Dignity Before Diets

The U.S. Department of Health & Human Services (HHS) has announced a new Medicare coverage policy that could make it easier for beneficiaries to receive weight loss treatment. Under the plan, anti-obesity interventions would be made available “if scientific and medical evidence demonstrate their effectiveness in improving . . . health outcomes.”

This new guideline from HHS’ Centers for Medicare & Medicaid Services (CMS) removes language in the Medicare Coverage Issues Manual stating that obesity is not an illness. This step allows the public to request that Medicare review medical evidence to determine whether specific treatments related to obesity—such as gastric bypass surgery and dietary counseling—would be covered.

Fat activist organizations such as the National Association to Advance Fat Acceptance (NAAFA) and the International Size Acceptance Association (ISAA) are concerned that the general public will take this policy change as another opportunity to further alienate plus-size people. “The HHS decision changes the way people look at me,” says Mary Ray Worley, NAAFA spokesperson. “I am now considered ‘diseased.’ Wouldn’t it be great if [Medicare] could pay for health club memberships instead?”

According to their websites, both the NAAFA and the ISAA promote size acceptance and believe that an individual can be healthy at any weight. “The widespread assumption is that people who eat healthfully and are active are thin, and people who have poor nutrition and are inactive are fat,” Worley says. “People take one look at me and think I’m going to die of a heart attack any second. They’re wrong—I’m actually a very healthy person.”

IDEA member MaryJane Hattala, RNC, thinks the policy is a step in the right direction. “I work with people who, because they are obese, are unable or unwilling to leave their homes due to their own shame, public scrutiny or both,” she says. “These people often have myriad medical problems: diabetes, hypertension, hypothyroidism, heart disease and chronic skin conditions. I advocate getting these people up, moving and involved in life again. Because I am in favor of anything that gets them treatment, I feel Medicare is moving in the right direction.”

Hattala, who trains and treats morbidly obese people as a personal trainer and a nurse, says the new plan also serves as a reminder to fitness professionals to show compassion and understanding. “In working with this population, my goal is not to get them into athletic shape,” she says. “Rather, I want to get them to a functional state where they can enjoy life again and be the best they can be.”

IDEA member Kelly Bliss, MEd, a personal fitness trainer who coaches clients by phone and in fitness classes, wants to shift the spotlight from weight loss to self-care and self-appreciation. “I teach my clients to stop loathing their own bodies and focus instead on changing their attitudes,” she says. “I think it’s important for fitness professionals to take a look at any hidden bias they may have when working with large people. Appreciate that a 300-pound person who walks up a flight of stairs is essentially doing 300-pound leg presses.”

The new Medicare policy isn’t expected to have an immediate impact and doesn’t affect existing treatment coverage for diseases resulting in or made worse by obesity—in particular, currently covered surgical treatments for morbidly obese individuals. While waiting for the details of the new plan to trickle down, Hattala says she’ll keep stressing inclusion and well-being with her clients. “Motivation is the key but the biggest thing is acceptance,” she says. “You must accept the person where they are now and work in a positive, supportive manner one step at a time and one day at a time. You have to help them accept themselves as they are now, while also seeing that some decrease in weight would enhance their lifestyle and overall health. Start with baby steps and be non-judgmental. When they slip along the way, realize that relapse is a part of recovery and that they can learn from the experience.”

The NAAFA encourages its members to exercise and eat a nutritious, balanced diet. Worley says that large people have several hurdles to overcome before feeling comfortable enough to start an exercise program. Fitness professionals can help by suspending judgment. “Don’t presume anything,” she says. “Be supportive and make exercise fun. Focusing on our weight is counterproductive. If you focus on the simple joy of movement, we’ll get a lot further.”

Bliss suggests that fitness professionals offer hope and a positive attitude above all else. “The number one challenge my plus-size clients face is hopelessness,” she says. “I have hope that everyone can live a healthier life and that hope is contagious.”

As the public requests coverage for obesity treatments, Medicare will review scientific evidence using the coverage determination procedures established in 1999 and modified by the Medicare Modernization Act of 2003. For detailed information on this process, visit www.cms.gov/coverage.

“large people have several hurdles to overcome before feeling comfortable enough to start an exercise program”