From left to right, healthy, overweight, and obese waist circumferences (FDA/Renée Gordon)
After six years living in New Zealand, Albert Buitenhuis may have to go back to South Africa. The government decided he's too heavy to stay.
Buitenhuis is now facing deportation after officials denied his request to renew his work visa. He and his wife claim to have had no previous trouble with their annual visa renewals.
New Zealand's immigration ministry maintains that, at more than 280 pounds, Buitenhuis's weight puts him at added risk for diabetes, high blood pressure, and heart disease. Despite reports from Buitenhuis's physician that he's on track to correct a number of his health problems, the ministry remains concerned that weight-related issues will translate into hefty future costs. New Zealand claims that it is simply exercising its policy to hold immigrants to standards that minimize their burdens on the country's health services. This year's assessments included flagging and reviewing every immigrant with a body mass index greater than 35 (medically defined as "severely obese"), meaning Buitenhuis no longer meets those standards.
Though the decision is potentially inflammatory, there is a medical and public health basis for it. Obesity clearly predisposes one to a number of diseases: high blood pressure, diabetes, high cholesterol, heart disease, sleep apnea, arthritis, liver and gallbladder disease, and even some cancers. It can limit the usefulness of diagnostic studies, necessitating special or repeat testing. It can affect therapeutic decisions, including those about drug dosages, anesthetic risk, and indications for additional surgery. When amplified on community and national levels, these issues create costs that can strain health systems. In New Zealand's case, leaders must find ways to finance the care of obese adults like Buitenhuis, who now comprise approximately 30 percent of the population.
We face similar problems here at home—more than one-third of the U.S. population is obese. The American Medical Association recently voted to officially classify obesity as a disease in order to increase awareness, encourage more aggressive treatment, and broaden insurance coverage for weight loss interventions. Other groups have made similar suggestions, realizing that prevention is much more cost-effective than treating complications after they develop. Waves of new obesity-related research and medications have further highlighted the issue. Medical evidence, public health, and societal stewardship compel us to do everything necessary to stem the tide of obesity. But what are we really doing when we use weight to change someone's immigration status?
The most obvious problem with doing this is that weight alone is not an absolute indicator of health. Not all overweight people become ill, while many thin or normal-weight people do (there are even a few conditions in which being thin can be worse than being slightly overweight). What's more, not all weight is the created the same. Weight from muscle affects us much differently than weight from fat; where fat accumulates (e.g. in arms and legs vs. in waists and hips) also matters. This has led some to argue cogently that contrary to recent rulings, obesity itself is not a disease.
There are historical precedents for denying rights to those with dangerous psychiatric conditions, drug abuse history, or transmissible diseases such as tuberculosis. But it is another thing altogether to deport those who are simply predisposed to disease. Would it be acceptable to preemptively deport healthy members of the urban poor, those taking medications that suppress the immune system, or those who've traveled to developing countries, just because they possess risk factors for developing tuberculosis? What about healthy homosexual or polygamous individuals, out of concern for future HIV-related costs? Such suggestions seem operationally impossible, if not ethically problematic.
Risk factors do not equal disease. And like other lifestyle habits with health implications such as smoking and alcohol use, obesity is only as dangerous as its complications. Outcomes are what ultimately matter. If we want to avoid costly endpoints like diabetes and heart disease, penalizing our heaviest residents is not the answer. We need far more comprehensive incentives for everyone at risk for those diseases—a group that includes the thin and the obese, the young and the old, the employed and the unemployed, the natural born and the naturalized.
As we do, we also need more nuanced understanding of how weight affects value and cost. We are frequently inundated with statistical analyses detailing how obesity burdens our healthcare system. But we would also benefit from recognizing examples of how healthy living alleviates or reverses that burden. For example, according to Buitenhuis's doctor, he was working on losing weight and had improved his blood pressure and cholesterol levels, positive progress toward resolving his weight problems. Individuals of identical weight may have very different health statuses. Trajectories matter. And because weight is an imperfect health indicator, we need perspective from higher dimensional data (e.g. magnitude and speed of weight trends, degree of risk factor reduction, and ability to perform daily functions).
Ultimately, obesity is associated with poor outcomes, and healthy weight reduction has clear individual and social benefits. However, passing judgment based on extrapolations about future health sets a dangerous precedent.
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