SSR 02-1p: Rescinded

Rescinded and replaced by SSR 19-2p effective May 20, 2019

[Federal Register: September 12, 2002 (Volume 67, Number 177)] [Page

57859-57864]

EFFECTIVE DATE: September 12, 2002.

This Ruling supersedes SSR 00-3p ,

Titles II and XVI: Evaluation of Obesity (65 FR 31039, May 15, 2000).

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.

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 1.00Q, 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.

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.

When we published that final rule, in response to public comments, we

stated that we would provide additional guidance in a Social Security

Ruling (SSR). (64 FR at 46126) On May 15, 2000, we published SSR 00-3p (65 FR 31039) to provide

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. Since then, we have published several final rules that revise

some of the criteria we use to evaluate disability claims under titles II

and XVI of the Social Security Act. We are issuing this SSR to reflect the

changes to the rules that we have published since we published SSR

00-3p.

Policy Interpretation

General

- 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)

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/m 2 ). 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. 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

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

to establish the diagnosis of obesity. (BMIs in the 95th 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.

- 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, respiratory,

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

us-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.

- 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.

ents 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.

- 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). 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

erally, 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.

- 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 the

listings.) 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.

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).

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.

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/m 2 ). 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.

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

to establish the diagnosis of obesity. (BMIs in the 95th 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.

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.

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, respiratory,

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.

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.

esity necessarily have any of these impairments.

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

other impairments.

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.

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.

How Is Obesity Identified as a Medically Determinable Impairment?

se 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.

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).

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.)

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.

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 the

listings.) 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

vidual 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

- 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 minimal functional limitations.) 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

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.

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 minimal functional limitations.) 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).

er

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.

Sequential Evaluation Step 3, The Listings

- 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

, 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 of function.

We will find the requirements of listing 12.05 are met if an individual's

impairment satisfies the diagnostic description in the introductory

paragraph of listing 12.05 and any one of the four sets of criteria in the

listing. In the case of an individual under age 18, we will find that the

requirements of listing 112.05 are met if the child's impairment satisfies

the diagnostic description in the introductory paragraph of listing 112.05

and any one of the six sets of criteria in the listing. (See sections

12.00A and 112.00A of the listings.) 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 the listings). For example, if the obesity

is of such a level that it results in an inability to ambulate

effectively, as defined in sections 1.00B2b or 101.00B2b of the listings,

it may substitute for the major dysfunction of a joint(s) due to any cause

(and its associated criteria), with the involvement of one major

peripheral weight-bearing joint in listings 1.02A or 101.02A, and we will

then make a finding of medical equivalence

of such a level that it results in an inability to ambulate

effectively, as defined in sections 1.00B2b or 101.00B2b of the listings,

it may substitute for the major dysfunction of a joint(s) due to any cause

(and its associated criteria), with the involvement of one major

peripheral weight-bearing joint in listings 1.02A or 101.02A, and we will

then make a finding of medical 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. 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.

How Do We Evaluate Obesity at Step 3 of Sequential Evaluation, the

Listings?

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.

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 of function.

We will find the requirements of listing 12.05 are met if an individual's

impairment satisfies the diagnostic description in the introductory

paragraph of listing 12.05 and any one of the four sets of criteria in the

listing

nt work-related

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

impairment imposing an additional and significant limitation of function.

We will find the requirements of listing 12.05 are met if an individual's

impairment satisfies the diagnostic description in the introductory

paragraph of listing 12.05 and any one of the four sets of criteria in the

listing. In the case of an individual under age 18, we will find that the

requirements of listing 112.05 are met if the child's impairment satisfies

the diagnostic description in the introductory paragraph of listing 112.05

and any one of the six sets of criteria in the listing. (See sections

12.00A and 112.00A of the listings.)

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 the listings). For example, if the obesity

is of such a level that it results in an inability to ambulate

effectively, as defined in sections 1.00B2b or 101.00B2b of the listings,

it may substitute for the major dysfunction of a joint(s) due to any cause

(and its associated criteria), with the involvement of one major

peripheral weight-bearing joint in listings 1.02A or 101.02A, and we will

then make a finding of medical 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.)

due to any cause

(and its associated criteria), with the involvement of one major

peripheral weight-bearing joint in listings 1.02A or 101.02A, and we will

then make a finding of medical 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. 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

nctional

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

- 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. 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

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. For a child applying for benefits under title XVI, we may 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 listings. For example, the functional limitations imposed by

obesity, by itself or in combination with another impairment(s), may

establish an extreme limitation in one domain of functioning (e.g., Moving

about and manipulating objects) or marked limitations in two domains

(e.g., Moving about and manipulating objects and Caring for yourself). As with any other impairment, we will explain how we reached our

conclusions on whether obesity caused any physical or mental

limitations.

tion with another impairment(s), may

establish an extreme limitation in one domain of functioning (e.g., Moving

about and manipulating objects) or marked limitations in two domains

(e.g., Moving about and manipulating objects and Caring for yourself). As with any other impairment, we will explain how we reached our

conclusions on whether obesity caused any physical or mental

limitations.

- How Can We Consider Obesity in the Assessment of RFC When SSR 96-8p says, “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.

How Do We Evaluate Obesity in Assessing Residual Functional Capacity in

Adults and Functional Equivalence in Children?

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.

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.

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

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.

For a child applying for benefits under title XVI, we may 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 listings. For example, the functional limitations imposed by

obesity, by itself or in combination with another impairment(s), may

establish an extreme limitation in one domain of functioning (e.g., Moving

about and manipulating objects) or marked limitations in two domains

(e.g., Moving about and manipulating objects and Caring for yourself).

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

conclusions on whether obesity caused any physical or mental

limitations.

How Can We Consider Obesity in the Assessment of RFC When SSR 96-8p says, “Age and Body

Habitus Are Not Factors in Assessing RFC”?

ing objects) or marked limitations in two domains

(e.g., Moving about and manipulating objects and Caring for yourself).

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

conclusions on whether obesity caused any physical or mental

limitations.

How Can We Consider Obesity in the Assessment of RFC When SSR 96-8p says, “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

- 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. However, different rules apply to individuals who were already found

eligible to receive benefits prior to October 25, 1999

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.

- 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. This is true even if we have since deleted the

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

provement 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.

- 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. 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

he 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.

- 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. (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)

ation, 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.

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.

- 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

o 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

till 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.

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.

ing 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.

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

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.

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.

ins 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.

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.

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. (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).

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.

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

e “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.

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.

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.

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.

- 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.

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.

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:

This Ruling is effective upon publication in the Federal

Register .

Cross-References:

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:

This Ruling is effective upon publication in the Federal

Register .

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;” 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.

, 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.

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.”

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.