Might it be the case that the fashion of foregoing sacrifice and discipline in our relationships, pursuing instability and indulgence, is the cause not only of Esther’s needless suffering, but a contributor to the epidemic of depression and anxiety plaguing the developed world? A world which has shattered relationships at all levels — romantic relationships, family relationships as people live apart from the parents, aunts and uncles and life-long friends that once characterized our lives, the communities that people could once rely on. Might Esther’s advice actually be leading people to the misery of trying to have it all, trying to maximize rather than optimize?
There was some controversy surrounding "Up the Down Steroid" and the 2005 film The Ringer , as both feature the same plot: someone pretending to be disabled in order to compete in the Special Olympics.  The Ringer was written and filmed months before this episode was aired, although, The Ringer was not released to the public until after this episode aired. According to the episode's DVD audio commentary, series co-creators Trey Parker and Matt Stone did not think that they ripped off The Ringer , since the idea to them did not seem hard to come up with, and they did not even think it was big enough for a twenty-minute episode let alone a two-hour film.  In the opening scene, the boys are playing the same "Investigative Reports with Bill Kurtis " funtime game as they did in the season two episode " Cartman Joins NAMBLA ".