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

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obesity management lessons and cautions from the tobacco experience

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@lsu.edu

http://biotech.law.lsu.edu/cphl/slides/naccho-2005.htm

learning objectives
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
history of tobacco
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
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
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
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
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
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
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
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
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
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
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
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
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 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
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
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
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
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
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
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

Footnote for another day:

Litigation is not the answer