By Robert Sallis, M.D.
Robert E. Sallis, M.D., FACSM, is a past president of ACSM and chair of the Exercise is Medicine Task Force. He originated the EIM concept and has been its leading advocate from the beginning. Dr. Sallis earned an M.D. from Texas A&M University and completed his residency in family medicine at Kaiser Permanente Medical Center in Fontana, CA. He has continued his medical career with Kaiser and now co-directs their sports medicine fellowship training program. Dr. Sallis is the founding editor-in-chief of ACSM’s Current Sports Medicine Reports journal. Exercise Is Medicine was launched in partnership with the AMA, and continues to work with AMA to find solutions to the obesity epidemic.
Viewpoints presented in SMB commentaries reflect author opinions and not necessarily the positions or policies of ACSM.
My first reaction to hearing that the AMA had voted to classify obesity as a disease last month was a positive one. That was until I heard the excited comments from those who will profit most from the increased use (and payment for) bariatric surgery and weight loss drugs. Right away these individuals and organizations began campaigns to gain more reimbursement for their treatments of this newfound disease. My concern is that pushing the same old overpriced treatments on patients is more likely to benefit the wallets of surgeon’s and pharmaceutical companies than the health of Americans. There must be a better way to deal with this newly labeled disease called obesity.
Unfortunately, obesity is a nebulous diagnosis that is most often defined by body mass index (BMI), which is simply one’s body weight divided by the square of their height. This measure does not take into account a person’s body composition and therefore extra muscle will raise BMI in a similar fashion to extra fat. Using BMI as a measure of obesity labels more than one third of Americans and 56% of NFL football players with a chronic disease! This hardly makes sense and it is a stretch to think that assigning such a label is going to improve health outcomes when it is widely acknowledged that using BMI as the gauge for obesity is fraught with error. If obesity is now a disease, clearly we need a better way to diagnose it.
More concerning to me is the fact that there are currently only three funded medical treatments for obesity; bariatric surgery, weight loss drugs and nutritional counseling. It is interesting to note that the most expensive obesity treatment by far (bariatric surgery), is also by far the one most often covered by health insurance. Is stapling the stomachs of obese Americans really the best way to spend our healthcare dollars? I certainly don’t think so and given the proven effect of exercise in preventing obesity and more importantly mitigating its harmful effects, why is it not funded as a medical treatment at all?
The problem lies in the fact that the American healthcare systems answer to dealing with most any disease is to prescribe a pill or a procedure. As a physician, I have seen first-hand the limited utility of weight loss procedeures, pills, and surgery – while they may help in the short run, the long-term effects are rarely significant. I have also observed the utter failure of the public health messaging around obesity over the past 20-some years. Efforts to inform the public just how fat they are, blaming the food companies, or pushing short-term feel-good solutions like bans and taxes have gotten us nowhere.
And there is another important factor to consider. At this year’s (and past) ACSM Annual Meeting, there were compelling state-of-the-evidence presentations on the “Obesity Paradox” and the ongoing debate about the importance of “Fitness vs. Fatness”. It is becoming increasingly clear that the best way to combat the harmful health effects of obesity is to get these patients to be more active, rather than just getting them to lose weight. Exercise is medicine for obese patients and getting more active is a much more positive and easily achieved goal than losing weight. Let’s face it, while not everyone can lose weight, almost everyone can go for a walk. I believe we have got to shift the public health focus off of obesity and on to physical activity. We must give Americans permission to be fat and still be healthy. This is possible and the way to do it is by getting them more active and whether or not they lose weight may not be that important.
Now there could be some positive effects from this new disease label for obesity. Perhaps it will open up doors to introduce more teaching about exercise and diet in medical school, since these are the major determinants of obesity. If obesity really is a disease affecting more than a third of the population with another third being pre-obese (or overweight), shouldn’t this disease be a prime target for medical school teaching? I would certainly think so. Another positive effect of this move could be reimbursement for exercise prescription and nutrition counseling. Currently, physicians are not able to get reimbursed for counseling in this area, certainly not to the degree they are paid for performing bariatric surgery or prescribing weight-loss drugs.
So I hope that all ACSM members will use this AMA announcement as an impetus to become stronger advocates for the best treatment we have for this new-found disease called obesity — Exercise! There are few others around the world who are better positioned to advocate this message. Unfortunately, no “Big Pharma” or device company funding exists to lobby for exercise as the primary treatment for obesity and to push public health messaging away from just weight loss and toward increasing physical activity. Exercise is the best medicine for an overweight and obese America and we need to ensure everyone knows it. We are the “Big Pharma” reps for exercise!