Should obesity be classified as a disease?

[PrincessFiona]

Should smoking be classified as a disease?

Isn't there a chemical addiction to tobacco?

So, yes. Imagine the savings from that!

[DCJenn]

I still say that for the majority of the people in this country the issue is economic, not whether there is a chemical or biological function involved.

I was a smoker- I loved,loved loved smoking. I would still be smoking to this day if I wasn't madly in love with my husband, who hates cigarettes more than I love them. Addictive- abso-freaking-lutely. Hooked me when I was 15 and I was an off and on smoker until I was 33. LOVED IT. I cannot even begin to describe to you all how much I love smoking. Still love it, still crave it, can still picture the first drag of the day and that cigarette in the car, the one at the beach and the one in the bar. (and look, my love for cigarettes has made me a poet)

So, if I develop lung cancer, you all will be paying for it- my insurance is through the Army. Is it fair? Nope. Did I make a bad decision? yep. and it is so addicting that I did the patch twice, guim twice, hipnotism once and any number of cold turkey times.

Food- there ARE chemical changes that happen when you eat- there are chemical changes to when you don't eat.

BUT if you can't afford the good stuff in the first place, and you have NO time to exercise- then there are problems chemistry has nothing to do with.

Jenn

[Auspicious]

eating as an addiction, Kelly? I don't buy it...unless you can bring the neurobiological data my way. Addiction implies not just a loss of control, but tolerance and withdrawal.

I feel that I have experienced both tolerance and withdrawl when it comes to food.

I can't really compare it to an addiction to a chemical substance because I've never experienced that, but I'm about 85 percent convinced that there's something chemical/biological going on when it comes to the compulsion to overeat. I predict the data is eventually going to show up. Because what makes one person weigh 300 pounds and another person weigh 600 pounds? Is it because the 300-pound person is in better contorl than the 600-pounder? No, I think that they're both totally out of control. The 300-pound person would probably be sickened by the amount of food that the 600-pound person had to eat to get that way. What makes different people sickened by different amounts of eating? There's something more going on there than just personal choices.

Which is not to say that I think we're all just victims of biology. Basically my theory is that there's a biological aspect, a cultural/family aspect, the socioeconomic aspect Jenn is talking about, and personal choice. Nature gives you a set of switches, and nurture flips them on or off. But personal choice can trump all if necessary.

[PrincessFiona]

Julie...to be quite honest....I've argueed myself into a box that I feel like I can't get out of...but I have had the same feelings in regards to overeating/binge-eating....sort of that ravenous, uncontrolled, shark-like eating feeling. Maybe my opposition to this is that medicare/medicaid will pay for it when many private insurance companies balk at paying for basic counseling for obesity and eating disorder related costs, etc.....defining obesity as a disease would likely change that from the perspective of insurance companies as well.

I'm going to go back through my notes and find the neurobiological data from UF and post it for us to browse through....

There have been some compelling arguments from the pro-side that I can't ignore...but if I change my opinion will you guys put a big ole' pancake house waffle as my avatar???


kris

[Auspicious]

I think being able to change one's mind is intellectually honest. Waffling is just doing what's convenient.

[houseelf]

MMM......WAFFLES.

I had better go hit up an IHOP right now.

Kelly

[PrincessFiona]

crack me up, Kelly!


Here are the fruits of my preliminary searches:

http://www.ncbi.nlm.nih.gov/entrez/quer ... ding=f1000

Opiate-like effects of sugar on gene expression in reward areas of the rat brain.

Spangler R, Wittkowski KM, Goddard NL, Avena NM, Hoebel BG, Leibowitz SF.

Laboratory of Behavioral Neuroscience, The Rockefeller University, 1230 York Avenue, New York, NY 10021, USA. rudolph.spangle@rockefeller.edu

Drugs abused by humans are thought to activate areas in the ventral striatum of the brain that engage the organism in important adaptive behaviors, such as eating. In support of this, we report here that striatal regions of sugar-dependent rats show alterations in dopamine and opioid mRNA levels similar to morphine-dependent rats. Specifically, after a chronic schedule of intermittent bingeing on a sucrose solution, mRNA levels for the D2 dopamine receptor, and the preproenkephalin and preprotachykinin genes were decreased in dopamine-receptive regions of the forebrain, while D3 dopamine receptor mRNA was increased. While morphine affects gene expression across the entire dopamine-receptive striatum, significant differences were detected in the effects of sugar on the nucleus accumbens and adjacent caudate-putamen. The effects of sugar on mRNA levels were of greater magnitude in the nucleus accumbens than in the caudate-putamen. These areas also showed clear differences in the interactions among the genes, especially between D3R and the other genes. This was revealed by a novel multivariate analysis method that identified cooperative interactions among genes, specifically in the nucleus accumbens but not the caudate-putamen. Finally, a role for these cooperative interactions in a load-sharing response to perturbations caused by sugar was supported by the finding of a different pattern of correlations between the genes in the two striatal regions. These findings support a major role for the nucleus accumbens in mediating the effects of naturally rewarding substances and extend an animal model for studying the common substrates of drug addiction and eating disorders.

http://www.ncbi.nlm.nih.gov/entrez/quer ... ding=f1000

Eating disorders with binge-eating behaviour are associated with the s allele of the 3'-UTR VNTR polymorphism of the dopamine transporter gene.

Shinohara M, Mizushima H, Hirano M, Shioe K, Nakazawa M, Hiejima Y, Ono Y, Kanba S.

Department of Neuropsychiatry, Graduate School of Medicine and Engineering, the University of Yamanashi, Nakakoma, Japan.

OBJECTIVE: The dopaminergic system is associated with feelings of pleasure and reward and with positive hedonic processes related to food, sexual activity and certain substances. Because it is recognized that patients who have eating disorders with binge-eating behaviour have a high comorbidity of substance dependence, we examined the association between the variable number of tandem repeats (VNTR) polymorphism in the 3; untranslated region of the dopamine transporter gene (DAT1) and eating disorders with binge-eating behaviour. METHODS: The subjects were 90 female Japanese patients with eating disorders diagnosed using DSM-IV; they were compared with 115 healthy female controls. Genomic DNA was extracted from whole blood, and standard polymerase chain reaction testing was performed. We compared the frequencies of a short allele (7 or 9 repeats) and a long allele (10 or 11 repeats) in both groups. RESULTS: In the group who had an eating disorder with binge-eating behaviour, the frequency of a short allele was significantly higher compared with the control group. CONCLUSION: It seems plausible that the association between the DAT1 VNTR and binge-eating behaviour indicates that dysregulation of dopamine reuptake may act as a common pathophysiologic mechanism in eating disorders with binge-eating behaviour and in disorders related to substance use.

(full text article is free, btw)

[PrincessFiona]

I'm changing my answer to maybe while I sort through more data.


:mrgreen

kris

[Sheherezade]

OK. Gotta post before Kris completely changes her mind.

I am also against stomach stapling as a common solution based on several reports I have read about complications. (Similar to Kris's info--I'd have to dig it out.) I think sometimes people are looking for a magic bullet and stomach stapling is the new "weapon of choice" in the war against obesity. I also agree that obesity results from myriad causes (behavioral, cultural, economic, and physical). For some, stapling will work and for others it will not. I don't think it is a clear medical model ala antibiotic/bacteria or surgery/appendicitis--I think the person's behavior after surgery significantly impacts treatment even if the treatment is rendered the same in each patient. This worries me because I feel our culture has such issues with weight/diet and seems to always be looking for a single "cure" to a multifaceted problem that probably has a different cure in each person. I don't like stomach stapling presented to the masses as a cure. (I do think it has been--not just for use in cases of extreme obesity, but in more "normal" obese people who would probably respond to other treatment more behavioral in nature....) It requires a new lifestyle after surgery---obesity treatment isn't over after you get the surgery. Is the new payment structure going to support the patients after the "procedure" phase is done? Will they get nutritional counseling, exercise support, therapy as needed, etc? Or will we just end up paying for complications when they occur?

Second problem. I have to agree with Kris that it makes me nuts this assigning everything a label of "disease" or "addiction". Maybe it is a science thing--the labels have more to do with working the system than with scientific "truth" about an issue. I understand the need to work the system, but it just rubs me the wrong way because the general population may not realize that something isn't technically "addiction" or a "disease" --we are just saying that to get payment. It just leads to more science illiteracy in a world growing more technical by the day. I feel that is the wrong education for the general public. I completely agree that prevention will save us money in the long run. I would like things to be paid for but not have to be called something they are not.

Third (and final ) problem. I think addiction and appetite are not well understood. I think we need to do much more research before we can make solid connections between obesity and addiction. It could be real, it could not. I just don't think the research is there yet, because neuroscience of both topics isn't there yet. I don't think we can jump to conclusions on this. One (or even 100!!) study on bits of this puzzle is not going to give us this answer. I'm betting you could pull up studies on both sides of the fence and poke tons of holes in all of them. This is not something we can call with science yet. (IMHO )

I am extremely in favor of preventative measures such as nutritionists and health clubs being sponsered by HMOs and insurance companies. I think they should reimburse and give some type of credits for weight loss etc. Stomach stapling may have its place as well with appropriate follow up care in extreme cases. I am just very wary of the current surgical obesity-fix climate and I think this classification is a result of it.

Just my two ( well, three or four..) cents.

Angie

[PrincessFiona]

I wondered if you were going to step in with your expertise Have no fear...I'm still at a maybe...I know that a few studies aren't enough to make a definitive conclusion. It certainly is an interesting direction to look though. I find it fascinating.

[Sheherezade]

And also --even if the whole obesity thing is neuro controlled through addiction or alternate metabolism or whatever--how would reducing the size of the stomach necessarily fix that?? (Now that I'm thinking about it..... ) Wouldn't you still have the underlying problem?

If it is addiction (classical) are we going to treat it with neurotropics or substitutions like methadone for heroin? If it is metobolic, do we know how to fix that? Either way, I don't think the "obesity as disease" hypotheses out there will lead to stomach stapling as the fix--unless there is research that shows that the majority of the obese have larger stomach volumes and this leads to increased appetite and overeating. ( I actually think I have seen that study....) It would surprise me if it ended up being so simple and universal. If it is a "disease" won't the stomach stapling be similar to treating alcoholism with antabuse but nothing else? I'm not sure that will address the underlying problem if it is biological--particularly metabolic. Although I guess reducing your food intake forever by force could be equated to learning to live with your disease

Maybe saying "obesity" is like "cancer"--many different diseases or conditions all traveling under one name. In order to treat them effectively you have to understand each case--some strictly behavioral, some economic, some a result of flaky metabolism, some from appetite disorders--the possible reasons could go on and on. I still think we are too early in the game to accurately define obesity and render medical treatment in a standard fashion.

Angie

[PrincessFiona]

Wouldn't you still have the underlying problem?

Yes...which is why I think that stomach stapling isn't the quick fix that many hope it will be. It would be interesting to see where the research leads on this topic and if there is ever some type of treatment based on 'biochemistry'...but I honestly have my doubts about it. Undertanding that a problem is related to metabolism and being able to pinpoint genetic/metabolic problems doesn't meant that we can come up with a safe/effective treatment....at least not in a very timely manner. 8)

I think the benefits of stomach stapling are that even if you have that metabolically induced 'must eat' craze...you can't....so you are limited by your anatomy...not your physiology?

The point where I could make an argument for stomach stapling (though I'm still strongly opposed) is that because we do not have the ability right now to tailor treatments to patients (and let's face it...even patients who undergo nutritional and psychological counseling have a poor long-term success rate) this is currently the only treatment that we have that has the highest success rate...don't somewhere around 85% of the people end up keeping the weight off in a stapling procedure?)

There are some larger societal issues at play here too...like the supersizing of all of our meals, etc. If I order a Cobb Salad at TGI, three people could eat from it!!! How about those 'big kids meals' now at burger king and mcdonalds? Also, in the schools the kids now have the option of ordering up to 3 meals in one day 8O and french fries have been reclassified as a vegetable.

Instead of looking at some of these issues and how they relate to obesity and childhood obesity we're eager to call this a 'disease'. Why is it that this new 'disease' has suddenly cropped up? Obesity rates are through the roof in this country in particular. Why do we have more 'obesity disease' than say people in Japan...and why is it that after fast food restaurants move into other countries that their incidence of this 'disease' goes up?

Why can't we be honest with ourselves...our portion sizes have become gradually larger over the years, we're supersizing ourselves into plus sizes and now we're doing it to our children too.

There are no quick fixes!

Kris

One thing that I have assumed in arguing for obesity being classified as a disease is that treatment of obesity itself (and not symptoms or consequences) would be successful. Perhaps it will not be. As I said earlier, there are programs with higher success rates available through Universities, etc that cost more than the average Weight Watchers sort of thing and emphasize exercise and long-term lifestyle changes. As Jenn points out, these programs aren't really an option for people with low incomes.
So, what if Medicare does start to pay for programs like these? Will people go? And be successful? Maybe having to shell out $1,000 or so of your own money gives a person more of a feeling of investment and incentive to stick to it. Along the lines of the addiction analogy, someone who is addicted to drugs or alcohol has to want to make a change themselves to be sober -- and having insurance cover treatment is usually not enough to make that change.

re: everything under the sun being classifed as a disease or disorder, such as shopping or gambling. I think I have read about some studies that show brain chemical changes or something in people who have addictive behaviors and "use" shopping or gambling. (Weak science background, my apologies for possibly incorrect terminology). Does that make it a legitimate disease -- something that a person is really at a ....chemical disadvantage...to suffer from? Or is this just medicalizing a lack of inhibition and self-control or a personality disorder? Would we all see some sort of brain chemical change when we shop or gamble -- or is more pronounced in people who have addictions to it? I think we will probably have better answers to this in 20 or 30 years.

[PrincessFiona]

The door is now open for medicare/caid to pay for a variety of diff. types of therapies.

But something like 85-95% of people who lose weight gain it within a year.
8O Very depressing. Imagine how expensive it will be to add the nutritional counseling, etc to medicare...only to have 85% of the people regain the weight. I'm starting to depress myself....

Interesting articles...

http://www.ama-assn.org/amednews/2001/0 ... sc0212.htm

http://www.naafa.org/press_room/rush.html

http://www.obgyn.net/NewsRx/womens_heal ... 004-22.asp