j_war06

I do agree with that. The kids that are younger than me today are really BAD kids, atleast in my school district. I dont know what happened to make them different than us. Yes, we have some bad kids that are my age, but they never woul dhave dreamed of doing the things these kids are doing now. I think parents around here are not involved in their kids lives enough, then when they get what is coming to them (usually one good hit) then the parents want to through a fit. Priorities are wrong. I NEVER had to use a clear backpack or go through metal detectors to get into school or worry about being hurt in school except for emotionally. Today's parents, in my small crazy town, are crazy as well hell lol, they have double-standards for their kids and they also have very little respect for them at the same time. hmmmmmmmm....... Well this is about discrimination, I have made it through, although I do see a psychiatrist every 2 weeks (and probably need to go more than that).

Yes, I think I may have saw part of that report. It's great that other people are realizing that its real

lol I am a freshman in college, half my college will be done by the time I get to a 4-year university. I do not know where to get protein from, I have figured out that I eat plenty or I wouldnt be as big as I am. No, my life isnt worse than everyone else's that is not how a pessimist looks upon things. A pessimist looks at things like nothing will work out for anyone, especially them. Not necessarily that they have the worst life in the world (thats severe depression), but that if something bad is possible, then it will happen to them. Also, I believe in not being over-confident because you will get struck down. Its not a depressed state it is a political state (yes it really is). Also, everything that is wrong in my life is contributed by my weight. I would have higher grades if I wasnt big (partially because I could goto school more), I would have more friends (because I wouldnt be bitter toward the skinny people when they talk about other fat people or because they can shop in these stores and I cant or because they make rude comments about my weight), I would be more active (because I could actually move, plus face a lot less discrimination), I wouldnt have to spend ALL this money (because there wouldnt be as many Dr.'s Bills). I dont know, I just think that my weight has ruined my life on so many levels including emotionally and socially. Yes, I would have had some problem if I wasnt obese like a big nose, or ears, or big feet or something else that would be wrong and I understand that. Thinness isnt everything, yet it is the social key to American soceity, education, and business.

more Protein?? from what? Also CFS is a comorbidy because it can not be solved unless I lose weight. To get rid of CFS you have to be able to move around and take shots, I cant even take the shots because the tissue it is injected in is soooo sensitive because of the high amount of nerves in it. Also, I became depressed because of my weight (I have been depressed since I was about 6). All my knee problems would not be problems if not for my weight. I have went about the appeal process correctly, I know this because I had help with an actual lawyer and I used my pre-law pass online to get laws and insurance policy information from websites devoted to law students. I am at my wit's edge. I don't have great or good days, I have okay days because a day doesnt go by that I am not discriminated against, messed with, penalized, or in pain because the insurance company would not cover me. The exclusion in the company policy is borderline illegal (not quite, it is legal) because it discriminates upon people who are obese, and that discrimination was made illegal within the last 3 years. Not to mention the fact that I have the WORST luck in the world, and I am a pessimist becauseof this. Anytime I just know something is going to happen, it doesnt. Even if I cant help but hope, it doesnt go through. But if I retain my position that its not going to happen, then maybe it will. This is how my life goes. No, being thin is not a solution to my problems, it is a relief factor because the weight has done the damage that can not be fixed even through surgery. P.S. Thanks for editing the letter for me, I was in a rush doing college homework, but Mom's SSN# wasnt on the top of it lol, but that information needed to be removed anyway

Im trying, I just wish for once I was "normal" I am tired of being different, I have always been different, for once I want to blend into the trendy teen scene. I dont know what God has up his sleeves for me, but is scares me sometimes because for the past 17 years he has put me through the hoops. I dont know, I get inspired to do different things, then realize that they are not right for me to do either. I am however looking at taking a computer job for Fastweb.com a scholarship resource in return they pay me a scholarship. The job is blogging about your daily life twice a week, I think it would be a great way of journaling, I just hope they will hire me. If they dont they dont know what they are missing out on because my Psychiatrist thinks I ought to write a book. I have also come to realize that this is gonna be a hard year, my g-pa died my sophomore year and this is my senior year, and he always asked me what I was going to do my senior year, if I wanted a new car, if I wanted to go on a trip, where I was going to school, and so on. I miss him so much, and he is going to miss it all physically, I dont know I just feel like I am falling apart and having to pick up the pieces, its been a hard summer knowing I am going to have to go back to school in August and that he is not going to be there to see everything not to mention the fact that my grandmother is trying to kill herself, she is always high on medicines and runs over ppl in town and tries to OD, I dont know, I really dont want another grandparent missing. I am having a hard time today with all this.

Well right now I have to take adepex (phentermine) for appetite suppressent. I have never eaten a whole lot, just a little of everything that is bad for you lol. I take so much medication that I dont eat right now, what if the band doesnt work? I will be eating even less than now I know, but I am worried, I wasnt worried 4 months ago before the insurance denied me. Now I am scared that it wont work, I do not eat a lot, today I ate a low-fat peach popsicle (all natural fruit), a single serving of red cabbage, and a hand full of crackers. For supper I will barely eat, I dont get it, even when I am not on my meds I am not hungry?????? How did I get this big??

I cant keep a journal, I cant write that much, I cant even type that much my hands hurt too badly, so if I want to do a long post I type it little bits at a time and copy and paste it on here. See, I am helpless, I feel like a vegetable except for the fact I could have prevented this from happening, I could have stayed on a diet, I could have exercised when I was younger. I feel so horrible, I feel like I am slowly killing myself. They originally thought that I had lupus, but I didnt, I am sorry though that you do and I will keep you in my prayers.

Well I have several conditions other than being obese, that is why I am having the surgery. Mom calls the insurance company like every other day, and they keep saying they need more time. I have 3 doctors referrels with the letter and a list of references that they can contact to validate information. Acid reflux disease, temperomandibular jaw disorder (TMJ), chronic pain, sleep apnea, panic disorder, chronic fatigue syndrome, kydney conditions, hyperextension, patella alta, patella tendonitis and depression. Below is a copy of my Appeal letter: Dear UnitedHealtthcare Appeals, <O:p></O:p> This letter is in regards to your recent denial to provide coverage concerning my request for morbid obesity surgery in the form of gastric banding. <O:p></O:p> On March 22, 2005 I visited the office of Dr. Ronald Lindsey in the matter of chronic severe knee and body pain. His diagnosis was that I had very small bones and joints for my weight (235 lbs) and that the cause for the smaller bones and joints was that I have a disposition of hyper-extension within my joints. According to Taber’s Medical Encyclopedia hyper-extension is the extreme ability to stretch out and/or abnormal extension. The significant amount of weight on these already flexible joints can be compared to placing a brick on top of a toothpick, the excessive amount of weight on my limbs (as ruled by Dr. Lindsey) will take its course someday. Dr. Lindsey’s prognosis was that unless I lost a great amount of weight in a short amount of time, that my knees would suffer substantial permanent damage. In lou of his prognosis he suggested bariatric banding surgery in order to lose the weight. <O:p></O:p> In response to Dr. Lindsey’s suggestion, I called and made an appointment with Dr. Felix Spiegel, a bariatric surgeon within the <?xml:namespace prefix = st1 /><st1:City w:st="on">Beaumont</st1:City> area of <ST1:place w:st="on"><st1:State w:st="on">Texas</st1:State></ST1:place>. Dr. Spiegel determined, based upon his professional experience and training, that weight loss via his surgery would indeed help my knees, since my BMI is 41 (normal is about 24, as determined by the World Health Organization), and will also significantly decrease my chances of developing other comorbid conditions, and would rid me of the ones that are already present such as acid reflux disease, temperomandibular jaw disorder (TMJ), chronic pain, sleep apnea, panic disorder, chronic fatigue syndrome, and depression. It has also come to my attention that although you stated in your denial letter that the GTECH Corporation’s benefit plan does not cover surgical and non-surgical treatment of obesity, your company (UnitedHealthcare) covered the costs associated with Dr. Spiegel’s consultation ($250), with me only paying a copay of $40. This discovery is contradictory to the policy exclusion, why would one choose to spend the money on a consultation of a patient by a doctor who specializes in a program that is not covered under the company policy? Why spend the extra money? <O:p></O:p> From the year 2002 to the present (Summer 2005), GTECH Corporation’s benefit plan through Cigna and UnitedHealthcare has spent approximately $9,716.89 on my medical costs alone. Every year my medical costs almost double due to knee pain which has been determined by medical professionals to be a direct cause for the chronic pain and inflammation that constantly plague my knees. Now that we have finally come to our last resort, surgery, the same pain is becoming more prevalent throughout all my joints, including my hands, elbows, wrists, feet, and lower back. With the pain spreading, it is projected that my medical costs will possibly triple by January 2006. A breakdown in costs reveals that my policy spent atleast $242.58 on orthopedic consultation and physical therapy in 2002. From 2003-2004 UHC has spent an estimated $4,931.79 on medical costs associated with obesity comorbidities. Just this year, 2005, UHC has spent an estimated total of $2,238.18 as of May 2005, that is not even half of the year and UHC has spent about half of the previous year’s expenses. If you were to add it all together, by the time I would no longer be carried by GTECH’s policy UHC will have spent over $35,000 or more in health care costs for me (Jodie Warner) only. Hypothetically, if UHC was to pay for the complete costs of the surgery, UHC would only total about $27,000. These figures do not even include the very real possibility of knee surgery resulting from damage to my knees caused by morbid obesity. <O:p></O:p> Morbid obesity as a disease, not as outward appearance, has truly taken over my life. I can neither stand nor sit for too long of periods, walk very far, or even drive my car most of the time. Morbid obesity is controlling my life, and simple diet and exercise can not fix the problem because it is impossible to exercise because of the crippling pain in my knees (and now throughout my body). Also, because of the pain I have had to unenroll from public school and am forced into a homebound program. In this program I have had to be placed within my school district as special education, although I am extremely intelligent and am in no way mentally retarded or paralyzed. My knee pain, as a result of morbid obesity has caused me to miss an estimated 50 school days per year, which takes a dramatic toll on my grades. Before I had knee pain I was an “A” student and in the top 10% of my class, now I make grades all over the chart and have stepped down into the first quartile of my class. Obesity will only worsen my condition, and could very possibly send me to an early death. Under Supreme Court ruling concerning morbid obesity, it has been determined that obesity and especially morbid obesity is a disease and a disability under the American Disability Act. As an obese, female teenager, I feel as though I am being discriminated against by GTECH’s policy because I am obese and I am experiencing unmentionable pain (like elephants standing on my knees all day). This surgery, gastric banding, is not for cosmetic purposes, if I want to look pretty I put on make-up, it is to save my future ability to walk. I believe people are beautiful no matter what their pant size is, but when the pants are not the right size, then they cause problems. This is what is happening to me, my weight is causing my body to be in severe and damaging pain. I have an extremely small frame that refuses to bear the burden of my weight any longer. If this issue is not addressed in a very timely and serious manner, my knees may collapse and cause serious and permanent injuries. <O:p></O:p> *If you would like to validate any of this information, I have provided the contact information on the following page* <O:p></O:p> Sincerely Jodie Warner <O:p></O:p> <ST1:p

I have terrible knee pain also, I cant even walk around my school so I am home-bound, and cant go do fun stuff, so I am HAVING Lap-Band to get the weight off of my knees. I have patella-alta, chronic inflammation, loose patella, and hyperextension and losing weight will help me because my knees are very unstable, so if I lose weight then I can exercise and strengthen them, but I cant exercise at all right now because I am too heavy to be on them (since they are incredibly small bones and joints). After I lose the weight, they are going to go through and check again to see if I actually have a disease or something in there. Just hang in there and be thankful you have had the surgery, my insurance company is claiming that it is cosmetic and unnecessary. Give it time. Your knees are still used to the weight being on them, its kinda like when you hold a heavy box for a while, then sit it down, and your arms still ache because they were getting used to the weight and still havent registered that it is gone. Trust me, youve got to feel better after you lose atleast three-fourths of your goal. Goodluck, oh yea, when they hurt try to slowly work them like bending and stuff to see if they will pop, sometimes that helps mine, sometimes it makes them worse.

I know, I am a firm believer in everything happens for a reason. And my impatiance goes against this, but I feel like I am dying, I really do. Everyday my body hurts more, my knees are stiffer, my hands are more cramped, and I am SOOOO tired all the time. I just know that everyone that was in that office with me today has gotten their bands, and it seems like everyone but me is getting it (those who want it). I just dont understand why I have all the bad luck and stupid luck.

I am not worried about the teasing, I have dealt with it from the same people all my life, and it never changes, its the fact I cant get around school, I cant sit in the desks for very long or I get stiff, if I stand or walk to long then my knees get too wobbly. I cant write very much with a pen or pencil (about a paragraph) because my hands hurt too bad. I cant do a lot that has to do with school. I cant do any exercises because my whole body is like my knees, too small and limber for the amount of weight on them. I have lost 14lbs because I take prescribed amphetemines because if I gain ANY weight over 240 there is a 10% increase every 5lbs or so that my knees WILL collapse. I just want to be able to go shopping, and actually be able to walk into the store instead of having to sit and rest ALL the TIME. I want to be able to go to college confident that I can do whatever the other kids are doing. I am tired of staying home every night! I just am physically unable to do much of anything. The insurance has everything they need I assure you, and then some. I am a pre-law student and wrote a 3-page letter entailing details of my conditions and doctors referrals and visits

Im just ready to get out of this HOUSE!! and be able to enjoy it, if the insurance does come back with something, anything (yes or no, preferably a yes) I am going to turn into an agoraphobic, I havent seen a crowd and not cried because they were stepping on my and pushing me in 6 or 7 years. I cant wait until I can push them back, rude SOBS. I just dont understand, dont they know I need an education, I am not even in school right now

Im glad u all can dance, I can't even do that. Why is it that when I NEED something it just doesnt happen?? I feel worse everyday like my knees are going to just bust

Yeah I know this should go under insurance, but its kinda talk too right? I was wandering how long an insurance company has to make up its mind about approving the surgery? They told me the other day that it would take 30 days, I have always heard that they only had 15 business days to overturn a denial?? I am so confused? School starts on August 15, looks like another stay at home year thanks to my great orthopedic surgeon and UnitedHealthcare. I have been thinking a lot about just getting the surgery done and forwarding them the bills and if they pay they pay, if they dont then they dont. I dont know I feel so bad about my parents paying for this, its soooooo expensive, but so is my life and I know that it will kill me pretty quickly with all my comorbities. How do I go about getting them to pay after I have the surgery, I have heard of it being done before, I just am really scared. But atleast it would be done in the right amount of time, and if they approve it then they can pay and pick up payments and if they deny it then we were going to pay for it anyway. Hmmm HELP??? ANYONE???

Plus, mom refuses to call and she has to be the one to make the call because I am a minor and the insurance is under her company, I just dont know what to do, I am hurting so bad, I barely got out of bed today.

My doctor keeps saying he will call, and will not (talking about my orthopedic surgeon). This surgery is not for me to look great in a mini skirt, it is so that I can walk again. We have called the insurance company every other day since they recieved the Appeal letter on July 11. August 11 might be too late, I cant go to school like this. I cant stand my orthopedic surgeon and hope that he has the same problems as me someday, but then ofcourse he would be able to pay for it right?

I am not worried about the legal side of it (for once lol). I just figure they will have to deal with it someday, so I don't worry about it. *Yes I really did weigh 240, but since I have lost weight do to being sick and my weight fluctuates really badly. Not to mention, when I had my consultation I only weighed 228. But now I back in the 220s.

Well, I know that being an overweight teen is hard, and that I have experienced disrimination based on all of these categories. I have not been able to get a job, although I am EXTREMELY qualified, more so than a lot, but it always seems that some skinny, cute, little partygirl (gets drunk and high every weekend) always gets the job. hmmmmm makes me wonder. In food establishments I have had the waitress (usually) bring me a lesser or bigger portion than what I ordered (if I wasnt big, I would think it was a nice gesture, but its something I can't stand). In clothing stores though is where I face the most discrimination, clerks won't help me (even if I ask), people in the dressing rooms are uninterested in me (but a skinny person comes in and they are excited). Only in plus sized stores do I get ANY help what-so-ever and then I cant get rid of them lol. I do not even go to public places anymore because I have been asked to leave more than once. I do not even go to school because the lunch lady tends to tell everyone whom she feels should drop some weight that they dont need to be eating, and should be puking in the bathroom. The other lunch servers are extremely rude and take me as a pushover, surprise im not one. In class, the teachers pay little attention to what I say, like I am invisible and I receive lower grades even though I had very similar answers to those of the thinner people. The staff is less likely to help me, and the kids are more likely to harass me. I know you all have experienced something like I have.

I find this interesting, just pick what you are interested in, I dont expect ppl to read all of this lol

Current Weight-Specific Legislation No federal laws exist to prohibit discrimination against obese individuals, and only Michigan’s civil rights legislation prohibits employment discrimination on the basis of weight at the state level (34) . The District of Columbia forbids discrimination on the basis of appearance including weight, and Santa Cruz, California includes weight in its definition of unlawful discrimination (129) . In the spring of 2000, San Francisco passed legislation to ban weight discrimination, adding weight and height to existing characteristics (such as gender, ethnicity, age, and sexual orientation) that are protected (130) . Advocates in San Francisco gained support for this legislation when a health club created a billboard with a space alien saying, "When they come, they’ll eat the fat ones first." Overall, few locations have weight-specific legislation, so most obese persons are forced to use existing human rights statutes for legal protection. In particular, overweight individuals have depended on the Rehabilitation Act (RA) of 1973 and the American Disabilities Act (ADA) of 1990 (131) . Employment discrimination cases encompass the vast majority of such actions. The RA was the first effort to prohibit federal employee discrimination against individuals with disabilities (32) . A person with a disability is one who has a physical or mental impairment that substantially limits at least one major life activity (activities such as walking, breathing, self-care, and working), has a record of such an impairment, or is perceived as having an impairment (34) (129) . The RA does not actually include obesity as a specific protected impairment (32) . The ADA expanded federal disability discrimination legislation by extending mandates to private employers, state and local employment agencies, and labor unions (23) (131) . Like the RA, the ADA protects disabled but qualified employees who can perform essential aspects of employment (131) . The Equal Employment Opportunity Commission (EEOC) implemented regulations for more flexible interpretation of ADA impairments, allowing obesity to be included in its broader definitions (129) (132) . The guidelines of the EEOC do not consider obesity alone to be an impairment. However, obesity can meet impairment definitions if one’s weight can be attributed to or results in a physiological disorder, or if a person’s weight is severe as in cases of morbid obesity (132) . Under the ADA two kinds of cases can be pursued: those involving actual disabilities, and those of perceived disabilities. An actual disability claim requires that an individual’s obesity be substantially limiting in at least one major life activity. A perceived disability occurs when one is regarded by others as having an impairment (131) . Here, the obese individual must demonstrate either an actual impairment that does not limit life activities but is perceived to be limiting by others or that there is no impairment at all but that the individual is perceived as having one. As many courts do not recognize obesity as an actual impairment, obese individuals must often use perceived impairment claims (131) . Inconsistent Rulings Although alleged discrimination is being met with lawsuits, the overall picture of cases pursued under these statutes is one of mixed results. The majority of courts have ruled that obesity, per se, is not a disability (32) . In Krein v. Marian Manor Nursing Home, for instance, an obese nurse’s aid was discharged because of her weight. The court held that her obesity was not a disability and, thus, was inadequate to qualify the plaintiff for discrimination protection (131) (133) . Similar court rulings were held for a flight attendant in Tudyman v. Southwest Airlines and for a labor worker in Civil Service Commission v. Pennsylvania Human Relations Commission, where both plaintiffs failed to show that their obesity caused, or was caused by, a condition that would qualify them for state protection (31) (37) . Later cases continue to follow this trend. In Cassista v. Community Foods Inc., an obese woman was denied a cashier/stocking position because of her weight (131) (134) . In the case of Philadelphia Electric Co. v. Pennsylvania Human Relations Commissions, an obese woman was refused employment in a customer service position due to her obesity, despite having passed pre-employment evaluation. The court ruled that her obesity did not impair her job performance and, thus, could not constitute a disability and receive protection (37) (135) . Although few cases have held that obesity on its own constitutes a disability, several court rulings have demonstrated circumstances in which obese plaintiffs have been successful. In the case of New York Division of Human Rights v. Xerox Corporation, an obese plaintiff was denied a computer programming position because her obesity made her medically unsuitable for the job, according to the company’s physician (32) (136) . The state court recognized broader definitions of disability under New York law and ruled that her obesity was an impairment as defined by Xerox’s medical staff, although she had no other medical conditions and could perform the duties of the position (32) (37) . In the case of King v. Frank, a postal worker alleged that he was fired because his supervisor perceived his obesity to be an impairment (137) . The commission ruled that because the employer perceived the worker to be substantially limited in work (one of the major life activities of the RA), he was granted protection under the RA (32) . Finally, the case of Gimello v. Agency Rent-a-Car Systems also accepted a disability claim in which the court concluded that the plaintiff’s obesity was a physical disability because he had sought medical treatment for his condition (36) . Unresolved Issues: Blame and Disability The legal issue of whether obesity is a disability has not been decided. Very obese persons or individuals whose obesity is attributed to an underlying medical condition may have the most success under the ADA (131) , but it is difficult to predict which cases will be successful. Court decisions of whether obesity is an impairment may be the result of many factors besides ADA guidelines, such as court beliefs, cultural perceptions, academic views, previous case rulings, and weight bias in judges. Inconsistent court decisions will likely continue until ambiguities in existing legislation are resolved. Under the ADA there is no standard for determining how obese a person must be for weight to be considered a disability (37) (132) . Being moderately fat will only be considered a disability if accompanied by an additional impairment, whereas obesity on its own does not meet ADA impairment definitions. Morbid obesity can meet disability requirements. Korn (138) notes that limiting the protection of the ADA to morbid obesity ignores the majority of the obese population and reinforces misperceptions that anything less than morbid obesity can be personally controlled. Courts have generally viewed overweight as voluntary and mutable and, therefore, have disqualified it as a disability (131) (138) . The ADA does not actually require a condition to be immutable or involuntary to be considered a disability (32) . The RA and ADA protect other mutable conditions like alcoholism, drug addiction, and acquired immune deficiency syndrome, all of which involve voluntary behavior (32) . Although the EEOC states that being voluntary is irrelevant in the definition of impairment, the fact that obesity is rarely considered an impairment without an underlying medical condition suggests that the EEOC sees obesity as controllable (138) . Another unsettled issue is the applicability of the perceived disability theory. Because courts are unlikely to accept obesity as an impairment, overweight persons can stand on this section of the law. Yet successfully applying this theory to obese individuals may be unlikely, because the plaintiff must prove that the employer perceived weight to be an impairment, not just that the employee was perceived to be overweight (131) . Legal pursuits are not necessarily easier for obese individuals proceeding under actual disability claims. Successfully proving that one’s condition substantially limits a major life activity does not necessarily satisfy legal requirements. Both the ADA and RA can deny protection even if one’s obesity does impair life activities (34) . The obese plaintiff must also prove that he or she can satisfy the essential functions of the position, and those who cannot perform job duties with or without reasonable accommodation will not be protected (34) . Whether it is advantageous for obesity to be considered a disability is a matter of debate. Despite the legal advantages of the disability label, considering obese persons disabled may have unwanted ramifications. For example, it may be undesirable for overweight children to consider themselves "disabled." Because weight is a disabling condition in only a minority of cases, it may be harmful to attach a disability label to a condition already severely stigmatized. A key problem is that existing statutes were not intended to protect against weight discrimination (129) . Categorizing discrimination claims under current disability definitions makes less sense than finding other strategies to fight weight discrimination. Several suggestions have proposed revising the ADA. One option may be to change definitions of disability in the ADA to explicitly include obesity (37) (138) . Doing this would allow individuals uniform protection for having limiting conditions due to obesity, although this option would also mean attaching a disability label (37) . Others have concluded that the EEOC should declare issues of voluntariness and mutability as irrelevant to decisions determining impairment and enforce that they be excluded (131) . An alternative is to create new legal options for obese employees other than the RA and ADA. Adamitis (129) suggests that the most appropriate alternatives are state and local laws for protection from weight discrimination. It may be more realistic to consider state statutes, which often provide broader coverage, than to focus on federal laws (129) . As mentioned earlier, legal cases prove only that discrimination based on weight is perceived and that legal justification for seeking relief is growing. One cannot infer that discrimination is widespread from such cases. Prevalence studies are necessary.

Housing One small study suggests that weight discrimination may exist for obese tenants seeking apartment rentals (124) . Obese and non-obese student confederates each visited 11 available rental units, pretending to be seeking each apartment for rent. All 11 landlords offered the units to the non-obese confederate, but 5 landlords would not rent to the obese confederate (124) . Three of these five actually increased the rental price with the obese confederate (124) . Because this study is both dated and limited in its small sample, additional research replicating these findings would be valuable and could broaden the present insufficient knowledge of this potentially discriminatory issue. Adoption Obesity could potentially be a basis for denying individuals the right to adopt a child. This issue has not been addressed in research, but several countries outside of North America may be using parental weight criteria in adoption procedures (125) . Anecdotal evidence suggests that this may occur in the United States, where obese women have reported being turned down by adoption agencies and told that they would be unfit mothers due to their weight (58) . NAAFA believes that weight discrimination in private American adoption agencies is a reality and has formulated an official position advocating equal access to adoption services for obese individuals and couples (126) . NAAFA has resolved to improve education about size discrimination in adoption, provide support to obese individuals facing such discrimination, and assist plaintiffs in litigation (126) . Because the issue has not been studied, research documenting whether this discrimination exists is important. Research It is critical that research itself not exclude obese persons. Overweight people have been underrepresented in research unless studies have focused on obesity (5) . As an example, the National Institute of Health funded the Women’s Health Initiative for over 600 million dollars to investigate cancer, heart disease, and osteoporosis in women. Although tens of thousands of women are participating in this longitudinal study, and despite overweight women having increased vulnerability for some of the diseases being investigated, the study excluded obese women (5) (127) . Limitations of Existing Research Laboratory studies addressing discriminatory attitudes and behaviors rely primarily on student samples, so generalization must be examined. Second, most studies on anti-fat attitudes among medical, educational, and hiring professionals have used nonrandom designs, self-report methods, and a variety of attitudinal assessment measures that may not have been tested for validity and reliability. Third, the literature is not sufficiently large or mature to draw conclusions across all areas in which discrimination has been claimed. For instance, there are hints but not documentation of obese individuals being denied children in adoption proceedings, the assumption being that weight reflects personal failings that would make people unfit parents. Finally, it is not clear whether the severity and frequency of discrimination increases as an individual becomes more obese. Many theoretical questions about weight stigma have yet to be studied. Although a few preliminary models have been proposed, theories have not been compared and there is no consensus of which factors best predict who will stigmatize obese people. Despite evidence of various cultural attributions toward obesity throughout history, there is also a need to examine the cultural factors that affect this population (128) . As research better documents weight discrimination, conceptual frameworks for understanding weight stigma can be refined, and hypotheses can be increasingly guided by theory. Ultimately, the integration of theory and empirical studies should be used to derive stigma reduction strategies and interventions to eliminate discrimination.

Peers in the School Environment Peer rejection may be an overweight individual’s first challenge in educational settings. Anecdotes have been noted where harsh treatment from peers has resulted in suicide (88) (89) . Such anecdotes are extreme, but research does show substantial rejection of obese children by peers at school. An often cited example is a study conducted in the early 1960s in which children in public school and summer camp settings (N = 600) ranked six pictures of children varying in physical characteristics and disabilities in order of who they would like most for a friend (90) . The majority of children ranked a picture of an obese child last among children with crutches, in a wheelchair, with an amputated hand, and with a facial disfigurement. A recent replication of this study among fifth- and sixth-grade students (N = 458) reported that the strongest bias was against the obese child and that there was an increase in prejudice against the obese child compared with the findings from 40 years earlier (91) . Other recent studies showing photographs of obese and non-obese persons to schoolchildren showed negative stereotypes and suggested that bias is formed by 8 years of age (92) . Some work shows anti-fat attitudes in 3-year-old preschoolchildren (93) . Research addressing children’s attitudes toward thinness and ideal body size indicate the same trend. One study of fourth-grade children (N = 817) found that 49% of girls and 30% of boys chose ideal figures thinner than themselves when shown a number of different body types (94) . Only 10% of boys and 11% of girls selected an ideal body size larger than their own. Other work has demonstrated that children in grades four through six endorse negative stereotypes for both obese children and adults, and regardless of the child’s own weight, age, and gender (95) . Children reported that they believed that obesity was under personal control; this belief was positively related with negative stereotyping. Another study examined knowledge about obesity among third and sixth graders who were randomly assigned to watch a videotape of a peer who was average weight, obese, or obese with a medical explanation for the obesity (96) . Obese children received the most negative judgments, and although children attributed less blame to the obese child with the medical explanation, this knowledge did not improve attitudes among children toward obese peers. This parallels findings from a study attempting to change negative attitudes about obesity among undergraduate students where an increase in knowledge did not alter attitudes (97) . Authors of both studies (96) (97) concluded that more powerful means are necessary to foster positive attitude changes toward obese individuals. For children, this might involve broad educational approaches to increase weight tolerance, which reduced teasing toward overweight peers and increased acceptance of diverse body types among fifth-grade students in a recent study (98) . One study assessed personal descriptions of perceived stigmatization among overweight adolescent girls (99) . Ninety-six percent reported negative experiences because of their weight, the most frequent being hurtful comments such as weight-related teasing, jokes, and derogatory names. Peers were the most common critics and school was the most common venue. Many reported being teased continually about their weight throughout elementary school, middle school, and high school and indicated that they had not yet learned how to cope with stigmatizing encounters with peers. Some research has examined the long-term impact of weight-based teasing in a clinical sample of obese women and found that more frequent teasing during childhood and adolescence was related to more negative self-perceptions of attractiveness and greater body dissatisfaction in adulthood (100) . The psychological and social consequences of these experiences have been addressed in the literature for many years (101) (102) (103) . Although obese pre-schoolchildren seem to have similar levels of self-esteem as non-obese preschoolers (104) , this drastically changes once children begin school. A study of children 9 to 11 years of age (N = 67) reported that clinically overweight children had significantly lower self-esteem than non-overweight children (105) . Self-esteem was lowest among overweight children who believed that they were responsible for their overweight and who believed that weight was the reason for few friends and exclusion from games and sports. In addition, 91% of the overweight children felt ashamed of being fat, 90% believed that teasing and humiliation from peers would stop if they lost weight, and 69% believed that they would have more friends if they lost weight (98) . These findings parallel other reports of low self-esteem and poor social and athletic competence among obese children 9 to 12 years of age (106) (107) . Weight Stigmatization in High School and College In addition to continued endorsement by college students of negative stereotypes about obese individuals as lazy, self-indulgent, and even sexually unskilled and unresponsive (108) (109) , weight stigmatization can be more overt at higher levels of education. There are reports of overweight students receiving poor evaluations and poor college acceptances and facing dismissal due to their weight (5) (110) . Most studies have addressed these issues at the college level. Canning and Mayer (111) examined school records and college applications of 2506 high school students and found that obese students were significantly less likely to be accepted to college despite having equivalent application rates and academic performance to non-obese peers. Moreover, obese women were accepted less frequently (31%) than were obese men (42%). Crandall (112) examined reasons for the lower college acceptance of obese women. In studies assessing issues of weight, financial aid, and college income among undergraduate students (N = 833), a reliable relationship emerged between BMI and financial support for education. Normal-weight students received more family financial support for college than overweight students, who depended more on financial aid and jobs; this effect was especially pronounced for women. Differences in family support remained despite controlling for parental education, income, ethnicity, and family size. In a study of overweight women, Crandall (113) again demonstrated parental bias. High school seniors (N = 3386) completed questionnaires about their weight, college aspirations, financial support, grades, and parental political attitudes. Both overweight men and women were underrepresented in those who attend college, and overweight women were least likely to receive financial support from families. Politically conservative attitudes of parents predicted who paid for college, where conservative ideological attitudes among parents (characterized by values of self-discipline and the tendency to perceive people as responsible for their own fate), were positively correlated with BMI of students. Crandall (114) theorized elsewhere that anti-fat attitudes are related to Protestant work ethic values of self-determination and the ideology that people deserve what they get. Thus, individuals with such ideological beliefs may be more likely blame their obese children for their weight (114) . There have been celebrated cases of obese students being dismissed from college because of their weight; one reached the U.S. Supreme Court. In 1985 an obese nursing student named Sharon Russell was dismissed from Salve Regina College 1 year before obtaining her nursing degree for failing to lose weight (110) (115) (116) . Although the school did not object to Russell’s obesity at admission to the program, her weight became an issue of public scrutiny and harassment by students and faculty (110) . Russell demonstrated good academic performance in her courses, though in her junior year she received a failing grade in one course (which was determined to be the result of her weight and not her academic performance) (110) . Instead of expulsion, Russell was asked to sign a contract agreeing that she could remain if she lost 2 lb/wk. A year later and several credits shy of her degree, Russell was dismissed from the school for her inability to lose weight (115) . Once successfully obtaining her degree at another college and obtaining her nursing license, Russell sued her previous college for wrongful dismissal, intentional infliction of emotional distress, and discrimination in violation of the Rehabilitation Act (115) . Six years later she was granted monetary damages and the case was concluded (117) . In a nursing journal, Weiler and Helmes (110) noted, "... what should be particularly troublesome for nurse educators, is that the nursing profession prides itself on providing caring and compassionate treatment for all patients, yet in this case it failed to extend this same sensitivity to a future colleague." It is possible that negative attitudes by educators toward obesity are more widespread than has been documented. Solovay (5) notes, "Many fat kids exist on a diet of shame and self-hatred fed to them by their teachers." One study reported that junior and senior high school teachers and school health care workers (N = 115) believed that obesity was primarily under individual control (118) . Although approximately one-half of the teachers did recognize biological factors in the etiology of obesity, teachers agreed that obese persons are untidy (20%), more emotional (19%), less likely to succeed at work (17.5%), and more likely to have family problems (27%). Forty-six percent agreed that obese persons are undesirable marriage partners for non-obese people, and fully 28% agreed that becoming obese is one of the worst things that could happen to a person (118) . These findings support the 1994 Report on Discrimination Due to Physical Size by the National Education Association, which stated that "for fat students, the school experience is one of ongoing prejudice, unnoticed discrimination, and almost constant harassment" and that "from nursery school through college, fat students experience ostracism, discouragement, and sometimes violence" (119) . Summary and Methodological Limitations Rejection, harassment, and stigmatization of obese children at school is an important social problem. The severity and frequency of this treatment by peers and teachers is disturbing, but, again, the literature must be strengthened to understand the entire picture. Self-reports are the most common method used. It is essential to collect both peer ratings and teacher ratings and to conduct behavioral observations in the classroom and schoolyard. College admission data are old, so it is necessary to determine the extent to which discriminatory practices now occur. Finally, some reports are anecdotal. Anecdotes can lead to needed research but do not prove discrimination.

Controversies in Coverage for Obesity Treatment and prevention have seldom been emphasized by insurance providers, despite spiraling health care costs attributed to obesity. With more Americans overweight, obesity has become a leading cause of preventable death (65) . Direct costs associated with obesity represent 6% to 7% of the National Health Expenditure (66) (67) ; 99.2 billion dollars were attributed to obesity in 1995, of which 51.6 billion dollars were direct medical costs (67) . A study examining the 25-year health care costs for overweight women over age 40 years using an incidence-based analysis, predicted that 16 billion dollars will be spent in the next 25 years treating overweight middle-aged women alone (68) . Other investigations have suggested a relationship between BMI and health care expenditures. In one study, medical and health care use records of obese women (N = 83) belonging to a health maintenance organization were compared with records of non-obese women (69) . As BMI increased, so did the number of medical diagnoses and the use of health care resources. In another analysis of employees of 298 companies (N = 8822), obesity was directly and significantly related to higher health care costs (an 8% higher cost), even when adjusting for age, sex, and a number of chronic conditions (70) . A longitudinal observational of obese individuals (N = 383) covered by the same insurance plan reported that the probability of health care expenditures increased at BMI extremes (71) . A study of over 17,000 respondents to a 1993 health survey reported a strong association between BMI and total inpatient and outpatient costs (66) . Compared with individuals with a BMI of 20 to 24.9 kg/m2, there was a 25% to 44% increase in annual costs in moderately and severely overweight people, adjusted for age and sex. Wolf and Colditz (67) reported an 88% increase in the number of physician appointments attributed to obesity from 1988 to 1994, and a total of 62.6 million obesity-related physician visits in 1994. A recent review of the scant literature on access to and usage of health care services suggests that obese persons use medical care services more frequently than do non-obese people and that they tend to pay higher prices for these services (72) . Beliefs that obesity treatment is unsuccessful and too costly have been challenged (73) . Weight losses as small as 10% are associated with substantially reduced health care costs, reduced incidence of obesity-related comorbid conditions, and increased lifetime expectancy (73) (74) . Recent research has addressed the cost-effectiveness of drug treatments and surgery for obesity. In 1999 Greenway et al. (75) found that weight losses produced by medications (fenfluramine with mazindol or phentermine) reduced costs more than standard treatment of comorbid conditions. Gastric bypass surgery has demonstrated even more impressive effects, with lower costs and greater long-term weight loss maintenance in comparison to low-calorie diets and behavior modification (76) , as well as significant reductions in BMI, incidence of hypertension, hyperinsulinemia, hypertriglyceridemia, and hypo-high density lipoprotein cholesterolemia, and sick days from work compared with matched controls (77) (78) . Current Coverage Practices Even with some evidence of cost-savings for some weight-loss methods, medical coverage is inconsistent. Surgical treatment is often not reimbursed even though diseases with less supported treatments are compensated (79) . Some have explicitly pointed to prejudice against obesity surgery by insurance providers who are preventing its broader acceptance and use in practices (80) . As Frank (81) concludes, "... no claim to justify the denial of benefits for the treatment of obesity has any validity when held to the standards of health insurance otherwise available in the United States. It should be obvious that such a judgment is ethically unconscionable." It is typical for health insurance plans to explicitly exclude obesity treatment for coverage (82) . Physicians often have difficulties receiving reimbursement for their services (79) . Many reimbursement systems do not categorize obesity as a disease, leading physicians to report comorbid disorders as the reason for their services (79) . In 1998, the Internal Revenue Service excluded weight-loss programs as a medical deduction, even when prescribed by a doctor. In response, several organizations such as the American Obesity Association (83) filed petitions for a ruling to allow the costs of obesity treatment to be included as a medical deduction. As of 2000, the Internal Revenue Service policy changed its criteria, allowing costs for weight-loss treatments to be deducted by taxpayers for certain treatment programs under a physician’s direction to treat a specific disease (84) . The Social Security Administration has eliminated obesity from its list of impairments, which is used to determine eligibility for disability payments (65) . Because individuals who receive social security disability benefits are also eligible for Medicare after 2 years, those who are denied disability also forgo opportunities for medical coverage (65) . Although few studies have addressed this issue, a recent cross-sectional analysis of third-party payer reimbursement for weight management for obese children reported low reimbursement rates (85) . Despite the medical necessity of weight management for obese children in the study, no reimbursement was given to 35% of the children enrolled in weight-management programs, and no association existed between the severity of obesity and the reimbursement rate (85) . Although this article does not intend to examine all of the potential factors that may underlie these coverage policies, one likely contributor are perceptions that obesity is a problem of willful behavior and that treatment is unsuccessful and expensive (81) . Although health insurance typically covers treatment for substance abuse and sexually transmitted diseases, which are also considered to be problems of willful behavior, obese persons may not receive the services they need (81) . Denying obese people access to treatment may have medical consequences, but also denies people an opportunity to lose weight, which itself may reduce exposure to bias and discrimination. For example, Rand and MacGregor (58) assessed perceptions of discrimination among morbidly obese patients (N = 57) before and after weight-loss surgery. Before their operations, 87% of patients reported that their weight prevented them from being hired for a job, 90% reported anti-fat attitudes from co-workers, 84% avoided being in public because of their weight, and 77% felt depressed on a daily basis. Fourteen months after surgery, every patient reported reduced discrimination, 87% to 100% of patients reported that they rarely or never perceived prejudice or discrimination, and 90% reported feeling cheerful and confident almost daily. A further study indicated that 59% of patients requested surgery for social reasons such as embarrassment, and only 10% for medical reasons (86) . After the operation, patients reported improved interpersonal functioning (51%), improved occupational functioning (36%), and more positive changes in leisure activities (64%). Although these studies are based on self-reports from selected samples and, therefore, have limitations, it is interesting to note the dramatic reduction in postsurgical perceptions of prejudice and discrimination, and the power of social perceptions in motivating surgery decisions. Summary and Methodological Limitations A "fat is bad" stereotype exists in the medical field (87) . Further study is needed to test the degree to which this affects practice. It seems that obese persons as a group avoid seeking medical care because of their weight. One barrier to drawing further conclusions, however, is that much of the research relies on self-report measures of variable reliability and validity. There is a need to move beyond reports of attitudes to actual health care practices.

Well, I am not worried about the guys. It has never really bothered me MUCH that I didnt have a lot of men, mainly because what I did have I broke up with. So I just left it alone. Plus, I was not willing to open myself up to that. It is the girls that used to be my friends before High School that will have nothing to do with me because I am fat. I just wish they would gain about 30 pounds (no not obese, i dont wish that on anyone) just to know how it feels to be overweight. hmmmm sorry, too sentimental, *I wish I could stand in a room, and not feel like I have to scan it to see if I am not only the biggest one there, but the youngest also. *I hope that after I lose the weight, my legs will look like they are walking instead of just rolling over one another (noticed this about a week ago) *I wish that ALL my stretch marks would disapear, and I would never have to explain to people what these funny marks are on my arms. *I wish that I could wear a mini skirt out in public *I can't wait to go buy pretty and sexy underwear *I want to spend $50 on a shirt because I feel like I deserve it and not because that is what plus sized clothing (that is made for my age) costs

Thanks for the article, especially since it pertains to me.