Thought Experiement: What If Obesity Was a Disability?

A quick note on language:
Obesity is a medicalized term and is used in many medical studies. However, advocates from The Fat Acceptance Movement prefer the word fat and see it as a neutral term. In this paper "people who are fat" will be used when referring to overweight and obese people in general and "obesity" will only be used when referring to sources that use the term and people with the condition (as described by the Body Mass Index).

Current State of Obesity as a Disability in the US
Currently the status of obesity as a disability is in a kind of limbo. On one hand, courts have ruled in favor of obesity being a disability in a few cases (Hawley, 2024). This was not the case at all until fairly recently and new treatments for obesity may complicate the progress on that matter. In 2013 the American Medical Association board decided to label obesity as a disease. This decision was not unanimous but it did change the way we view obesity, instead of simply viewing it as a lifestyle choice- obesity is also a set of symptoms to be treated (Rosen, 2014). This opens up a strange can of worms. It incentivized the market to send weight loss drugs to be tested by the FDA for that purpose (rather than relying entirely on off-label use). It also added more nuance to conversations (legal or otherwise) about the nature of fatness. Is it fair to discriminate against someone for having a disease? What if it were a disability? Would it be fair to medicalize it?

It's clear that people who are obese experience a range of discriminatory behavior. This doesn't stop with simple social stigma. There is no federal protection against weight discrimination in the US. Workers who are intentionally denied promotion, harassed by peers, and/or paid less have very little (if any) recourse. Only a few states and municipalities have protections against discrimination for weight in any capacity. Many courts do not rule in favor of their legal cases under existing law such as Title VII of the Civil Rights Act of 1964. So far, lawsuits citing the Americans with Disabilities Act have had a few victories but mainly rely on the plaintiff proving that their Obesity is physiological (Hawley, 2024). The burden of proof relies on doctors proving that their fatness is medical in nature- when in many cases the causes are more complex.

As if issues with employment and public shaming weren't enough, the effects of anti-fat bias also extend into the medical system. Obese clients report a number of issues related to recieving medical care. These issues can come from anti-fat perceptions such as medical staff making assumptions about patient weight gain, attribution of possibly unrelated health problems to patient's weight, lack of medical staff training in working with people who are fat, and even downright patronizing/ disrespectful treatment. Likely due to this very treatment fat patients reported less trust between them and the medical establishment, a tendency to doctor shop, delaying getting care, and general expectations of differential care (Alberga et al., 2019).

Treating Obesity as a Disability

Treating obesity as a disability could over time change the way we view the condition. First of all we would have to grapple with questions of comparison. Is it fair to try to eliminate obesity as a condition? Would it be fair to say the same thing of autism? Imagine if you had a body that vastly differed from what was considered acceptable by society. To divorce it from fatness, let's say you have horns. Maybe you like your horns or at the very least accept them- what would it feel like to have the society around you medicalize your horns or want people with horns to no longer exist? Would you prefer a system that says your horns are treatable and a thing to be gotten rid of or a system that says people with horns should be protected from discrimination? 

Social workers will need to walk a fine line. On one hand, the client's biological reality should be taken into account as well as their internal one. We know that diet culture can cause a host of bad effects for people who are fat (as well as those who are skinny). For example, studies indicate that severe dietary restrictions can heighten the risk of binge eating in overweight individuals (Luz et al., 2015). Practitioners will need to to question anti-fat social norms and to investigate ways they can incorperate body-positive interventions at all levels of practice (Sorensen & Krings, 2023). Weight loss can be a goal so long as it is fueled by healthy motivations and done in a healthful way. Many clients who are obese may not be able to lose weight sustainably due to biological factors, these clients should not have to feel ashamed of their bodies. Clients should be aware of all risks associated with losing weight alongside the risks of remaining obese.

How would treatment for people with obesity change if we treated it as a disability? For one thing, the person with the condition would have recourse if they were discriminated against by the medical system. Another change could be a subtle and perhaps slow change of societal perspective. For example our perceptions of autism has changed dramatically over a relatively short period of time. Autism has gone from a purely medicalized model of understanding to a neurodiverse perspective. Proponants of the Neurodiversity Movement celebrate the parts of autism that make autistic people who they are and accept autism as part of who they are (Kapp et. al., 2013). This movement calls for both celebration and amelioration- treatment toward a cure is considered an attack on the individual experiencing autism. In addition, treatment that increases the individuals ability to function either through external acceptance or internal behavior change is the preferred. These changes have changed the way doctors treat autism, how society views autism, and how individuals with autism get around in the world. So the question at this point is, when is fatness' time to shift away from medicalization?

References
Alberga, A. S., Edache, I. Y., Forhan, M., & Russell-Mayhew, S. (2019). Weight bias and health care utilization: a scoping review. Primary Health Care Research & Development, 20(e116). https://doi.org/10.1017/s1463423619000227

Hawley, A. M. (2024). Weighing in: Why obesity should be considered a qualifying disability under the americans with disabilities act. The University of Chicago Law Review, 91(8). https://lawreview.uchicago.edu/sites/default/files/2024-12/04_Hawley_CMT.pdf

Kapp, S. K., Gillespie‐Lynch, K., Sherman, L. E., & Hutman, T. (2013). Deficit, difference, or both? Autism and neurodiversity.. Developmental Psychology, 49(1), 59-71. https://doi.org/10.1037/a0028353 

Luz, F. Q. d., Hay, P., Gibson, A. A., Touyz, S., Swinbourne, J., Roekenes, J., … & Sainsbury, A. (2015). Does severe dietary energy restriction increase binge eating in overweight or obese individuals? a systematic review. Obesity Reviews, 16(8), 652-665. https://doi.org/10.1111/obr.12295

Rosen, H. (2014). Is obesity a disease or a behavior abnormality? Did the AMA get it right? Missouri Medicine, 111(2), 104. https://pmc.ncbi.nlm.nih.gov/articles/PMC6179496/

Sorensen, B. L. and Krings, A. (2023). Fat liberation: how social workers can incorporate fat activism to promote care and justice. Affilia, 38(4), 724-731. https://doi.org/10.1177/08861099231183672