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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



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
  • 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
  • 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