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Weighty disease: Handling of obese patients by doctors, insurers may change with new AMA label


Chattanooga Times Free Press (TN)

06-21-13

June 20--Obesity is a disease, the American Medical Association decided this week, and that new label could change the way doctors and insurers handle obese patients, local bariatric experts said.

The new classification could encourage doctors to create serious treatment plans for extremely overweight patients and put pressure on insurance providers to expand bariatric coverage.

"You have another organization of really smart people who are saying this is a disease and we should treat it just like any other disease," said Chris Sanborn, director of metabolic and bariatric surgery at Erlanger hospital. "It's the culmination of scientific evidence and people analyzing the evidence, and now we can more easily treat obesity like a disease -- because it is one."

There's no doubt obesity is a major public health issue in the United States. One-third of American adults are obese, according to the Centers for Disease Control and Prevention. In 2008, medical costs associated with obesity hit $147 billion, the CDC reported. Obesity is linked to dozens of other health problems, like heart disease, diabetes and cancer.

Yet the medical community's current approach to treating obesity isn't working, said Tennessee Medical Association President Chris Young.

"I think [the decision] expresses physicians' frustration that we have this growing problem and what we've done thus far hasn't worked to try to control it," he said, adding that the American Medical Association includes more than 500 voting delegates.

"I've heard proponents say that not treating obesity as a disease because people eat too much is like calling lung cancer not a disease because people smoke," he said. "It is a condition that has a real impact on people's health."

That analogy doesn't quite hit the nail on the head for Jack Rutledge, a metabolic and weight loss surgeon at Memorial Hospital. Smoking is a choice, he said, but obesity, while it can be exacerbated by choices, starts with a biological regulation of how much fat the body is set to carry.

That biological regulation sets the ground level for what amount of fat the body considers normal. Some people, he said, are genetically set up to carry more fat than others. And if a patient is genetically set up to carry more, the body won't lose that extra fat through exercise and diet alone.

"We think, 'Oh the amount of fat we carry is up to us," he said. "The general thought about obesity is that people are lazy, they don't push back from the table, they don't change their habits. But the explanation has come through genetics."

He expects that the American Medical Association's decision to call obesity a disease will push primary care physicians to discuss treatment options with patients more regularly.

"What's happening now is that they don't talk about it at all," he said. "It's so awkward. It's so offensive. And they don't have answers for these people."

Medicalizing obesity could open up a wider range of options for obese patients, like drug treatments or surgery, he said. But opponents argue it could drive up treatment costs and increase patient reliance on medical solutions in situations where just plain diet and exercise could have done the trick.

"When something is labeled a disease, the American people seem to embrace that idea and say 'Oh I have a disease. It's not my responsiblity to fix it. It's the health care system's responsibility," said Ed Jones, owner of Nutrition World in Chattanooga. "And that's the crux of the problem ... they didn't assume responsiblity to begin with. If it was my vote, I'd say it's not a disease. It happens because of choices we make each and every day."

Jones isn't alone in his hesitation to call obesity a disease. Even the Council on Science and Public Health, a committee that prepares reports for the American Medical Association, recommended against labeling obesity a disease before the vote Tuesday -- because both "obesity" and "disease" are vague terms without widely-accepted definitions.

Body Mass Index, calculated from a person's height and weight, has been used to determine whether a person is obese -- anything over 30 counts. But it's not an accurate measure for every individual. Some people with BMIs above 30 are not obese, Young said.

If doctors and insurance providers do recognize obesity as a disease, they'll have to decide what, exactly, qualifies a person as obese. Both Cigna and BlueCross Blue Shield of Tennessee said they aren't making any immediate policy changes because of the American Medical Association's announcement.

"I don't think labeling it as a disease is likely to have a large impact, and it's not likely to change what treatments health insurers cover," said Julie Kessel, senior medical director for coverage at Cigna, adding later, "It's possible that more employers will opt to include bariatric surgery now that it's being classified as a disease, but we have no way of knowing that now. It's too soon to tell."

At BlueCross, regional medical director John Wright said the company takes the classification seriously.

"We feel the AMA's decision is significant because it brings added recognition to obesity and the severity of the health problems linked to this disease," he said, adding, "While we don't see any immediate changes to our policies due to this announcement from the AMA, it certainly requires ongoing review and study of the recommendations."

North Alabama resident Muriel Gaskell, who hit 254 pounds before having gastric bypass surgery to get back down to 150, believes obesity is a mix of choices and hereditary predisposition.

"I had tried everything," she said. "I'd tried diet pills, eating salad weeks on end, diet shakes. I had a gym buddy and I was there for two hours a day. I hit that 60 pound loss and it just didn't move after that, for about a year."

She grew up with a single working mom who tended to leave her $10 for dinner instead of cooking healthy meals. Her mom and her grandfather were both overweight.

"I didn't eat vegetables until I was 18," she said. "I think if I had made better choices I might not have gained the weight."

But she added, she thinks the factors that lead to obesity vary from person to person.

"It's hard to say so and so is being fat and lazy because some of the fattest people I know were at the gym working harder than the skinny girls," she said. "And that's not laziness. That's their body not being able to get rid of what they need to get rid of."

Contact staff writer Shelly Bradbury at sbradbury@timesfreepress.com or 423-757-6525.

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