Are you sick because you're fat, or fat because you're sick? Maybe you're just sick of being fat.

Or are you sick of people insisting you should be thin?

If you're not certain how to answer, then you're in good company. Even the experts can't agree whether or not obesity is a disease.

When it comes to carrying extra weight and its consequences-obesity afflicts more than 300 million people worldwide-there are no easy answers or solutions. The only apparent source of agreement is that more people are fat and getting fatter-in the US alone there are triple the number of overweight kids than there were 25 years ago-and there's no failsafe plan or program for making them thin.

At a recent meeting in Finland of international experts-the 14th Congress on Obesity-much discussion centered on designating obesity as a disease, calling it one of the major causes of preventable death, which is connected to diabetes, respiratory and cardiovascular problems, depression and some cancers.

Should obesity be considered a disease? The National Institutes of Health and the World Health Organization are persuaded and Medicare in the US has recently decided in favor of the designation.

"I have mixed feelings about this. If obesity is a disease, then using the tools of medicine become the accepted way to treat it. Pills and surgery are not the answer for every physical, social and behavioral problem, and the designation of obesity as a disease is a vote for abdicating the difficult daily grind of making different food choices and exercising. On the other hand, obesity is an intractable condition for so many people, why shouldn't we use the tools of modern medicine to address it? And if, in order to get insurance reimbursement for doing so, it must be designated as a disease, what's the harm? The government doesn't just call it a disease; it calls it an epidemic. I think the answer is some place in the judicious middle," says Dr. Jessie Gruman, president and executive director, Center for the Advancement of Health in Washington, D.C.

Those opposed object to the idea that being thin is better than being fat, pointing out that you can be fat and healthy, that the real culprit is inactivity, and not excess weight. Being heavy may predispose you to some illnesses, in the same way that smoking does, but neither obesity nor smoking are diseases, opponents argue.

Advocates state that by declaring obesity a disease it would make it easier and less stigmatizing for people to seek and receive treatment and that new and better therapies would develop as a result.

"Who needs to know that obesity is a complex health issue, anyway? Doctors and insurance plans? Parents? People who are trying to lose weight? People who discriminate against obese individuals? I would say all of them, but what each of them needs to know about it is slightly different if they are going to act effectively to reduce its impact. Who is to say that an aesthetic preference for a leaner body is not a legitimate reason to invest energy in losing weight? Yet there are some recent studies indicating you can be overweight and healthy. As for preference, it is ever shifting from society to society. Marilyn Monroe was a size 16. Where do we get the word Rubenesque?" notes Dr. Gruman.

She says we need to work on obesity as a public health issue since it is implicated in nearly every life-shortening disease.

"And if it is a public health issue, then it requires a public solution, at least in part. And this implies social action and the elimination of nutrition, fitness and medical disparities. In short, I think that appearance and health concerns are inextricably linked and that this is part of the challenge of addressing this problem in a way that preserves the dignity and autonomy of people regardless of their weight."

In many ways obesity is still viewed as a failure of will that implicates and defines character and appearance. Despite the increasing call to 'medicalize' excess pounds, questions still revolve around how to treat obesity; who will benefit and who should ultimately accept financial responsibility if the government decides to officially intervene?

According to Dr. Gruman, there are few effective medical or behavioral treatments for obesity available today.

"The approved drugs produce only limited weight loss (although they deliver significant reductions in clinical risk), bariatric surgery is a serious, life-altering intervention that works for a minority of those who receive it; behavioral programs have mixed success as people cycle in and out of them over time."

Obesity among children is so widespread and its health implications so alarming that many experts argue that it is for their long-term wellbeing that designation must be immediately undertaken.

"The question is whether obesity in children stigmatizes them or labels them as a special class to whom special attention (and funding) should accrue. If obesity is designated a disease, we need to look at who benefits (Pharma, obesity nonprofits) from the designation," suggests Dr. Gruman.

"Obesity is already been designated as 'pre-disease' and I don't see this changing particularly with the designation of disease. The revolution will come when interventions are developed that are successful in reducing weight reliably and permanently with no long-term side effects. I have no doubt that such interventions will be a combination of behavior and drugs or surgery. There are few signs that the revolution is just around the corner."