The Weighting Game

by Cara Gardner


"We've been a spoiled country for a long time. You know what the number one health risk in America is? Obesity. Obesity. They say we're in the middle of an 'obesity epidemic.' An epidemic, like it's polio. Like we'll be telling our grandkids about it one day: The Great Obesity Epidemic of 2004. 'How'd you get through it, Grandpa?' 'Oh, it was horrible, Johnny, there was cheesecake and pork chops everywhere.'


"Nobody knows why were getting fatter? Look at our lifestyle. I'll sit at a drive-thru. I'll sit there behind 15 other cars instead of getting up to make an eight-foot walk to the totally empty counter. Everything is mega-meal, super-sized. Want biggie fries with that? Want a jumbo fry? You want to have 30 burgers for a nickel? There's room in the bag. Take it! Want a 55-gallon drum of Coke with that? It's only three more cents." -- comedian Greg Giraldo





Though painful to millions of overweight Americans, jokes about fat people abound -- on sitcoms, from radio DJs, in office break rooms and forwarded e-mails. But even with all joking aside, the topic of obesity in general is popular -- pick up The New York Times, National Geographic, Time and, this week, The Inlander.


The "Obesity Epidemic," as it's been coined by the Centers for Disease Control, is in full swing -- and we're fascinated. Why are Americans so fat? Too many carbs, not enough exercise, automated work, cheesecake and pork chops everywhere. Pundits, lawmakers, lawyers and researchers are jumping into the ring with theories and scapegoats for our nation's growing waistline. But as experts argue over why Americans are fat, another controversial and equally perplexing debate has emerged: Is it anybody's business if we're fat? Sure, obesity is a health issue, but is it also a civil liberties issue? Should the government have a say over how much we weigh?


Lynn McAfee is the director of medical advocacy for the Council on Size and Weight Discrimination. She weighs 400 pounds and says that no matter how much money the government pours into preventing her obesity, she's never going to get thin.


"Having a campaign against obesity is a campaign against fat people," McAfee says. "What it does is identify people who are fat and leaves them open to attacks. It facilitates the discrimination, and that makes us very angry." McAfee says obesity has always been around and she doesn't think the government should spend a bunch of money on keeping people skinny or trying to get them to lose weight.


"The oldest statue in the world is the Venus of Willendorf, and it's of a fat woman," McAfee says. "It's 25,000 years old. It's not from a time when there were Oreo Double Stuf cookies; it's from a time when obesity was a tremendous biological advantage. There are people who will always be heavy, and there will never be a time when there are only thin people. That's why it's important to protect our rights."


Perhaps obesity has always been around, as McAfee points out, but never before, in any part of the world, have children faced the risk of type 2 diabetes like U.S. children face today. The CDC estimates that an unprecedented level of children -- as many as 30 percent of boys and 40 percent of girls -- born in the U.S. will have diabetes at some point in their lives. Obesity is a contributing factor to diabetes. In addition, the New England Journal of Medicine published a controversial study in March declaring that, for the first time in 200 years, this generation of American children will have a shorter life than their parents.


Those are a couple of the reasons that at least 25 states are considering nearly 140 bills having to do with preventing or ending obesity. Far fewer bills address protecting the rights of fat people. These 140 "anti-obesity" bills address everything from increasing funds for public health education to taxing junk food. The Washington State Senate just voted unanimously for a bill that would put an emphasis on supporting public facilities that offer free or inexpensive public exercise programs. Something like that isn't too controversial. But critics of "anti-obesity" legislation fear obesity will become legislated against like smoking. In fact, some advocates of the "Twinkie tax," which would generate revenue for states by taxing junk food like soda and cookies, have suggested businesses should place certain junk foods behind the counter; you'd have to ask for those double-stuffed Oreos and your Marlboro Lights. Some advocates claim that a one-cent tax on every soft drink sold in the United States would generate $40 billion in a year.


Pete Cutler is the outgoing director of the Washington State Health Care Authority, the organization that administers the state's Basic Health, Community Health Services, Prescription Drug Program and Public Employees Benefits Board. He says taxing certain junk foods makes sense because the revenue could go toward recouping some of the costs of obesity-related health care.


"I'm a fan of higher taxes on soft drinks because studies -- such as one that recently came out from England with disciplined research -- showed that those who had more than one or two sodas a day had a much higher incidence of diabetes than those who didn't [drink soda]," he says. "There are certain foods that clearly make no contribution to your health. Whether you don't get increased revenue because people stop purchasing the [food] because of the tax, or whether you do get more revenue to put into health education and recouping [state health care costs], taxing it is win-win."


McAfee agrees that soda and junk food shouldn't be readily available in public schools, but she thinks taxing or hiding bad foods isn't the answer. "Demonizing food is what gave a lot of us eating disorders in the first place," she says. McAfee says state and federal lawmakers should focus on passing legislation that protects the rights of fat people and that focuses on more holistic definitions of health, rather than bills based on weight and size. Still, others believe the government should steer clear of any legislation to do with weight, whether it protects people, prevents obesity or punishes junk food lovers.


These critics worry that if what we eat is a political issue, then what isn't a political issue? Even in the name of public health and disease prevention, should there be policies regarding, say, how much sleep we get or TV we watch, or how much time we spend with our families? Where's the line between a government that protects obese people from discrimination and a government that controls individuals' diets? Where's the line between a government legislating against industries that create costly health problems for the public and a government that allows its citizens to blame companies for making them fat?


The line on the obesity issue, it turns out, is pretty thin.





The Skinny on What's Fat


The CDC defines obesity as a body mass index (BMI) of more than 30, which is calculated based on height and weight. A BMI over 25 means you're overweight. Some say the definition of obesity, as well as the CDC's determination that it has become an "epidemic" in America, is too simplistic and alarmist, and that it stigmatizes people unnecessarily. As Jacob Sullivan writes in the article, "War on Fat," published by Reason Online, "calling rising BMI trends an 'epidemic' ... obscures the fact that obesity is not a contagious disease; it does not spread from person to person in a way that justifies state action."


Those who compare obesity legislation to tobacco legislation miss major points, Sullivan claims. Tobacco affects the health of non-smokers, but obesity doesn't hurt non-obese people. You can't catch fat; it doesn't float over from across the room.


"The whole BMI thing is a huge disaster," says McAfee, who claims the CDC established BMI for the wrong reasons. "[Creating the BMI chart] was pushed by the drug companies. For instance the [pharmaceuticals] said, 'Here's what we'll do for fat people: We'll put a whole bunch of money into having all people know what their BMI is.' What it really does is make it easier for doctors to prescribe drugs [for weight loss]." McAfee points out a common critique of the BMI -- that it's too standardized and doesn't make allowances for different groups of people. "It's not helpful; it's just one more number to obsess about."


Dr. Lawrence Schrock, a general surgeon with the Surgical Specialist of Spokane, has been involved with the surgical treatments of obesity since the late 1970s. He performs drastic but often lifesaving procedures like stomach stapling and gastric bypass. Schrock doesn't share all of McAfee's views on obesity, having seen the disastrous affects it can have on people's health and the strain it puts on the health care system, but he does agree that the CDC's BMI standards are somewhat limiting.


"They're having us using ideal body weight standards that Met Life Insurance Company developed probably 30 years ago," he says. "So I don't think you can truly use some of these older standards to define [what's] overweight." Schrock says it's important to look at obesity on a case-by-case basis, and he says some fat people are perfectly healthy. "We see patients who are 300 [percent] or 400 percent over their ideal weight and don't have any [health] problems. But as time goes on," he concedes, "they do have a lowered life expectancy and will get problems down the road."


Though most medical professionals agree that even if an obese person is healthy now, they'll most likely have health problems later on, there is controversy over whether the CDC is being hysterical about the severity of this "epidemic." For instance, a highly publicized CDC report revealed that deaths resulting from obesity claim about 400,000 American lives a year, which is just 35,000 less than those who die from tobacco-related illnesses, the leading preventable killer. The report was one of the motivating factors in the Bush Administration's November 2004 launch of a campaign to fight the "obesity epidemic." But that study was later found to be full of errors, and the authors admitted that the reported number of obesity-related deaths had been inflated.


Schrock says Spokane surgeons perform about 300 or 400 obesity-related surgeries a year. "Is it an epidemic?" he muses. "Just go to the mall and look around."


McAfee says obesity is partly genetic and therefore it's not fair to use the term "epidemic." And she's not alone; an increasing number of experts believe this to be true. "You can't ever say anything is purely genetic or purely lifestyle," she says. "But with those of us with a genetic propensity for gaining weight, even if you changed the environment completely, I'm not sure we'd ever have [a society] of all thin people."


Whether being fat is an irreversible and natural genetic response, the evidence that obese people suffer from more health problems and require more costly health care than non-obese people is overwhelming. High blood pressure, heart disease, vision problems, cancer, sleep apnea, varicose veins, hypertension, diabetes -- the list of maladies is long and scary. But what insurance companies, health care experts and the government are more alarmed at is not just the number of things that might afflict obese people, but also the cost of those illnesses.





Weighing Down Health Care


In a system that's already in a perpetual state of crisis, obesity threatens to become one of the most expensive burdens yet. According to a study from the Feinberg School of Medicine at Northwestern University, annual average Medicare charges for severely obese people are between $5,500 and $6,500 more than for non-overweight people. In another study, published by the medical journal Health Affairs, health care costs associated with "excessive weight" were reported to amount to about $93 billion a year, half of which is covered by Medicare and Medicaid. Still, some say it's not clear whether subsidized health care to treat obesity-related illness is really costing taxpayers more, based on the fact that, statistically, obese people have a shorter life expectancy, balancing out the higher cost of their health care.


This topic is offensive to McAfee, who says obese people should be treated the same as any group of people who have a propensity for certain illnesses.


"There are many ethnicities and races of people that cost more to insure and to treat for different medical conditions," McAfee says. "For instance, young teenage boys are much more likely to have injuries resulting from traffic accidents. Should we not treat or insure them because they are young teenage boys? The point is, no matter how much you yell and scream and punish us, the fact is, our bodies are different -- and over thousands of years, that has not changed." McAfee thinks the discussion on how much fat people cost the health care system is discriminatory.


Many others, however, disagree. Cutler, with the Washington State Health Care Authority, says the cost of obesity-related illness is an important topic: "Up until about two years ago, the HCA was not concerned about, as a purchaser, obesity. But partly because of the trends in society and partly because of the costs we incur that are related [to obesity], we [have come] to the conclusion that the most important strategy we can take is to have people adopt lifestyles that are healthier so they don't have these problems and don't need to go to the doctor for them." Cutler says the HCA is working closely with regional health districts and other health organizations -- and spending hefty sums of money -- on campaigns to prevent obesity. He is adamant that this is not discriminatory.


"Usually, when you talk about discrimination, you're talking about limiting rights. We're encouraging positive activities. It's not at all discriminatory."


Nancy Fisher, the medical director for HCA, agrees. "At one time, everyone focused on [preventing] breast cancer. Do those people feel discriminated against?"


Cutler says it's in the HCA's best interest to be proactive about obesity as a medical condition, but he's sensitive to the fact that many fat people feel stigmatized by the focus on their weight. "I've been officially listed as obese for the past 10 to 15 years," he says. "It's easy for people to generalize the obesity problem and to think that getting people to be skinnier is a definition of success. We think it's about how healthy you are."





Companies Respond


No doubt you've heard about one case or another regarding McDonald's getting sued by obese people and their hungry lawyers. Though Congress is pushing for bills that would prevent these types of lawsuits, the food industry is hard at work defending itself. McDonald's recently unveiled a marketing strategy aimed to encourage its customers to get exercise. Peppy, active people have been chosen to announce the company's new slogan: "It's what I eat, it's what I do ... I'm lovin' it." Cheesy, perhaps, but by slapping exercise-positive messages onto its marketing identity, the fast food giant may effectively protect itself from more obesity lawsuits. Other fast-food companies are following suit by donating exercise equipment to public schools, co-sponsoring fitness challenges and marathons and offering new, healthier options (like Wendy's fruit plate instead of fries). Even Starbucks has jumped on board, with its pamphlet, "You, Starbucks and Nutrition," providing complete nutritional information on all of its drinks.


"I'm not fond of litigation," McAfee says. "But if it educates the public and the restaurant industry as to some of the issues and if it scares [the industry] a little, that's fine." McAfee says sometimes lawsuits are the only reason companies begin to take consumer-wellness into account. "As consumers, we have to respond to that."


But while the fast food industry is on the defense, other companies, it seems, are on the offense. A casino in New Jersey made headlines earlier this year after telling employees if they gained more than 7 percent of their body weight at the time of hiring, they'd be put on unpaid leave until they lost the weight. Obviously, it wasn't a popular move; the employees' union and women's advocacy groups have responded by saying weight restrictions constitute discrimination. The casino isn't alone, though. Several cases have emerged in the courts involving flight attendants (all women) who were given an ultimatum: Lose the weight or lose your job. In 2002, Southwest Airlines made an official policy that their flight attendants must determine if passengers "of size" should be made to pay double for an extra seat; the attendants can evict the person from the flight if the passenger refuses to pay.


"I think it is discrimination," McAfee says of Southwest's policy. "Bottom line: I'm a fat person and I need to fly. Having to buy two seats is not fair."


McAfee says Southwest's policy is an example of why the government should get involved with obesity -- not in preventing it, but protecting it. "My issue with the government," she says, "is if they want to put programs that add to discrimination, the least they could do is add protection, too."


Those against weight and size discrimination are quick to call foul over these instances of singling out obese individuals, but none seem to mind the fact that in 2002, the IRS decreed that obesity "is medically accepted to be a disease in its own right"; therefore, obese taxpayers can deduct "uncompensated amounts paid by individuals for participation in a weight-loss program as treatment for a specific disease ... diagnosed by a physician." In other words, the government says those expensive gym memberships can be written off for fat people, but not anyone else.


Whether being proactive about exercise and diet or getting strict about the size of customers and employees, obesity-related policies are costing business lots of money. Even companies and organizations that haven't taken a proactive stand on obesity are doling out cash. The ferries in Puget Sound had to increase the width of their seats from 18 to 20 inches to accommodate the increasing size of passengers. Ambulances in Colorado were retrofitted to fit obese patients (though Colorado has the lowest percentage of obese people in the nation). Hospitals and health care clinics across the country are struggling with how to diagnose people too big to fit into MRI and CT scans, oftentimes missing crucial details that end up costing the patient and the system more later on.





Personal Pain


As people weigh in on whether fat is a political issue, most everyone can agree that it's a personal one. And, unlike alcoholism, debt or depression, for instance, obesity can't be hidden from others. Though obesity is usually the result of chronic overeating -- a recognized eating disorder -- an increasing number of medical experts insist that obesity is also a genetic disorder that strikes randomly. Some obese people consume fewer calories than the FDA recommends each day and continue to gain weight.


"Personal choice is sometimes an illusion if you have a genetic background that facilitates weight gain," McAfee says. It's easy to believe that overweight people simply lack willpower, but the key to understanding who gets fat and why is much more complicated. Obesity has social, psychological and biological roots. When those roots intermingle, you get what has propelled more than 65 million Americans past the BMI mark of 25.


"Being fat is not healthy in the way it's not healthy to be any other oppressed minority in this country," McAfee says. Though many would disagree with the fairness of that analogy, there's no denying that fat people are treated worse than thin people. Studies have shown that overweight people face discrimination in the workplace and in public. Now that insurance companies are seriously discussing raising their rates for people with higher BMIs, overweight people are facing not just social discrimination, but government-sanctioned discrimination.


"It's one thing to be supportive and positive, but another to start charging more," says Cutler. "I've always been above my ideal weight and I'd probably be in that category. Then again, if it did motivate people to start taking care of themselves and the good of the whole is more important, then OK."


McAfee is less likely to be persuaded that charging fat people more for health insurance is for the good of the whole.


"It's called cherry-picking. You can't just insure people who have no risk." She says if overweight people have to start paying more, insurance companies might start charging more for blacks, who have a higher instance of sickle cell anemia, or for women who have a family history of breast cancer. For a society devoted to equal rights, McAfee says, singling out fat people as the "spoilers" of health care is a slippery slope.





Super-Sized Life


"Do you want that casket super-sized?" It sounds crass, but casket manufacturers actually are selling XXL caskets in record numbers. For the first time ever, the world has as many over-fed and obese people as it does under-fed and malnourished people. The world has never had, as the CDC says, an "obesity epidemic" before. According to the federal government, 65 million Americans are overweight -- and it's affecting everything from our health care system to mass transit. Whether people agree with Lynn McAfee's perspectives on obesity, she's right when she says, "If it's an easy solution, it's not the right solution."


Whether you think the government should protect obese people from discrimination or punish them for costing taxpayers more, it's going to take thoughtful, sustainable measures that include a balance of personal responsibility and government protections.


"The focus should be on health, not weight, and offering choices," McAfee says. "There should not be anti-obesity programs, there should be pro-health programs. I don't know that it will be helpful to demonize food or fat people."





FAT FACTS


- More than 50 percent of Americans are overweight and one out of three is obese, according to the Centers for Disease Control's method of calculating obesity through the body mass index (BMI).





- 15 percent of children and teens are overweight





- The average U.S. child sees more than 10,000 commercials for food and beverages each year. (Journal of Nutrition Education)





- For the first time in history, there are as many overfed and overweight people in the world as there are underfed and underweight people. (Worldwatch Institute)





- At least 25 states are currently debating more than 140 bills aimed at ending or preventing obesity. (Washington Post)





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Publication date: 04/21/05