Childhood Obesity is, unfortunately, a growing problem in many countries all around the world, and is only getting worse. This is, therefore, a subject in whom there is plenty of research to be conducted and papers to be written. Below are listed 12 of the strongest ideas for writing on this controversial and difficult topic.
This is still a question that is hotly debated by scientists and has a lot to do with childhood obesity. If genetics plays a part, what can we do to a child’s youth to help them keep fit?
Most countries in the world have more weight problems now than ever before, so you can write this paper on almost anywhere in the world.
A greater weight during the younger years can often mean health problems later in a person’s life. Are there any particular problems that occur over and again in many different people? What are they?
What measures can we put in place to prevent children from gaining too much weight? Who need to put these measures in place? Do parents, teachers or the government have the most responsibility in this matter?
Sometimes, the sheer amount of fast, cheap and easy food that is high in sugar, fat and calories seems to be increasing. However, can the same be said for the healthier options out there, too?
With so many video games being released every day, children never need do anything but sit and stare at the screen. However, the lack of physical play is a contributing factor to the increase in obesity in younger people. How can we encourage kids to be more active?
Additionally, there are six slightly more general examples.
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The Obesity Society (TOS) commissioned a panel of experts from among its members to undertake a review of the issue of labeling obesity a disease and to examine pertinent evidence and arguments. The panel unanimously and strongly stated that obesity is a complex condition with many causal contributors, including many factors that are largely beyond individuals' control; that obesity causes much suffering; that obesity causally contributes to ill health, functional impairment, reduced quality of life, serious disease, and greater mortality; that successful treatment, although difficult to achieve, produces many benefits; that obese persons are subject to enormous societal stigma and discrimination; and that obese persons deserve better.
Whether obesity should be declared a disease is controversial, and thoughtful arguments have been made on both sides of the issue. The panel recognized that there is a clear majority view among the general public as well as among authoritative bodies that it is reasonable to call obesity a disease. The panel reviewed three broad classes of argument as to whether obesity is rightly classified as a disease.
The first, the scientific approach, proceeds in two conceptually simple steps: i) identify the characteristics that entities must have to be considered diseases and ii) examine empirical evidence to determine whether obesity possesses those characteristics. The scientific approach would be well suited to answering the question “is obesity a disease?” rather than “should we consider obesity a disease?,” were the former question answerable. However, after much deliberation, the panel concluded that the former question is ill posed and does not admit an answer. This is not because of a lack of agreement or understanding about obesity but rather because of a lack of a clear, specific, widely accepted, and scientifically applicable definition of “disease” that allows one to objectively and empirically determine whether specific conditions are diseases.
The second type of argument, the forensic approach, entailed looking to the public statements of authoritative bodies as evidence of whether obesity is a disease or should be considered a disease. A nearly exhaustive search for and consideration of the statements made by ostensibly authoritative bodies made apparent that there is a clear and strong majority leaning—although not complete consensus—toward obesity being a disease. However, although some authoritative bodies have offered statements that obesity is (or is not) a disease, very few of them have published a thorough and rigorous argument or evidential basis in support of the statement. Moreover, and far more importantly, the panel held that the opinions of authoritative bodies tell us—at most—what is lawful, consistent with mainstream opinions, or likely to be supported by others. Such opinions are insufficient to tell us what is true or what is right. The panel strongly endorsed the position that there can be no higher authority than reason. Hence, the forensic approach was judged to be inadequate to help us determine either whether obesity is a disease or whether it should be considered a disease.
The third approach to this question we termed the utilitarian approach. Recognizing that there is no clear agreed-on definition of disease with precise, assessable criteria that can be articulated, it seems that conditions that produce adverse health outcomes come to be considered diseases as the result of a social process when it is assessed to be beneficial to the greater good that they be so judged. Such judgments about likely benefit to the greater good are utilitarian judgments that may take empirical input but must also assume certain values. We considered the likely outcomes of considering obesity to be a disease to address the question “should obesity be declared a disease?” (as opposed to “is obesity a disease?”). Necessarily, our utilitarian analysis was speculative. The disease label tends to confer certain benefits, obligations, motivations, and legal considerations in our society.
The panel concluded that considering obesity a disease is likely to have far more positive than negative consequences and to benefit the greater good by soliciting more resources into prevention, treatment, and research of obesity; encouraging more high-quality caring professionals to view treating the obese patient as a vocation worthy of effort and respect; and reducing the stigma and discrimination heaped on many obese persons. The panel felt that this utilitarian analysis was a legitimate approach to addressing the topic, as well as the approach used for many other conditions labeled diseases, even if not explicitly so. Thus, although one cannot scientifically prove either that obesity is a disease or that it is not a disease, a utilitarian approach supports the position that obesity should be declared a disease.
The prevalence of obesity has been increasing for over a century (1) and has increased substantially in the past several decades (2). Clear and consistent evidence shows that obesity increases the risk of many morbidities and reduces both the quality and the quantity of life (3,4,5). These facts lead many to conclude that the time for concerted action to reduce levels of obesity and the deleterious effects of obesity is clearly upon us. In preparing for such action and in an attempt to enlist the participation and aid of broad sectors of society, many believe that labeling obesity a disease and having society accept this label is vital. However, is the label warranted? Prominent obesity experts have offered the opinion that it is indeed warranted, but equally prominent (although fewer) obesity experts have disagreed.
Similarly, writers in the mass media, advocates for obese persons' rights and welfare, and members of the general public have also expressed strong opinions both for and against the appropriateness of labeling obesity a disease. The National Consumers Union reported that in a national survey 78% of respondents somewhat or strongly agreed with the statement “obesity is a serious chronic disease” and 22% did not (6). Given this diversity of views, TOS commissioned a panel of experts from among its members to undertake a rigorous review of the issue of labeling obesity a disease and of the pertinent evidence and arguments. This report presents the results of that review.
The Question to be Addressed
The formal question to be addressed is “should obesity be considered a disease?.” This question is closely related to but fundamentally distinct from the question “is obesity a disease?.” The panel concluded that the latter question—a seemingly empirical question that should (in principle) yield to scientific inquiry—is ill posed in that its sensibility is based on premises that are not true. It is therefore insensible and unanswerable. In contrast, “should obesity be considered a disease?” is a question that is fundamentally not empirical or scientific. Its reliance on the word “should” (read equally “ought”) immediately signals that it is a social, political, and fundamentally ethical and moral question (7), because what one should do depends not only on the likely effects of one's actions (empirical input) but fundamentally on how one values various outcomes. Such values, although scientifically estimable, are not scientifically determinable. That is, although ethical and moral questions may be addressed in part by using scientifically generated empirical input (8), such questions should not be conflated with scientifically evaluable empirical questions that concern matters of fact rather than matters of value. Finally, there is substantial interest in many contexts as to whether obesity constitutes a disability (e.g., refs. 9, 10); to avoid any confusion, we note that this should be recognized as a distinct question that we are not addressing here.
Why are we addressing this?
As others have remarked (e.g., ref. 11) and as we elaborate below, whether obesity is considered a disease may have a profound impact on the lives of millions of obese individuals as well as on multiple aspects of our society. We therefore believe that, as the leading professional obesity society in North America, TOS has the obligation to provide leadership on this issue. We hope that by providing an answer to the question of whether obesity should be considered a disease—an answer that is based on sound reasoning and represents the collective wisdom of this leading professional society—we may catalyze society at large to come to a consensus view on this point. In turn, we hope that reaching such a consensus may enable efforts to ameliorate the problems of obesity to move forward more effectively.
Our panel struggled with the complexity of the issues surrounding the question; the members held a diversity of views, as did the field of obesity researchers. Nevertheless, the panel's members wish to note that there was absolutely no disagreement on the following fundamental points, which we voice loudly and clearly:
•Obesity is a complex condition with many causal contributors, including genetic ones and many environmental factors that are largely beyond individuals' abilities to choose or control (12,13,14,15).
•Obesity causes much suffering.
•Obesity causally leads to many aspects of ill health (16), to functional impairment (17) and reduced quality of life (18), to serious disease (4), and to greater mortality (19). Successful treatment, although difficult to achieve, produces many benefits, including prevention of disease (20) and reduced mortality rate (21,22,23).
•Obese persons are subject to severe societal discrimination in ways that those with seemingly similar chronic conditions, such as hypertension, dyslipidemia, and diabetes, are not. For example, obese individuals are waited on more slowly by salespersons, less likely to be rented apartments, less likely to be offered jobs, even when as qualified as other applicants, and less likely to receive support for higher education from parents, and often are looked down on by educators and health professionals (24,25,26).
These points underpin our concern for obese individuals and provide the motivation for undertaking the charge of this panel.
The process of developing this document
The Executive Committee of TOS wished to have a formal position statement on whether obesity is justifiably called and should be declared a disease and commissioned this white paper as a critical evaluation of relevant arguments and evidence. The panel, convened from among TOS's leaders and members, equally represented those who had previously expressed skepticism and those who had expressed belief that obesity is justifiably called a disease. The panel attempted to conduct an exhaustive search of the professional literature on this topic, discussed the various arguments that had been advanced, and agreed that the highest standards of intellectual rigor should be applied when considering the cogency of any position. Differences of opinion were discussed until consensus was reached in most cases. Some topics resisted consensus, and the panel members' divergent viewpoints are reflected in this document. The final draft was presented to TOS's council to be used as a basis of informed decision making about whether to offer a formal position statement on obesity as a disease and, if so, what that position should be.
What is obesity?
We define obesity as an excess of body fat. It may be of either total body fat or a particular depot of body fat. The excess may even be in the morphology and function of body fat such that, for example, adipocytes, independent of total fat mass or fat mass distribution, are excessively enlarged. The adverse health consequences of accumulation of enlarged visceral or other adipocytes may tentatively be accounted for by enhanced secretion of most products of adipocytes that act as endocrine and paracrine factors on other cells, as well as the reduced production of adiponectin (27). Note that we do not define obesity as a BMI greater than or equal to 30 kg/m2. That is a useful operational definition (28) for many contexts but should not be used as the conceptual definition. Even as an operational definition, a BMI greater than 30 may not be ideal, and authors are beginning to question whether the field should adopt a more useful operational definition (e.g., refs. 29, 30).
In our definition of obesity, excess of body fat denotes an amount sufficiently large to cause reduced health or longevity. This reduction in health will not be noticeable in all cases and may not be realized immediately, but obesity probabilistically threatens to reduce health in the future even if no health impairment is observed in an individual in the present. For example, as fat cells increase in size, they begin to produce substances (e.g., tumor necrosis factor-α) in excess of normal levels. For some people this causes insulin resistance and diabetes, but for others who have sufficient adaptive capacity, no deterioration of body function or health is apparent. As with hypertension and elevated blood glucose, many people initially demonstrate no obvious health problem yet health deteriorates over time.
The effects of accumulation of adipose tissue depots and possibly of enlarged adipocytes appear to vary as a function of age, ethnicity, sex, and other factors. Hence, operational definitions of obesity may also need to vary as a function of these factors even if the conceptual definition remains constant.
How might one approach the question “should obesity be considered a disease?”
To address the question of whether obesity should be considered a disease, we identified three major approaches that have been or could be used, approaches that go beyond rhetorical assertions. We term these the “scientific approach,” the “forensic approach,” and the “utilitarian approach.” (Commonly used arguments that we believe to be patently invalid and worthy of only brief consideration are listed in Appendix 1.) The authors of most documents that attempt to address the issue of obesity as a disease have not described a thorough and organized argument or approach to reaching their conclusions. This does not necessarily mean that they did not use such an argument or approach, only that none was described. Authors who have tried to be more thorough and rigorous in their analysis have generally used the scientific approach, the forensic approach, or both. In this document we argue that the scientific and forensic approaches are not useful in addressing this question and then move to the utilitarian approach, which, to our knowledge, has not been used as a primary approach. We argue that this is the most appropriate approach and use it to form the basis of our conclusion.
More than 2,500 years ago the physician Hippocrates, often called the father of medicine, recognized that people who were overweight were at higher risk for sudden death. Closer to our times, Malcolm Flemyng, a physician from the 18th century who wrote one of the two earliest books on overweight in the English language, stated that “corpulency” (i.e., obesity) can be a disease in some cases. Table 1 lists historical quotations on obesity as a disease, from the 1600s to 1934. Inspection of these quotations makes clear that the idea that obesity may appropriately be called a disease is not new; it has recurred throughout the past several hundred years. Multiple authors (see, for example, refs. 31,32,33) said that obesity is appropriately considered a disease only when it reaches a certain degree of severity, implying that they conceived of obesity as a disease in some but clearly not all cases. Conversely, some authors (e.g., refs. 36,37) said that obesity is not a disease in all cases, implying that it is in some. None of these authors provided a through discussion of why obesity should or should not be considered a disease. The primary form of “argument” used was simply ipse dixit, a rhetorical assertion without a valid supporting argument. This has been the most commonly used approach to this issue, even in the past 20 years, and remains the one in most frequent use.
Arguments and Evidence: the Scientific Approach
Explication of the approach in general terms
The scientific approach is well suited to the question “is obesity a disease?” or, more abstractly and generically, to the question “does a class of entities A rightly belong as a subset of the larger class of entities denoted B?” Phrased in this more generic way, the way to proceed is obvious. It involves two conceptually simple steps. Step 1 is to identify the characteristics that entities must have to be considered members of class B. Step 2 is to examine empirical evidence to determine whether all entities in class A possess those characteristics. This is an approach taken by several authors (e.g., refs. 39,40,41,42), at least one legal proceeding (43), and a recent video, “Is Obesity a Disease?,” produced by the American Medical Association (AMA) (44) and offered on the website of the US Agency for Healthcare Research and Quality (45).
Some key facts about obesity
Some key facts are germane in attempting to scientifically address the issue of obesity as a disease. In most cases, these facts are well known and well established and we do not dwell on the evidential basis. Instead, we simply state the fact and refer to an appropriate source for details of supporting evidence.
1. Obesity (or, more precisely, variations in BMI or body fat mass among individuals) has many causes both across and within individuals (12,13,14).
2. The prevalence of obesity has increased substantially in the past half century, both within the United States and globally. This increase has occurred in virtually every age, race, and sex group (46). A current estimate is that roughly one-third of US adults (more than 50 million persons) are obese (46).
3. Obesity increases the risk of many morbidities (5,41,47) and reduces quality of life (18), functional capacity (17), and lifespan (19).
4. Animal model studies (48,49,50), studies of lifestyle intervention in humans (20), and studies of bariatric surgery in humans (21,22,23) all show that when weight and fat loss can be induced by medically recommended interventions among obese organisms, morbidities are reduced and lifespan can be increased.*
5. Statement 3 applies in probability; that is, any obese individual may experience only minor adverse effects of obesity in any one or more of these categories and may experience no adverse effects of obesity in some categories (39,41,51).
6. Apart from an expanded fat mass, which is inherent in the definition of obesity used herein and in a prior TOS (formerly NAASO) position statement (52), there is no characteristic sign or symptom that is present in all obese persons (39).
7. Obesity, at least when operationally defined as the exceeding of a specific amount of body fat or a specific BMI, is also associated with certain health benefits (53). These include the now rarely needed but obvious protection against starvation in times of food scarcity (54), protection against osteoporosis and fractures in the elderly (51), possible prevention of frailty in the elderly, reduced mortality rate in the elderly with mild obesity (55), and reduced mortality rate in certain severe illnesses or injuries (56). The extent to which these associations represent causation is not clear in all cases.
Definitions of disease
Kincaid (57) wrote, “There is a long-standing debate, inside medicine and out, about how to define disease and whether such definitions are value free.…The two predominant attempts at value-free notions of health are the biostatistical theory…and evolutionary functions approaches. The biostatistical theory holds that disease is deviation from species-typical functioning; disease is deviation from the average. In the evolutionary function view, disease occurs when an organ is not performing the job that allowed it to evolve via natural selection.”
Taking a somewhat different approach, Heshka and Allison (39) consulted multiple ordinary and medical dictionaries and extracted four points common to most definitions of disease:
“(a) a condition of the body, its parts, organs, or systems, or an alteration thereof;
(b) resulting from infection, parasites, nutritional, dietary, environmental, genetic, or other causes;
(c) having a characteristic, identifiable, marked, group of symptoms or signs;
(d) deviation from normal structure or function (variously described as abnormal structure or function; incorrect function; impairment of normal state; interruption, disturbance, cessation, disorder, derangement of bodily or organ functions).”
Taking a similar approach, the American Medical Association (44) offered the three points depicted in Figure 1 and indicated that all three conditions need to be met to for obesity to be defined as a disease.
The US Food and Drug Administration (FDA) advanced a definition of disease based on an extensive, thoughtful process. Following enactment of the Dietary Supplements Health and Education Act (DSHEA) (58), the FDA had to establish a definition of disease. The manufacturers of dietary supplements would not be allowed to make statements that a dietary supplement product could be used to diagnose, treat, prevent, cure, or mitigate a disease but could make claims about the product's effects on the structure or function of the body. The FDA process, which began in 1998, involved numerous public comments and a public hearing that involved senior FDA officials and representatives of a broad cross-section of scientific, medical, industry, and advocacy organizations (59). At the end of the process, the agency decided to retain a definition issued in 1993 as part of the implementation of the Nutrition Labeling and Education Act (60), which defines disease as “damage to an organ, part, structure, or system of the body such that it does not function properly (e.g., cardiovascular disease), or a state of health leading to such dysfunctioning (e.g., hypertension); except that diseases resulting from essential nutrient deficiencies (e.g., scurvy, pellagra) are not included in this definition.” As indicated in Appendix 2, the FDA subsequently concluded that obesity is a disease by this definition (61).
Downey (40) and Conway and Rene (41) relied on a definition of disease found in Stedman's Medical Dictionary that Downey described as a representative definition: “1. An interruption, cessation, or disorder of body functions, systems, or organs. Syn. Illness, morbus, sickness. 2. A morbid entity characterized usually by at least two of these criteria: recognized etiologic agent(s), identifiable group of signs and symptoms, or consistent anatomical alterations. See Also: syndrome. 3. Literally, dis-ease, the opposite of ease, when something is wrong with a bodily function.”
Consideration of the above definitions begins to make apparent some of the difficulties with this approach. Are the definitions equivalent? If not, whose definition should be considered paramount? Are the definitions precisely interpretable and applicable? Are they sensible on their face, likely to admit to the class of diseases all the entities that common parlance and societal consensus accept as diseases, and likely to reject from the class of diseases all the entities that common parlance and societal consensus would not accept as diseases?
What can we conclude if we take this approach strictly?
With respect to what Kincaid (57) terms the biostatistical theory, it would be difficult to argue that obesity constitutes a statistical rarity given that roughly one-third of the US adult population is obese. Moreover, even if we allowed that one-third was a sufficient minority for obesity to merit the disease appellation, such a decision process would invalidate that conclusion if obesity occurred in more than 50% of the population, as some authors have speculated it will (e.g., ref. 62). The decision to declassify a condition as a disease simply because too many people have it makes little sense.
In the evolutionary function approaches described by Kincaid (57), “disease occurs when an organ is not performing the job that allowed it to evolve via natural selection.” However, apparently not all would accept such a definition. For example, a document issued by the National Institutes of Health (NIH) said that irritable bowel disease is not a disease: “It's a functional disorder, meaning that the bowel doesn't work, or function, correctly” (63). According to the NIH, then, an organ that is not functioning correctly is not sufficient for the condition to be labeled a disease.
On this point, Temblay and Doucet (64) wrote, “Obesity facilitates the maintenance of body homeostasis probably because of an increased hormonal gradient which favours the regulation of energy balance, to give but one example. The regulation potential of excess body fat is particularly apparent in the reduced-obese state where a reduction of energy expenditure, fat oxidation and some immune system markers, as well as an increase in appetite, stress vulnerability and circulating and adipose tissue organochlorines, have been observed. These constitute another category of risk factors which can certainly favour the accumulation of body fat to reestablish body homeostasis on other fronts. Under such conditions, obesity is perceived by the physiologist as a necessary biological adaptation rather than a disease.” In contrast, others argue that, although adiposity might be protective in some cases, this does not necessarily support the conclusion that obesity is therefore homeostatic or beneficial overall. Extra fat might protect against toxins or offer some beneficial effects yet simultaneously have deleterious effects that outweigh the benefits. Similarly, if there are mechanisms that promote fat deposition as a defense against environmental toxins, then those toxins might be seen as etiologic mechanisms for obesity. Homeostatic mechanisms are not always clinically good or desirable, especially in environments that are not closely aligned with those in which the species evolved.
A further line of argument along evolutionary lines considers that the key organ in obesity is adipose tissue and a purpose of adipose tissue is to store excess available energy as triglyceride for future use. When adipose hypertrophy occurs beyond some point and new adipocytes cannot be proliferated, adipose tissue may no longer effectively serve this function and metabolic aberrations may result (65). Although this may be true, it is not likely that that this is the sole or primary means by which obesity adversely affects health, function, and longevity. Finally, although storing triglyceride is one function of adipose tissue, it is certainly not the only function.
Thus, the evolutionary approach permits an interesting array of perspectives and does not offer a clear path by which obesity may be classified as a disease. De Vries (66) also considered these biostatistical and evolutionary definitions and came to the same conclusion that we do.
We now consider the approach of comparing the known facts about obesity to the dictionary-based definitions offered by Heshka and Allison (39), Conway and Rene (41), Downey (40), and the AMA (44). Referring to their four key elements in common definitions of disease, Heshka and Allison wrote that there should be little disagreement that obesity satisfies the first two elements: an excess accumulation of fat can certainly be thought of as a condition of the body and the list of potential causes is so extensive that the causes of obesity must surely be found there. However, they expressed concerns about the third element because, as we offered above when discussing key facts about obesity, no signs inevitably characterize the condition of obesity other than excess adiposity, which is the definition of obesity. Similarly, the AMA (44) noted that obesity failed to satisfy what it listed as the second criterion of a disease: characteristic signs and symptoms (Figure 1). Specifically, the AMA stated, “Three criteria must be met. … The second criterion of disease, characteristics signs or symptoms, is not fully met by obesity. There are no specific symptoms of obesity and the only sign is a greater weight and an excessively large appearance.” The AMA explicitly states that obesity is not a disease. Given that the organization asserts that three criteria must be met, explicitly states that one of the three is not met, and strongly questions the third, the conclusion from its point of view is obvious. In contrast, Downey (40), referring to Stedman's second definition of a disease—i.e., “identifiable group of signs and symptoms” (emphasis added)—wrote, “Obesity clearly meets all 3 criteria, not just 2. … The signs and symptoms of obesity include an excess accumulation of adipose tissue and are likely to include insulin resistance, increased glucose, elevated cholesterol and triglyceride levels, decreased levels of high-density lipoprotein and norepinephrine, and alterations in the activity of the sympathetic and parasympathetic nervous system.”
There are other differences between the definitions used by Heshka and Allison and the AMA and that used by Downey. Downey requires that two of three criteria be met, whereas Heshka and Allison and the AMA require all criteria to be met, an increase in the burden of proof. Heshka and Allison's requirements seemed to be the proper distillation of the many definitions they reviewed. The reasons for the AMA's choice are unknown to us, but we may speculate that they are similar. Additionally, only as implied by the language of their fourth criterion does the definition used by Heshka and Allison refer to resultant mortality or morbidity, whereas Downey's definition does so more explicitly. Curiously, Oliver (42) also relied on Stedman's definition but came to the conclusion opposite from that of Downey (40) and Conway and Rene (41). Oliver wrote, “Even Stedman's Medical Dictionary does not call obesity a disease, it is simply ‘excess subcutaneous fat in proportion to lean body mass' or, at worst, ‘a public health problem.’”
How is it that these authors disagree on the fundamental issue of whether obesity has an identifiable group of signs and symptoms, characteristic signs and symptoms, or a characteristic, identifiable, marked, group of symptoms or signs? Key issues seem to be the inclusion or interpretation of words such as “characteristic” and the eschewing or lack thereof of tautological reasoning.
Both Heshka and Allison (39) and the AMA (44) use the word “characteristic” and interpret it to imply a certain degree of inevitability. Thus, although there is no dispute that, as Downey (40) wrote, the adverse effects of obesity are “likely [emphasis added] to include insulin resistance, increased glucose,” as Downey's use of the word “likely” implies and as stated earlier in the key facts about obesity, these are only likely outcomes of obesity, not inevitabilities. Some might question whether an entity must have characteristic signs to be considered a disease and note that tuberculosis, for example, is usually considered a disease and has characteristic signs of bloody cough and fever, yet this condition—sometimes referred to as “the great pretender”—can alternatively present as back pain, fever without respiratory symptoms, adrenal crisis, and headache, and in many other noncharacteristic ways. This example reinforces the notion that no existing definition of disease seems entirely satisfactory to capture entities generally accepted as disease and to exclude entities not accepted as diseases.
An example of tautological reasoning is the listing by Downey (40) of excess accumulation of adipose tissue among the signs and symptoms of obesity. Heshka and Allison (39) see this as a trivial truth because it is part of the definition of obesity. To return to the abstract version of “does a class of entities A rightly belong as a subset to the larger class of entities denoted B?,” if a criterion for membership in class B is having a characteristic sign and we admit that a sufficient characteristic sign is that an entity has been labeled as being in another particular class (e.g., class A), then all identifiable classes of entities will meet this criterion and it ceases to have any discriminating meaning and becomes superfluous. If we are to take seriously the idea that dictionaries are authoritative sources on definitions of disease, then we need to assume that these definitions are meaningful and therefore do not contain superfluous elements. Tautological interpretation that makes elements superfluous thereby vitiates the scientific approach to evaluating obesity as a disease.
We turn to the fourth criterion of Heshka and Allison (39) (i.e., deviating from normal structure or function) and the third criterion listed by the AMA (44) (resulting in harm or morbidity to the entity affected). Heshka and Allison wrote, “The deviations specified range from simple deviation from normality, to impairment, interruption or cessation of vital functions. Moreover, what is meant by deviation from normality is not clear—it can imply undesirable variation or simple statistical rarity.” Tremblay and Doucet (64) make clear that it is not obvious that obesity can be uniformly described as an impairment in function, and, as we noted in the key facts about obesity, obesity is only associated with various adverse events and limitations in probability. The AMA (44) arrives at essentially the same conclusion. In contrast, the definition used by Downey (40) and Conway and Rene (41) does not require that such a criterion be met. According to this approach, for example, stroke might not considered a disease or illness because it does not uniformly result in an impairment of function and its effects range from subclinical ones (normality) to massive impairment and death. This further reinforces the point that existing dictionary definitions of disease seem ill suited to capturing entities that society clearly recognizes as disease (and also to excluding things clearly not recognized as diseases) and the subsequent conclusion that entities do not come to be classified or not classified as disease on the basis of comparing facts known about the entities with accepted defining criteria of diseases.
Thus, an analysis of attempted applications of the scientific approach to determining whether obesity is rightly labeled a disease reveals that differences in conclusions do not stem from disagreements about the facts regarding obesity but rather from whether those facts justify declaring obesity a disease on definitional grounds because of disagreement about the precise definition of “disease” and how that definition should be legitimately applied.
Is the question ill posed?
A question can be said to be ill posed if it is insensible and will be insensible if its sensibility depends on premises that are not true. Asking and answering the question “is obesity a disease?” is predicated on the premise that there is a clear concept of disease. As shown above, we do not struggle with answering this question because of disagreements about facts regarding obesity; we struggle because of a lack of clarity and consensus as to the definition of disease (57). The struggle is not solved by simply adopting the definitions and interpretive approach used by Downey (40) and Conway and Rene (41) on the one hand or by Heshka and Allison (39) and the AMA (44) on the other hand. Strict application of Downey's definition and approach would result in the labeling of any characteristic or habit that causes increased risk of morbidity or mortality as a disease, including being male, being over age 40, riding a motorcycle without a helmet, not sleeping 6–8 hours per day, and not regularly consuming moderate amounts of alcohol. All of these are associated with increased morbidity and/or mortality (i.e., are morbid entities), all have causes (i.e., etiologic agents), and all have characteristic signs (especially if one admits tautological identification of such signs), and the first two have characteristic anatomic alterations. Inclusion of such entities in the category of diseases seems absurd. (In some of these examples the characteristic sign would simply be a behavior, but if one rules this out as a legitimate qualifier, then almost all forms of mental illness would not qualify as disease.) Similarly, strict application of the approach used by the AMA and Heshka and Allison might exclude many entities from the category of disease that society at large seems to have agreed to label as diseases, including hypertension, alcoholism, and many psychological disorders. This in no way implies that hypertension, alcoholism, and many psychological disorders should not be considered diseases but rather that available definitions of disease are wanting and do not in practice serve as the foundation for determining which entities come to be considered diseases.
The idea that disease is not a crisply defined category that admits strict scientific or empirical verification of an entity's eligibility for the category was nicely articulated by Richard Levinson, the associate executive director of the American Public Health Association. “During my lifespan,” he noted, “the infectious disease of children were regarded as part of the normal process of growing up. We now regard them as totally avoidable and eminently preventable, and we consider, those of us who have been in public health, we consider it a stain on our escutcheon if a single child shows up in our jurisdiction with one of these illnesses. This was not true for centuries and eons. So this definition is highly fluid and we must be aware of it, and what is a natural state today may not be regarded as a natural state in the near future.” He added, “I think that it is absolutely clear that there are not two categories in this world, disease and not disease, or disease and natural state. This is a continuity between the two, and…the boundaries are, at best, arbitrary” (59). This point is further reinforced by the FDA's exclusion of “diseases resulting from essential nutrient deficiencies” from its definition of disease for the purposes of enforcing DSHEA (67). By the agency's own language, some of the things it excludes from the category of disease are diseases, implying that the FDA considers that something may properly be labeled a disease in one context and not in another.
The fact that a single definition and its use cannot be agreed on and that adoption of initially seemingly reasonable definitions may lead to absurd outcomes if rigorously applied, suggests that as a community we do not have precise well-accepted definitions of disease that can be applied in a scientific manner to determine whether something is a disease. Hence, if there is no clear precise definition of disease, it makes no sense, from a strictly scientific point of view, to ask whether obesity is a disease.
The scientific approach would be well suited to answering the question “is obesity a disease?” rather than “should we consider obesity a disease?” were the former question answerable. However, we believe the question is ill posed and does not admit an answer. This is not because of a lack of agreement or understanding about obesity but rather because of the lack of a clear, specific, widely accepted, and scientifically applicable definition of a disease.
Arguments and Evidence: the Forensic Approach
By a forensic approach, we mean looking to the public statements of authoritative bodies as evidence for the validity of a proposition. Some authors (e.g., ref. 40) and some legal proceedings (e.g., ref. 68) have relied heavily on the forensic approach to determine whether obesity is rightly considered a disease. Application of the approach involves two simple steps: identifying an authoritative body and determining its stated position on whether obesity is or should be considered a disease. Although these steps are conceptually simple, there are practical challenges and fundamental questions as to the worth of the forensic approach.
The importance of distinguishing offhand statements from official declarations
In adopting the forensic approach, it is important to distinguish casual statements from official positions. For example, if the president of the United States were to state in a speech that despite the tribulations of today, the sun will rise tomorrow, we would not take seriously a claim that this demonstrated that the federal government's official position is that the sun moves relative to the earth. So, too, if an excerpt from a book offered on the website of the American Diabetes Association (ADA) says, “Obesity is not a disease but a prominent risk factor for many diseases” (69), this should not be assumed to be the ADA's official position. On the other hand, some statements are clearly meant to be official positions; e.g., see the statement by the Centers for Medicare & Medicaid Services (CMS) in Appendix 2. These examples are exceptionally clear. In many other cases, however, the extent to which a statement is the opinion of a spokesperson, the opinion of the larger body, an official declaration of a position, or an offhand remark is ambiguous. Readers should consider this in weighing the quotations provided.
A summary of what has been said by authoritative bodies
We summarize statements by authoritative bodies in Appendix 2. Many statements may be construed to imply that the organizations take the position that obesity is a disease. Sources of such statements include the National Academy of Sciences, the NIH, the FDA, the former US Surgeon General, the World Health Organization, the American Association for Clinical Endocrinology/American College of Endocrinology, the American Gastroenterological Association, and an expert committee convened by the Maternal and Child Health Bureau. At least one agency, the CMS, has made a formal statement that leaves little doubt that they take no formal position on the question. At least one advocacy group (the International Size Acceptance Association) has made a clear statement that it does not consider obesity a disease. At least two organizations (the AMA and the Belgian Health Care Knowledge Centre) have made multiple statements that are seemingly contradictory.
Problems with the forensic approach
As addressed above, it is difficult to distinguish between offhand (or well-thought-out) statements by an employee or affiliate of an organization and the organization's official position (if it has one). Determining which bodies are appropriately judged to be authoritative is challenging. We suspect that not everyone would agree that all the groups represented in Appendix 2 are indeed authoritative bodies, but how exactly do we make this distinction?
Apparently authoritative bodies may (and do) disagree with one another. How, then, do we reach a decision if we are basing a decision on the opinions of such bodies? If we were to weigh the number of bodies that offer the opinion that obesity is a disease against the number that maintain that obesity is not a disease, not only would we be engaging in the logical fallacy argumentum ad numerum, but we would likely be ignoring a plausibly potent form of selection bias. Specifically, just as post offices do not post least-wanted posters of people widely believed to be guilty of nothing, some members of our panel intuitively believe that medical, scientific, and academic agencies and experts do not typically take the time to write articles stating that certain entities are not diseases even if they believe that to be the case.
Relying on the opinions of authoritative bodies risks reifying the political status quo and potentially makes progress the slave to the courage and perspicacity (or lack thereof) of large and often bureaucratic organizations. Some authoritative bodies (e.g., the US Congress, the Supreme Court, and the United Nations) have not spoken at all on the subject. Should their silence be weighed? Most importantly, relying on the opinions of authoritative bodies that have the power to make laws is appropriate for determining which behaviors are lawful, but is it appropriate for determining which conclusions are reasonable? Clearly the answer must be “no.” We can judge the reasonableness of a conclusion only by examining the reasoning supporting that conclusion regardless of who offered the opinion. In this regard, it is noteworthy that none of the statements listed in Appendix 2 was accompanied by thorough and rigorous explication—if any explication at all—of the reasoning underlying the statements.
First, consideration of the statements in Appendix 2 makes apparent that there is a lack of consensus among bodies that some might consider authoritative as to whether obesity is rightly called a disease, although there is a clear and strong majority leaning in this direction. Second, and far more important, the opinions of authoritative bodies tell us, at most, what is lawful, consistent with mainstream opinions, or likely to be supported by others. Such opinions, even if clear and consistent, are insufficient to tell us what is true or what is right. Our panel strongly endorsed the position that there can be no higher authority than reason. Hence, the forensic approach cannot help us determine whether obesity is a disease or whether obesity should be considered a disease.
Arguments and Evidence: the Utilitarian Approach
Given that no clear agreed-on definition of disease that has precise and assessable criteria can be articulated, how are things judged to be diseases? It seems that conditions that produce adverse health outcomes come to be considered diseases as the result of a social process when it is assessed to be beneficial to the greater good that they be so judged. Such decisions about likely benefit to the greater good are utilitarian judgments that may take empirical input but must also assume certain values. We examine the likely outcomes of considering obesity a disease and try to make clear the empirical input and value judgments being made. Necessarily, our comments concerning future effects must be speculative, and we offer them with humility as to our ability to forecast the future. In this light we are mindful of the principle of medicine that, if one can do nothing else, one should at least do no harm. We note also that the utilitarian argument in favor of labeling obesity a disease is not that this benefits some small special-interest group such as obesity researchers or treatment providers. Rather, the argument is that the disease label might have broad effects for a large portion of society, for the greater good.
Finally, we note that the utilitarian argument should not be confused with the argument from consequences, which is a fallacious argument for the truth of a proposition on the basis that belief in the truth of the proposition has benefits. In contrast, a utilitarian argument is not fallacious when it concerns the benefit of courses of action as opposed to the truth of propositions. For this reason the utilitarian argument can address the question “should obesity be declared a disease?” as opposed to “is obesity a disease?”
Anticipated effects of labeling obesity a disease
Effects on public understanding of obesity and social stigma. The current understanding of obesity by the public at large consists mainly of two positions. One position equates obesity with poor character, lack of self-control, laziness, and gluttony. It views obesity as the result of an individual's choice of behavior, like smoking or driving without a seatbelt, that has relatively little effect on others—a lifestyle choice. The other position sees obesity as a risk factor or a stage on the path to a real disease such as heart disease or diabetes. In this view, a reduction in obesity is seen as useful in reducing the risk of other diseases. However, reduction in body weight for its own sake is often associated with vanity or seen as a cosmetic issue. A third viewpoint is that obesity is a genetically determined trait (evidence clearly indicates that both genetic and environmental factors contribute to obesity), not very different from hair or eye color, and not a disease.
Viewing obesity as a disease may—depending on the breadth and depth of future public knowledge—affect these prevailing attitudes. The view of obesity as a lifestyle choice will be less widespread if the public begins to appreciate that it results from a combination of genetic predisposition, behavioral factors, and environmental influences, much like other diseases. By bringing the genetic and physiological influences more clearly into focus, the condemnation of individuals who cannot maintain a normal weight may be diminished. This may reduce the stigma and resulting discrimination experienced by persons with obesity.
On the other hand, labeling obesity a disease may further stigmatize some obese individuals who would now be marked as having a disease whose existence is visually detectable. Although the panel members acknowledged the reasonableness of this conjecture, they felt that using the reasoning that elements of society will further discriminate against obese people if obesity is called a disease does not seem a good justification for refraining from categorizing obesity as a disease. As with other entities labeled diseases, one may be able to combat such unjust stigmatization and any attendant discrimination more effectively and aggressively once the disease label has been assigned openly. If society does declare that obesity is a disease, we are then obligated to ensure that it is treated as other diseases are and that those afflicted are afforded whatever protection the label can offer, without the stigma.