Obesity Management: Lessons and Cautions from the Tobacco Experience

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Obesity Management Lessons and Cautions from the
Tobacco Experience

• Edward P. Richards
• Director, Program in Law, Science, and Public
  Health
• Harvey A. Peltier Professor of Law
• Louisiana State University Law Center
• richards_at_lsu.edu
• http//biotech.law.lsu.edu/cphl/slides/naccho-2005
  .htm

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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

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Key Differences Between Tobacco and Food
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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

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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

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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

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Behaviors v. Conditions

• Smoking is a behavior
• When you arent 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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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Footnote for another day

• Litigation is not the answer