Tag Archives: disease

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.


Fasting Girls: A Feminist Social History of Anorexia

Debbie says:

My friend Lizzie, who is a regular commenter here, gave me a copy of Fasting Girls: The History of Anorexia Nervosa by Joan Jacobs Brumberg.

I was skeptical about reading it, only because it’s twenty years old. I figured most of the information would be out of date. That’s because I hadn’t paid real attention to the subtitle. What Brumberg did two decades ago is exhaustively research and examine the (Western) history of women and girls who eat nothing or almost nothing, and follow the different implications of that behavior over several centuries. She takes a complex view of anorexia throughout, trying (and very largely succeeding) to keep a balance of medical, psychological, and cultural factors in mind.

After a brief overview of “contemporary” anorexia nervosa at the time when she was writing, Brumberg starts by discussing a syndrome I was completely unaware of: anorexia mirabilis (“miraculously inspired loss of appetite”), which was at least somewhat common or familiar in medieval times, and was considered to be about sustaining oneself through the life of God and the spirit, rather than through food. While some historians believe that anorexia mirabilis and anorexia nervosa are the same condition, viewed through different lenses, Brumberg (and I) see it differently.

they would have us believe that Karen Carpenter and Catherine of Siena suffered from the same disease. Advocates of this view naively adopt and apply the biomedical and psychological models of anorexia nervosa as if there was absolute certainty about the etiology of the disease and as if there were complete, verifiable case histories available on historic subjects. … It may well be that … particularly after chronic starvation has set in, the medieval ascetic and the modern anorectic have the same biomedical experience–that they are actually unable to eat. But it is abundantly clear that on the issue of recruitment, the routes to anorexia mirabilis and anorexia nervosa are quite different.

After a detailed examination of anorexia mirabilis, Brumberg spends most of the rest of the book tracing the transition from eating as a choice of flesh over spirit to eating in the modern world. To do this, she has to wander down many historical paths, looking at the difference between plentiful and scarce food, the transition from religious to scientific models, the social role of eating in different times and classes (anorexia nervosa is still primarily a syndrome of middle- and upper-class girls and women, though its scope has broadened since Brumberg was writing.

Of particular interest is her discussion of the pressure on mothers to feed their children appropriately, and the way this creates an opportunity for an otherwise powerless adolescent girl to take power by refusing to cooperate.

[In Victorian times], in America, the feeding of middle-class children, from infancy on, was a maternal concern that was considered inappropriate to delegate to wet nurses, domestics, or governesses. … When an adolescent daughter became sullen and chronically refused food at table, the behavior was therefore very threatening and confusing. On the one hand, the girl was perceived as willfully manipulating her appetite as a younger child might do. … As emaciation became visible and the girl looked sick, many [parents] violated the canon of prudent child rearing and put aside their moral objections to pampering the appetite. Eventually they begged their daughter to eat whatever she liked–but eat she must, “as a sovereign proof of affection” for them. From the parents’ perspective, a return to eating was a confirmation of filial love.

She also examines the growth of modern medicine, the role of asylums and asylum heads as opposed to private physicians, changes in views of general mental illness, and much more. In the excellent chapter “The Appetite as Voice,” Brumberg traces in more detail what little first-hand information there is about Victorian anorexia nervosa from the point of view of the patient, and also the wider relationship between women and food in Victorian and Edwardian times.

She returns frequently to the point that all kinds of anorexia (except for those associated with other physical and psychological illnesses) are much more common in girls and women than in men. She concludes that this is evidence that the issues are primarily cultural; I did wish that she had given more thought to the possibility of hormonal influence on this discrepancy, and I’m now very curious about whether the gender-linked pattern is true in non-Western cultures.

Towards the end of the book, she begins to trace the advent of “obesophobia,” and the medicalization of obesity. From 2009, or even from 1979 when I was a young adult, it’s hard to imagine that underweight and thin-ness in children was a highly disturbing disease, and a source of guilt to parents, for at least a century before the question of overweight was ever raised as a child-rearing issue. Because she is interested in the medicalization eating patterns in general, she also discusses how and when obesity became “linked” to various diseases, and the creation of height/weight charts.

Unsurprisingly, as the book gets closer to the time in which Brumberg was writing, it becomes somewhat less interesting to the reader from 2009, except to note how much has not changed in the intervening twenty years. Nonetheless, there’s room for an updated version of this book, covering such topics as the spread of anorexia nervosa to some boys and some girls from different classes, the changing attitudes of the African-American community toward weight, the “pro-ana” websites on which girls reinforce each others’ choice not to eat, and much more.

From a reluctant start, I found myself not only glad I was reading this book but ready to recommend it to anyone interested in the social history of these times, whether or not anorexia is a particular interest.