Obesity Is A 'Disease.' Now What?
CELESTE HEADLEE, HOST:
This is TELL ME MORE from NPR News. I'm Celeste Headlee. Michel Martin is away. Coming up, you've heard about gay marriage and affirmative action cases before the Supreme Court, but we'll talk about another important case that isn't getting a lot of attention, in just a few minutes. But first, over the past few decades, obesity has become a serious health care issue in the United States. The obesity rate was 13 percent in 1962; it now stands at 34 percent of adults, and 17 percent of children.
As a health condition, it costs the country nearly $150 billion every year. But obesity is not just a health condition anymore - at least, according to the American Medical Association. The nation's largest group of doctors voted this week to classify obesity as a disease. And here to help us understand the implications of that change, we have Dr. David Kessler. He's the former commissioner of the Food and Drug Association and author of the book "The End of Overeating." Doctor, welcome to the show.
DAVID KESSLER: Thank you for having me.
HEADLEE: As I understand, we don't actually have a universally accepted definition of disease. So what does it mean when the AMA uses that label?
KESSLER: Well, I have to admit that I Googled the term before I walked into the studio. So let me give you the definition. A disease is an abnormal condition that affects the body of an organism - an abnormal condition. Certainly, obesity affects the body, no question. Is it an abnormal condition?
HEADLEE: Is it?
KESSLER: Well, if you take fat, sugar and salt; put it on every corner; make it available 24/7 - make it acceptable to eat anytime; allow people to walk in and eat, virtually, in an unlimited way - we're living in a food carnival. Is that abnormal with what we have done? Isn't that an adaptation of how our body works?
HEADLEE: But the AMA's own Council on Science and Public Health advised against making this change, and their argument is that there's not really a reliable diagnostic tool. Right now, many people use BMI - or body mass index - but that's flawed. Somebody with a very healthy BMI could actually have health problems associated with obesity. Somebody with a BMI that raises red flags could be perfectly healthy. So how do we tell, medically, when someone is obese?
KESSLER: Well, I really don't need a physician to tell me if I'm fat. Look, there's no doubt that weight has increased dramatically. When I was growing up as a kid in 1950s, 1960s, you entered your, you know, adulthood, maybe you gained a few pounds over, you know, 20 and 50 years of age; you lost a few pounds in your senior years. But weight was relatively flat. Today, you enter your adult years, and you continue to gain weight. And not only that, when you enter those adult years, you're entering it 18 pounds heavier than just a few decades ago. We all know that we're getting bigger and bigger.
HEADLEE: You know, it appears that a major factor in the vote to call it a disease was the reluctance of doctors, in the past, to speak to their patients about weight problems. Studies have shown that more than half of obese patients have never been told by their doctor, or any other medical professional, that they should lose weight. So does calling it a disease change that? Do you think more doctors will be likely to speak to their patients about losing weight?
KESSLER: I mean, it's certainly interesting that it took 'till 2013 for the medical community to say, this is a disease. You know, where has the medical community been? I went - I gave a lecture on obesity. And I said, here are three factors - and let me just give you them: a loss of control in the face of highly palatable foods; a hard time stopping eating; a preoccupation, a thinking, about foods. And I said, how many - what percentage of your overweight, obese patients does that describe?
What do you think the answer I got was?
KESSLER: A hundred percent.
HEADLEE: Oh, I was going to say 90.
KESSLER: They all raised their hands. And then I said to them, what do you think causes that? And they said, we never thought about it. You know, as physicians, we used to think, you know, there was a set point; you know, there was a body set point, and the reason I had a hard time losing weight, sure I could do it, but I would gain it back and somewhere biologically, in my head, in the brain, in the hypothalamus, there was a set point.
That's what I was taught in medical school. But in fact, if there was a set point, we wouldn't be getting bigger and bigger. The fact is that we, as physicians, haven't been very good at this. Calling obesity a disease can help people. But let's realize, this is somewhat semantic.
HEADLEE: If you're just joining us, I'm speaking to Dr. David Kessler, author of "The End of Overeating," about the AMA's decision to classify obesity as a disease. Let me push back just a little bit on the idea that calling it a disease - which you admit, is semantic - might help. And I wonder, to what extent that helps if the problem is behavioral. Can't we say that for many people, they know that eating the bag of Doritos - as opposed to eating the bag of carrots - is not going to be good for their health? Doesn't that make it behavioral?
KESSLER: So you're saying it's my fault, right? Let me give you the science. My own interest in that question really came from asking, you know, why does that chocolate chip cookie have such power over me? I mean, what - name - what's your favorite food?
KESSLER: Nachos - so they're there, right? They're sitting right in front of you. You can smell them, right? You see the layers and layers of the toppings, all right? What's going on? The fact is that based on past memory and past learning, we get cues, all right? Cue can be the time of day; it can be just those nachos sitting in front of you; it can be the smell.
Every time I land at San Francisco Airport, you know, my brain starts thinking about dumplings because in that airport, there's this place for dumplings. The plane acts as a cue. So I get cued, I have this arousal, I have this increased attention, I have these thoughts of wanting. I'm focused on wanting to get that food, I go eat the food; I have this momentary bliss. Two minutes later, I go, why did I do that? The next time I do it, I strengthen the neural circuits.
The fact is, if you take people who have loss of control, lack of satiation, preoccupation - and the vast majority of people who are obese, have those conditions - and you scan their brains, you see that there is hyperactivation of the emotional core of the brain - the amygdala region of the brain - just when they're cued. And when they start eating, that activation stays activated until all the food is gone.
So now the question is, is that my fault? And just because my brain is being activated, my attention is being focused automatically, just because there's a biological reason, doesn't mean there's, you know, not things I can do to take responsibility. But when I show people who struggle with their weight - I explain to them the neuroscience, what's going on - what do you think they say?
HEADLEE: "I had no idea"?
KESSLER: They had no idea. But they sort of knew it, right? They intuitively knew about that pull. But they say, "you mean, it's not my fault?" But then again, if - you know, it's not your fault, doesn't mean you can't do things about it.
HEADLEE: But I don't understand how labeling obesity as a disease would change that. I mean, if we take as given that the food industry, lack of oversight - or perhaps the way our food is constructed - is part of the problem, how does that change? Does oversight become more strenuous because we're now calling obesity a disease?
KESSLER: I mean, is hypertension a disease?
KESSLER: If hypolipidemia a disease?
KESSLER: Is diabetes a disease?
KESSLER: So all those things that flow from obesity, are diseases. We can agree on that.
KESSLER: All right - and if I create an environment where a third of Americans are now obese, all of a sudden, I wake up one day and say: A third of Americans have a disease. So, I mean, you're right. Is this an adaptive condition to our environment? Certainly, there are downstream consequences, right - I mean, that are diseases that we can agree on.
But look, this may help. I mean, even as physicians, I don't think we really understand the struggle that is associated with it. I mean, when I see somebody who is obese today, even the average doctor goes, you know, there's negative connotations, that patient may lack willpower; that's what we think of. If anything, I think we need to be more and more empathetic - I mean, with that struggle.
And even if it's just, you know, getting an insurance company to pay for treatment, to get an employer to pay for treatment; to give people the tools so that they can get healthier, that we can all get healthier; maybe it's a good thing. Is it going to turn this around? No, but it's the most important public health challenge we have.
HEADLEE: Do you think it helps, in terms of motivating patients and getting them to do what they need to do? Is there a chance that by labeling this a disease, that the response of the patient is great, give me the pill that will treat it, give me the surgery that will treat it; and it still doesn't address lifestyle issues?
KESSLER: Well, I think you're exactly right. Let me just, you know, give you the bad news. There's not going to be a pill that's going to really work here. I mean, sure, there's a pill that can get you to lose weight, but what are the neural circuits that pill has to affect in order for you to do that? It has to affect the learning, memory, habit and motivational circuits of the brain.
What do we need those learning, memory, habit, and motivational circuits for? We need them to function in our daily lives. So I can give you a pill; I mean, it's going to work. But you're going to have to give me back certain IQ points. Why don't diets work? Sure, they work. Sure, we can - you know, 30 days, 60 days, 90 days, deprive ourselves of food. We can lose the weight.
But if we haven't developed new learning, if we haven't put down new neural circuitry, if we haven't really changed our lifestyle, what's going to happen when we get cued again? We're just going to gain it back.
HEADLEE: Dr. David Kessler is the former director of the FDA. He's also the author of the book "The End of Overeating." He joined us from our bureau in New York. Dr. Kessler, thank you so much.
KESSLER: Thank you.