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Last Updated: Tuesday, 27 July, 2004, 11:11 GMT 12:11 UK
Whose fat is it anyway?
By Clare Murphy
BBC News Online

Blogs devoted to the miracle of stomach surgery abound on the web, detailing the painful emotional and physical journey to achieving that now much coveted quality - thinness.

Weighing oneself
As long as the kilos come off, it could be paid for

At a cost of $30,000 (16,000) such operations - in which the stomach is shrunk to reduce the amount one can physically eat - are not for the light of pocket. But in the future, heavy Americans may be able to get the state to pay for the procedure.

The federal Medicare health programme has now abandoned a long-standing policy that obesity is not a disease.

This potentially opens the door for millions of overweight Americans to make medical claims for treatments like stomach surgery as well as more conventional diet programs - provided they are effective.

Health and Human Services Secretary Tommy Thompson, a self-confessed obesity obsessive who has been known to chide overweight aides, declared the condition to be "a critical public health problem in our country" as he announced the changes to Medicare policy.

But whether America's burgeoning bellies and bottoms are the responsibility of the nation at large or the large individual has become grounds for a meaty row.

Your problem

All parties involved in the obesity debate see the decision to recognise the condition as an illness rather than a private behavioural issue to be a deeply significant one.

To anti-obesity campaigners, it is as an important step towards tackling a problem which affects one in three Americans and which increases one's risk of developing other conditions - including diabetes, heart failure and cancer.

31% of US adults obese
Cost $78.5bn in 2002
50% paid from tax
Source: Department of Health and Human Services

But an unlikely grouping of overweight people, social libertarians and food industry representatives have rejected it outright, arguing that branding obesity as a disease exaggerates the health risks, stigmatises the fat - and makes a mockery of the notion of personal responsibility.

"The culture of victimhood, where individuals can shunt the blame for their own actions on to someone else, has reached epic proportions in the US," says Dan Mindus, a senior analyst at the food industry funded Centre for Consumer Freedom.

"This Medicare decision truly dumbs down the term disease. Obesity is the only disease I know of which can't be largely prevented by getting up off the sofa and taking some exercise."

Others question whether it is appropriate to ask the taxpayer to cough up for treatments, noting that programmes to help people stop smoking - another of the country's biggest health issues - are not covered.

And they remain unconvinced by research which suggests that billions of tax dollars are already paid out each year for the health consequences of obesity, arguing that it is impossible to separate the factors which contribute to illness.


Not all those who welcome the Medicare decision reject the notion that people do make their own decisions about what they eat - although many point to what they refer to as America's "toxic" environment, where tasty treats are marketed at every opportunity and calorie-rich, nutritionally-poor food is cheap and freely available.

There is tremendous anxiety about consumption in America - that we're too big, that our SUVs use up too much fuel, that we're trying to do too much abroad, that we eat too much. Instead of concentrating on the big problems, we've decided to focus on food
Paul Campos
Obesity author

"Of course personal responsibility plays a role - people do make choices," says Professor John Foreyt, director of Baylor College's Behavioral Medicine Research Center. "But that doesn't detract from our need to treat this as a disease - and indeed one that has become an epidemic - in America and increasingly around the world."

Similarly, critics of Medicare's decision do not uniformly embrace the idea that people have free rein over what they consume.

"I certainly don't subscribe to this libertarianism in which everyone is free to choose," says Paul Campos of Colorado University. "There are sometimes immense structural constraints. Education can be an issue, not everyone has access to affordable fresh fruit and vegetables - convenience food is sometimes the only real option."

But Mr Campos' primary bone of contention - as author of The Obesity Myth: Why America's Obsession with Weight is Hazardous to Your Health - is the cultural hysteria surrounding weight, of which he argues the Medicare decision is symbolic.

A small but not insignificant number of scientists are increasingly questioning both the current definition of obesity, and the consensus that there is a necessarily a relationship between being overweight and being unhealthy.

Fitness is more important than fatness, and being fat does not necessarily mean you are not fit, according to leading sceptic Steven Blair of the Cooper Institute in Texas. He has followed 25,000 patients over eight years and concluded it is better to be fat and active than skinny and sedentary.

And while concerns about fatness mount, Americans, as the Department of Health and Human Services has itself stressed, "are now living longer and living better than ever before".

Professor Campos sees the country playing out its current cultural hang-ups and expressing class-based and racial tensions in the obesity debate.

"There is tremendous anxiety about consumption in America - that we're too big, that our SUVs use up too much fuel, that we're trying to do too much abroad, that we eat too much. Instead of concentrating on the big problems, we've decided to focus on food," he says.

It has long been the case that overweight and obesity rates in the US occur at higher rates in ethnic minority populations such as African Americans and Hispanic Americans than among the white American community.

"Obesity is used as a socially legitimate means for the rich, who are often thinner, to express their revulsion at the poor, who tend to be fatter. By focusing on fat, it's perfectly OK for a skinny white person in an SUV to condemn a fat Guatemalan woman."

Some of those working with America's obese agree that the debate can verge on a hysteria which implicitly stigmatises the fat.

Steven Gortmaker, professor of Society, Human Development, and Health at Harvard School of Public Health, says there is a "balancing act" ahead.

"The question is how we draw attention to an epidemic without giving people a licence to discriminate."

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