From Body of Truth: How Science, History, and Culture Drive Our Obsession with Weight—and What We Can Do about It by Harriet Brown. Reprinted courtesy of Da Capo Lifelong Books.

Money, Motivation and the Medical Machine

“It is difficult to get a man to understand something when his salary depends upon his not understanding it.”

—Upton Sinclair, from I, Candidate for Governor: And How I Got Licked

Not long ago, I rode up in a hospital elevator with a bariatric surgeon, a trim, smiling man in his forties holding a box of doughnuts. I didn’t know he was a bariatric surgeon—he wore no white coat, no identifying badge—but we got off on the same floor, which housed both the bariatric wing and the ICU, and headed in the same direction, and I saw him approach a cluster of nurses (all women, as it happened) and present the doughnuts with a little bow. “This is for you lovely ladies,” he announced. He turned, recognized me from the elevator, and explained, “Always looking for new customers.” He patted his own flat stomach and rolled his eyes, as if to say he couldn’t imagine eating a doughnut himself, and walked away.

That encounter disturbed me for days. For one thing, the surgeon was assuming (jokingly or not) that eating doughnuts makes people fat, that weight issues are all about personal responsibility, just saying no to sugar or carbs or fat. That bugged me; shouldn’t a doctor who specializes in treating fat people know better? Then there was his self-righteous stomach-patting, the way he implied both his horror at the idea of eating doughnuts and his disdain for anyone who did. But what really bothered me, what has stayed with me since that day, was his self-serving cynicism. Can you imagine a lung surgeon handing out cigarettes as “gifts”? Or a hepatologist distributing bottles of vodka? And if they did, would they roll their eyes afterward, as if to say “People are idiots to smoke/drink/eat, but better for my business”?

I know the bariatric surgeon was only one doctor, and hey, maybe he just happened to be a jerk. I’m sure there are plenty of surgeons who genuinely care about their patients and who would never make that kind of tacky joke. At least I hope there are.

But I also know that bariatric surgery is very, very lucrative. And popular, especially since 2009, when Medicare started covering some weight-loss surgeries. In 2000, some 37,000 bariatric surgeries were performed in the United States; by 2013, the number had risen to 220,000. “Right now, every hospital wants to have a bariatric surgery program because so many obese people are looking for the surgical way out,” says Bradley Fox, a family physician in Erie, Pennsylvania, who’s written about money and medicine. “Bariatric surgery is a booming business. It’s huge.”

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Other weight-loss treatments are cash cows, too, as evidenced by a series of advertising campaigns rolled out by the Center for Medical Weight Loss, a national for-profit program. With headlines like “Jenny Craig didn’t go to medical school,” “How weight loss improved my family practice,” and “Increase your practice income by $20,000 per month,” the ads try to recruit doctors to incorporate the center’s programs into their practices. And it’s no coincidence that they started running in late 2011, soon after Medicare announced it would cover treatments for obesity as long as they were supervised by doctors.

Weight loss is a big business, and, since it’s rarely successful in the long term, it comes with a built-in supply of repeat customers. And doctors have been involved in the business one way or another for a long time. Some two thousand years ago, the Greek physician and philosopher Galen diagnosed “bad humors” as the cause of obesity, and prescribed massage, baths, and “slimming” foods like greens, garlic, and wild game for his overweight patients. More recently, in the early twentieth century, as scales became more accurate and affordable, doctors began routinely recording patients’ height and weight at every visit. Weight-loss drugs hit the mainstream in the 1920s, when doctors started prescribing thyroid medications to healthy people to make them slimmer. In the 1930s, 2,4-dinitrophenol (DNP) came along, followed by amphetamines, diuretics, laxatives, and diet pills like fen-phen, all of which worked only in the short term and caused side effects ranging from the annoying to the fatal.

The national obsession with weight got a big boost in 1942, when a life insurance company created a set of tables that became the most widely referenced standard for weight in North America. The Metropolitan Life Insurance Company crunched age, weight, and mortality numbers from nearly five million policies in the United States and Canada to create “desirable” height and weight charts. For the first time, people (and their doctors) could compare themselves to a standardized notion of what they “should” weigh.

And compare they did, using increasingly clinical-sounding descriptors like adipose, overweight, and obese. The new terminology reinforced the idea that only doctors should and could treat weight issues. The word overweight, for example, implies excess; to be overweight suggests you’re over the “right” weight. The word obese, from the Latin obesus, or “having eaten until fat,” handily conveys both a clinical atmosphere and that oh-so-familiar sense of moral judgment.

By the 1950s, even as Hollywood glamorized voluptuous actresses like Marilyn Monroe and Elizabeth Taylor, medicine was taking a different stance. In 1952, Dr. Norman Jolliffe, director of New York City’s Bureau of Nutrition, warned doctors at the annual meeting of the American Public Health Association that “a new plague, although an old disease, has arisen to smite us.” He estimated that 25 to 30 percent of the American population at the time was overweight or obese, a number he essentially made up. “No one loves a fat girl except possibly a fat boy, and together they waddle through life with a roly poly family,” wrote Paul Craig, an MD from Tulsa, Oklahoma, in 1955. Craig was enthusing over a 1907 study that claimed “gratifying results . . . on the problem of obesity” by putting people on eight-hundred-calorie-a-day diets and dosing them liberally with amphetamines, phenobarbital, and methylcellulose. (Craig concluded, in a comment that fails to inspire confidence in his methods of scientific inquiry, “Not all people who eat gluttonously grow fat, but no fat man or woman eats, as they claim, like a bird, unless they refer to a turkey buzzard.”)

In 1949, a small group of “fat doctors” created the National Obesity Society, the first of many professional associations meant to take obesity treatment from the margins to the mainstream. Through annual conferences like the first International Congress on Obesity, held in Bethesda, Maryland, in 1973, doctors helped propagate the idea that dealing with weight was a job for highly trained experts. “Medical professionals intentionally made a case that fatness was a medical problem, and therefore the people best equipped to intervene and express opinions about it were people with MDs,” says UCLA sociologist Abigail Saguy.

Those medical experts believed that “any level of thinness was healthier than being fat, and the thinner a person was, the healthier she or he was,” writes Nita Mary McKinley, a professor of psychology at the University of Washington–Tacoma. This attitude inspired a number of new treatments for obesity, including stereotactic surgery, also known as psychosurgery, which involved burning lesions into the hypothalami of people with “gross obesity.” Jaw wiring was another invasive procedure that gained traction in the 1970s and 1980s. It quickly fell out of favor, maybe because it stopped working the minute people starting eating again. (At least one dentist in Brooklyn still promotes it.)

Bariatric surgery is the latest medical development in the world of obesity treatment. While such surgeries are safer now than they were ten years ago, they still lead to complications for many, including disordered eating, long-term malnutrition, intestinal blockages, and death. “Bariatric surgery is barbaric, but it’s the best we have,” says University of Alabama’s David B. Allison, PhD. “And I hope we’ll look back at some point in the future and say, ‘We can’t believe we did that.’”

Long-term success rates for these surgeries are hard to analyze because they take varying forms and they haven’t been around that long. There’s lapband surgery (laparoscopic adjustable gastric banding), where a band with an inflatable balloon is surgically fixed around the stomach; the balloon can be inflated or deflated to control how tightly the band restricts the size of the stomach. There’s the sleeve gastrectomy, where part of the stomach is amputated and what’s left is formed into a small tube that can’t hold much food at one time. There’s the duodenal switch, where most of the stomach is amputated and parts of the small intestine are altered so food is rerouted away from the intestine and calories and nutrients can’t be absorbed. And finally there’s Roux-en-Y gastric bypass, one of the most popular surgeries, which involves the same kind of intestinal rerouting as well as reshaping the stomach into a small pouch that holds very little food at one time.

The best estimates suggest that about half of those who have some kind of bariatric surgery regain some or all of the weight they lose. Some doctors say the surgeries cure type 2 diabetes (though remission is likely the better word, since many cases recur) and therefore save health-care dollars. A 2013 review of thirty thousand cases found no such savings, maybe because the surgeries are expensive—between $12,000 and $35,000, according to the National Institutes of Health—and require a lot of follow-up care.

The more weight loss is reframed as “obesity treatment” best left to medical professionals, the more doctors stand to gain from it. Medicalization tends to lead to more diagnoses, as the definition of a disease inevitably expands. And more diagnoses lead inevitably to higher revenues and profits. I don’t have a problem with doctors making money; I want my physicians to be rewarded for their expertise and knowledge and dedication. I want them to stay in practice.

But I do have a problem with the fact that profits drive a lot of the research into and treatment of obesity. In these days of dwindling medical salaries, many doctors look for other revenue streams, and they find them. Bariatric surgeons and other physicians own weight-loss treatment centers and clinics. They hold stock in or take money from meal-replacement companies and pharmaceutical makers. They own surgical practices or are partners in hospitals that do bariatric surgeries. And these other ventures create conflicts of interest that directly affect patients.

Some doctors argue that being involved in these so-called subsidiary services—say, owning a bariatric surgery center— means better care for patients, since they’re in a position to oversee and direct treatments, and can offer improved continuity of care. But the research does not bear this out. In fact, patients in doctor-owned clinics wind up going to (and paying for) 50 percent more office visits but getting no better care. That’s no surprise; in fact, professional medical organizations have been warning doctors of the dangers of double-dipping for years. “A perception that a physician is dispensing medical advice on the basis of commercial influence is likely to undermine a patient’s trust not only in the physician’s competence but also in the physician’s pledge to put patients’ welfare ahead of self-interest,” says a 2002 position paper from the American College of Physicians–American Society of Medicine. A list of best-practice recommendations from the Pew Charitable Trusts suggests setting clear, strong boundaries between academic doctors and industry. A report from the National Academy of Sciences says bluntly, “Physicians’ ownership interests in facilities to which they refer patients constitute a conflict of interest.”

Well, yes, though that doesn’t stop them from doing it. Some people believe that telling patients about such potentially profitable ties makes them ethical. “No doctor is unconflicted, and there is no unconflicted research,” says Justin Bekelman, a professor of radiation oncology at the Hospital of the University of Pennsylvania who has studied medical research. “But doctors should be disclosing their financial interests. If a doctor says, ‘I recommend this but you should know I have a stock ownership in it because I believe in the company,’ I don’t think that discredits the doctor or interrupts the doctor–patient relationship.”

Subsidiary services are only one of several kinds of conflicts of interest that plague the medical profession, especially when it comes to weight loss. One of the most fundamental of those conflicts came to a head on a cool June afternoon in 2013, when hundreds of doctors from around the country streamed into the Grand Ballroom of the Hyatt Regency Chicago. They were there, on Day 3 of the American Medical Association’s annual meeting, to vote on a list of organizational policies—boring but necessary stuff, for the most part. But one item on the ballot that day would prove contentious, and not just within the paneled walls of the Grand Ballroom. Resolution 420 was short and to the point: “That our American Medical Association recognize obesity as a disease state with multiple pathophysiological aspects requiring a range of interventions to advance obesity treatment and prevention.”

The question—whether to classify obesity as a disease in and of itself, or continue to consider it a risk factor for diseases like type 2 diabetes—had been under discussion for years, both within the organization and outside it. Months earlier, the American Medical Association (AMA) asked its own Committee on Science and Public Health to explore the issue; the committee came up with a five-page opinion suggesting that obesity should not be officially labeled as a disease, for several reasons

For one thing, said the committee, obesity doesn’t fit the definition of a medical disease. It has no symptoms, and it’s not always harmful—in fact, for some people in some circumstances it’s long been known to be protective rather than destructive.

For another, a disease, by definition, involves the body’s normal functioning gone wrong. But many experts think obesity—the body efficiently storing calories as fat—is a normal adaptation to a set of circumstances (periods of famine) that’s held true for much of human history. In which case bodies that tend toward obesity aren’t diseased; they’re actually more efficient than naturally lean bodies. True, we live in a time when food is abundant for most people and life is more sedentary than it used to be, when we don’t have the same need to store fat. But that simply means the environment has changed faster than we can adapt. The body’s still doing what it’s supposed to, so how can you call that a disease?

The AMA committee also pointed out the correlation-but- no-causation links between obesity and illness, and obesity and mortality. Katherine Flegal and others had established over and over that carrying some extra weight often correlates with living longer, which again argued against the disease appellation. Finally, the committee worried that medicalizing obesity could potentially hurt patients, creating even more stigma around weight and pushing people into unnecessary—and ultimately useless—“treatments.”*

(*Rarely does the move toward medicalizing actually help people; for instance, the classification of homosexuality as a mental disorder in the DSM-1 in 1952 led to President Eisenhower’s ban on hiring gay employees in the federal government, Senator Joe McCarthy’s claims that gays in the military posed security risks, and an uptick in anti-gay prejudice in American society that’s only now, sixty-some years later, quietly evaporating.)

The AMA membership didn’t agree with the committee; they passed Resolution 420 in an overwhelming voice vote. I asked the organization’s president, Ardis Hoven, MD, an internist who specializes in infectious diseases, to help me understand why the membership voted that way despite the committee’s recommendation. She wouldn’t talk to me directly, instead writing through a spokesperson, “The AMA has long recognized obesity as a major public health concern, but the recent policy adopted in June marks the first time we’ve recognized obesity as a disease due to the prevalence and seriousness of obesity.”

In other words, obesity is a disease because there’s a lot of it and because it’s serious (though Hoven wouldn’t define “serious.”) And because there’s a lot of it we should consider it a disease. This is just the kind of circular reasoning that’s gotten us where we are on weight issues in the first place.