Obesity Management: Lessons and Cautions from the Tobacco Experience

1. 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

2. 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

3. Key Differences Between Tobacco and Food

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. Footnote for another day: Litigation is not the answer