What Is a Disease, or: Is Obesity a Disease, and Why? (Column 146)

With God's help

Well, they served it up for me again, so forgive me if I couldn't resist. I just saw an article by Revital Blumenfeld discussing whether obesity is a disease. To be sure, one should know that the headline and subheadline are usually supplied by the editorial desk and not by the reporter, but even so, the folly of these headlines displays the problem in all its splendid nakedness:

 

Factually incorrect: Public health physicians oppose defining obesity as a disease  The Association of Public Health Physicians expressed opposition to the decision of the Medical Association and the Society for the Study and Treatment of Obesity, which last month declared obesity an epidemic. The Association emphasized that the definition creates a stigma for those coping with obesity and proposed working to subsidize healthy food and tax harmful food products.

 

'Factually,' no less! Well, one does not argue with science. So which of these 'scientific' determinations is the one that is 'factually' correct, that of the Association of Public Health Physicians or that of the Medical Association and the Society for the Study and Treatment of Obesity?

We are used to reading things like this and moving on, but it gets me every time. If this were merely the foolishness of a reporter, or of some editor at Walla, I would have kept quiet. But since I have already seen more than once that this folly and lack of understanding also characterize expert and intelligent physicians, who time and again turn out not to have the faintest idea about their own field of expertise (more precisely, about defining that field)[1], it is worth examining and discussing. I should just preface this with a disclosure: after the bariatric surgery I underwent, I am no longer an interested party J.

Brief recap of previous installments

I will not go back over the principles here in detail, since I have explained them more than once, especially in the context of homosexuality but also with regard to disease in general. See, for example, my debate with Prof. Yoram Yovel in columns 25 and 26, and my comments on homosexuality and the Medical Association (yes, that same collection of witless people again) in column 16 and at the end of column 73.

In short, I explained there that there is no way whatsoever to determine scientifically whether some condition is a disease or not. This is either a purely normative determination, which has nothing whatever to do with science, or else an empty definition devoid of meaning. Science can of course stipulate some definition for the concept, but it will have no value-laden or practical implications. Kant already taught us, in his critique of the ontological proof, that a definition is a definition and nothing more. As for the concept of disease in its ordinary and relevant sense (not the scientific one), science can of course determine what causes it, how it is treated, and what the risks are in each treatment. It can also examine and discover whether it is hereditary, whether it is contagious, and the like. All of these are scientific questions, and even if the information about them is not always available today, in principle these are questions entrusted to scientific research. If information is missing, that simply calls for more scientific research. By contrast, the question whether some phenomenon is a disease is a value-laden, normative question, and as such it is given over to the judgment of the public or of each one of us. If we do not want this state of affairs, it is a disease. If it is good for us, it is not a disease. Does that sound Foucauldian to you?[2] Indeed, as I have mentioned more than once, even a stopped clock shows the correct time twice a day.

You might expect me to say that these are my views and positions, but I am careful not to write that. These are simple facts, not views or positions. There is no way to argue about this, and anyone who does so, whatever his academic title or office may be (especially if he is the head of the Medical Association, as you can see in the columns above), simply has no idea what he is talking about.

Let me sharpen the point further: I am not claiming that the DSM (=the psychiatric diagnostic manual; in plain Hebrew: the list of diseases) is a scientific fact beyond dispute. What I am claiming is that DSM manuals reflect values, not facts, and therefore a professional has no added value in the discussion of what should be included in them and what should not. He can of course express his own view on whether homosexuality is a disease or not, exactly as I can. I am not claiming that I am more qualified than he is, only that I am no less qualified than he is. And I further claim that if he drags his professional hat into this, then he is simply mistaken and misleading others.

Back to the question of obesity: my motivation for this discussion

As I already noted in the above sources, these points hold true with respect to organic and physical diseases as well, not only mental illnesses. This is true of the physiological 'DSM manuals' too, not only the psychiatric ones. There is, however, a certain difference between the fields. With respect to physical diseases, the social determination is more consensual: almost all of us do not want to die, and do not want to be in pain or to suffer, so we usually agree that whatever causes these things is a disease and whatever does not is not. Hence it is reasonable to leave the determination of what counts as a disease in the physical realm to physicians, because there is no dispute about the value-laden normative dimension involved, and all that remains is to make the professional determinations (what endangers our lives and our quality of life, and what does not). In the mental realm, by contrast, the situation is more delicate and less consensual. The value dimension is not always agreed upon (as, for example, with regard to homosexuality), and therefore it is not right to let professionals determine it there.[3]

In my experience, people find this claim absurd and implausible. It is obvious to them that, at least in the case of organic diseases, this is a purely professional determination (and most of them think the same is true of mental illness). Then came the discussion of obesity and slapped them in the face. Obesity is an excellent example of my claims, and that is why I return to them here once again. I want to illustrate my arguments through the discussion of obesity. Since I have already clarified the theory and conceptual analysis quite thoroughly elsewhere, I will not repeat them here. All that remains for me is to read the article critically, and that is exactly what I shall now do.

An annotated reading of the article

The article opens with the following report:

The Association of Public Health Physicians today (Monday) expressed opposition to the decision of the Medical Association and the Society for the Study and Treatment of Obesity, which last month declared obesity a disease. The Association published a detailed position paper according to which, although this decision joined decisions made by international health organizations – among them the American Medical Association, the World Health Organization, and the World Obesity Federation – defining obesity as a disease is a move subject to ongoing scientific controversy.

This is 'a move subject to ongoing scientific controversy.' From this one could understand that the relevant facts are not yet fully known, and so there is still debate about them. The physicians' association warns against hasty decisions that do not rest on complete information. They are surely calling on us to wait for comprehensive research that will clarify the facts. That can certainly happen in any scientific field. After all, there is almost no context in which we are equipped with the full facts, and therefore there is certainly room for factual-scientific disagreement between disciplines and between people of differing views. In such a case, one should present the two scientific possibilities and try to decide between them by empirical test. We first need to understand the scientific theory of each side. What are the disputed facts and what does each side think? Then we can try to move forward.

All right, let us keep reading:

In last month's announcement, it was determined that obesity is not only a disease but an epidemic. Obesity is the fifth most common cause of death in the world, and according to estimates, about 2.8 million people die every year from excess weight. The probability that an obese person will reach age 70 is only 70%. The Medical Association and the Society for the Study and Treatment of Obesity reported that only 10% of people who reduced weight by changing their lifestyle alone succeeded in maintaining the weight reduction for a year. Therefore, the organizations decided that a person suffering from obesity needs comprehensive counseling and treatment in order to change his condition.

For the time being we are still in the realm of statistical facts and not on the scientific plane at issue. I get the impression that none of these facts is disputed between the sides. From the continuation of the article, it is clear that the Association of Public Health Physicians does not object to these factual descriptions either. So why, in their opinion, is this not a disease?

Patience; we must keep reading:

The rationale for defining obesity as a disease is based on several factors: raising the awareness of treating physicians that this is a problem requiring attention; an attempt to remove the stigma from those suffering from obesity; encouraging investment of resources in research; and prodding pharmaceutical companies to find a drug for the phenomenon.

Here I am already stuck. After all, above we learned that the definition of disease is scientific-factual, whereas here only social motivations are presented for why one should or should not vote to label something a disease. All these are reasons to insert the definition of obesity as a disease into the medical diagnostic manual. But they cannot be the reasons why it actually is a disease. Is the desire to remove a stigma a scientific reason to define something as a disease? (Incidentally, I did not really understand why defining something as a disease necessarily removes stigma. Some would say that it does precisely the opposite.) I remind you of what we saw in the statements and headlines cited above: the dispute is scientific-factual. And in the subtext, the determination whether something is a disease is scientific-factual. The reasons given in this paragraph do not belong to that category.

So why, really, does the Association of Public Health Physicians oppose this entire blessed move? Do they not agree with the benefits described here? Do they not want to reduce stigma or encourage the allocation of resources? Presumably the dispute is scientific. Apparently they have scientific arguments indicating that obesity is not a disease, and therefore in their opinion these benefits should be achieved in some other way and not by defining obesity as a disease.

And indeed, that is immediately clarified at the start of the next paragraph. Let us keep reading:

The Association of Public Health Physicians in Israel welcomes the spotlight being directed at obesity as a central problem in public health and the opening of a discussion regarding the definition of obesity and how it should be addressed. At the same time, however, the Association warns against defining obesity as a disease and limiting its treatment to the medical arena alone, while ignoring critical social and environmental aspects. Proper treatment of the problem of obesity requires a broad approach that includes changes in the personal, social, environmental, and economic spheres.

The definition of obesity as a disease has medical significance for the health system, the medical teams, and also for the patient himself, and it is intended to state clearly that people suffering from obesity need medical help and counseling. The definition states that obesity is a chronic disease stemming from malfunctioning psychological and genetic mechanisms and not from behavioral failure. Therefore, the Medical Association and the Society for the Study and Treatment of Obesity called for the establishment of a national system for treating obesity, for the establishment of clinics for treating obesity disease in hospitals and in the community, and for making all proven medical treatments accessible through the health basket.

The Association welcomes the spotlight and the need to treat obesity. That is, it agrees with what has been said so far. So why, nevertheless, is this not a disease in its view? It seems mainly because of the social and public implications (see below as well). This is still not a factual-scientific disagreement, of course.

However, one should note that this passage already hints at a certain disagreement that does touch on a scientific point. The claim of those who hold that obesity is a disease is based on the following definition of disease: disease is rooted in malfunctioning psychological-genetic mechanisms and not in behavioral failure. The subtextual assumption is that behavioral failure is not a disease.

And what does the Association think? Here it comes:

However, the Association of Public Health Physicians did not agree with the far-reaching decision and noted that although the prevalence of obesity is indeed rising, the prevailing approach of relating to obesity as an individual behavioral problem has proved mistaken, in their words. They added that today it is known that obesity is a complex interaction of genetic, environmental, and other factors, not all of which are under the individual's control. The Association illustrated that diets intended to treat obesity through controlled reduction of calories often fail, because they address only one factor in the problem.

The Association explained that obesity in itself is not a disease, but a physiological adaptation of the body to circumstances in which there is excessive calorie consumption. The Association further noted that obesity is indeed associated with a high prevalence of chronic illness, but one cannot posit an equation according to which an obese person is sick, because that is an incorrect definition. Moreover, moderate obesity also has survival advantages in old age.

They hold that this is the result of a complex interaction between genetic, environmental, and other factors, not all of them under the individual's control. Fine, but above we saw that their opponents agree with that too, did we not? They too hold that this is a genetic phenomenon that has nothing to do with behavioral failure. So what is the dispute about?

You will say I am being petty. Surely there was some typo here. To explain why there is a principled claim here, I challenge you: try to determine by your own reasoning which side says what. I am willing to bet you will not succeed, because the question whether there is here a behavioral problem, a genetic one, or a combination of the two, has nothing whatsoever to do with defining obesity as a disease, of course. Either side can support any of those views (and therefore it is not very surprising that this confusion occurred).

The initial tendency is to think that if obesity has genetic causes, then it is a disease, and if it is a behavioral failure, then it is not. That can of course be a definition in the medical dictionary, since there is no point in arguing about definitions. But I do not see any practical implications to that definition. Both this and that require treatment, since the problematic consequences described above (the danger of mortality and the inability of most human beings to cope with it without help) are agreed upon by everyone. At most, there may be a dispute about the proper form of treatment, but what does that have to do with defining obesity as a disease? Is there anyone here who thinks that dietitians, psychologists, or physicians are not supposed to help us with this? So what is the dispute about?

As an aside, I will add that I did not understand at all the argument at the end of the paragraph about moderate obesity. Let them define moderate obesity as health and non-moderate obesity as disease. Why is that an argument against defining obesity in general as a disease? After all, a reasonable amount of sugar is not a disease but a vital bodily need, yet a high sugar level is a disease. So is diabetes not a disease either? And in general, what is moderate obesity? If this is a healthy condition, perhaps it would be more accurate to call it non-obesity. Who decided from what point some condition may already be called obesity? Just as a normal sugar level is not called diabetes at a low level. It is simply not diabetes at all.

Surely you will not be surprised to discover that the article now hastens to abandon the stormy scientific plane and returns to the social parameters (which of course merely accompany the deep and objective scientific discussion described above):

The Association further argues that defining obesity as a disease actually narrows the overall approach to the problem, removes responsibility from a whole range of factors responsible for it, and places it at the doorstep of the health system, which currently has no real solutions. The systems that, according to the Association of Public Health Physicians, should take part in treating the problem of obesity include, for example, the food industry, the education systems, the employment sector, the Ministry of Transport, and the local authorities. In addition, the Association explained that defining obesity as a disease also removes responsibility from those coping with it.

The position paper further noted that defining the phenomenon as a disease has considerable significance on the social plane of stigma, since in this way about 18% of the adult population in Israel became patients overnight. The stigma of 'disease' has negative effects on health and ethical planes, and also economically – in terms of health-insurance payments.

These are foolish claims, of course. Does the fact that some food causes disease exempt food companies from responsibility? Why? Cancer too is a disease, and yet we still have demands and assign responsibility to cigarette companies. In any case, what has all this to do with the scientific claim (which is supposed to determine whether this is a disease)? If it is a disease, then all these claims are irrelevant; and if it is not a disease, then even without these claims it is still wrong to call it a disease.

Moreover, did it happen only by chance that those who think it is a disease believe that the social consequences do not exist or are not important, whereas those who think it is not a disease point to the social consequences? How does this fascinating correlation arise between two independent questions?[4] And in general I wonder how it came about that the thousands of physicians who belong to the Association all converged around one set of independent scientific and social conjectures, whereas their colleagues who belong to the Medical Association all converged around the opposite set. Strange, is it not?

And here is another independent dispute that 'just happens' to line up with the parties' other arguments:

The Association concluded that defining obesity as a disease is a mistake that is not factually correct, and that in that case smoking, alcohol consumption, and prolonged sitting could also be defined as diseases. They agreed that there is a national obligation to address obesity in a comprehensive way and to implement policy that promotes a healthy lifestyle in all areas of life. Accordingly, the Association proposed not to make do with medical solutions and with encouraging the public to choose correctly by means of labeling unhealthy foods, but rather that the state should prohibit the advertising and marketing of harmful food, subsidize healthy food, and impose taxes on harmful or sweetened food.

Why, indeed, are smoking, prolonged sitting, and alcohol consumption not diseases? Are scientific criteria involved here as well? More likely, society does not define them as disease simply because these are accepted and normative actions. And indeed eating and obesity (to a degree) are such things too, but that is not a scientific argument; it is a social-normative one. Anyone can make that claim, not necessarily one physicians' association or another. But it is interesting that the dispute over it is being conducted between two physicians' associations that just happen to differ both in a scientific-factual dispute and in social-normative disputes. Along these three supposedly independent axes of disagreement, a truly surprising phenomenon occurs: all the hundreds or thousands of physicians who belong to the Association think X, and all the thousands of physicians who belong to the Medical Association think Y. Are there physicians who belong to both associations? I see no reason there should not be. I wonder what they think.

Summary and conclusions

The basis of the dispute here is not on the scientific plane but on the social one. Questions such as what the label of disease will bring about, or what consequences this definition will have on the social and personal planes, are social-normative questions and not scientific ones. The dispute on these planes is of course legitimate, but it has absolutely nothing to do with science and scientific facts, and therefore there is no significant added value to the positions of different physicians' associations. Still less plausible is the idea that positions on these issues should divide according to membership in different medical guilds. The clustering of physicians and the adoption of a collective position on medical and other issues arouse discomfort. It indicates that this is not a scientific-medical dispute but a social-normative one. As stated, this is a legitimate dispute, but physicians' associations have no special standing in it, and it is wrong to present it as a scientific dispute.

So why do they do this? My feeling is that presenting the dispute as a medical-scientific dispute is tendentious, and at least partly deliberate. It enables physicians to take for themselves the mandate to express an authorized and binding view, and to exclude the rest of the public from the debate without any justification. The same thing happened in the cases described in the columns to which I referred above (regarding homosexuality).

True, one cannot ignore some scientific dispute that was described above. After all, there was some reference here to scientific questions, and ostensibly there is a scientific-factual basis for the discussion. But when we examine it, we see that the statistical facts are agreed upon (how dangerous obesity is, and to what extent it can be dealt with without assistance, etc.). There is apparently some dispute over whether obesity is the result of some genetic defect, or behavioral failure, or a combination of the two (it is quite clear that this is the correct answer, and there is no universal prescription that is right for all people. Therefore this dispute too seems rather idiotic to me). In any case, even with respect to these questions I get the impression that there are no clear and agreed-upon facts (as we saw regarding many scientific details in connection with homosexuality), and therefore each side tendentiously recruits the partial facts that suit its position.

But above all, it is really not clear to me why any of this matters to the issue of the definition as a disease. The question whether it is genetic or behavioral probably bears on the forms of treatment and the chances of success, but either way there is no obstacle to defining it as a disease. Why are phenomena rooted in genetics diseases, whereas those rooted in behavioral failure are not? Or the opposite (depending on how you correct the typo above). If it bothers us, it is a disease; and if not, then not. My height too is the result of genetics, and yet no one proposes defining it as a disease. It will be defined as a disease the moment it starts bothering me.

Ironically, my conclusion is that the social consequences are actually a much better reason to define obesity as a disease than its genetic source. If society does not want it, then it is indeed a disease. If so, I actually agree with part of the presentation of the dispute (although the semantic question of what a disease is seems to me pointless and meaningless); I simply object to treating it as a scientific-factual dispute. It is a value-laden, normative, social dispute, and as such society should decide it, not one physicians' association or another.

[1] This is a common phenomenon: experts in various scientific fields display insensitivity and even ignorance regarding the methodological, conceptual, and philosophical foundations of their own fields. See several examples in my books The Science of Freedom and God Plays Dice.

[2] Foucault, one of the heralds of postmodernity, is known for his challenge to psychiatric diagnosis, and especially for his claim that it is culture- and value-dependent (especially in his book History of Madness in the Age of Reason). You may be surprised, but despite his being a loathsome postmodern rebel, he is entirely right about this.

[3] Usually they do not wait for us to grant it to them, but feel that this mandate is entrusted to them by virtue of their education and role, and precisely for that reason it is so important to make this egregious mistake clear to them.

[4] On spurious correlations, see in column 1 (I returned to this several times in later columns).