Myths, Presumptions, and Denying Access to Obesity Care

It sounded like she was thinking about scrambling eggs. “I don’t want to crack open Medicare Part D for obesity meds,” said this bright young Senate health staffer last week. “Don’t you think a lot of this is coming from depression?” she asked.

Such are the questions we hear from some policymakers about obesity care.

One of Many False Presumptions

Our conversation with this thoughtful person made it clear that mental health is high on her list of health policy concerns. Bravo.

What’s more, there’s a tiny bit of truth in her thinking. Sometimes depression and obesity can be found in the same patient. Maybe, in some cases, obesity leads to depression. And in some cases, depression might lead to obesity. However, sweeping generalizations about mental health and obesity are both unsupported by science and unhelpful. It’s simply another false presumption about obesity. Worse, it’s a lame excuse for doing nothing.

In a commentary on Medscape, Professor Nikhil Dhurandhar lists four more false presumptions about obesity. They’re so common that many people regard them as facts. But they’re not.

1. Food Causes Obesity

Food doesn’t really cause obesity any more than water causes edema, says Dhurandhar. Edema results from problems with how the body retains or releases water. Drinking too much water is not the cause. Likewise, the body regulates how much energy it stores in the form of fat.

Unencumbered by facts, policymakers pursue food policies to reverse obesity based on logical deductions about what should work. Call it trial and error, with a big emphasis on the error part.

2. Obesity Is a Choice

Eating and being active are choices that people make, right? Thus, if you presume that too much eating and too little movement causes obesity, it’s easy to assume that obesity is a choice.

But it’s not quite true, as Dhurandhar explains. Choice plays a role, but physiology has the central role in determining how much energy the body absorbs, burns, stores, and sheds. It’s more like an election than a choice. You get to vote, but you don’t get to decide.

3. Calories In, Calories Out

This popular catchphrase is seductive. When you eat 3,500 calories more than you burn, you gain a pound. Simple and false. The relationship is not linear and it’s governed by physiology that adapts. Some bodies resist gaining weight, while others gain weight quite easily. Genetics play a big role and Dhurandhar explains the research behind this fact.

4. Willpower

Impaired physiology that’s causing weight gain cannot be fixed with willpower. Dhurandhar says it’s like thinking you can control your rate of breathing for days on end. That’s simply not how it works. It’s an unconscious brain function that does this.

Looking Beyond Presumptions

Decisions and policies based on false presumptions explain a lot. They’ve given us three decades of relentlessly increasing obesity and a standard of care that that amounts to “we don’t care.”

Our friend, the Senate health policy staffer, presumes that obesity is coming from mental health issues. So despite the availability of a new generation of obesity meds that can be very helpful to some people, she would deny them access under Medicare. (Right now, Medicare Part D arbitrarily excludes obesity meds.) We don’t need drugs, we just need to fix the root cause, she says.

Good idea, but the fact is that obesity doesn’t have a single root cause. Many factors can contribute and it’s different for different people.

So we must stop repeating the same mistakes over and over. We must choose facts over presumptions, stop denying people access to care, and pursue the science of obesity to find more effective ways to prevent and treat it.

Click here for Dhurandhar’s full commentary on Medscape.

Cracked Egg, photograph © frankieleon / flickr

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March 4, 2019