Obesity Management: Lessons and Cautions from the Tobacco Experience

Edward P. RichardsDirector, Program in Law, Science, and Public Health

Harvey A. Peltier Professor of LawLouisiana State University Law Center

richards@lsu.eduhttp://biotech.law.lsu.edu/cphl/slides/naccho-2005.htm

Learning Objectives

Understand how obesity and smoking differ Understand why stigmatization, the core of anti-

smoking strategy, is inappropriate for obesity Understand how obesity control differs from

tobacco control

Key Differences Between Tobacco and Food

History of Tobacco

Smoking is a very old problem, with roots in the US colonial experience Tobacco was the major trade good

Demographics Tobacco was always bad for you If you died from yellow fever, it did not matter

Tobacco was not a public health issue until life expectancy reached the 60s

History of Obesity

Like tobacco, its sequella are chronic diseases and were not a significant issue when life expectancy was short

Unlike tobacco, obesity was not a widespread problem until relatively recently It is the rate of increase, especially in children,

that makes obesity a high priority Obesity is a new cultural phenomenon

Stigmatization of Smokers

The main strategy for tobacco control is stigmatizing smoking Smoking is bad for your health Second hand smoke injures others

It is OK to treat smokers as bad people

Behaviors v. Conditions

Smoking is a behavior When you aren’t smoking, no one knows you

are a smoker Quit smoking, you are instantly a non-smoker

Obesity is a condition You are obese all the time While you try to lose weight, you are still fat

Love the Sinner, Hate the Sin

Smokers are only stigmatized when smoking You can be a secret smoker

Fat people are fat all the time Stigmatize being fat and you stigmatize fat

people There are no secret fat people

Does Obesity need More Stigma?

Smoking was cool Smoking is still cool for kids

Fat has not been cool in the US for a 100 years No kid wants to be fat to be cool Being fat has been a stigma for a long time

Differential treatment always causes stigma

Who is Obesity Bad For?

Smoking is bad for everyone Gross obesity

Bad for everyone Moderate obesity

Risks depend on the predisposition to diabetes Ignoring this differential risk is bad policy Recognizing differential risk complicates policy

Race and Class and Gender

Obesity is strongly correlated with race and class and gender Poor black women have the highest rates Rich white women have the lowest Fat is beautiful is predominately a minority

cultural value Using stigma and differential treatment as public

health strategies has significant racial impact

Good Food is a Luxury Good

Fresh fruit and vegetables are expensive They are available at limited locations and

times in many stores Can everyone shop at Whole Foods?

Agriculture policy focuses on grains and meat Lends itself to American strengths Fresh produce requires people, not machines

Cheap Calories are Important to the Poor

For some people, super-sizing is a good deal A fast, cheap meal may be the only meal option Not everyone who eats fast food is fat Not everyone who eats health food is thin Not everyone has time to prepare cheap,

nutritious foods

Relative Costs

Stopping smoking saves a lot of money Eating healthy costs a lot of money or time This cannot be addressed just through education

Physical Activity is a Luxury for Many

Exercise policy tends to be made by people who have time to go to the gym

Advice about incorporating exercise in daily life is not realistic for many poor people

Poverty and Obesity

Obesity is related to education, poverty, and difficult working situations

Without addressing the underlying issues, it is impossible to address obesity

Without addressing this, we risk shifting obesity to another source of discrimination against the poor

Tobacco v. Food Companies

Tobacco companies are the enemy Their products are bad Their cooperation is a sham

Food companies are essential There are no bad foods, just bad diets McDonalds sells health foods in India

Food companies must be partners, not enemies

National v. Local Problems

Tobacco is a national product with local sales Local restaurants are more important than

national chains National policy ignores them Local health departments already have

relationships with them Their cooperation is essential and only local

public health can make that work

The Effect on Others

Smoking in public is a nuisance to non-smokers Banning smoking in public benefits non-smokers

Mostly pretty speculative – the big benefit is to the smokers who cannot get as many puffs

Gets rid of the choice issue, however Being fat has no direct effect on others

Addiction

Tobacco is addictive Addiction means tobacco is the main problem Culture grows from addiction

Food is not addictive Culture drives obesity Psychiatric problems drive obesity Genetics drive obesity

Treatment

Smoking treatments are cheap and safe Once you have been off for a while, you can

stop the treatment Obesity treatments are expensive, dangerous, and

mostly failures They have to be life long, because the problem

is with the person and not with the food

Protection against Snake Oil

Physicians are rushing to offer dangerous medical and surgical treatments Remember Phen-Fen? Obesity surgery is the last resort, not the first

The federal government does not regulate medical practice, just initial drug approval

The states must act aggressively to stop quackery

Special Issues for Local Public Health

National policy is set at 30,000 feet Focuses on national concerns and cannot

address local issues Food and food culture are local and regional Food is essential to local culture and food policy

must be tailored to individual cultural and regional needs

Footnote for another day:

Litigation is not the answer