of the American Assn. of Clinical Endocrinologists. He wrote the resolution on designating obesity as a disease with colleagues from his organization and others.
The new AMA policy comes as the nation’s obesity epidemic has skyrocketed to epic proportions, with more than a third of adults and 17% of youths age 2 to 19 considered obese, according to the Centers for Disease Control and Prevention. Researchers are projecting a dramatic increase in adult obesity and related health care costs by 2030 if the trend continues.
The seriousness and broad scope of the problem prompted Dr. Mechanick and others to introduce the resolution at the AMA meeting. Another contributing factor was a report by the AMA Council on Science and Public Health that recommended against classifying obesity as a disease.
Because of that report, “a lot of organizations feared the AMA would defer or simply not declare it a disease, which we felt was important,” said Dr. Mechanick, an endocrinologist and clinical professor of medicine at the Icahn School of Medicine at Mount Sinai in New York. There is “a contingent that believes obesity is a lifestyle or behavioral choice. … The AACE fervently opposes that. Obesity has the characteristic signs, symptoms and morbidities that qualify it as a disease.”
Hope that payment will improve
The Treat and Reduce Obesity Act, which lawmakers introduced June 19, would require Medicare to cover additional obesity treatments such as prescription drugs for chronic weight management and to make it easier to receive weight-loss counseling.
Although Medicare covers a series of primary care visits for obesity counseling among patients with a body mass index of 30 kg/m2 or greater, such appointments are not covered by most other insurers. As a result, physicians squeeze complicated discussions on improving diet, boosting physical activity and changing eating behaviors into short appointments that are scheduled for a separate health problem.
In such instances, physicians often code for conditions such as dysmetabolic syndrome or type 2 diabetes, Dr. Mechanick said. Although there’s a code for morbid obesity, a BMI above 40 kg/m2, he said it’s unclear how well it’s covered.
The AMA’s declaration is expected to improve physician payment for efforts to prevent and treat obesity, some medical experts say.
“When you identify something as a disease, it encourages insurance companies to cover proven treatments,” said Jeffrey Cain, MD, president of the American Academy of Family Physicians.
But Susan Pisano, spokeswoman for America’s Health Insurance Plans, said classification doesn’t affect coverage.
“Whether you call something a disease, or a risk factor, or a condition, what’s going to change coverage is going to be evidence that a particular treatment is safe and effective,” she said.
Such evidence for obesity prevention and treatment strategies are expected to become more abundant due to increased research funding following the AMA’s declaration.
“If [obesity] is taken more seriously, it would make sense for the government to provide more research funding … to really identify the types of changes that need to occur” and treatments that need to be implemented to effectively address the obesity epidemic, Schwartz said.
Reservations about impact
Some physicians remain skeptical, however, that the classification will result in improved health consequences. Robert A. Gilchick, MD, MPH, a member of the AMA Council on Science and Public Health, said he’s concerned about the implication of labeling the nation’s nearly 75 million obese adults as having a disease, even if an individual isn’t sick.
Another concern of some health professionals is that there will be an increased emphasis on treating the disease with medication and surgery rather than improving diet and boosting physical activity. Two new obesity drugs came to the market in 2012 — Belviq (lorcaserin), which is manufactured by Arena Pharmaceuticals, and Qsymia (phentermine/topiramate) by Vivus Inc.
AMA President Ardis Dee Hoven, MD, said the classification would not lead physicians to prescribe medicine improperly for obesity. “We have the capacity to determine what’s best for our particular patients,” she said.
The classification fits in perfectly with the first phase of the AMA’s initiative to improve health outcomes by preventing cardiovascular disease and type 2 diabetes, said Dr. Hoven, an internal medicine and infectious diseases specialist in Lexington, Ky.
“Obesity is a big risk factor” in those conditions, Dr. Hoven said. She added, “In the past, we talked about diet and exercise, but we’re missing something. We have to figure out what we can do to keep people from becoming obese.”
A key step to preventing obesity is screening, just as physicians screen patients for diabetes and hypertension, Dr. Mechanick said. Beyond calculating patients’ BMI, he encourages doctors to ask all patients about their risk factors for developing obesity. Such factors include having obese family members, sitting for prolonged periods, having unhealthy eating habits and using medications that can promote weight gain, he added.
He suggests screening for obesity at least annually in low-risk patients and more frequently in those with multiple risk factors. This recommendation is part of the AACE’s type 2 diabetes treatment algorithm, published in the March/April issue of Endocrine Practice.
“When you screen for obesity, not only do you pick up obese patients with a high risk of obesity-related complications, but you now have a disease that you can prevent,” Dr. Mechanick said.
During the next few years, the Rudd Center probably will monitor how the classification is affecting doctors’ feelings toward obese patients, Schwartz said.
Despite the nation’s obesity rate, studies show some doctors have biases toward obese patients. For example, a 2009 Journal of General Internal Medicine study of 40 Baltimore-area physicians and 238 of their patients found that doctors have lower respect for patients with high BMIs.
Schwartz expects that the AMA’s declaration will lead to improved physician attitudes toward patients who are an unhealthy weight.
“When you say obesity is a disease … it has the potential to remove the stigma, because you start seeing it as a place where people need help,” she said.
Schwartz encouraged physicians to help these people, rather than just telling them to “push away from the table.”