Is obesity a ‘disease’? And, if it is, who wins?

What’s in a word? Large sums of money, it turns out, when that word is “disease”.

The Novo Nordisk pharmaceutical company has invested a great deal of marketing nous in creating a new narrative around obesity. Old words have been relaunched with new meaning. In the drug company’s world, people aren’t “obese”; they are “living with obesity”. People don’t have a “condition” that might be borne of poor diet, eating too much and/or lack of exercise; they have a “disease”.

This shift in language has generated a culture war within the medical community that’s being waged by two opposing groups:

• The “obesity is not a disease” forces: The doctors who see the label of “disease” as emblematic of a move to cast the individual as being helpless, thus delivering power into the hands of those with a medical solution.
• The “obesity is a disease” forces: On the other side are those, frequently supported one way or another by Novo Nordisk, who push for the “disease” category partly to grab more government attention, and perhaps to get anti-obesity medication listed on the Pharmaceutical Benefits Scheme, the Holy Grail for pharmaceutical businesses.

In the crossfire is an ever-growing group of overweight and obese Australians. 67% of Australia’s population is classified as obese or overweight according to the latest Australian Bureau of Statistics figures. One-quarter of Australian children are overweight (17%) or obese (8%). Obesity is more common among those living in poorer and less educated parts of Australia.

Obese people are also likely to have other serious medical conditions, such as coronary heart disease, hypertension and/or type II diabetes. Obesity is also linked to several types of cancer, including liver, kidney and pancreatic cancer. Other co-travellers are depression and infertility.

In the face of this reality, Novo Nordisk has developed a marketing strategy that aligns its interests with those of doctors, governments and patients.

It’s a win-win narrative, wrapped in the language of social responsibility in which the company’s drug is a logical and, for some, necessary solution. It’s a pitch made in the certain knowledge that patients rarely, if ever, take real responsibility for their health.

Yet the company’s story is meeting pockets of stubborn resistance.

“We’ve got a sedentary lifestyle, an obesogenic environment, too much fast food, bigger portion sizes, and we’ve got governments that believe in individual responsibility rather than treating it as a public health crisis,” says Dr Ken Harvey, associate professor of public health at Monash University, and a lifelong campaigner for health consumers.

“Clearly it’s in the industry’s interest to say, ‘yes it’s a disease, here give us lots of money, and here is a drug that will fix it’,” Harvey explains.

Queensland GP Dr Paul Neeskens, former chair of the Wide Bay Medicare network of doctors, is particularly caustic about the new forms of language demanded of him in the surgery. He’s reacted sharply to a Health Department edict that GPs refrain from using the O word and to instead refer to patients as being “well above a healthy weight”. Neeskens is equally dismissive of the D word.

“Obesity is not a disease,” he argues. “It’s ridiculous. It’s turning people into victims who need to be somehow saved — it’s all about profits for pharmaceutical companies. They want to turn patients into victims and say we’ve got a magic wand that will fix you.”

“They say to me, ‘doc if I’m fat I don’t mind you calling me fat’,” he says, in answer to the charge his language might stigmatise people.

The Australian Medical Association (AMA) has refrained from falling into line with the Novo Nordisk narrative. Its official policy avoids referring to obesity as a disease. Nor does it see any real benefit in anti-obesity medication.

Novo Nordisk’s views, though, have gained traction with doctors who specialise in diabetes and obesity and who are influential in the medical debate. Inq’s investigations show that a number of these specialists have been funded by Novo Nordisk for providing professional advice, research, or for education.

The not-for-profit advocacy bodies Obesity Australia, and the Australian and New Zealand Obesity Society (ANZOS), back the idea that obesity is a disease. Both also receive funding from Novo Nordisk.

In the case of ANZOS, the decision came after internal disagreement over whether or not calling obesity a disease — or a “chronic relapsing disease process”, as it settled on — would put medical treatment ahead of prevention. It’s understood the doctors won out over the concerns of non-medical members.

Bond University academic, Dr Ray Moynihan, who’s been a close observer of Big Pharma’s influence on Australian health policy, sees a “typical pattern” playing out.

“It’s common for specialist groups to back expanding the definition of a disease because they have a lot more to do with pharmaceutical companies than GPs do.”

When asked, a Department of Health spokesperson told Inq the government’s preferred approach to tackling obesity was to “actively educate, support and encourage Australian families to adopt and maintain a healthy lifestyle rather than classify obesity as a disease.

“The World Health Organization considers being overweight and obesity to be major risk factors for a number of chronic diseases, but does not consider them to be chronic diseases,” the Department says.

“These risk factors are considered modifiable and the same in men and women. They include such things as unhealthy diets and physical inactivity.”

According to one source familiar with the process, one concern is the so-called “floodgate” argument: that treating obesity as a disease has the practical implication that patients have no “engagement” with their condition and cede power to the doctor.  In other words: give me a drug to fix it.

For mass sales Novo Nordisk would need its drug (Saxenda) to get taxpayer subsidy via the Pharmaceutical Benefits Scheme, a step it hasn’t taken yet — but which is a key aim for the company. At $400 per month, the treatment is too expensive for most patients even if doctors want to prescribe it. Cholesterol drugs by comparison cost around $35 per month. Blood pressure medication, also subsidised by the PBS, come in at about $15 a month.

The drug’s efficacy, for the present, continues to be a problem. An independent UK study in 2017 cast doubt on Saxenda’s effectiveness as a medium term medication, given that patients regained weight within 12 months of stopping the drug. The drug was also found to have side effects such as nausea and vomiting. 

For now, with no gold standard pharmacological treatment, the debate is somewhat moot. In the interim however, it’s important to not lose sight of the main issue — that disease or not obesity is a growing problem, and that when it comes to solving it, prevention and treatment are going to need to find their meeting point.

Tomorrow: ‘We are making a bet on obesity.’