What is in a Name?

I was reminded of a very old movie recently, Don't Raise the Bridge, Lower the River (1968). The theme involves a con artist demonstrating the old adage "There is more than one way to skin a cat." In that vein, some have apparently finally found a way to address the growing issue of obesity in society. They have boldly . . . changed the definition of obesity.

The British Broadcasting Corporation (BBC) reports that Canada has overcome obesity by concluding Obesity should be defined by a person's health - not just their weight, says a new Canadian clinical guideline. This is inventive and novel, certainly. 

The Centers for Disease Control in the United States has a clear definition of obesity:

"Weight that is higher than what is considered as a healthy weight for a given height is described as overweight or obese. Body Mass Index, or BMI, is used as a screening tool for overweight or obesity."

That is fairly simple to comprehend and to communicate to others. If my weight is above the standard, that is seen as problematic. I first confronted that fact years ago when I entered the world of workers' compensation. My early practice was focused on employer reimbursement claims against Florida's Special Disability Trust Fund, see section 440.49, Fla. Stat. 

One of the criteria under that statute, constituting a "preexisting permanent physical impairment" is:

"Obesity if the employee is 30 percent or more over the average weight designated for her or his height and age in the Table of Average Weight"

That led me to those charts, which led me to calculate my own statistics, which led me to label myself "obese." The Government published an ideal weight range for my gender and height, and I was well above it. There were self-attempts at justification, at disbelief (in the standard, not the scales), at denial. But, the definition and the standard remained. I was obese.

We are an obese society. According to the American Cancer Society, many of us are obese, and the percentage is growing:

"between 2007-2008 and 2015-2016, the report says the rates of obesity rose significantly among adults, from 33.7% to 39.6%. Rates of severe obesity increased during this time from 5.7% to 7.7%."

Who can forget the tower scene from Airplane (1980) in which we learn "Leon is getting larger." In fact, recently it seems many of us are getting larger. 

There are implications and problems. The American Society for Metabolic and Bariatric Surgery says there are potential health impacts:

"Obesity can cause a lot of damage to your body. People with severe obesity are more likely to have other diseases. These include type 2 diabetes, high blood pressure, sleep apnea, and many more."

Note that they say "cause." There are others who note various potentials for obesity to aggravate various maladies and conditions. But, also to "cause." Over the years I have seen a great many of those government standard height/weight charts in doctor's offices. My impression has been that there is general consensus that overweight can increase health risks. 

Are we worried about obesity? (Alfred E. Neuman: "what, me worry?") Some conclude that we are, both individually and collectively. According to Thinkbynumbers.org, Americans alone spend vast sums on weight loss and fitness.

"Americans spend more than $60 billion annually to try to lose weight, on everything from paying for gym memberships and joining weight-loss programs to drinking diet soda."

The site claims that world hunger could be eradicated for half that amount. The news focuses on this topic. This year it noted the obesity rate is now over 40%, that weight may implicate COVID complications, and that obesity has implications for heart disease. Obesity is not a new topic or concern. 

Canada's solution is interesting. According to the BBC, it is not suggested that "diet and exercise" be forgone, but it is now advising "doctors to go beyond simply recommending diet and exercise." The plan is to "focus on the root causes of weight gain and take a holistic approach to health." That may or may not be consistent with merely changing the definition. Without an objective standard like the charts, how does one decide if they are or are not a healthy weight?

Well, the Canadian Medical Association has determined that there is a potential for "weight-related stigma against patients," and it cautions practitioners against that. There are cultural assumptions, it notes, regarding "personal irresponsibility and lack of willpower." The result is "blame and shame upon people living with obesity," The Canadian approach seeks to remove the stigma attached to obesity, by redefining it, and thus purportedly empower clinicians to treat it. 

The Canadian effort concluded that "many doctors discriminate against obese patients." There is a ""weight bias" that leads to practitioner behavior. The sense is that many have operated on a simple advice of less calories and more activity. The new guidelines continue to focus on a healthy and balanced diet as well as "regular physical activity" But, there is a significant focus on the mental aspects of both hunger and weight gain. 

The new Canadian guidelines will continue to utilize the body mass index (BMI) ensconced in that government height/weight chart. The waist size will also remain as a measure. But, the focus will shift from attaining "ideal weight" essentially to attaining some improvement. Size will not matter as much as making some progress. The authors of the standard point out that small weight reductions can affect improved health. 

The new guides specifically claim to not abandon the long-standing advice of "eat less, move more," but to shift focus to supporting the patient psychologically, medically (drugs), and even surgically (gastric bypass). Is it practical to conclude that surgery is the answer? Bypass surgery is nothing new. The Mayo ClinicMayo Clinic labels it a "major procedure" and notes it "can pose serious risks and side effects." And, it adds that "you must make permanent healthy changes to your diet and get regular exercise to help ensure the long-term success." In other words, surgery is not apparently an independent, risk-free, solution to the issue.

The issue seems to be both complex and vexing. Vast sums are invested annually in addressing it, and despite that rates of obesity are increasing. We like sugar, convenient processed foods, eating out, large portions, and more. We tend to like exercise, activity, and self-discipline less. We are engaged in a societal battle of the bulge, and many signs indicate we are losing. Changing definitions may help. The path of the Canadian effort will be interesting to watch. 

I for one hope they are proven correct and that weight loss can be more easily attained through their new redefinition and removal of stigmas. Clearly, something needs to change and obesity trends need to improve. Too much is riding on it for us personally and collectively. But, let's hope we are not just naively lowering the river. You think about it, I am going to get some breakfast. 

Obesity Can Kill Me? What Could Be Worse!?

Early in my career, I worked on claims against the Florida Special Disability Trust Fund. In the days before the Americans with Disabilities Act (ADA) there were efforts to encourage employers to hire those with pre-existing medical concerns. These "second injury funds" were designed to soften the financial impact on the employer of a workplace accident if some pre-existing condition contributed to the resulting disability or need for treatment. Florida has sunset its Fund, as have other states to varying degrees. 

How do these funds work? In Florida, the conditions that might qualify were listed in the statute, Fla. Stat. 440.49. The list included a variety of potentially serious medical conditions such as diabetes, Parkinson's diseases, cardiac disease, and more, One on that list that surprised many was obesity. It may be that surprise was influenced by realization, such as my own, that the law was calling me obese. What the statute actually provided was:

Obesity if the employee is 30 percent or more over the average weight designated for her or his height and age in the Table of Average Weight of Americans by Height and Age prepared by the Society of Actuaries using data from the 1979 Build and Blood Pressure Study.

As a young lawyer, I was surprised to learn that obesity was viewed in the same category with these other medical conditions. I looked-up that average weight and did the math. I found myself barely under the mark for the label "obese." Back then I did not consider myself obese, though in ensuing years I went through a weight gain that removed all doubt. When I was learning about the SDTF, we had not yet heard the national cacophony on obesity. 

That national focus has come in the last 25 years. We have heard and learned a great deal, particularly in the last decade or so, about obesity and the health risks that are associated with it. It is somewhat comforting to know that Florida had recognized the seriousness of obesity in the SDTF statute before it became a national focus. I wish I had recognized it earlier myself. 

Now we face a "national obesity epidemic." A recent post on Jon Gelman's blog cites to Kaiser Health News. It notes that as obesity increased in particular populations, the incidence of "chronic diseases" also increased. They note that this trend is worrisome. And that "one out of every three adults in the U.S. are clinically obese." Yes, that includes me, which means two of the rest of you are in the clear.

This reminds me of a quote from the beginning of The Paper Chase, which influenced a generation regarding attending law school. The protagonist there was giving the new law students a reality check when he said "look to your left, look to your right, because one of you won't be here by the end of the year." This analogy works with obesity, one in three. A staggering statistic.  

The Kaiser article notes potential for health complications that may be suffered by those of us that are obese. One cited study concluded that "obese people have higher health care costs." They note that obese people are heading into nursing homes at younger ages, and that there is added expense associated with care "for heavier residents."

Not shocking news, I grant you. The last 25 years have seen a variety of reports, publicity and news trying to convince us all to lose a few pounds. We as a nation are obsessed with weight. The "annual revenue of the U.S, weight-loss industry" is about $20 billion dollars. So, it is a problem that has gained recognition, and is receiving focus. Whether I individually will prevail in my own little battle of the bulge is up to me though. Some days I feel I am winning and other days I surrender to the sweet lure of chocolate.

With this backdrop of the seriousness of obesity, I was surprised to run across a headline trumpeting another recent study. In February 2014, the Guardian announced Loneliness Twice as Unhealthy as Obesity for Older People, Study Finds. The conclusion is that "a long-term feeling of extreme loneliness can have a worse impact on increasing potentially lethal health risks than obesity."

The study found that "chronic loneliness increases the risk of premature death by 14%." This was compared to obesity. The study concludes that loneliness increases the risk of premature death twice as much as the increase caused by being overweight. This is perhaps worrisome. As a side note, worse than either obesity or loneliness is poverty, which increases the risk about 19% according to this study. So being poor increases risk the most, then loneliness, then obesity. 

I wondered, as I read that, what that means for those who suffer all three, poverty, loneliness and obesity? Not an encouraging thought.

The authors claim that this loneliness finding portends a "crisis as the population ages and people increasingly live alone or far from their families." The Guardian discusses this recent study and cites previous studies that are supportive of their conclusions. It says that loneliness has been implicated in "a range of health problems, from high blood pressure and weakened immune system to a greater risk of depression, heart attack and strokes." Serious concerns. 

One author of the Guardian story suggests that individuals need to protect themselves from the threats presented. He suggests that remaining engaged in a community has merit and benefit. He advocates taking "time to enjoy yourself and share good times with family and friends." 

But, these are not infallible solutions. The study found some people "suffered the impacts of loneliness even with family and friends close by." Likewise, the "researchers found that some people were happy living a life of solitude." It may be that the impact depends somewhat on how the particular individual feels about the solitude or the companionship.  

One solution to both of these issues may be to find a social environment in which to exercise. I have tried for years to make exercise part of my daily routine. My continued obesity tells you my success has been limited. However, perhaps the solution is not a quiet, i-pod ensconced treadmill walk, but instead some engagement in a group social activity? At my age, I am not advocating touch football. But perhaps there is merit in the idea of group exercise class or a walking partner? 

While it does nothing for the biggest threat, poverty, perhaps it helps us with the other two? Besides the fact that I am perhaps more likely to exercise with company than alone. 

Stool Transplant?

Science is fascinating. There is ample evidence that it is not always correct. The acceptance of geocentricity, vitalism, the four humors, and more illustrate how wrong scientists have gotten things over the eons. These examples are notable because they were spectacularly incorrect and yet had popular acceptance at one point or another. There are undoubtedly many other debunked hypotheses littering our path to today, perhaps less known, perhaps more or less incorrect. However, there are likely just as many scientific successes and miracle cures that sounded a bit off-base when they were proposed. 

That occurred to me recently when I ran across an article on ENM News Seeking an Obesity Cure, Researchers Turn to the Gut Microbiome. This describes a scientist in Boston who sought to study the causes of our burgeoning obesity epidemic. She hypothesized that our modern world is deleterious to "the community of trillions of microbes that live in the gut." Yes, we are all full of bugs essentially. The scientists concede that the role of these microbes on our lives, and whether they play a role in our bodies' propensity for weight retention is not fully understood. 

There is no doubt that we are increasingly obese. The Centers for Disease Control has studied this. The prevalence of obesity is increasing. The medical risks associated with our body weight are gaining recognition. The financial costs of our obesity and related medical conditions are estimated at a staggering ($147 billion annually). And, there is evidence that it disproportionately afflicts particular ethnicities, economic groups, education groups, and ages. There is ample justification for science to work towards helping us address obesity.

The Boston endocrinologist hypothesized that the microbiome has either a causative or cooperative involvement in obesity. To test that hypothesis, "she put out a call a few years ago for overweight people" to participate in a study. The enthusiastic response was overwhelming. It was more so considering that the test subjects were asked "to swallow capsules containing stool." You read that right. The experiment involved harvesting stool from thin patients and then introducing that into the digestive tracts of the test subjects.

The theory was that the elements of the microbiome contribute to how we digest food, absorb nutrients, and/or store fat. The ENM reports that "the link between the gut and metabolic disease is a growing area of obesity research." There are literally "trillions of microbes that live in the gut," and the question is essentially whether metabolism and weight can be affected by transplanting "fecal microbiota."

To say that this has attracted skepticism would perhaps be an understatement. The ENM story reminds us that "fecal transplants will never replace diet, exercise, (and) behavioral therapies. There is seemingly consensus that one of the great challenges with obesity is that it "is a very complex disorder." One expert on microbiome cautions that obesity is more complex than the repopulation issue (when antibiotics destroy one's bugs). He notes that there are an array of factors, including genetics, diet, environment, and lifestyle" that influence obesity. Therefore, he concludes it is unlikely that "a single intervention, a transplant of a new community of microbes," could be an effective singular solution to obesity.

Despite the caution that this will not be a singular solution, there is evidence of its potential. Prior studies have demonstrated increased "microbial diversity" as well as "insulin sensitivity," which researchers in Holland concluded as support for a change in metabolism following such transplants. There have also been reports of medical benefits in "small studies." Contrarily, the recent testing in America did not reveal similar metabolic improvement.

Researchers are not, it seems, contending that the microbiome is singularly "the" obesity solution or even a major solution. however, they contend that in a particular patient, it may be "playing a big part." They advocate for researching it not as a be-all and end-all, but as believing that it may help some to overcome obesity challenges.

Scientists have concluded that there are clear distinctions in the "microbiomes of obese and lean people." And, it may be that distinctions begin very early in life. Using tests on the gut bacteria of children as young as 6 months old" has allowed the scientists to draw conclusions and make predictions of that person's "future weight gain." It appears that some of us may be blessed, or cursed, with digestive systems that are more efficient and effective than others. If we are in that efficient group, then we perhaps absorb nutrients more than other people, and thus gain weight more easily. 

These scientists are building upon research that has demonstrated the benefits of "fecal transplant" when repopulating a patient's bacteria, which has been compromised through the use of antibiotics. That success perhaps drives current research despite critics' doubts about the parallel to obesity. Knowing that stool transplants have worked in that situation, scientists are seeking to transplant lean or thinner people's microbiomes to the obese through stool pills. They hypothesize that such a transplant may affect the donee's microbiome and aid the battle against obesity. 

In the end, none of the studies has proven a connection between stool transplantation and weight loss. That is perhaps because no studies have been long enough to measure that, or because there is no connection. Time will tell if there is a medical benefit to transplanting these microbes or whether the theory finds a place on the list of unproven theories with geocentricity and more. 

Comorbidity of Obesity

Issues of obesity are receiving attention recently. USA Today noted in September that the Centers for Disease Control recently issued a report concluding that "the number of states with high obesity rates nearly doubled over two years." The Pandemic has been a challenge for many, with impacts professional and personal. The tenor of this article is that "pandemic stress" has fed the growth in our girth. The report notes that "16 states had obesity rates of 35% or more in 2020." In 2018, there were nine. That is disturbing. However, the more disturbing point is that "Just two decades ago, no state had an adult obesity rate above 25%." There is clearly a pattern, and the trend is not positive.

It is not just the macro (state) analysis that is of interest. U.S. News reports that "42% of adults in the U.S. reported gaining an undesired amount of weight" in a recent poll. Some have joking referenced "The COVID 19" (note the lack of hyphen), a attempt at humorous reference to the "19 pounds I gained during the pandemic." Yale Medical references a similar play on words with the "Quarentine-15." Catchy, yes. Humorous, perhaps not so much. 15 pounds is too easy to gain and can be hard to lose. I have personally spent most of my adult life struggling with weight.

I cannot help but recall a line from the control tower scene in Airplane (Paramount 1980). One of the characters mentions, out of context, that another named Leon is "getting larger." Maybe we all are? Leon looks at his coworker askance and pinches his own waistline in apparent doubt or disbelief. Are we honest with each other, and with ourselves on this topic? In today's world of "I'm O.K., you're O.K.," are we honest with friends and family about the need to lose a few pounds? 

The implications are of note with some now openly calling for the denial of medical care to those who do not satisfy critic's perceptions of appropriate self-care. When Obamacare was passed, there were those who saw the potential there for rationing medical care. See The Washington Times Obamacare death panels should be ended. Many decry that terminology and insist that rationing could/would never happen in America. See U.S. News The Truth behind Obamacare Death Panels and NPR From the Start Obamacare Struggled with Fallout from a kind of Fake News. See Science, Standards, and Government (April 2020) for more on obesity and the challenges it posed with COVID-19

Obesity is an expensive challenge. The USA Today notes "obesity is linked" to a variety of medical conditions. It is perhaps causative or at least exacerbating. The article mentions "type-2 diabetes, heart disease, stroke and many types of cancer." According to the authors, obesity "increases health spending by $149 billion a year." What we have learned in the last 18 months is that obesity also "raises the risk of COVID-19 hospitalization and death." Will those who advocate no medical intervention for those who fail to vaccinate be as vociferous, immature, and crass regarding those who are obese or who fail to manage their diabetes or similar? Some insist we are better than that, but there is perhaps uncertainty nonetheless.  

Despite the risks, obesity is rising, at least in some areas. The list of states now reporting more than 35% are "Alabama, Arkansas, Delaware, Indiana, Iowa, Kansas, Kentucky, Louisiana, Michigan, Mississippi, Ohio, Oklahoma, South Carolina, Tennessee, Texas and West Virginia." It appears that this is not an issue of which we are oblivious. U.S. News reports that "Americans spend north of $60 billion annually to try to lose pounds." If anything, we seem acutely aware of the problem and yet it continues to grow. If you are keeping track, Dirkson, that is over $200 billion on medical care and attempted prevention ($149B + $60B). You know, "a hundred billion here, a hundred billion there . . .."

The USA Today blames in part a change in our physical activity during the pandemic. Certainly, there have been places in which gym access has been limited by lockdowns. Even where gyms remained open, there may have been distancing constraints, shorter hours, and even patron's own fears. Each limited access. As I traveled, I was pleased to find hotels with an open workout room but was periodically frustrated back to the city sidewalk by capacity restraints (e.g. "two persons permitted at one time"). However, the article also lays the blame on stress. Certainly, there has been stress from the pandemic, work changes, school changes, shopping changes, vacillating mask requirement changes, and even childish profanity-laced ad-hominem attacks on social media. It has been a stressful time for many. The fact is there has been one notable and persistent consistency throughout the pandemic, inconsistency. Doubt and uncertainty cause stress. 

There is also a suggestion of various groups demonstrating higher rates of obesity. A physician is cited concluding that obesity is related to the stress of racism. There might be challenges regarding stress of economic status, and gender. There is a tendency toward our core belief of created equal, but in impact, it is possible that some have been more challenged by COVID-19 than others. The USA author suggests that stress may have changed the way we eat. There is some chance, he explains, that "your cravings for food change when you undergo stress." I know I love comfort food, but that is anecdotal. Do you? The author also suggests that "food insecurity" increased during the pandemic. It cites school closures and changes in families' incomes. The conclusion is seemingly that income impacts access to nutritious food. It is shocking that for some the only chance for a nutritious meal is seemingly at the public school. 

In another reference to stress, A study published by Plos.org suggested there is a correlation or perhaps causation between "adverse childhood experiences" and "childhood obesity." Others have found a correlation claiming "childhood adversity has been associated with poor adult health" in a more general sense. Yet another finds a correlation between childhood obesity and adult obesity. So, there are challenges in childhood that produce long-lasting effects. I know some who suffer from very challenging obesity who in fact had very stressful and challenging childhoods. I cannot make the correlation clinically, but some faces came to mind as I read these articles. I also know some who suffer from morbid obesity and have since a very tender age. I am no scientist, but I do personally know anecdotal examples of these propositions.  

The Yale Medicine article notes that the "COVID curves," or "Quarentine-15" are not universal: "in fact, there are reports that some people are losing weight." I have been on a personal odyssey to reduce my mass since 2019. I had a good year in 2019 with some reasonably simple changes. Note, I am no nutritionist, no doctor, and no scientist, and am not providing dietary advice. But, I made simple reductions in fast food, carbohydrates, and sugar. I lost weight. I began exercising regularly. I lost weight. I do not crave the exercise, but I do it daily. And, I am now maintaining a healthy weight. 

I did not start walking miles a day. I began by walking to the end of my street and back. I added a few steps daily. In 2020, I averaged 7.5 miles per day. That is extreme, but it sure does relieve the stress. I had no gym, no treadmill, no trainer. I simply walked every day, rain or shine. Furthermore, eating right is not the challenge people think. I found lots of fruit and vegetable alternatives to sandwiches and found my grocery bill decreasing markedly by shopping for nutritious food. I convinced myself that apple was as desirable as the cookies. 

2020 brought stress. There is no denying that. From various directions, challenges arose. But, we can all learn to recognize stress. We can all find ways to deal with stress. And, it is critically important that we find healthy ways of dealing with stress.  While my "go-to" solution used to be a full package of a certain cookie that will remain nameless, the better "go-to" has become a mile walk in my neighborhood. That this works for me is personal, and I note it only as an example. The solution is not for you to do as I do, but to recognize your stress and to find your healthy way of addressing it (beginning with a consultation with your physician). If you desire it, you can accomplish it. 

If you are not persistently taking care of yourself, where will you end up? Certainly, we all have those who depend upon us, but as the nice attendant reminds on each flight, "Put your mask on first then assist those around you." If you are not healthy, how can you assist those around you? Obesity is a killer. It is a pandemic with potential way beyond COVID-19. It is time we found a way to address it, and I think that will mean a lot of different solutions for different people, lifestyles, and histories. Regardless, we really need to find a path. As COVID-19 comes to a close, this obesity pandemic is getting away from us and will continue to kill. What will you do about it?

Fat Discrimination

Obesity is an issue in America generally, and it is becoming a workplace challenge. Unfortunately, many in society find themselves incapable of shedding the pounds. I have written significantly about the challenges, but in this context, perhaps the path to progress is to quit admitting we are obese? See Obescity Again (January 2023). See also What's in a Name (August 2020); The BMI Conundrum (August 2022).

Changing the name or definition will not change the fact that obesity affects people. There are health risks. Obesity can Kill me? What Could be Worse? (March 2015); Comorbidity of Obesity (October 2021). Obesity is dangerous. "A rose by any other name would smell as sweet." Billy Shakespeare (Romeo and Juliet, 1591). Regardless of how we label obesity, it will nonetheless contribute to and predispose to health problems (according to Harvard). 

Beyond denying obesity, there are many efforts at diminishing body weight. There is debate about the cause of our personal and collective gathering of weight. Disease or Choice (March 2023). There is advocacy for drastic approaches, including surgery. Obesity Yet Again (January 2023). There are billions (<$30) spent annually on fitness. And there are even some peculiar examples of procedures engaged to accomplish weight loss. Stool Transplant (October 2019). That is right, people tried feces transplants, but apparently, that did not help. 

And obesity has long been on the scope of employers. See How will risky Behavior and Choices Affect Employment Decisions (April 2013). For more than a decade, we have heard that employers will consider predisposition questions and issues in the hiring process. There is the risk of health issues associated with obesity. Should employers be able to choose whether to shoulder that risk, the same as they might if I am a smoker, a skydiving enthusiast, or pose other risks? I have heard no one persuasively argue that discrimination against smokers should be illegal (dope or tobacco). 

Well, not so in New York City. That glistening city in the north is a paragon of such policy failures as rodent control, Homelessness, crime, and more. The New York Times recently inquired "If you were mayor, what problems facing your community would you try to solve?" That expose discussed multiple pressing issues. It outlined a city with many large challenges. The Times ignored or forgot being fat. 

Despite not making the Times' list, according to British Broadcasting Corporation (BBC), the big issue in the Apple is obesity. More specifically, employment and accommodation decisions based on obesity. With a smorgasbord of challenges before it, Gotham decided that the most important, the one to deal with now, is that employers are (apparently) less willing to hire the obese. The solutions (hopefully) that were considered included weight loss and better health. But, in the end, the solution selected was to strive to force employers to accept the risks that may come with hiring the obese.

The BBC contends that this is a "growing movement" equating obesity "with race and gender." There was a time when we all assumed that those two were immutable and there have historically been great efforts in this country to prevent discrimination based on such characteristics. More recently, we have learned that in the perspectives of some both gender and race may be more changeable than we thought. 

Well, the philosophers are perhaps thinking that way. And don't try to tell Rachel Dolezal, Jessica Krug, or Martina Big any different.  Those examples are interesting and bring new meaning to mom's assurances when we were kids: "you can be anything you want when you grow up." You may disagree with the fluidity arguments, and that is your right also. Is it fluidity or is it appropriation? Ask St. Louis, The Academy Awards, or even cooks. There is not unanimity on the appropriation discussion. 

There is likely room for discussion of whether race, gender, and obesity share. Some contend they should be treated similarly, but there seems doubt and discussion in some quarters. As those discussions change, protections from federal laws such as Title VII. and Title IX. seem to be in flux. Women and other minorities remain challenged.  

But the "Apple in decay" (Foreigner, Long, Long Way from Home, 1977) is seemingly accepting that obesity is immutable, or is at least worthy of protection from discrimination. It asserts that there is a stigma attached to being large, and that weight discrimination delivers "pervasive stigma," "bias," "lower wages," and other "sharp costs." One advocate asserted that "weight discrimination was 'a silent burden people have had to carry.'" The burdened assert that being of larger size impacts a variety of activities. 

As a recovering "healthy" person (Oh, PC, you got me there with an antonym used coyly), I can tell you size does impact your life. Yes, the obese balk at being referred to with a variety of words. Their preference is to be called "healthy." Would anyone ever suggest that we refer to smokers instead as "healthy?" There is a move afoot to use that term for the obese. Perhaps some are merely healthy, and others are really healthy, or morbidly healthy? Do such word choices help us with battling the health risks or does this merely ignore the risks?

There are allegations of the "healthy" with challenges in finding accommodating "seating at restaurants and theatres," discrimination in housing, and even "weight limits on the city's bike sharing program." Such arguments led to the imposition of the new city ordinance banning weight discrimination (I guess you should buy bigger, stronger bikes, chairs for your business, etc.). This is the same city that solved obesity years ago by banning large soft drinks. Can I get a "Team Gulp? (July 2014). 

With a decade of smaller sodas, can this weight challenge still a thing there? They claimed the smaller cups would alleviate the problem. It was a weak-minded solution that blamed the food instead of those that consume it. The soda is not making us obese, it only affects us when we chose to drink it. The same may be said of candy (they never banned the large chocolate bars), and an assortment of other foods. 

Maybe it is a more widespread challenge. The BBC reports that "Michigan has barred workplace discrimination based on weight since 1976," but it identifies no other state laws in this regard (It notes bills have been introduced elsewhere, but a bill is but a bill). There is mention of discrimination bans in "a handful of other cities," but the two specifics are "San Francisco and Washington DC." Those are another two municipalities that perhaps have no larger challenges to tackle? (Crime, homelessness, feces on the streets, retail flight). It is perhaps hard for anyone to seriously consider recommending we look to those two as urban management leaders. 

The effort in New York is led by the "National Association for the Advancement of Fat Acceptance," NAAFA. I for one am not at all sure that this use of the "F" word is PC or acceptable. My righteous indignation is past simmering. This effort against F__ discrimination, the advocates say, is "a larger conversation of framing this beyond health." They say body size is "not a health issue. It's a civil rights issue." In the end, it is "about if people are safe and protected and have the right to be in spaces." 

I am persuaded by the arguments personally. I can buy that it is more important to accept these risks and accommodate size. Let's drop the efforts at fighting the weight and just be more accepting and accommodating. However, it is harder to negotiate with diabetes, heart disease, stroke, and cancer. We can be as accepting as we want of the weight, and it will continue to kill people. 

In our new world, perhaps people impacted by one of these diseases will simply explain to the disease how unfair,  discriminatory, and hurtful they are. Perhaps if we all look down on these diseases, they will just leave? Maybe we can legislate these diseases and make it illegal for obesity to impact diabetes? It sounds ridiculous, but no more so than regulating the size of soda cups (some critics back then cynically suggested people would buy two cups of soda to beat the size limit. for whatever reason, the cup-size legislation did not end the obesity). 

There is debate as to what causes obesity. Many claim it is a disease, many espouse it is a symptom of various disease, and some perceive it to be mathematical (calories consumed less calories burned equals either gain or loss). There is much to unpack there. Certainly, there are some that are not able to maintain an ideal weight despite their many efforts. I know some that cannot do so even with the help of various pharmaceuticals and surgery. I commiserate with them, understand them, and wish we could be better to them. I was "them" for many years. 

But, for employers in the Big Apple, there is now the potential for employers to be sued for discrimination "based on 27 characteristics" according to the BBC (without further illumination). A quick check of the New York City Equal Employment Practice Commission revealed the following 15 listed. It is not clear what the other 12 might be (although obesity is seemingly on the way).

"age, race, creed, color, national origin, sexual orientation, gender identity or expression, military status, sex, disability, predisposing genetic characteristics, familial status, marital status, or status as a victim of domestic violence."

How this new effort will integrate into the fabric of employment in New York will be an interesting process to observe. Whether the NAAFA perceives an improvement in the situation of those who identify as obese "healthy" will be interesting as well. Will other states or cities follow the path as hoped and encouraged by this Big rotten Apple effort? Or is this just another cup limitation? Time will tell. 

For me, I have decided to drop ten pounds myself and see if that improves my lot in life. I have found late in life that the math works for me. It is painful to walk daily, to regularly deny myself foods I love, and to persistently watch my calories. That said, it does not mean the math works for everyone. Certainly, obesity is at least a medical result or symptom of many diseases that disrupt the math, the motivation, and/or the results. Some people cannot lose weight and that must be acknowledged and accepted. They should not be faulted for that. But, should employers be forced to accept those burdens? 

It is beyond doubt that we should not mistreat people based on immutable characteristics. There is a seemingly increasing willingness to discount the immutability of various characteristics. And there is room to discuss whether the government is capable of legislating away untoward or undesirable behavior. How many burdens must an employer carry in striving to keep a business afloat, employment available, and a market viable? 

Or, will legislative efforts at accommodation merely drive business from particular communities? There is much to unpack, and there are likely no easy answers. In a society, there will be interests that compete. For now, there is a new right for the "healthy," and time will tell. Can government legislate acceptance? Will people accept weight as immutable? 

How will Risky Behavior and "Choices" Affect Employment Decisions

Medical care costs are rising. There is also a trend recently for employers to be more concerned about the habits of their employees. Monitoring behavior that is perceived as "risky" is nothing new. I can remember one of the first times I was asked whether I smoked. It was on a life insurance policy application that I completed in college. 

They also asked me if I was involved in skydiving. It did not strike me then that this insurance company apparently saw these two activities of similar interest, along with alcohol use. These perceptions are finding their way into employment decisions though, and there is a growing debate as to whether employers should be allowed to make employment decisions based on their perceptions of risk and cost associated with a prospective employee's habits. 

According to the Unites States Parachute Association, 19 people died in skydiving accidents in 2012, out of roughly 3.1 million jumps. This represents a great decrease from the 43 people who died each year in the 1970s. While the actual volume of deaths has been decreasing in recent years, we have not reached the baseline of 14 fatalities that was recorded in the first year of record-keeping, 1961. I reflect on this because I did sign up to jump out of plane once. I can hear my father now,"why would anyone jump out of a perfectly good airplane."  I got my money back.

According to the Centers for Disease Control (CDC) smoking causes cancer, heart disease, stroke, and lung diseases. They estimate that smoking causes more than 5 millions deaths annually. Smoking is a little more dangerous than skydiving. There is expense involved also. The CDC estimates that actual smoking costs $193 billion ($193,000,000,000) each year in lost productivity ($97 billion) and actual medical cost ($96 billion). They claim that second-hand smoke adds another $10 billion. There are about 315,637,919 people living in the United States. That $203 billion is costing each American about $646.00 annually.

Obesity is harder to estimate. Fat is accused of death and other health complications, but does not directly kill.  So, according to the U.S. National Library of Medicine, "estimates of deaths attributable to obesity in the United States rely on estimates from epidemiological cohorts of the relative risk of mortality associated with obesity." They concede that it is difficult to determine the death rates from obesity with any real accuracy. However, studies have opined on the cost of obesity. CNN cites a figure of another $147 to $210 billion for adult obesity. That is another to $468.28 to $669.00 for each of us.

So each American is underwriting the cost of about $1,100 to $1,300 per year for treatment of smoking and obesity related medical care. 

Obesity has also been linked to increased costs of workers' compensation claims. A 2010 NCCI study concluded "there are systematic differences in the outcomes for obese and non-obese claimants with comparable demographic characteristics. The study also concludes that there is greater risk that injuries will create permanent disabilities if the injured worker is obese."  NCCI also lists smoking as a "risk factor" in injury claims. Both are viewed as a valid consideration in risk management or risk avoidance. 

Recently, companies have found their way to publicity or with  pronouncements on hiring practices. The University of Pennsylvania recently announced recently that they will not hire smokers. Some employers are even screening for nicotine, like other drugs, in their hiring process. There is an apparent trend in this direction. There are some who question whether there is any point in such a policy, as someone could cease smoking long enough to get hired and then resume smoking once an employee. Likewise, one could crash diet to achieve a particular weight or body mass and then, after being hired, return to their former weight or body mass.

In addition to UPA, other hospitals have taken the anti-smoking approach.  Companies adopting these practices cite the high cost of health care associated with such habits in their employees. I have not found any legal authorities that argue this new practice is illegal, unless smoking is protected specifically by state law. I found a few that have such laws. I could find only one state, Michigan, that protects the obese from discrimination in hiring in a general way. However, it is arguable that obesity could be protected by the Americans with Disability Act. The future of these practices regarding the smokers and the obese is therefore not certain.

What is clear is that popular opinion is against the practice of denying employment based on obesity or smoking. Many believe that it is inappropriate for an employer to even ask about health risk issues in the hiring process. 

We know that medical costs will continue to rise. We will see whether legislatures will act to require employers to hire employees they perceive to be high risk. This will be a different debate than previous discrimination debates. Many, perhaps most, Americans view both smoking and obesity as individual choices people make, which they see as different from inherent characteristics such as gender, race, and national origin. Anyone can choose not to skydive. Whether smoking and obesity are similarly "choices" and whether discrimination upon "choices" will be condoned are interesting questions. Will employers be allowed to avoid the direct medical costs and the productivity costs associated with these perceived risky behaviors?

This will be a complex issue. As employers seek lower health premiums and greater productivity in an increasingly competitive job market, and as the number of obese Americans continues to grow, there will be more debate about whether obesity, or smoking, is preventable, whether these behaviors are choices or truths, and whether such behaviors will be protected by the law.  Already, some advocates are arguing that these "behaviors" are more prevalent among the poor. They argue that discrimination on these behaviors will at least have a disparate impact on the poor and that this discrimination is inappropriate.

Obesity - a Better Definition?

There is a challenge with body mass. We have been seeing increased discussion about being "obese." The problem is growing. The British Broadcast Corporation (BBC) reported last year that Half of (the) world (is) on track to be overweight by 2035 Half of (the) world (is) on track to be overweight by 2035. 

2035 is closer than it sounds. Coincidentally, Florida's workers' compensation law celebrates its centennial in 2035, so I have been otherwise focused on that year. We are less than a dozen years from that mark.

The story says that this could impact about "four billion people," and the greatest risk is to children and the "low or middle-income countries in Africa and Asia." The focus is on a report from World Obesity, and the impacts are clearly on health and on the economic aspects of this "chronic, relapsing disease." Fat, they say, is a disease.

I have been advocating for better personal habits for years. One of my late-life realizations has been that fat kills. In 2020, I noted the BBC reporting on defining what "obese" means. See What is in a Name (August 2020). That also highlighted some of the spending we see on obesity.

But, further back, I started raising the topic of obesity and its definition. See Obesity Can Kill Me? What Could Be Worse!? (March 2015). What is obesity, how do we define it, is our trajectory in that regard appropriate and efficacious?

I have highlighted a variety of paths people have elected regarding weight reduction. There was Stool Transplant (October 2019). But the fact is that we spend billions on losing weight. A great many people are so bent on their physique that they take drugs. Some of those have the assistance and advice of a physician, others not so much.

The popular course today is a diabetes drug. Some people are taking it to lose weight, which may deprive a diabetic of the benefits it could bring. We can discuss whether obesity is a disease. I am doubtful, but I am no doctor. We cannot discuss whether diabetes is a disease. It is. It is a systemic failure of the body. Ozempic may help it. But, the supply is impacted by those using it to trim and slim.

Some worry that taking such drugs may become a lifetime commitment. There are those who warn that bodies will adjust to the drug, and that cessation of it will lead to body challenges. The New York Times reported last year that "going off these drugs can take a toll." They suggest that for ex-users, appetite may be a problem and some report being "hungry all the time" in the wake of using the drug.

Whether being fat is a disease remains a discussion. In today's world of "see it my way or face ostracism," perhaps some will throw hate for my having said that. But I think we can rationally discuss what causes fat. Certainly, I can accept that many diseases impact body mass, energy, and more that contribute to the problem. In other words, many disease processes can contribute to and cause obesity.

But, I struggle with obesity itself being a disease. Fat is fat. If a medical issue causes or contributes, then fat may be a symptom. But is it actually a disease? And it if is not, then "treating" it is of particular curiosity. See Disease or Choice (March 2023)

Yes, a disease may cause or contribute to fat. And, as prominently, fat may contribute to an array of other issues. We often see the Comorbidity of Obesity (October 2021). Being overweight can aggravate and complicate a raft of other medical conditions. Obesity puts strain on joints and other orthopedic structures. It can stress the heart, lungs, and more.

More recently, the BBC reported that obesity may already be a greater problem than we have thought. It claims that "millions of middle-aged people have been mistakenly led to believe they are not obese." A new Italian study has been looking beyond the constraints of the Body Mass Index (BMI) that has been our fat standard for decades.

I have been critical of BMI. See The BMI Conundrum (August 2022). I have also been curious about the trend to changing definitions as if that will change the facts of obesity. See Obesity yet Again (January 2023). If we change the parameters, and the definitions, will it make us healthier or not? I suggest that whether you call it this or that, the fact is that body fat and mass have an impact on health.

So, this most recent pronouncement is about Italian research that considers "body fat instead of weight related to height (which is BMI)." This research is said to focus on the presence of fat, and that deals with the conundrum that large, muscular people are often mislabeled as "obese" using the BMI. Their weight-to-height ratio labels them obese, but they are not fat. They are muscular and that muscle is heavy.

The Italians propose more expensive testing (scanning). They are critical of the BMI, a "quick and easy method, supported by the World Health Organization (WHO)," and their study supports that the BMI may reach an untoward diagnosis in some instances. Their research concluded that of their test subjects

"Just 38% of the men and 41% of the women had a BMI above 30 - but when their body fat percentage was calculated using scans, 71% and 64% were found to be obese."

That means that BMI is underreporting obesity. To make the BMI decision, you need a scale and a tape measure. The Italians suggest we should have more expensive tests. 

Nonetheless, a number of muscular people with little fat are being included in "obese" using the BMI and a seemingly much larger number of obese people are being told they are not obese because the BMI is too simple and underinclusive. The cynical among us might wonder if the new definition is a pursuit of more scans, more drugs, and more doctor visits.

The challenges are significant in both instances. Telling someone they are obese may result in various measures like diet, exercise, and even prescription medications. Some treat fat as if it is a medical condition. Special foods are prescribed for fat. Drugs are prescribed for fat. All drugs present a potential for side effects, and the Ozempic discussion suggests that some may contribute to long-term body changes even when one stops taking them.

The results of the Italian study are simple. They recommend that the BMI be dropped. Either quit using it, or lower the standard. That is, with our path projected to half the world being fat in 2035, the Italians suggest we lower the threshold for that label, and increase the obese. This is not an irrational guess or gesture. Their suggestion is based on the fat research and their amazing conclusions regarding obesity and the BMI.

At the end of the day, the decrease in the threshold would also perhaps justify more scans for more people, more drugs for more people. The fact is that doctors will not prescribe medication for weight loss for those who are not obese. The proposal to decrease the threshold and create a larger population of obese for treatment might thus be viewed cynically.

In the end, the bottom line, is that weight loss is a reasonably simple calculus of calories consumed versus calories burned. Your body will be different than others. Your metabolism will be faster or slower than others. In large part, this will be what you were born with, but your choices can have influence. In the same manner, as unfair as it is, some people can eat piles of food and never gain a pound while others of us get fat looking at cheesecake across the room.

The problem is not in definition. The debate should not be about thresholds, treatments, and drugs. The fact is that fresh foods, whole grains, and protein are both good for us and expensive. Cheaper foods, processed foods, and preservatives likely not so much. We can each choose more exercise, less calories, and better health. Or, we can resort to drugs and fads.

What we need is to focus on the real problems. More on that in a post to come.

The BMI Conundrum

Years ago, as a young lawyer working in a narrow corner of Florida workers' compensation, I helped employers recover money from the Florida Special Disability Trust Fund. Section 440.49, Fla. Stat. This was a pre-Americans with Disabilities Act (ADA) effort to encourage hiring, retention, and accommodation of those with medical conditions. The statute included a list of "preexisting permanent physical impairments," which might form the foundation for recovery. See I am what I am (July 2013). What I was when I penned that was (still) obese.

I was troubled, in that regard, when I discovered that one of the qualifying foundations was obesity:

"Obesity if the employee is 30 percent or more over the average weight designated for her or his height and age in the Table of Average Weight of Americans by Height and Age prepared by the Society of Actuaries using data from the 1979 Build and Blood Pressure Study."

There was a chart in the back of the FWCI Reference Manual (the Workers' Compensation Institute used to be the Florida Workers' Compensation Institute). The first time I used the chart for a case, I surreptitiously checked my own weight against the chart. I was deeply troubled to find I was obese. When I complained about that, a friend assured me "you are just big-boned." That did not really make me feel better. Yes, back then I had feelings and that hurt them.

I noticed then that the listings were divided with different values for men and women and at different ages ("in indoor clothing," whatever that meant). For example, someone five foot eight inches tall would have an "average weight" of 138 pounds (female, age 15-16) to 168 pounds (male, age 50-59). I was six feet tall, and my body weight was none of your business. But, notice here that obesity is conditional on age. 

I was reminded of this when a story crossed my news feed in June regarding Queen Latifah and the "stigma around obesity." She described how she responded when told her body mass index (BMI) equated with obesity; she told the trainer "I'm just thick." This alerted me to the conversation about BMI and its origins, efficacy, and flaws. It got me thinking about airplane seats also, see The FAA and Seats (August 2022). The Buzzfeed article regarding Ms. Latifah led me to do some research. 

The Washington Post concluded in 2021 that "BMI is Flawed," and that there is a disparate impact on "people of color." I have written about racist medicine in the past. See Race-Based Medicine (August 2021); Hippocrates, Harm, Racism (May 2022). The Hippocrates article provides some insight into the manner in which racism has influenced medical care criteria and decisions. Various professional groups are "reexamining" guidelines and advice with an eye toward the potential or probability of bias and untoward outcomes.

The Post describes instances in which people have been denied medical care because their weight is a contraindication or discouraging factor. In some instances, care is allegedly denied to those with a BMI exceeding some threshold. BMI can also be a benefit. In some instances, the high BMI might encourage care. For example, in the recent Great Panic of COVID-19:

"certain jurisdictions prioritized people with higher BMIs in vaccine distribution plans because some research suggests that obesity can be a risk factor for more severe covid-19 outcomes"

The Post says that the BMI has "long been controversial." There are critics who say it is "overinterpreted as a catchall for body fat, nutritional status, and health risk." Others are more critical still, noting its "origin is racially problematic." The BMI idea was invented by a mathematician, not a doctor(s). It is based upon averages from studies the mathematician considered, and was based upon "a sample of White, European men," that the mathematician saw as "ideal." The mathematician's idea was labeled as the "BMI" by a physiologist in 1972.

Over the last 200 years, the measure has been used in insurance underwriting, in actuarial tables, and in making medical analyses and decisions. The Post suggests there may be evidence to support that different "metrics" might be aptly applied instead as regards different ethnicities, including "people of color" and those of Asian descent. The article describes how BMI plays a role in reaching a diagnosis and how the application of the "white European men" standard may lead to underdiagnosis or overdiagnosis depending on how it is engaged or perceived.

Despite that, weight is an important metric and can impact physical well-being, and beyond. 

I was contemplating these various articles, and reminiscing on my "big-boned" past when Yahoo published a story about a dancer named Cheryl Burke and her "body dysmorphia." She frankly lamented her frustration that "the nation decided to call me fat." This story is not about BMI per say, but is about perceptions of weight. She described how she denies others' perceptions that she "look(s) amazing" and instead perceives herself in the mirror as "someone who is overweight."

Ms. Burke describes how she is "doing the work" to find a "better place in her relationship with her body." She describes a family environment history of a persistently dieting mother and the self-image she has as a dancer. She notes that in this regard, she has "been judged my whole life." Is it possible that in the same way she looks in a mirror and sees a "fat" person that some of the rest of us look in the mirror and see someone that is not? 

This all implicates the ongoing discussion of obesity in this country generally. In How Can They Both Increase (February 2019), I noted the dramatic increase in obesity in America. Both exercise efforts and obesity were reportedly increasing, albeit perhaps in different subsets of American society. But, be that as it may, obesity is increasing, and there are arguments that we are measuring that based upon some 200-year-old mathematician data about European males. Despite the potential for flaws in that metric, the rates are nonetheless increasing despite the metric remaining static. 

Since there are charts specific to women, and since the BMI calculators differentiate on gender, there have likely been further efforts in the last 200 years, beyond that original "European Males" sample. The fact that has occurred suggests that further study and adjustment is both possible and practical. Is there a reason for differences based on genetic heredity that is similarly justified to the gender distinctions already recognized? 

Accepting that BMI may be a flawed standard, or even that it is a racist standard as some argue, the fact remains that many believe obesity is a significant health concern. Harvard contends that "Excess weight, especially obesity, diminishes almost every aspect of health." Seeming to support the example of Ms. Burke, this may include mood. The causes include direct stress on our structure (skeletal, nervous, etc.) as well as "complex changes in hormones and metabolism." The Centers for Disease Control (CDC) lists many health challenges that pose "increased risk" for those with "overweight or obesity."

Thus, it seems that we have some valid concerns with the increasing rate of obesity and the health challenges that it may cause or to which it may contribute. But, we have concerns about the standard or definition that is being applied, BMI, and whether it is appropriate, predictive, and unbiased. In the mix, we have medical decisions being made or influenced based upon the BMI standard. Injured workers may be receiving care they do not want/need (over-diagnosis) or being denied care they want/need (under-diagnosis).

As with the other reconsiderations of standards discussed in Race-Based Medicine (August 2021) and Hippocrates, Harm, Racism (May 2022), there should perhaps be some urgency to the consideration of whether the BMI is the best that science can do in establishing definition and standard. In the meantime, it is likely that avoidable harm is being done, whether physical, emotional, or both. And, there are costs associated with both under and over-care. See Someone has to Pay (May 2016).

Disease or Choice?

There is a developing tendency to consider obesity from different perspectives. Body habitus is not new to these pages. See Can I Get a Team Gulp (July 2014), Stool Transplant (October 2019), What's in a Name (August 2020), Comorbidity of Obesity (October 2021), The BMI Conundrum (August 2022), and Obesity Yet Again (January 2023).

There is a fascination in America with body habitus and health. We spend tens of billions each year on workout equipment, gym memberships, diets, drugs, and more. And, there is a growing sentiment, it seems, that fat is inevitable and unassailable through simple diet and exercise. The Yet Again (January 2023) post notes the latest scientific conclusion that drugs and surgery for children is the right path to svelt.

In a recent article, focused on the off-label use of diabetic medication for weight loss, there is a repetition of the word "disease." Repeatedly, I have noted the distinction between science and consensus. and the potentiality for them to become intertwined, intermingled, or even confused. And, in our world, there is an ever-present effort to manipulate and persuade through the careful selection of words.

In that vein, there may be some challenge in the medical community with differentiating a diagnosis (malady, damage, or disease) from symptomatology. For a layperson, this is an easy dichotomy to overgloss. The simple question “what is wrong?“ when directed at a patient, is likely to evoke a list of symptoms ("it hurts when I do this"). When someone asks us what is wrong, it is our habit to tell them our perceptions. In terms of what is actually wrong (causation), it is the scientist's job to name and explain the damage, the dysfunction, or the disease.

Doctors have long distinguished between the two in their discussions of “complaint(s)." This section of the medical record or report is an opportunity for the doctor to delineate those complaints or symptoms voiced by the patient: pain, discomfort, dysfunction, or inability. In an utterly distinct section, there is the conclusion of cause, the “diagnosis.“ This is the scientist's delineation of damage or dysfunction or disease from which the scientist believes the symptoms emanate.

For the sake of clarity, I am neither a scientist nor a patient. I have never played one on TV. It has been a long time since I stayed in a Holiday Inn Express.

The diabetic drug article demonstrates what seems to be a growing tendency toward confusion between the cause (the illness) and the effect (symptom). A doctor is quoted in the article, acknowledging a perception that one demographic "struggle(s) with the disease of obesity." The article also notes that this diabetic medication, may not be the answer for "everyone with obesity . . . As with treating other diseases, different types of therapy may be needed."

That seems to overstate obesity. It is hard to consider body weight itself as a disease. However, as it is defined, this is perhaps accurate. 

Brittanica says that "disease" means

disease, any harmful deviation from the normal structural or functional state of an organism, generally associated with certain signs and symptoms and differing in nature from physical injury.

Websters defines it as

a condition of the living animal or plant body or of one of its parts that impairs normal functioning and is typically manifested by distinguishing signs and symptoms

It is difficult to perceive that symptom is synonymous with disease. However, it appears that at least some consider obesity in this category. And, with the off-label success some are having in using this diabetes drug as a weight loss tool, there is lamentation that some obese people cannot afford this medication. The spirit of the article seems focused on a perceived inequity in access to financial resources. A better focus might be on how increased exercise and decreased caloric intake can result in weight loss. 

The perspectives on this obesity epidemic are intriguing and troubling. As a species, we are apparently losing this war on every continent. CNN reports obesity is growing at such a rate that "more than half of the world’s population will be overweight or obese by 2035." That is roughly 4 billion people reaching that threshold in the next dozen years, an expansion from the 2.6 billion now obese. This is based on a recent report. 

The article acknowledges the recent endorsement of drugs and surgery for children. It laments the predicted doubling of "childhood obesity." The fat wars could cost us 3% of global GDP by 2035. The most significant growth rates are predicted in "low- or middle-income countries in Asia and Africa."

An article from the British Broadcasting Corporation provides an analysis of the causes of this trend of increasing obesity. It lists:

1. dietary preferences towards more highly processed foods,
2. greater levels of sedentary behavior,
3. weaker policies to control food supply and marketing, and
4. less well-resourced healthcare services to assist in weight management and health education

These seem to provide some reasonably simple solutions (1-3). They are not treatment foci, as with disease, except perhaps 4. They largely come down to prevention foci on not eating categories of food, getting off the couch, avoidance, and education. Perhaps the marketing aspect of such things as the Food Pyramid and MyPlate are not answering the need for public information? Do people even know what MyPlate is? As a publicity campaign, might the lack of exposure be indicative of its failure?

There are likely those who are predisposed to issues with body habitus. But, in the end, we each can control what we consume and how we spend our time. Caloric intake and activity level are the calculus of this growing epidemic. Characterizing the resulting obesity as a disease, and thus casting it as an effect for which we bear no responsibility, is unfortunate and with most inaccurate. The enemy is processed foods, empty calories, and inactivity. We have seen the enemy, and it is us. That is not encouraging, but with the knowledge comes the power to defeat it.