Tag Archives: BMI

Know Your Rights: Obesity, Disease, Employment Discrimination

Laurie and Debbie say:

In the last month or so, the AMA, acting against its own science council’s advice, has declared obesity to be a “disease.

Vik Khanna is an “independent health consultant with extensive experience in managed care and wellness.Looking at the first of his two-part series on obesity and the AMA, it is clear that he is no fat activist, and not much of a believer in HAES:

This decision’s willful disregard of salient facts is staggering: first, most obesity is not the result of a disease process or a frank genetic defect, it’s the result of algebra. We eat more and move less than our ancestors, even of just four generations ago. Second, a surprising number of obese people are still quite healthy. Third, the ones who work hard enough to improve their fitness level will do more for their survival than those who remain unfit, regardless of BMI. Fourth, telling everyone who’s obese that they are sick is a cruel canard that encourages dependency on the professions in such a way that must make Ivan Illich roll over in his grave.

So, here’s the challenge for the AMA. Since you’ve now told the culture to show you the (obesity-related) money, here’s what we taxpayers and funders of your enterprise want: win the war on obesity using a very clear metric…restore the status quo ante…the distribution of BMI in American adults in 1980. And, while you’re at it…fix the industry’s obsession with overdiagnosis and overtreatment because there’s no money to be made in the obverse. Finally, measure both fitness and health-related quality of life in all these “sick” people so we can see how much they really benefit from your efforts. Still think that medicalizing a lifestyle problem was the best step toward long-term success? Fat chance.

So far, this is centrist common sense, and we wish doctors would listen. The second part of his post, however, is even more important. In this post, Khanna is talking about how the disease label can be used in employment discrimination. He doesn’t address the ongoing issue of people not being hired because they are fat, including the relatively new version of that where fat people are seen as more expensive employees. (Of course, to the extent that this is true at all, the medical/social perception that fat people are unhealthy is the reason fat employees can be more expensive.) Instead, he is focusing on mandatory wellness programs, which gain significant teeth from this decision. And he’s giving us a roadmap for how to face these programs in our various workplaces. As Khanna says, these “wellness programs … often hinge [on] vastly overblown claims of being able to help the obese who they almost universally label as ‘high risk’ people.”

Well, what if people who are obese, who are no doubt tired of being condescended to, first by wellness companies, and now by the AMA, decide that they are going to seek medical approval to opt out of wellness programs?  A study recently published in the journal Translational Behavioral Medicine reports on a highly coercive, electronically monitored walking program for obese people: 17% opted not to participate and another 5% actually got their physician’s approval to opt out.  The physician approval to opt out is key to any resistance strategy.

Under the final wellness rules issued by the federal government earlier this year, physician certification that it is medically unadvisable for an employee to participate in a wellness program creates a burden for the employer and wellness vendor.  They must provide reasonable alternatives that do not disadvantage the employee in terms of either time or cost and that address the physician’s concerns. … The coup de grace is that “adverse benefit determinations based on whether a participant or beneficiary is entitled to a reasonable alternative standard for a reward under a wellness program are considered to involve medical judgment and therefore are eligible for Federal external review.”

As many fat people know, it isn’t usually going to be easy to convince your doctor that such a program is bad for you, but it will probably be easier than convincing your employer, if your employer is the type of place that goes for these horrible programs. (Electronically monitored walking programs can kiss my ass!)

Khanna goes on to state his opinion of current medical thinking on fat in no uncertain terms, and we intend to quote this forever:

Targeting people based on body mass index (BMI) is an intellectually, morally, scientifically, and mathematically bankrupt approach.

Finally, his clear conclusion is not only an argument against the disease model of obesity, it’s a brilliant argument against the childhood obesity panic. We’d like everyone in the country–every teacher, every doctor, every employer, every parent–to post it on the wall and read it every day.

Above all else, tell your people (obese or not) that your wellness goal is not to insult them, diminish them, or make them feel sick when they aren’t.  Wellness, by any reasonable definition, should give people tools that empower them.  How much they are willing to do is ultimately up to them.

More on Cadaver Donation Selection

Debbie says:

I owe an apology to MedCure for sitting on their response to my post about their policies for so long; the reasons have to do with me and my situation, and not with Body Impolitic or their response.

Valere at MedCure sent a long email a day or two after I posted, most of which is below with my comments interspersed:

In a nutshell, MedCure’s sole mission and reason for existence is to create an opportunity for people to donate their bodies after death in support of medical education and research. The criteria for acceptance or suitability for donation is driven by the medical researchers and educators that rely on us to find them suitable donors for their purposes. In other words, we are not the decision makers on what is acceptable and not acceptable but follow criteria handed to us in screening potential donors for research purposes.

Let me be completely clear. I think this is a marvelous service and I’m very glad it exists. I’m still interested in exploring and understanding specifics.

So regarding the finer points discussed in your blog…

We do not actually conduct autopsies. Autopsies are scheduled by a medical examiner if there is a suspicious cause of death or to rule out how and what a person died from. If someone does require an autopsy after death, it is usually because death occurred by some misfortune other than natural causes. An autopsy will prevent a person’s donation from being suitable because of the added time in getting this completed. In addition, once the body has been “opened” for inspection, it creates potential problems for transportation (e.g. leakage). I know that might be TMI (too much information), but that is the case.

I’m not sure how I got the impression that autopsy was included; looking at their site now, I can’t find that information anywhere.

Regarding infectious diseases… We screen for diseases not to discriminate; this is requested and required by us from the medical researchers. Some diseases are still contagious after death. VERY rarely, we receive a request for a donation with the very diseases we state we do not accept. The request is so infrequent however that I feel it is more honorable to tell people that we DON’T accept those donations so they aren’t mislead into thinking they will be accepted. It seems to cause families more grief and despair for the body of their loved one to be unsuitable and learn of this after death has already occurred than to be up front that it will likely not happen at all.

Of course, screening for diseases makes perfect sense, and I said so in the original post. And I completely agree that it’s more honorable to state refusal policy up front.

All of the criteria for donor suitability is determined AFTER DEATH. We do have a pre-registry screening process that we offer to those who are severely ill or on hospice and their life expectancy is less than 6 months. Whole-body donation is much like transplant donation in that HOW and WHAT you die of along with the body’s condition may prevent donation. We know people like to “make a plan” and know that it is certain, but the only assurance we can give is to provide this screening to identify anything we foresee (red flags?) that might prevent a donation being accepted in advance. Even then, we still encourage prospective donors and their families to have a plan B “just in case”. Another problem we encounter sometimes is weather problems! If we cannot make transportation arrangements for a donor to get to us in a timely manner, that is also a reason for decline.

The uncertainty is completely understandable to me, and not especially relevant to the points I was making. It does seem that in many cases, it would be possible to confirm that a body was unacceptable for donation long before death, including both in the case of the infectious diseases in the case of someone in prison and (if severely underweight or overweight was quantifiable and/or consistent) in those cases for someone whose weight was unlikely to change in the months or weeks before death.

History of illegal drug use depends on the drug used and the method of delivery. It is very common for persons to test positive for Hepatitis or HIV if they had a history of drug abuse. Many never had any symptoms of having these diseases during their life. This is the same for incarceration. We define incarceration as serving time in a federal prison for 6 months or more. There is a really strong correlation with people being incarcerated and a high incidence of testing positive for Hepatitis especially. I’ve always wondered why this is the case, but it is. I’ve seen the test results to prove it over and over again.

As I suspected, these regulations are about the correlations between certain behaviors and certain infectious diseases. If they test the bodies anyway for infectious diseases, why involve the correlating factors? Why exclude prisoners or drug abusers who do not have HIV or hepatitis? Any correlation that is not 100% is a form of stereotyping, and the tests have to be conducted anyway. I do see that the correlations probably lead to cost savings, which is almost certainly a factor.

Overweight and underweight more than just a body image problem. When it comes to transporting an overweight donor, it can add a significant cost as well as create injury to our employees and the medical researchers that are the recipient of the donor. The expression “dead weight” is a real one. We all feel like we weigh twice as much once we spiritually exit our bodies for some reason. But it is important to distinguish that this criteria is at the time of death. A person’s weight can fluctuate a great deal if they are ill for several months or years prior to death so we do not prevent people from registering their intent to BE a donor but I want people to know in advance this may prevent donation from occurring. In regards to low body weight, donors that are severely emaciated are not requested by researchers because they do not represent the norm. But again, sometimes the researchers request these donations. …This criteria fluctuates often so I just list it as “severely under or overweight” to represent what is usually the truth. This criteria is subject to change so I don’t put an actual BMI number on our website. Many people register their intent to donate far in advance of their eventual death and I am certain that criteria will continue to evolve and change.

Well, “dead weight” may be a real phrase, but in terms of pounds, if I die tomorrow my body will weigh then what it weighs now, or very close to it. I would personally be happier if they gave a maximum number of pounds, rather than “severely overweight,” since (as our readers know), a 300-pound football player is not considered overweight and a 300-pound woman is. And if the issue is that researchers’ needs change, then why not just say something like “we may have weight restrictions at given times depending on researchers’ needs”? Meanwhile, I cut material about Valere’s own weight, which she might not want to see plastered over the Internet. She’s discovering the crazy randomness of BMI, which I’m always glad to see someone learn.

As far as race, age, ethnicity, disability and any other things that make us human, that criteria has never been a consideration by our researchers. In other words, they are not requesting donors of a specific race or ethnicity but they do sometimes request certain disabilities or age ranges. Our program does NOT consider these factors for donation acceptance however and neither do the researchers we work with. The more you “live” in your body, the better for medicine I say!

Fabulous! One way to make this policy operational would be to disconnect incarceration and history of drug abuse from HIV and hepatitis, and just use the tests for those diseases to set criteria for donation, although again I acknowledge the cost-saving factor.

Once again, I’m really glad MedCure is in the world, and I thank Valere for her detailed and thoughtful response.