Obesity as a disability.

FAT can BE disabling, but is being FAT a disability? 

Uh.  *whistling, avoiding*

I guess it depends on what you're looking to do about it.  If you're in the position of looking for health insurance coverage to help you lose the weight or cover weight loss surgery, it might be helpful to be labeled.  Or - if you're so effected by the problems your obesity has caused that you cannot work and need to provide basics to survive - it would surely help.

But, what about ME (using myself as an example because I don't care to offend) and gaining up to super-morbid obesity by eating?  Should I have been considered  "disabled?"  Hello?  What about my husband, pushing 400 pounds and working 50 hours a week -- he should be disabled?  No.

In my immediate family, my father, mother in law, two sisters' in law, husband and self = all were or are SUPER MORBIDLY OBESE.  Should we be blanketed with a disability label?  

From ABC News:

Fat can be disabling. A person 180 pounds over a healthy weight is susceptible to arthritis, has increased blood pressure, a weakened heart and could soon need a walker just to get around.

Under the Americans with Disabilities Act, such a person could legally be labeled as disabled.

But should obesity be considered a disability? On Tuesday the American Medical Association voted a resounding no at its annual meeting.

But in a country where nearly one in three people is obese but where laws do not always cover size discrimination, and many health insurance policies do not cover obesity treatments until a patient develops a more serious health condition -- not all who deal with obesity agree on the matter.

"We believe that we passed this for the patient's benefit," said Dr. Domenic Federico, an AMA delegate from Michigan. "We do not want to have this limit the ability to have doctors talk about a very serious condition."

Federico explained that doctors are worried they could be legally reprimanded for discussing obesity with a patient who doesn't want to hear it.

"If obesity is designated as a disability, physicians could be sued or reprimanded for discrimination under the Americans with Disability Act if a patient takes offense at the physician discussing obesity," the resolution states. "Therefore be it resolved that our American Medical Association not support the effort to make obesity a disability."

Obviously there's got to be a LINE somewhere.  If a person's obesity causes the snowball effect of being too SICK to function, something has to change, medically, right?   Maybe then, they are disabled by the extreme effects TRIGGERED by the initial problem.  Nobody dies of fat.  They die of co-morbid conditions caused by The Fat, co-morbids that might be disabling.  I feel doctors SHOULD remain allowed to discuss obesity with a patient, because they need to help prevent the co-morbids.  In a country with a rate of 1 out of 3 people overweight - there has GOT to be a line somewhere.

AP News:

The American Medical Association has taken action to support doctors' ability to discuss obesity with their overweight patients.  Under a new policy adopted Tuesday, the AMA formally opposes efforts by advocacy groups to define obesity as a disability.  Doctors fear using that definition makes them vulnerable under disability laws to lawsuits from obese patients who don't want their doctors to discuss their weight.

From the AMA:

Obesity as a disease

Over the last ten years, the scientific concept of obesity has evolved such that obesity is no longer viewed as simply the result of energy imbalance, with energy consumed exceeding energy expended. While the influence of behavior and environment cannot be ignored, the genetic and molecular basis of obesity have received increasing scrutiny.^8,9 Nevertheless, the question remains whether obesity can be considered a disease or is more appropriately addressed as an evolving public health crisis.

The CMS has become central to this debate because of questions that revolve around obesity and its impact on health and reimbursement for related treatment. In July of 2004, the CMS changed the wording of its Coverage Issues Manual to read:

Obesity may be caused by medical conditions such as hypothyroidism, Cushing's disease, and hypothalamic lesions or can aggravate a number of cardiac and respiratory diseases as well as diabetes and hypertension. Services in connection with the treatment of obesity are covered services when such services are an integral and necessary part of a course of treatment for one of these medical conditions.

This statement reflects the role that obesity plays in certain illnesses; however, the agency is explicit in also saying that the manual is "intended to address the coverage of particular care and services, rather than the definition of illness [and] furthermore, [CMS's] review of current literature indicates that there is no general agreement on the classification of obesity as an illness."¹⁰

To understand the relationship of obesity to disease models in this report, a simple approach was used. Multiple English definitions of "disease" were examined and some common precepts were identified. These are (1) an impairment of the normal functioning of some aspect of the body; (2) characteristic signs or symptoms; and (3) resultant harm or morbidity to the entity affected.

Argument for obesity as a disease. According to Greenway and Smith, obesity was first recognized as a disease in 1985.¹¹ Those who agree with that premise have cited many reasons why obesity should be classified as a disease. It is argued that although obesity may be facilitated by certain behaviors, such as overeating or not expending enough energy, it does lead to an altered physiological state, much the same as smoking and risky sexual behavior can lead to lung cancer and AIDS.⁸ Proponents of the disease model argue that obesity is a physiological dysfunction of the human organism with environmental, genetic, and endocrinological etiologies.¹² The role of endocrine dysfunction is supported by studies showing that adipose tissue produces leptin, a molecule that regulates food intake and energy expenditure.¹³ Excess adipose tissue can cause an overproduction of leptin and other mediators, which leads to abnormal regulation of food intake and energy expenditure.^8,9 Excess adipose tissue also alters immune and endocrine functions, which contributes to morbidity.⁸ Obesity also modifies vital bodily functions, places excess stress on the heart, alters pulmonary functions, and increases stress on weight-bearing joints. This last argument also points to the "resultant harm" aspect of the definition of disease.

The second common precept (characteristic signs or symptoms) is straightforward. The only sign of obesity is excess fat. Excess fat can be determined in multiple ways, including measurement of BMI, the finding of increased triceps skin fold thickness, or increased waist circumference measures.

The argument that establishes harm as a result of obesity, the third precept, is exemplified by a well-designed study by Peeters et al, which followed 30- to 49-year-old adults and found that overweight and obesity were associated with large decreases in life expectancy, averaging more than seven years in the 40-year-old female nonsmoker.¹⁴

Argument against obesity as a disease. Those who argue against classifying obesity as a disease might begin by looking more closely at the definition of "obesity" as well as the definition of "disease". The definition of obesity states that obesity is an overproduction of adipocytes; however, overproduction is not necessarily impairment. Instead it is much the same as the overproduction of earwax in some human beings, the presence of additional digits in others, or even the continued development of the appendix. It has been argued that the tendency of the body to increase fat stores is a useful biological adaptation that has only been identified as dysfunctional because of drastic changes in the current economic environment, including the ready availability of food. In support, studies are cited that show deregulation of certain necessary physiological processes once the obese person attempts weight loss and that adipose tissue-related factors can protect some of the body's homeostatic mechanisms.^12,15

Arguments relying on the second precept (related signs and symptoms) to define obesity as a disease may prove to be the weakest. The presence of excess fat is the only sign of obesity and that is also inherent in the definition of obesity. There are no symptoms. This is akin to saying the only sign or symptom of diabetes is elevated blood sugar. It is true that obesity has been linked to the development of other disorders; however, a direct causal relationship has yet to be established and these conditions are not inevitably present.¹⁵ There is also the argument that cites data indicating that obesity accounts for approximately 300,000 deaths each year. However, these deaths result largely from co-morbidities of obesity, diseases for which obesity has been established as a major risk factor.¹⁶ None of these studies have proven the complications associated with obesity to be either caused by obesity or signs or symptoms of that physiological state.

The third precept of disease, showing that harm is caused by the state of obesity, is based on being able to prove causality and thus far, research has not made the causal connection between obesity and morbidity and/or mortality. There is an epidemiological approach by which causal relationships can be determined.¹⁷ Currently, there are many clinical observations and ecological studies that make some statistical associations between obesity and certain diseases. However, the studies that can determine whether these observations are real have not been performed. Gordis has put forth guidelines for judging whether an association is causal. [These guidelines include determination of temporal relationship; strength of the association; dose-response relationship; consistency of the association; effect of removing the exposure; biologic plausibility; extent to which alternate explanations have been considered; and specificity of the association.] The kinds of studies that can establish those determinations are not yet available. At best it can be concluded that obesity is a mediating factor for the diseases it is associated with, but true causality has yet to be determined.

The argument that obesity should be considered a disease may be a case of the end justifying the means. It is true that the ability to call a condition a disease gives enhanced credibility to the condition and its outcomes. It allows the public health community to feel confident and justified about the call to action and enlisting aid to fight the condition's untoward effects. To classify a condition as a disease strengthens public health's voice and position. In the case of obesity, it may even help enlist the aid of the government, scientific revenues, and social concern that is lacking in the current effort to control the epidemic. While it is true that obesity-related illnesses deserve far more attention than they currently receive, it does not necessarily follow that obesity should be classified as a disease. Even if obesity is not classified as a disease, its public health impact is severe enough that the AMA should advocate strongly for policies such as reimbursement for obesity in addition to its co-morbid conditions and increased awareness of its effects. Based on the arguments of technical definition and the fact that no one has yet proved that obesity in and of itself is a disease state, it seems premature to classify obesity as a disease, but this question deserves further careful study.