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Thursday, May 17, 2018

Thoughts on Obesity as "Disease" or Choice ~ Part 1: Smoking & Lung Cancer Analogy


Recently (May 2018) comments about obesity at a Pediatric conference have made the rounds. Specifically: Obesity Is a Disease, Not a Choice, Experts Advise.  Here is link to the full text in  "print version".


The AMA classified Obesity as a disease in 2013. Five years later we've made little to no progress, likely because we've got "experts" pontificating and arguing over semantics and false dichotomies.  The false dichotomy of Disease vs. Choice is right out of whatever master playbook teaches that if you keep the "masses" arguing, they might not notice you're full of it.  It's really the only explanation I can think of for the circular arguments made with nary a tinge of irony on board straight faces.

I have a bunch of stuff in the draft pile here on this topic, but cannot seem to organize it. I decided to start a series.  In no particular order.  

This installment deals with the following statement from the 2013 Resolution by the AMA:

Whereas, Progress in the development of lifestyle modification therapy, pharmacotherapy, and bariatric surgery options has now enabled a more robust medical model for the management of obesity as a chronic disease utilizing data-driven evidenced-based algorithms that optimize the benefit/risk ratio and patient outcomes; and

Whereas, The suggestion that obesity is not a disease but rather a consequence of a chosen lifestyle exemplified by overeating and/or inactivity is equivalent to suggesting that lung cancer is not a disease because it was brought about by individual choice to smoke cigarettes; and

Whereas, The Council on Science and Public Health has prepared a report that provides a thorough examination of the major factors that impact this issue, the Council’s report would  receive much more of the recognition and dissemination it deserves by identifying the enormous humanitarian and economic impact of obesity as requiring the medical care, research and education attention of other major global medical diseases; therefore be it 



I felt compelled to include the two paragraphs/statements this analogy is sandwiched between.  To my reading, the preceding paragraph claims "the science" is so convincing that there are effective protocols in place that are showing results, while the paragraph following the analogy basically says that the scientists would be more convincing if they had abandoned science and instead appealed to emotion.  You can't make this kind of stuff up!!

That said, when I (and perhaps you?) read the lung cancer/smoking analogy, it initially makes you go Hmmmm.  Yes, indeed, the fact that the *behavior* of smoking increases the risk of developing lung cancer (to an extent that most would agree smoking has a causal effect on developing lung cancer despite the fact it would be unethical to perform the definitive RCT) does not change the fact that lung cancer is a disease. 



Lung (or any) Cancer IS (many) Disease(s)! 



The cells of ANY malignant tumor are pathological by definition.  Even an untrained eye could probably look at cancer cells under a microscope and conclude "something's not right there".

Cancer cells do not look or behave like the normal adult cells of multicellular organisms from which they originate.

They do not display the special characteristics/functions (cellular phenotype) of normal adult cells,  nor do they "play well" with other cells/tissues.   Lung cancer  -- ANY cancer -- is a pathological state.  Pathological being not normal.  But I'm repeating myself.

The best way I can think of to describe a cancer cell is that it is a cell that has gone rogue.  Something happened that rendered that cell deaf and blind to proper signals from other cells or the central programming of multicellular organism.    Their outgoing signals are abnormal as well.  It's more than a cell that exhibits impaired functioning of some sort (like a pancreatic β-cell in the early stages of T2 diabetes).

Although modern medicine has yet to prevent or cure lung cancers (full disclosure, this is what took my father-in-law's life), there are effective treatments in many cases that can eradicate the cancer or slow its growth.  The diagnosis of "lung cancer" is one of considerable sophistication in the current day, there are different types of lung cancer warranting radically different treatment approaches.



So Maybe Adiposopathy is a Disease Then?



Readers of this blog are aware that I'm a proponent of sorts of the "sick fat" etiology for many chronic diseases. Adiposopathy -- the idea that fat tissue becomes dysfunctional releasing excessive fatty acids, recruiting macrophages, and secreting abnormal levels of various adipokines -- is consistent with and supported by a wide body of research. 

Based on the scientific evidence to date, I believe "sick fat" could be described relatively easily as a disease. There would likely be considerable argument as to exactly which direct or indirect markers of sick fat would best be used to detect the condition, and where to draw the diagnostic lines.  But I don't think there would be much disagreement over whether or not we're talking about pathology. 

Certain high levels of adiposity are simply not pathological in some individuals, whereas far lower levels of excess fat are highly pathological in others.

Despite some, like Gary Taubes, describing growing fat cells as akin to a growing cancer, sick fat really is no such thing.   Whereas a cancer cell has "gone rogue", a "sick adipocyte" would be better described as one that has been overwhelmed.

Obesity arises from fat tissue and the cells that comprise it behaving NORMALLY.  Sequestering excess energy as fatty acids in triglyceride lipid droplets, in cells with the specific cellular phenotype to do just that, is NORMAL FUNCTION.  

Then, at some point, you exceed what is becoming increasingly referred to in the peer review literature as your "personal fat threshold".  The dysfunctional fat cells of one's overfilled fat stores is NOT normal.  This is pathological.  This qualifies as disease.

I hope to expand on this in a future installment, but those diagnosing obesity as a disease, are not looking to diagnose adiposopathy, or, more importantly, to treat the dysfunctional fat tissue.  If we can agree that adipose tissue is an endocrine organ, then at least the endocrinologists ought to be concerning themselves with treating the dysfunctioning endocrine organ.  But they are not.

Which brings me back to the lung cancer analogy the AMA put forth as a "Whereas" in its resolution.



Let's Look at the Lung Cancer Analogy in Reverse, Shall We?



Lung cancer is a disease that may be caused directly by smoking.  But there are also people who develop lung cancer who have never smoked and/or for whom no known cause can be identified.

If you're not familiar with the process, here's the Mayo Clinic's page on Diagnosis and Treatment of Lung Cancer.  I'll summarize the high points.

Diagnosis:
  • Imaging tests:  X-ray and/or CT scan
  • Sputum cytology
  • Biopsy
"Careful analysis of your cancer cells in a lab will reveal what type of lung cancer you have. Results of sophisticated testing can tell your doctor the specific characteristics of your cells that can help determine your prognosis and guide your treatment."

Then, I've C&P'd this entire part for emphasis.

"Once your lung cancer has been diagnosed, your doctor will work to determine the extent (stage) of your cancer. Your cancer's stage helps you and your doctor decide what treatment is most appropriate.

Staging tests may include imaging procedures that allow your doctor to look for evidence that cancer has spread beyond your lungs. These tests include CT, MRI, positron emission tomography (PET) and bone scans. Not every test is appropriate for every person, so talk with your doctor about which procedures are right for you.

The stages of lung cancer are indicated by Roman numerals that range from 0 to IV, with the lowest stages indicating cancer that is limited to the lung. By stage IV, the cancer is considered advanced and has spread to other areas of the body."
Then, Treatment:
  • Surgery
  • Radiation
  • Chemotherapy
  • Targeted Drug Therapy
  • Immunotherapy

All of these treatments are aimed at eradicating or containing the cancer REGARDLESS OF WHAT CAUSED THE CANCER.


Notice anything missing?  


Oh yeah ... there are only two references to smoking on that Mayo page.  One is a reference to screening for cancer in heavy smokers.  The other is a question on the list for the doctor (I note they don't even list the possible answers):  "Is there a benefit if I quit smoking now?"

While a current smoker might be advised to quit, I don't think you'll find many (doctors or otherwise) who believe that this will do much if anything about the cancer itself at that stage of the game.  

"Quit Smoking" is not a treatment for lung cancer.  

A lung cancer patient is not sent home with nicotine patches or gum.  They are not sent away with a script for Chantix or Zyban.  Whether their smoking behavior caused the cancer or not, it is irrelevant at the point when the person has cancer.  (A 2010 meta-analysis showed a pretty significant effect on all cause mortality or recurrence or development of a second tumor.  So to be sure I'm being clear, stopping smoking is not a treatment for the cancer.)

I attended quite a few sessions with my father-in-law following his diagnosis where treatment options and expectations were discussed.  Somewhere in his file it probably stated he had quit smoking thirty years prior, but at NO time was smoking ever mentioned. 

So if obesity is a disease like cancer .....

And that right there takes all the air out of the Lung Cancer Analogy balloon. 


Unlike the disease of cancer, *EVERY* treatment for obesity begins with some version of "Eat Less, Move More".  


Despite the name of this website/organization, Rethink Obesity, there's NOTHING NEW HERE.

"When discussing treatment for weight management with your patients, incorporating healthy eating and physical activity habits should always be included along with any potential discussion about medical or surgical treatment options available."



"Note: All patients with BMI ≥ 25 have either Overweight, Obesity Stage 0, Obesity Stage 1, or Obesity Stage 2 depending on the initial clinical evaluation for presence and severity of complications. These patients should be followed over time and evaluated for changes in both anthropometric and clinical diagnostic components. The diagnoses of Overweight/Obesity Stage 0, Obesity Stage 1, and Obesity Stage 2 are not static, and disease progression may warrant more aggressive weight loss therapy in the future. Patients with increased BMI due to muscularity should be excluded." 



The footnote on that table is maddening.  Because essentially, offering no real guidelines for assessing "muscularity", ANYONE with a BMI greater than or equal to 25 has a disease.  

Don't look now if you are "just" overweight, they are coming for you with a "pre-obesity" official disease diagnosis on your medical record.  

Medications, such as they exist, are only there to assist in compliance with "diet and exercise".  (But read the background discussions going back a decade or so.  It's ALL about drugs and surgery.)  How is this even Endocrinology?

Dr. Amy Fleischman, Director of Dr David Ludwig's Optimum Weight for Life (OWL) program in Boston, was quoted in the recent Disease v. Choice pep talk:


The concept of obesity as a physiologically driven chronic illness that requires treatment with physiologic-based interventions makes sense.

Sure it makes sense.  But that's not what you're doing!  Where are the physiologic-based interventions?  Instead, here's the OWL program:  (note since 1996!)

 We primarily help our patients using a combination of nutritional counseling and behavioral modification.
Nutritional counseling
Dietary modification is a primary treatment used in the OWL program. We frequently prescribe a "low glycemic index" diet to help control excessive appetite, but depending on your child’s needs, other dietary approaches are also available.
During the initial evaluation, your family meets privately with a dietitian to discuss how to ease the transition to a more healthful way of eating for your child and your family.
Behavior modification
Behavior modification uses a combination of short-term individual and family psychotherapy sessions to increase motivation to change diet and physical activity level. These treatments may also help children cope with the emotional stresses associated with being overweight and boost confidence.
Here at the OWL program, we believe strongly in the value of a strong support structure, and we can put you in contact with other families and access other community resources. Together, we can help your child switch to a more healthful lifestyle.


I could amass countless more examples.  These all demonstrate that ...


The Lung Cancer Analogy to Support Obesity-As-Disease is Fatuous.  


The fact that lifestyle can lead to disease does not discredit a disease designation.  Fair enough.  Everything else about lung cancer as a disease simply doesn't hold up:

  • Gaining excess weight (fat) to become obese is not pathological.  When a lung cell becomes cancerous, it is by definition pathological.
  • Treatment for lung cancer is based on pathophysiology of the cancer, not the underlying cause.  This is directly opposite to treatments for obesity.
  • To the degree obesity can be pathological (e.g. "sick fat") we,
    • Have existing diagnostic and treatment protocols for issues that may be due to this:  e.g. antihypertensives for high blood pressure, insulin/insulin-secretagogues for diabetes, statins for dyslipidemia
    • Have no existing criteria for "sick fat" and no known treatments of the fat itself (caveat: Thiazolidinediones are a notable exception, which generally, paradoxically,  INcrease fat mass) 
  • Obesity treatment are primarily lifestyle interventions.  Those that are not directly so, must still involve a lifestyle change component to be successful.
  • The "first line" treatment of obesity -- diet and behavior modification -- is akin to instituting a smoking cessation protocol to "manage" lung cancer.  I think we can all agree that's absurd!





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