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,
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.
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.
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, 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.
3. How do we consider obesity in the sequential evaluation process?
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).
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. 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?
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.
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 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
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.
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
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. (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.
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.
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.
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.  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
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.
9. 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
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.
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.
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
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
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?
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
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
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.
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
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
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.
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.