In the current issue of Obesity Reviews, the World Obesity Federation publishes its consensus statement defining obesity as a disease process [1]. The statement follows a document from the World Obesity's predecessor body, the International Association for the Study of Obesity, which in 2013 issued a discussion paper, Is obesity a disease? [2], raising several issues concerning the policy implications of classifying obesity as a disease. That paper explains that a rise in the prevalence of unhealthy weight gain is an understandable and predictable biological response in an inappropriate, ‘obesogenic’ environment [3]. It also acknowledges that declaring obesity to be a disease could benefit those people who are suffering with obesity and wish to have access to medical advice and support. In this Comment, we argue that recognizing obesity as a disease can serve this function for those already overweight or obese whilst also strengthening the call for dealing with the social determinants, obesogenic environments and systemic causes of individual weight gain.
World Obesity has a number of policy-related activities already in action that may be enhanced by describing obesity as a disease or disease process. Current activities include close collaboration with the World Health Organization (dating back to a 1997 joint WHO-IOTF Consultation on Obesity [4] that declared obesity as a disease) and working alongside other international non-profit health organizations advocating on food, nutrition and physical activity at intergovernmental, governmental and local levels. We also participate in research programmes with clinicians and research departments, supporting scientific dissemination and assisting in the interpretation of project outcomes and working with healthcare professionals to promote best-practice interventions to support people with obesity.
World Obesity also contributes to major efforts to identify the determinants of obesity and the best forms of intervention to prevent weight gain and to alleviate the disease consequences, including contributing to two Lancet Series on these issues [5, 6] and co-hosting the Lancet Commission on Obesity [7]. We work on projects to identify disparities and inequities in health and their social determinants, including barriers to obesity treatment, and we host a regular series of webinars and round-tables to alert advocacy organizations and commercial operators to the current issues and concerns in obesity policy development. World Obesity works to reduce weight bias and stigma and has produced a freely available image library promoting positive images of people with weight problems for use by journalists. World Obesity also provides online resources on obesity including a series of educational modules for health professionals promoting best practices in patient care and treatment.
We are keenly aware that arguments against the classification of obesity as a disease can be made on the grounds that obesity is primarily a risk factor for other conditions rather than a disease in its own right and that ‘medicalizing’ obesity by declaring it as a disease defines large sections of the population – including more than one-third of American adults and one-quarter of UK and Australian adults [8] – as being ill. There are also fears this perpetuates an arbitrary definition of excess adiposity and emphasizes individualized reliance on costly drugs and surgery while neglecting critical public health measures, many of which lie outside the health system, to address the underlying social and commercial determinants of obesity [9, 10].
Supporting treatment
In terms of supporting treatment, we believe there are potential benefits of applying the disease label to obesity. Firstly, a medical diagnosis can act to help people to cope with their weight concerns by reducing their internalized stigma or the belief that their problems are self-inflicted and shameful. Such internalized stigma is itself a barrier to effective weight loss [11] and may impair weight loss maintenance [12, 13].
Secondly, we are hopeful that a classification of disease, or disease process, may help to change the public discourse about blame for the condition. Blame for heart disease or cancer is rarely put on the individual. Even in the case of lung cancer related to a history of tobacco use, patients are usually seen as victims trapped by their addictions. If a medical classification can help to reduce the persistent weight bias narrative in the mainstream media [14, 15] and social media [16, 17], this is also a compelling justification for the World Obesity position.
The weight bias narrative is also very common among healthcare professionals, even in the clinics responsible for helping people manage their weight [18]. Classification as a disease may have some impact here, encouraging greater empathy with patients and raising the patient's expectations of unbiased care from health professionals [19].
Thirdly, recognition of obesity as a disease may have benefits in countries where health service costs are funded from insurance schemes that limit payments for non-disease conditions or risk factors. Even in countries where health services are largely funded from general taxation, as in the UK, there are arguments over whether people with obesity who ‘fail to look after themselves’ should be offered treatment [20] along with proposals to withhold standard surgical procedures for hip and knee operations for people with obesity unless they can show they can lose at least 10% body weight [21].
Supporting prevention
We underscore the importance of ensuring that defining obesity as a disease does not divert attention from the social and commercial determinants of the condition and the need to take a holistic or systems-wide view of disease causation. To define the condition as a disease must not weaken our resolve to advocate for measures such as controls on the promotional marketing of unhealthy foods and beverages to children or the taxation of sugar-sweetened beverages. We agree with the view that overemphasis on individual-oriented solutions to reducing the obesity epidemic, which depend on high levels of personal agency in resisting or overcoming obesogenic environmental forces, is unrealistic and potentially widens health inequalities [21, 22].
Tackling obesogenic environments is not simply a preventive measure; it is also integral to the treatment process. Failure to maintain weight loss is the major problem for obesity management [23]. Weight re-gain is as much a problem as weight gain, and environments that lead to weight gain for the population generally are as likely to encourage weight re-gain among patients attempting to reduce and manage their weight [24]. Preventive measures therefore help prevent initial weight gain and reduce the risk of relapse for those receiving treatment.
In summary, while unhealthy weight gain in an obesogenic environment is a predictable biological response, the resulting excess adiposity is neither a biologically ‘normal’ nor healthy condition. Whilst recognition of obesity as a disease has the potential to over-medicalize a problem of societal origins, it also has the potential to improve treatment access and outcomes and can serve to strengthen measures to reduce the obesogenicity of the environment to which the population is exposed. This serves to strengthen arguments for the advocacy and public health activities of the World Obesity Federation.
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