Tuesday, November 10, 2009

Punishing the overweight into slimness

A recent article I read about opposition to healthcare reform from the “fat pride” movement proved to be a learning moment. And it wasn’t from the story, but my reaction to it. Plus-size advocacy groups, such as the National Association to Advance Fat Acceptance, and the Council on Size and Weight Discrimination oppose proposed provisions that would penalize them for their increased health risks. Responding in part to a societal tendency to view the overweight and obese as being lazy and glutinous, these advocacy groups push the argument that you can be healthy at any size.

To a certain degree the health literature supports this idea: You can be heavier for your height than an ideal body-mass scale would suggest is healthy, but have no increased risk for disease. And there are lots of slender folks with high blood pressure, clogged arteries, and cancers. Smoking, perhaps the single riskiest health behavior, kills the skinny with as much fervor as the large. Beyond a certain size, however, evidence is indisputable: Excess weight increases the risk for conditions varying from arthritis to heart disease, diabetes to cancer.

Initially I responded with scorn: It was the “its all about me” attitude of fringe advocacy groups. I mean, “weight diversity”? “Fat pride”? Give me a break. Then it dawned on me: One of the key proposals of current health reform is the abolishment of pre-existing condition exemptions. Those exemptions currently allow insurers to refuse coverage to people who need it most: These who already have chronic, difficult to manage health conditions. There is relatively little opposition to the abolishment of pre-existing clauses as they apply to bio-medically defined diseases such as cancer or Parkinson’s. So why is being overweight any different? If we agree that it increases disease risk, how is being overweight different from cancer? Even if you argue that the causes of obesity are behavioral rather than genetic, it still pre-disposes you to increased disease risk, plain and simple. And risk factors for many conditions such as cancer and heart disease, which most people are comfortable giving pre-existing condition status, are heavily influenced by behavior.

Perhaps most importantly, lifestyle causes for obesity are socially constructed: Economic incentives to over-produce fattening high fructose corn syrup; mass advertising of nutritionally poor, high calorie fast foods; housing, transportation and workplace trends that discourage exercise; all of these are designed to make us fat. People don’t arrive at fatness by choice, they are led there by following social signs and trends. Finally, punishing people for unhealthy behaviors that are socially promoted may not be the best way to induce healthier choices. It’d be more acceptable to do this with overweight folks than those with cancer, but no less unjust, and no more effective. How does making it more difficult to get healthcare help people improve their health? Would you argue that obesity is a lifestyle choice that warrants punishment? Do you suppose that approach would slim down our epidemic of fatness?

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