SSR 00-3p: Superseded

SSR 00-3p (Superseded 9/12/2002 by SSR

02-1p )

EFFECTIVE/PUBLICATION DATE: 5/15/00

Policy Interpretation Ruling

PURPOSE:

To provide guidance on SSA policy concerning the evaluation of obesity in

disability claims filed under titles II and XVI of the Social Security Act

(the Act).

CITATIONS:

Sections 216(i), 223(d), 223(f), 1614(a), and 1614(c) of the Act, as

amended; Regulations No. 4, subpart P, sections 404.1502, 404.1508,

404.1509, 404.1512, 404.1520, 404.1521, 404.1523, 404.1525, 404.1526,

404.1528, 404.1529, 404.1530, 404.1545, 404.1546, 404.1561, 404.1594, and

appendix 1; and Regulations No. 16, subpart I, sections 416.902, 416.908,

416.909, 416.912, 416.920, 416.921, 416.923, 416.924, 416.925, 416.926,

416.926a, 416.928, 416.929, 416.930, 416.933, 416.945, 416.946, 416.961,

416.994, and 416.994a.

INTRODUCTION:

On August 24, 1999, we [1] published a final rule in the Federal Register deleting listing 9.09, Obesity , from the Listing of Impairments in 20 CFR, subpart P,

appendix 1 (the listings). The final rule was effective on October 25,

1999. 64 FR 46122 (1999).

We stated in the preamble to the final rule that we deleted listing 9.09

because our experience adjudicating cases under this listing indicated

that the criteria in the listing were not appropriate indicators of

listing-level severity. In our experience, the criteria in listing 9.09

did not represent a degree of functional limitation that would prevent an

individual from engaging in any gainful activity.

the preamble to the final rule that we deleted listing 9.09

because our experience adjudicating cases under this listing indicated

that the criteria in the listing were not appropriate indicators of

listing-level severity. In our experience, the criteria in listing 9.09

did not represent a degree of functional limitation that would prevent an

individual from engaging in any gainful activity.

However, even though we deleted listing 9.09, we made some changes to the

listings to ensure that obesity is still addressed in our listings. In the

final rule, we added paragraphs to the prefaces of the musculoskeletal,

respiratory, and cardiovascular body system listings that provide guidance

about the potential effects obesity has in causing or contributing to

impairments in those body systems. See listings sections 1.00F,

3.00I, and 4.00F. The paragraphs state that we consider obesity to be a

medically determinable impairment and remind adjudicators to consider its

effects when evaluating disability. The provisions also remind

adjudicators that the combined effects of obesity with other impairments

can be greater than the effects of each of the impairments considered

separately. They also instruct adjudicators to consider the effects of

obesity not only under the listings but also when assessing a claim at

other steps of the sequential evaluation process, including when assessing

an individual's residual functional capacity.

In response to public comments, we stated that we would provide additional

guidance in a Social Security Ruling (SSR). (64 FR at 46126) This SSR

provides that additional guidance by discussing how we evaluate obesity in

disability claims filed by adults and children under titles II and XVI of

the Act.

POLICY INTERPRETATION:

General

1. What is obesity?

Obesity is a complex, chronic disease characterized by excessive

accumulation of body fat. Obesity is generally the result of a combination

of factors (e.g., genetic, environmental, and behavioral).

dditional guidance by discussing how we evaluate obesity in

disability claims filed by adults and children under titles II and XVI of

the Act.

POLICY INTERPRETATION:

General

1. What is obesity?

Obesity is a complex, chronic disease characterized by excessive

accumulation of body fat. Obesity is generally the result of a combination

of factors (e.g., genetic, environmental, and behavioral).

In one sense, the cause of obesity is simply that the energy (food) taken

in exceeds the energy expended by the individual's body. However, the

influences on intake, the influences on expenditure, the metabolic

processes in between, and the overall genetic controls are complex and not

well understood.

The National Institutes of Health (NIH) established medical criteria for

the diagnosis of obesity in its Clinical Guidelines on the

Identification, Evaluation, and Treatment of Overweight and Obesity in

Adults (NIH Publication No. 98-4083, September 1998). These

guidelines classify overweight and obesity in adults according to Body

Mass Index (BMI). BMI is the ratio of an individual's weight in kilograms

to the square of his or her height in meters (kg/m²). For adults, both men

and women, the Clinical Guidelines describe a BMI of 25-29.9

as "overweight" and a BMI of 30.0 or above as "obesity."

The Clinical Guidelines recognize three levels of obesity.

Level I includes BMIs of 30.0-34.9. Level II includes BMIs of 35.0-39.9.

Level III, termed "extreme" obesity and representing the greatest risk for

developing obesity-related impairments, includes BMIs greater than or

equal to 40. These levels describe the extent of obesity, but they do not

correlate with any specific degree of functional loss.

al Guidelines recognize three levels of obesity.

Level I includes BMIs of 30.0-34.9. Level II includes BMIs of 35.0-39.9.

Level III, termed "extreme" obesity and representing the greatest risk for

developing obesity-related impairments, includes BMIs greater than or

equal to 40. These levels describe the extent of obesity, but they do not

correlate with any specific degree of functional loss.

In addition, although there is often a significant correlation between BMI

and excess body fat, this is not always the case. The Clinical

Guidelines also provide for considering whether an individual of a

given height and weight has excess body fat when determining whether he or

she has obesity. Thus, it is possible for someone whose BMI is below 30 to

have obesity if too large a percentage of the weight is from fat.

Likewise, someone with a BMI above 30 may not have obesity if a large

percentage of the weight is from muscle. However, in most cases, the BMI

will show whether the individual has obesity. It also will usually be

evident from the information in the case record whether the individual

should not be found to have obesity, despite a BMI of 30.0 or above. See

question 4, below.

The Clinical Guidelines do not provide criteria for

diagnosing obesity in children. However, a BMI greater than or equal to

the 95 th percentile for a child's age is generally considered

sufficient to establish the diagnosis of obesity. (BMIs in the

95 th percentile vary by age and sex of the child.)

BMI-for-age-and-gender charts are published in medical textbooks or

professional journals and by the National Center for Health Statistics. As

with adults, the amount of body fat is considered in making the diagnosis

of obesity in children.

Treatment for obesity is often unsuccessful. Even if treatment results in

weight loss at first, weight lost is often regained, despite the efforts

of the individual to maintain the loss. See question 13, below, for

additional discussion of obesity treatment.

onal Center for Health Statistics. As

with adults, the amount of body fat is considered in making the diagnosis

of obesity in children.

Treatment for obesity is often unsuccessful. Even if treatment results in

weight loss at first, weight lost is often regained, despite the efforts

of the individual to maintain the loss. See question 13, below, for

additional discussion of obesity treatment.

2. How does obesity affect physical and mental health?

Obesity is a risk factor that increases an individual's chances of

developing impairments in most body systems. It commonly leads to, and

often complicates, chronic diseases of the cardiovascular, pulmonary, and

musculoskeletal body systems. Obesity increases the risk of developing

impairments such as type II (so-called adult onset) diabetes

mellitus—even in children; gall bladder disease; hypertension; heart

disease; peripheral vascular disease; dyslipidemia (abnormal levels of

fatty substances in the blood); stroke; osteoarthritis; and sleep apnea.

It is associated with endometrial, breast, prostate, and colon cancers,

and other physical impairments. Obesity may also cause or contribute to

mental impairments such as depression. The effects of obesity may be

subtle, such as the loss of mental clarity and slowed reactions that may

result from obesity-related sleep apnea.

The fact that obesity is a risk factor for other impairments does not mean

that individuals with obesity necessarily have any of these impairments.

It means that they are at greater than average risk for developing the

other impairments.

3. How do we consider obesity in the sequential evaluation

process? [2]

We will consider obesity in determining whether:

- The individual has a medically determinable impairment. See question

4.

- The individual's impairment(s) is severe. See question 6.

sity necessarily have any of these impairments.

It means that they are at greater than average risk for developing the

other impairments.

3. How do we consider obesity in the sequential evaluation

process? [2]

We will consider obesity in determining whether:

- The individual has a medically determinable impairment. See question

4.

- The individual's impairment(s) is severe. See question 6.

- The individual's impairment(s) meets or equals the requirements of a

listed impairment in the listings. See question 7. (We use special rules

for some continuing disability reviews. See question 11.)

- The individual's impairment(s) prevents him or her from doing past

relevant work and other work that exists in significant numbers in the

national economy. However, these steps apply only in title II and adult

title XVI cases. See questions 8 and 9.

4. How is obesity identified as a medically determinable

impairment?

When establishing the existence of obesity, we will generally rely on the

judgment of a physician who has examined the claimant and reported his or

her appearance and build, as well as weight and height. Thus, in the

absence of evidence to the contrary in the case record, we will accept a

diagnosis of obesity given by a treating source or by a consultative

examiner. However, if there is evidence that indicates that the diagnosis

is questionable and the evidence is inadequate to determine whether or not

the individual is disabled, we will contact the source for clarification,

using the guidelines in 20 CFR 404.1512(e) and 416.912(e).

ontrary in the case record, we will accept a

diagnosis of obesity given by a treating source or by a consultative

examiner. However, if there is evidence that indicates that the diagnosis

is questionable and the evidence is inadequate to determine whether or not

the individual is disabled, we will contact the source for clarification,

using the guidelines in 20 CFR 404.1512(e) and 416.912(e).

When the evidence in a case does not include a diagnosis of obesity, but

does include clinical notes or other medical records showing consistently

high body weight or BMI, we may ask a medical source to clarify whether

the individual has obesity. However, in most such cases we will use our

judgment to establish the presence of obesity based on the medical

findings and other evidence in the case record, even if a treating or

examining source has not indicated a diagnosis of obesity. Generally, we

will not purchase a consultative examination just to establish the

diagnosis of obesity.

When deciding whether an individual has obesity, we will also consider the

individual's weight over

time. [3] We will not count

minor, short-term weight loss. We will consider the individual to have

obesity as long as his or her weight or BMI shows essentially a consistent

pattern of obesity. (See question 13 for a discussion of weight loss and

medical improvement.)

Finally, there are a number of methods for measuring body fat and, if such

information is in a case record, we will consider it. However, we will not

purchase such testing. In most cases, the medical and other evidence in

the case record will establish whether the individual has obesity.

5. Can we find an individual disabled based on obesity

alone?

n of weight loss and

medical improvement.)

Finally, there are a number of methods for measuring body fat and, if such

information is in a case record, we will consider it. However, we will not

purchase such testing. In most cases, the medical and other evidence in

the case record will establish whether the individual has obesity.

5. Can we find an individual disabled based on obesity

alone?

If an individual has the medically determinable impairment obesity that is

"severe" as described in question 6, we may find that the obesity

medically equals a listing. (In the case of a child seeking benefits under

title XVI, we may also find that it functionally equals a listing.) We may

also find in a title II claim, or an adult claim under title XVI, that the

obesity results in a finding that the individual is disabled based on his

or her residual functional capacity (RFC), age, education, and past work

experience. However, we will also consider the possibility of coexisting

or related conditions, especially as the level of obesity increases. We

provide an example of when we may find obesity to medically equal a

listing in question 7.

Sequential Evaluation: Step 2, Severe

Impairment

6. When is obesity a "severe" impairment?

As with any other medical condition, we will find that obesity is a

"severe" impairment when, alone or in combination with another medically

determinable physical or mental impairment(s), it significantly limits an

individual's physical or mental ability to do basic work activities. (For

children applying for disability under title XVI, we will find that

obesity is a "severe" impairment when it causes more than a minimal

functional limitation.) We will also consider the effects of any symptoms

(such as pain or fatigue) that could limit functioning

ical or mental impairment(s), it significantly limits an

individual's physical or mental ability to do basic work activities. (For

children applying for disability under title XVI, we will find that

obesity is a "severe" impairment when it causes more than a minimal

functional limitation.) We will also consider the effects of any symptoms

(such as pain or fatigue) that could limit functioning. (See SSR 85-28 , "Titles II and XVI: Medical

Impairments That Are Not Severe" and SSR

96-3p , "Titles II and XVI: Considering Allegations of Pain and Other

Symptoms In Determining Whether a Medically Determinable Impairment Is

Severe.") Therefore, we will find that an impairment(s) is "not severe"

only if it is a slight abnormality (or a combination of slight

abnormalities) that has no more than a minimal effect on the individual's

ability to do basic work activities (or, for a child applying under title

XVI, if it causes no more than minimal functional limitations).

There is no specific level of weight or BMI that equates with a "severe"

or a "not severe" impairment. Neither do descriptive terms for levels of

obesity (e.g., "severe," "extreme," or "morbid" obesity) establish whether

obesity is or is not a "severe" impairment for disability program

purposes. Rather, we will do an individualized assessment of the impact of

obesity on an individual's functioning when deciding whether the

impairment is severe.

Step 3, The Listings

7. How do we evaluate obesity at step 3 of sequential evaluation,

the listings?

Obesity may be a factor in both "meets" and "equals" determinations.

ity is or is not a "severe" impairment for disability program

purposes. Rather, we will do an individualized assessment of the impact of

obesity on an individual's functioning when deciding whether the

impairment is severe.

Step 3, The Listings

7. How do we evaluate obesity at step 3 of sequential evaluation,

the listings?

Obesity may be a factor in both "meets" and "equals" determinations.

Because there is no listing for obesity, we will find that an individual

with obesity "meets" the requirements of a listing if he or she has

another impairment that, by itself, meets the requirements of a listing.

We will also find that a listing is met if there is an impairment that, in

combination with obesity, meets the requirements of a listing. For

example, obesity may increase the severity of coexisting or related

impairments to the extent that the combination of impairments meets the

requirements of a listing. This is especially true of musculoskeletal,

respiratory, and cardiovascular impairments. It may also be true for other

coexisting or related impairments, including mental disorders.

For example, when evaluating impairments under mental disorder listings

12.05C, 112.05D, or 112.05F, obesity that is "severe," as explained in

question 6, satisfies the criteria in listing 12.05C for a physical

impairment imposing an additional and significant work-related limitation

of function and in listings 112.05D and 112.05F for a physical impairment

imposing an additional and significant limitation[s] of function. We will

find the requirements of those listings are met if an individual meets all

of the other requirements of the listings, including the capsule

definition of mental retardation contained in the listings. (See SSR 98-1p , "Title XVI:

Determining Medical Equivalency in Childhood Disability Claims When a

Child Has Marked Limitations in Cognition and Speech.")

icant limitation[s] of function. We will

find the requirements of those listings are met if an individual meets all

of the other requirements of the listings, including the capsule

definition of mental retardation contained in the listings. (See SSR 98-1p , "Title XVI:

Determining Medical Equivalency in Childhood Disability Claims When a

Child Has Marked Limitations in Cognition and Speech.")

We may also find that obesity, by itself, is medically equivalent to a

listed impairment (or, in the case of a child applying under title XVI,

also functionally equivalent to a listed impairment). For example, if the

obesity is of such a level that it markedly limits the individual's

ability to walk and stand, it may substitute for arthritis (and its

associated criteria) of a weight-bearing joint with "gross anatomical

deformity of a hip or knee" in listing 1.03A, and we will then make a

finding of equivalence. (See question 8 for further discussion of

evaluating the functional effects of obesity, including functional

equivalence determinations for children applying for benefits under title

XVI.)

We will also find equivalence if an individual has multiple impairments,

including obesity, no one of which meets or equals the requirements of a

listing, but the combination of impairments is equivalent in severity to a

listed impairment. For example, obesity affects the cardiovascular and

respiratory systems because of the increased workload the additional body

mass places on these systems. Obesity makes it harder for the chest and

lungs to expand. This means that the respiratory system must work harder

to provide needed oxygen. This in turn makes the heart work harder to pump

blood to carry oxygen to the body. Because the body is working harder at

rest, its ability to perform additional work is less than would otherwise

be expected

additional body

mass places on these systems. Obesity makes it harder for the chest and

lungs to expand. This means that the respiratory system must work harder

to provide needed oxygen. This in turn makes the heart work harder to pump

blood to carry oxygen to the body. Because the body is working harder at

rest, its ability to perform additional work is less than would otherwise

be expected. Thus, we may find that the combination of a pulmonary or

cardiovascular impairment and obesity has signs, symptoms, and laboratory

findings that are of equal medical significance to one of the respiratory

or cardiovascular

listings. [4]

However, we will not make assumptions about the severity or functional

effects of obesity combined with other impairments. Obesity in combination

with another impairment may or may not increase the severity or functional

limitations of the other impairment. We will evaluate each case based on

the information in the case record.

Sequential Evaluation: Steps 4 and 5, Assessing

Functioning in Adults Step 3, Assessing Functional Equivalence in

Children

8. How do we evaluate obesity in assessing residual functional

capacity in adults and functional equivalence in children?

Obesity can cause limitation of function. The functions likely to be

limited depend on many factors, including where the excess weight is

carried. An individual may have limitations in any of the exertional

functions such as sitting, standing, walking, lifting, carrying, pushing,

and pulling. It may also affect ability to do postural functions, such as

climbing, balance, stooping, and crouching. The ability to manipulate may

be affected by the presence of adipose (fatty) tissue in the hands and

fingers. The ability to tolerate extreme heat, humidity, or hazards may

also be affected.

exertional

functions such as sitting, standing, walking, lifting, carrying, pushing,

and pulling. It may also affect ability to do postural functions, such as

climbing, balance, stooping, and crouching. The ability to manipulate may

be affected by the presence of adipose (fatty) tissue in the hands and

fingers. The ability to tolerate extreme heat, humidity, or hazards may

also be affected.

The effects of obesity may not be obvious. For example, some people with

obesity also have sleep apnea. This can lead to drowsiness and lack of

mental clarity during the day. Obesity may also affect an individual's

social functioning.

An assessment should also be made of the effect obesity has upon the

individual's ability to perform routine movement and necessary physical

activity within the work environment. Individuals with obesity may have

problems with the ability to sustain a function over time. As explained in SSR 96-8p ("Titles II and XVI: Assessing

Residual Functional Capacity in Initial Claims"), our RFC assessments must

consider an individual's maximum remaining ability to do

sustained work activities in an ordinary work setting on a regular and

continuing basis. A "regular and continuing basis" means 8 hours a day,

for 5 days a week, or an equivalent work

schedule. [5] In cases involving

obesity, fatigue may affect the individual's physical and mental ability

to sustain work activity. This may be particularly true in cases involving

sleep apnea.

The combined effects of obesity with other impairments may be greater than

might be expected without obesity. For example, someone with obesity and

arthritis affecting a weight-bearing joint may have more pain and

limitation than might be expected from the arthritis alone.

al's physical and mental ability

to sustain work activity. This may be particularly true in cases involving

sleep apnea.

The combined effects of obesity with other impairments may be greater than

might be expected without obesity. For example, someone with obesity and

arthritis affecting a weight-bearing joint may have more pain and

limitation than might be expected from the arthritis alone.

For a child applying for benefits under title XVI, we will evaluate the

functional consequences of obesity (either alone or in combination with

other impairments) to decide if the child's impairment(s) functionally

equals the severity of a listed impairment that includes disabling

functional limitations among its criteria. For example, the functional

limitations imposed by obesity, by itself or in combination with another

impairment(s), may establish an extreme limitation in one broad area of

functioning (e.g., motor) or marked limitations in two broad areas of

functioning (e.g., motor and social). We may also find that the functional

limitations imposed by obesity establish functional equivalence based on

one of the other methods set out in 20 CFR 416.926a.

As with any other impairment, we will explain how we reached our

conclusions on whether obesity caused any physical or mental

limitations.

9. How can we consider obesity in the assessment of RFC when SSR 96-8p "Age and body habitus are not

factors in assessing RFC"?

limitations imposed by obesity establish functional equivalence based on

one of the other methods set out in 20 CFR 416.926a.

As with any other impairment, we will explain how we reached our

conclusions on whether obesity caused any physical or mental

limitations.

9. How can we consider obesity in the assessment of RFC when SSR 96-8p "Age and body habitus are not

factors in assessing RFC"?

The SSR goes on to say that "[i]t is incorrect to find that an individual

has limitations beyond those caused by his or her medically

determinable impairment(s) and any related symptoms , due to such

factors as age and natural body build, and the activities the individual

was accustomed to doing in his or her previous work." (Emphasis added.) We

included the italicized statement in the SSR to distinguish between

individuals who have a medically determinable impairment of obesity and

individuals who do not. When we identify obesity as a medically

determinable impairment (see question 4, above), we will consider any

functional limitations resulting from the obesity in the RFC assessment,

in addition to any limitations resulting from any other physical or mental

impairments that we identify.

Effect of the Rules Change: Claims in Which

Prior Listings Apply and Do Not Apply

10. How does the deletion of listing 9.09 affect claims pending on

October 25, 1999?

The final rules that deleted the listing became effective on October 25,

1999. The final rules deleting listing 9.09 apply to claims that were

filed before October 25, 1999, and that were awaiting an initial

determination or that were pending appeal at any level of the

administrative review process or that had been appealed to court. The

change affected the entire claim, including the period before October 25,

1999. This is our usual policy with respect to any change in our

listings.

deleting listing 9.09 apply to claims that were

filed before October 25, 1999, and that were awaiting an initial

determination or that were pending appeal at any level of the

administrative review process or that had been appealed to court. The

change affected the entire claim, including the period before October 25,

1999. This is our usual policy with respect to any change in our

listings.

However, different rules apply to individuals who were already found

eligible to receive benefits prior to October 25, 1999. For an explanation

of how we apply listing 9.09 in continuing disability reviews, see

question 11.

11. How does deletion of listing 9.09 affect claims already

allowed?

Deletion of listing 9.09 does not affect the entitlement or eligibility of

individuals receiving benefits because their impairment(s) met or equaled

that listing. We will not find that their disabilities have ended just

because we deleted listing 9.09.

We must periodically review all claims to determine whether the

individual's disability continues. When we conduct a periodic continuing

disability review (CDR), we will not find that an individual's disability

has ended based on a change in a listing. For individuals receiving

disability benefits under title II and adults receiving payments under

title XVI, we apply the medical improvement review standard described in

20 CFR 404.1594 and 416.994.

We will first evaluate whether the individual's impairment(s) has

medically improved and, if so, whether any medical improvement is related

to the ability to work. If the individual's impairment(s) has not

medically improved, we will find that he or she is still disabled, unless

we find that an exception to the medical improvement standard applies.

Even if the impairment(s) has medically improved, we will find that the

improvement is not related to the ability to work if the impairment(s)

continues to meet or equal the same listing section used to make our most

recent favorable decision

as not

medically improved, we will find that he or she is still disabled, unless

we find that an exception to the medical improvement standard applies.

Even if the impairment(s) has medically improved, we will find that the

improvement is not related to the ability to work if the impairment(s)

continues to meet or equal the same listing section used to make our most

recent favorable decision. This is true even if we have since deleted the

listing section that we used to make the most recent favorable decision.

See 20 CFR 404.1594(c)(3)(i) and 416.994(b)(2)(iv)(A). We apply a similar

provision when we do CDRs for individuals who have not attained age 18 and

who are eligible for title XVI benefits based on disability (20 CFR

416.994a(b)(2)).

Even if the individual's impairment(s) has medically improved and no

longer meets or equals prior listing 9.09, we must still determine whether

he or she is currently disabled, considering all of the impairments.

12. What amount of weight loss would represent "medical

improvement"?

Because an individual's weight may fluctuate over time and minor weight

changes are of little significance to an individual's ability to function,

it is not appropriate to conclude that an individual with obesity has

medically improved because of a minor weight loss. A loss of less than 10

percent of initial body weight is too minor to result in a finding that

there has been medical improvement in the obesity. However, we will

consider that obesity has medically improved if an individual maintains a

consistent loss of at least 10 percent of body weight for at least 12

months. We will not count minor, short-term changes in weight when we

decide whether an individual has maintained the loss consistently.

If there is a coexisting or related condition(s) and the obesity has not

improved, we will still consider whether the coexisting or related

condition(s) has medically improved.

aintains a

consistent loss of at least 10 percent of body weight for at least 12

months. We will not count minor, short-term changes in weight when we

decide whether an individual has maintained the loss consistently.

If there is a coexisting or related condition(s) and the obesity has not

improved, we will still consider whether the coexisting or related

condition(s) has medically improved.

If we find that there has been medical improvement in obesity or in any

coexisting or related condition(s), we must also decide whether the

medical improvement is related to the ability to work. If necessary, we

will also decide whether any exceptions to the medical improvement review

standard apply and, if appropriate, whether the individual is currently

disabled.

13. What are the goals and methods of treatment for

obesity?

Obesity is a disease that requires treatment, although in most people the

effect of treatment is limited. However, if untreated, it tends to

progress.

A common misconception is that the goal of treatment is to reduce weight

to a "normal" level. Actually, the goal of realistic medical treatment for

obesity is only to reduce weight by a reasonable amount that will improve

health and quality of life. People with extreme obesity, even with

treatment, will generally continue to have obesity. Despite short-term

progress, most treatments for obesity do not have a high success rate.

Recommended treatment for obesity depends upon the level of obesity. At

levels I and II (BMI 30.0-39.9), treatment usually consists of behavior

modification (diet and exercise) with the option of medication, usually

either in the form of a fat-blocking drug or an appetite suppressant. Some

people do not respond to medication, while others experience negative side

effects

a high success rate.

Recommended treatment for obesity depends upon the level of obesity. At

levels I and II (BMI 30.0-39.9), treatment usually consists of behavior

modification (diet and exercise) with the option of medication, usually

either in the form of a fat-blocking drug or an appetite suppressant. Some

people do not respond to medication, while others experience negative side

effects. (In making our decision, we will also consider any side effects

of medication the individual experiences.) Individuals with coexisting or

related conditions may not be able to take medication because of its

effects on their other conditions.

Generally, physicians recommend surgery when obesity has reached level III

(BMI 40 or greater). However, surgery may also be an option at level II

(BMI 35-39.9) if there is a serious coexisting or related condition.

Obesity surgery modifies the stomach, the intestines, or both in order to

reduce the amount of food that the individual can eat at one meal or the

time food is available for digestion and absorption. Surgery is generally

a last resort with individuals for whom other forms of treatment have

failed. Some individuals also experience significant negative side effects

from surgery (e.g., "dumping syndrome" — that is, rapid emptying of

the stomach's contents marked by various signs and symptoms).

Obesity is a life-long disease. Even when treatment has been successful,

individuals with obesity generally need to stay in treatment or they will

gain weight again, just as individuals with other impairments may need to

stay in treatment. Individuals who have had surgery should receive

continuing follow-up care because of health risks related to the surgery.

As with other chronic disorders, effective treatment of obesity requires

regular medical follow-up.

14. How do we evaluate failure to follow prescribed treatment in

obesity cases?

gain weight again, just as individuals with other impairments may need to

stay in treatment. Individuals who have had surgery should receive

continuing follow-up care because of health risks related to the surgery.

As with other chronic disorders, effective treatment of obesity requires

regular medical follow-up.

14. How do we evaluate failure to follow prescribed treatment in

obesity cases?

Before failure to follow prescribed treatment for obesity can become an

issue in a case, we must first find that the individual is disabled

because of obesity or a combination of obesity and another impairment(s).

Our regulations at 20 CFR 404.1530 and 416.930 provide that, in order to

get benefits, an individual must follow treatment prescribed by his or her

physician if the treatment can restore the ability to work, unless the

individual has an acceptable reason for failing to follow the prescribed

treatment. We will rarely use "failure to follow prescribed treatment" for

obesity to deny or cease benefits.

SSR 82-59 , "Titles II and XVI:

Failure To Follow Prescribed Treatment," explains that we will find

failure to follow prescribed treatment only when all of the following

conditions exist:

- The individual has an impairment(s) that meets the definition of

disability, including the duration requirement, and

- A treating source has prescribed treatment that is clearly expected to

restore the ability to engage in substantial gainful activity, and

- The evidence shows that the individual has failed to follow prescribed

treatment without a good reason.

If an individual who is disabled because of obesity (alone or in

combination with another impairment(s)) does not have a treating source

who has prescribed treatment for the obesity, there is no issue of failure

to follow prescribed treatment.

engage in substantial gainful activity, and

- The evidence shows that the individual has failed to follow prescribed

treatment without a good reason.

If an individual who is disabled because of obesity (alone or in

combination with another impairment(s)) does not have a treating source

who has prescribed treatment for the obesity, there is no issue of failure

to follow prescribed treatment.

The treatment must be prescribed by a treating source, as defined in our

regulations at 20 CFR 404.1502 and 416.902, not simply recommended. A

treating source's statement that an individual "should" lose weight or has

"been advised" to get more exercise is not prescribed treatment.

When a treating source has prescribed treatment for obesity, the treatment

must clearly be expected to improve the impairment to the extent that the

person will not be disabled. As noted in question 13, the goals of

treatment for obesity are generally modest, and treatment is often

ineffective. Therefore, we will not find failure to follow prescribed

treatment unless there is clear evidence that treatment would be

successful. The obesity must be expected to improve to the point at which

the individual would not meet our definition of disability, considering

not only the obesity, but any other impairment(s).

Finally, even if we find that a treating source has prescribed treatment

for obesity, that the treatment is clearly expected to restore the ability

to engage in SGA, and that the individual is not following the prescribed

treatment, we must still consider whether the individual has a good reason

for doing so. In making this finding, we will follow the guidance in our

regulations and SSR 82-59 , which

provide that acceptable justifications for failing to follow prescribed

treatment include, but are not limited to, the following:

- The specific medical treatment is contrary to the teaching and tenets

of the individual's religion.

still consider whether the individual has a good reason

for doing so. In making this finding, we will follow the guidance in our

regulations and SSR 82-59 , which

provide that acceptable justifications for failing to follow prescribed

treatment include, but are not limited to, the following:

- The specific medical treatment is contrary to the teaching and tenets

of the individual's religion.

- The individual is unable to afford prescribed treatment that he or she

is willing to accept, but for which free community resources are

unavailable.

- The treatment carries a high degree of risk because of the enormity or

unusual nature of the procedure.

In this regard, most health insurance plans and Medicare do not defray the

expense of treatment for obesity. Thus, an individual who might benefit

from behavioral or drug therapy might not be able to afford it. Also,

because not enough is known about the long-term effects of medications

used to treat obesity, some people may be reluctant to use them due to the

potential risk.

Because of the risks and potential side effects of surgery for obesity, we

will not find that an individual has failed to follow prescribed treatment

for obesity when the prescribed treatment is surgery.

EFFECTIVE DATE:

CROSS-REFERENCES:

SSR 82-52 , "Titles II and XVI: Duration

of the Impairment;" SSR 82-59 ,

"Titles II and XVI: Failure To Follow Prescribed Treatment;" SSR 85-28 , "Titles II and XVI: Medical

Impairments That Are Not Severe;" SSR

96-3p , "Titles II and XVI: Considering Allegations of Pain and Other

Symptoms In Determining Whether a Medically Determinable Impairment Is

Severe;" SSR 96-6p , "Titles II and XVI:

Consideration of Administrative Findings of Fact by State Agency Medical

and Psychological Consultants and Other Program Physicians and

Psychologists at the Administrative Law Judge and Appeals Council Levels

of Administrative Review; Medical Equivalence;" SSR 96-8p , "Titles II and XVI: Assessing

Residual Functional Capacity in Initial Claims;" SSR

s

Severe;" SSR 96-6p , "Titles II and XVI:

Consideration of Administrative Findings of Fact by State Agency Medical

and Psychological Consultants and Other Program Physicians and

Psychologists at the Administrative Law Judge and Appeals Council Levels

of Administrative Review; Medical Equivalence;" SSR 96-8p , "Titles II and XVI: Assessing

Residual Functional Capacity in Initial Claims;" SSR 98-1p , "Title XVI:

Determining Medical Equivalency in Childhood Disability Claims When a

Child Has Marked Limitations in Cognition and Speech;" and Program

Operations Manual System sections DI 23010.005 ff., DI 24510.006, DI

24570.001, DI 34001.010, DI 34001.014, and DI 34001.016.

[1] The terms we and us in this Social Security Ruling have the same meaning as in 20

CFR 404.1502 and 416.902. We or us refers to either the

Social Security Administration or the State agency making the disability

or blindness determination; i.e., our adjudicators at all levels of the

administrative review process and our quality reviewers.

[2] For ease of reading, we

refer in this Ruling only to the steps of the sequential evaluation

processes for initial adult and childhood claims. 20 CFR 404.1520,

416.920, and 416.924. We use separate sequential evaluation processes when

we do continuing disability reviews; i.e., reviews to determine whether

individuals who are receiving disability benefits are still disabled or

when we determine whether an individual has a "closed period of

disability." These rules are set out in 20 CFR 404.1594, 416.994, and

416.994a, and the guidance in this Ruling applies to all of the

appropriate steps in those regulations as well. However, in some

continuing disability review cases, we will still consider the provisions

of former listings 9.09 and 10.10. See question 11.

ed or

when we determine whether an individual has a "closed period of

disability." These rules are set out in 20 CFR 404.1594, 416.994, and

416.994a, and the guidance in this Ruling applies to all of the

appropriate steps in those regulations as well. However, in some

continuing disability review cases, we will still consider the provisions

of former listings 9.09 and 10.10. See question 11.

[3] As with all impairments, to

establish a finding of disability based on obesity, in whole or in part,

the statutory duration requirement must be satisfied. See 20 CFR 404.1509

or 416.909, and SSR 82-52, "Titles II and XVI: Duration of the Impairment"

(superseded in part by SSR 91-7c).

[4] For our regulations and

rulings on the consideration of medical or psychological consultant

opinions in determining medical equivalence, see 20 CFR 404.1526(c) and

416.926(c), and SSR 96-6p, "Titles II and XVI: Consideration of

Administrative Findings of Fact by State Agency Medical and Psychological

Consultants and Other Program Physicians and Psychologists at the

Administrative Law Judge and Appeals Council Levels of Administrative

Review; Medical Equivalence."

[5] However, see footnote 2 of

SSR 96-8p. That footnote explains that the ability to work 8 hours a day

for 5 days a weeks is not always required for a finding at step 4 of the

sequential evaluation process for adults when an individual can do past

relevant work that was part-time work, if that work was substantial

gainful activity, performed within the applicable period, and lasted long

enough for the person to learn to do it.