Should obesity be recognised as a disease?

In January 2019, the Royal College of Physicians (RCP) called for the government and health sector to recognise obesity as a disease in the UK, arguing that until this happens its prevalence is unlikely to be reduced. ¹ At present, the National Health Service (NHS) states that the term ‘obesity’ is used to describe ‘a person who’s very overweight, with a lot of body fat’ ² – but it is not a disease. The World Health Organization (WHO) also does not describe obesity as a disease but as ‘abnormal or excessive fat accumulation that presents a risk to health’. ³ However, as worldwide obesity rates have continued to rise, a number of countries and organisations have shifted their position to recognise obesity as a disease, including the Canadian and American Medical Associations, Israel, Japan, Portugal and The Netherlands.

In the UK, the case for reclassification as a disease has gained considerable support in recent years. Along with the RCP, there is pressure from the European Association for the Study of Obesity, the World Obesity Federation and the Obesity Society. Patients have also gone on the record to support this movement. ⁴

The main arguments these groups and individuals make for recognising obesity as a disease are first, that it could improve the treatment on offer to obese people within the healthcare system, and second, that it may help society acknowledge that obesity is a complex issue, which is not solely the fault of the individual.

The case for a change in terminology is based on the argument that formal disease recognition would make it easier to secure more funding for obesity treatment and prevention, which is currently woefully inadequate. With better funding, weight management services and other treatment options could be improved and offered more extensively. For instance, while there may be some local initiatives, current obesity treatment does not usually include psychological or environmental elements of support and training. Given that the causes of obesity include biological, behavioural, psychological, environmental, cultural and socio-economic factors, ⁵ the most effective treatment would address all of these components. The RCP also stated that disease recognition would ‘allow the creation of formal healthcare policies to improve care both in doctors’ surgeries and hospital’. ¹

Greater funding would also present an opportunity to boost prevention. With the Department for Health and Social Care’s Prevention Green Paper, due for publication in Summer 2019, the opportunity to drive healthy eating and physical activity initiatives is ripe. Improved prevention and treatment could ultimately curb the increasing rates of obesity, reduce costs from the associated ill health and decrease morbidity.

The view that recognising obesity as a disease could alter society’s perception of it – and therefore address the stigmatisation that commonly occurs – is not as clear-cut as some have made it out to be. On one hand, if obesity is labelled as a disease, it may help to move away from the ‘eat less, move more’ narrative, and remove the blame that is often placed on people who have tried everything to manage their weight but are physiologically inclined to gain weight. It is also argued that it would help public understanding of the obesogenic nature of our environment and the root causes of this. In the words of RCP President, Professor Andrew Goddard, ‘It is important to the health of the nation that we remove the stigma associated with obesity. It is not a lifestyle choice caused by individual greed but a disease caused by health inequalities, genetic influences and social factors’.

On the other hand, precedent tells us that having disease status does not always have this destigmatising effect. Sexually transmitted diseases and drug-related diseases are prime examples of diseases associated with a heavy degree of stigmatisation. It may well be that instantly labelling a large proportion of the population as having a disease would fuel the stigmatisation and ‘othering’ of obese individuals. In fact, if obesity was recognised as a disease, 29% of adults ⁶ and 20.1% of Year 6 children ⁷ would suddenly have a disease. Much of the opposition to recognising obesity as a disease has made the point that this would remove agency from people who are obese.

Another argument made against classification, championed by the Secretary of State for Health and Social Care, Matt Hancock, in the wake of the RCP announcement, is that it would lead to a lack of individual responsibility. He stated that identifying people who are obese as having a disease would risk them feeling helpless about their condition and without the power to change their situation, though it is unclear whether this is borne out of evidence.

Another reason against recognising obesity as a disease is that there is a lack of consensus on which criteria would equal disease status. With many diseases, there are specific indicators, such as blood tests and scans, which are used to diagnose and classify patients. Body mass index (BMI) is the tool the NHS currently uses to categorise people as underweight, healthy weight, overweight or obese. BMI is a problematic measurement: it is calculated from height and weight but does not take into account the amount of fat, muscle or bone. ⁸ Sportsmen and women such as rugby players can fall into the obese category because they weigh more due to having a large muscle mass, when in fact they have a low body fat percentage and are physically fit.

If obesity was recognised as a disease and the NHS moved away from using BMI, then what could replace it as a reliable diagnostic tool? One suggestion is to diagnose obesity by its associated comorbidities. This could prove difficult for diagnosing children, as most obese children do not develop comorbidities until later life.

Clearly, there are still many aspects of recognising obesity as a disease to explore before we can determine whether it would be useful for health professionals and help those affected by obesity. Recent polling of Royal Society for Public Health (RSPH) members indicated that there was a mixed response, with an equal split as to whether disease classification would be a beneficial development or not. More broadly, whether the UK recognises obesity as a disease or not, we must ensure that we keep messages of body positivity at the forefront of the debate. We all know that being overweight is not good for our health, yet the amount of degrading comments people have reported is shocking. Whatever the outcome, we must strive to improve the lives of people living with and affected by obesity.

RSPH is actively working in this area to further explore both public and professional opinion on the issue. Our Annual General Meeting held this month features a debate on whether obesity should be recognised as a disease. We are interested to hear what our members think – please email Louisa Mason on lmason@rsph.org.uk to give your opinion.