Bioethics Forum Essay

What Is Preventable About Obesity?

The suggestion that obesity is a preventable disease has been weighing heavily on my mind ever since I read a recent article in the Hastings Center Report.  The article claims to focus on “ethical, policy, and public health concerns” related to anti-obesity medications, but there is a strong undercurrent of bias throughout. As an endocrinologist who specializes in medical weight management, my clinical experience informs my understanding that obesity is almost never entirely preventable, but bias against those with obesity certainly is.

Like other metabolic diseases, obesity has a range of genetic and other nonmodifiable risk factors. Obesity is no more or less preventable than other metabolic diseases, including hypertension, high cholesterol, and Type 2 diabetes, and yet it is the only condition among these that is blamed primarily on a patient’s choice.

The argument that medications that can help people lose weight should be used with caution because they might discourage “good lifestyle choices” is rooted in bias against obesity and people with it. Do we tighten our belts when it comes to using medication to lower cholesterol or blood pressure because it might give “weak” people the ok to eat more red meat or put extra salt on their food? We certainly don’t hold back on using medication for Type 2 diabetes because it might suggest to millions with the disease that it’s ok to have ice cream and cake and let the glucose-lowering medication mop up the excess blood sugar.

Implicit bias against the newest anti-obesity medications has nothing to do with their cost. When we elevate the bar for using pharmacotherapy to treat high body weight, we do so because, consciously or not, we are labeling obesity a disease of choice.

On any given day, my clinic schedule might include several patients with the same body weight and BMI (body mass index), but almost never the same narrative. It is the physician’s job to ask about, listen to, and hear every story. I have yet to hear a patient describe their lifetime weight history and conclude that their current weight, which is often their highest weight, was preventable. Should we call obesity preventable for a patient with binge eating tendencies who for years has gone to the grocery store every single day to buy exactly what he plans to eat to avoid having extra food in the house? Or for a patient who was “skinny as a stick my whole life” until she assumed primary caregiving responsibilities for her verbally abusive mother with dementia, leading to weight gain because, at the end of long days, she sometimes uses food as a reward? Or the many women who have not changed a single thing about their food intake or exercise and gained 25-to-30 pounds during menopause? How about all those people with childhood obesity or a strong family history of obesity for whom I have ordered genetic testing that identified no specific genetic mutation to explain obesity?

There are so many more: people with severe asthma, juvenile rheumatoid arthritis, or other autoimmune diseases who become at least 8-to-10 pounds heavier each time they use steroids to treat a disease flare. Those whose neural networks are such that food noise always plays on very high volume, and those who tell me, “I don’t know what it feels like to feel full.” And, importantly, those who need to take weight-promoting atypical antipsychotics for depression, mood stabilization, or psychotic illness. Last, let’s not forget those suffering from chronic stress, social isolation, or social defeat—resulting from society’s choices rather than their own—all of which can cause problems with metabolism that include significant weight gain. In my experience, people are doing the very best they can with the information and resources they have. The prevention they need is against belittling obesity by calling it a disease of choice.

The existence of expensive, often very effective medications to treat obesity, including the GLP1 receptor agonists (Saxenda and Wegovy) and the dual GLP1/GIP agonist (Zepbound), may, ironically, contribute to another angle of bias. If you don’t understand how many people lack access to these medications (everyone with Medicare, many with Medicaid or commercial insurance, and all the uninsured), and that a significant minority of people do not tolerate these medicines or lose much weight when taking them, you might go along with the social media/lay press narrative that weekly injections provide a complete cure for everyone with obesity. They do not. With respect to social justice, the government should consider applying price caps to cure the sky-high cost of these medications, as it has for insulin.

There is a final way in which bias against obesity is literally hardwired into medical care: the ICD 10 coding system. I am urged to bill using HCC (hierarchical condition category) codes, as they glean the highest reimbursement from insurance. Fact: these prized HCC billing codes are pejorative, insulting, and physiologically reductive:  E66.01, “morbid obesity due to excess calories,” and E66.09, “other obesity due to excess calories.”  Non-HCC codes, which report BMI numerically without qualifiers, are reimbursed at a much lower rate. What is preventable about obesity? Personal and systemic bias.

Jody Dushay, MD, MMSc, is an assistant professor of Medicine at Harvard Medical School and an attending endocrinologist at the Beth Israel Deaconess Medical Center in in Boston.