Region
II HHS Conference on Obesity
Neil
Calman, MD
President and CEO
The Institute for Urban Family Health, Inc
July
14, 2004
Looking
Towards a Movement for Legislation on the
Crisis of Obesity in the U.S.
Thank
you for inviting me to speak this morning and also for putting
the tremendous effort into creating this conference – a
conference which is very timely given the growing concern we have
developed lately for the topic of obesity. I look forward to working
with you today to explore the many complex issues that are raised
by the rapidly proliferating epidemic of obesity.
What
is obesity?
Is
it a disease in itself? Something that needs to be diagnosed and
treated like ulcer or arthiritis? Will we someday discover an
obesity gene and use gene therapy to treat obesity?
Or
is obesity an outcome of a behavioral problem that some people
have? They eat too much, exercise too little and get fat?
Is
obesity not a disease in itself at all but merely a risk factor
for other diseases? We know that people who are obese more likely
to get cancer, hypertension and diabetes?
Is
obesity the result of horrific policies of our government concerning
food, how it is grown, its preparation and its distribution? Or
the result of a fast-food industry gone wild on Americans?
Or
is obesity simply a normal variant of the broad range of weights
that people have? Is it just that we call the people on the high
end of the scale for any given weight obese – and those
on the low end undernourished?
Obesity
is a little of all of these … which is why it is so difficult
for us to understand and to treat successfully. It is also a socially
determined definition – We have all had the experience that
people’s weight are viewed differently in different cultures
or at different ages.
Through
the haze of complexity that obesity presents a few things show
through with undeniable clarity ---
·
Obesity is epidemic in the United States and on the rise. Depending
on the statistics you read, approximately 2/3 of adults in the
United States are overweight and half of those – approximately
1/3 of all adults are obese.
·
Obesity in children is also becoming an epidemic. Over 10% of
all children between 6 and 18 years of age are obese and many
more are overweight.
·
With rare exception, people who are obese – at least for
one period of their life – ate more calories than they burned
and put on substantially more weight than is healthy for them.
That is the problem we are dealing with.
·
People who are obese are suffering from a chronic disease –
one that is rarely curable, often waxes and wanes in severity,
and one that predisposes people to a vast array of other medical
problems.
·
Obesity, like other problems that are at least in part determined
by an individual’s behavior – is also the result of
many societal ills that may be amenable to policy interventions.
·
Obesity, like other societal problems, effects people of color
and people who are poor more severely, is more prevalent in those
populations and contributes to some extent to disparities in health
outcomes.
I was invited here this morning because I am the Principal Investigator
of Bronx Health REACH, a coalition of over 40 organizations dedicated
to ending racial and ethnic disparities in outcomes for people
with diabetes and heart disease.
Our
work involved multiple focus groups with community residents to
determine the obstacles they encounter in getting good health
care. This was followed by the development of community-based
interventions around nutrition, fitness and health education in
dozens of settings around the Bronx. Finally, the knowledge we
received through our interactions with many people, including
some of you here today – helped us to construct a legislative
agenda to address the barriers people have to good health care
and why people of color have worse outcomes in almost every disease
entity and every study published.
One
of the trickiest parts of our work on disparities has been to
try to differentiate those areas where people bear the lion’s
share of responsibility for their own health outcomes and those
areas where the health care system bears responsibility for their
poor health outcomes – and nowhere is this question more
important than in the area of nutrition.
As
we have worked through problems with disparities in health outcomes
in diabetes, we have become aware of how complex this issue is
and how difficult it is to address. The primary prevention of
diabetes involves promoting appropriate nutrition and normalizing
weight - behavior changes that have no simple solutions. It also
requires us to dig deep into the economic structure of society
– the way cities and towns are constructed to promote or
impede walking and other forms of exercise, the marketing strategies
of fast food companies, and the health education and nutrition
education programs that are deficient in our schools.
In
fact, I propose to you that dealing with the rising epidemic of
obesity in this country forces us to look at every aspect of American
life – including the very freedoms which our National leaders
so proudly claim as ours.
It
forces us to ask:
“What role does government have in protecting the American
people against the rising obesity epidemic?” Or is this
just an issue of individual responsibility?
Could
anyone, ten years ago imagine that smoking would be banned in
bars in New York City? That outside of every office building people
would congregate in all kinds of weather to smoke their cigarettes?
Would
anyone have imagined that American legislators would pass laws
which allow police to ticket people for not wearing their seatbelts
– an issue that is surely one of personal preference?
And
now as we seek to improve the Nation’s exercise and eating
habits – can this we again envision a way for government
to get involved?
Will
the American people accept a role for government in telling them
what to buy, how to prepare their food, what to eat, and how much
to eat?
We
can’t legislate this at home but can we legislate this in
restaurants? Can we force restaurants to offer healthy food choices?
Cook with healthier oils? Add nutrition information to their menus?
Can
we force supermarkets to carry a basic line of healthier foods
– low-fat alternatives, leaner meats, whole wheat bread,
fat-free milk? What about the bodegas?
I
believe that over the next few years and decades, a movement will
emerge that will have some of the same characteristics as the
anti-smoking movement and the anti-drug movement. I think we need
to put our backs and our minds and our money into this effort
in order to reverse this galloping epidemic.
Let me predict some of the things that might emerge as public
policy issues in our City in the next decade as obesity awareness
continues to build.
1.
Fat will be out.
Fat has always been out of fashion – at least in
my lifetime. But I predict that pressure will build for people
to lose weight as “fat” begins to be equated with
unhealthy. There will be enormous pressure on fat people to lose
weight, as they will increasingly be viewed as unable to control
themselves – as chronically ill. This will be similar to
the social pressures that smokers face with our new view of smoking
as unhealthy and self-destructive.
2.
School-based interventions will emerge quickly
We will see a movement nationally to re-emphasize physical
education in school at every level and there will be money and
effort into promoting sports in the school system.
Candy
and soda machines will gradually disappear from schools around
the country. Nutritional standards for school meals will emerge
and be enforced.
3.
Pressure will build on parents to feed their children healthier
foods
Allowing normal children to become grossly obese may
even come to be viewed as a form of child abuse or neglect –
the same way that starving a child is viewed. Parents who send
their kids to school with unhealthy snacks will be looked down
upon.
4.
Advertising snacks and other foods to children will eventually
be banned
Parents
will realize the enormous pressures that they are under to keep
their children from becoming fat and will support legislation
that bans advertising unhealthy snacks, candy and soda from television.
They will do this to help end the “harassment” they
suffer in the food market as their children are wheeled past the
displays which have the packaging they have come to recognize
from the barrage of food ads they see every day.
In
this effort to get food ads banned they will have powerful foes.
In a speech he gave in February of 2002 to the GMA ( Grocery Manufacturers
of America), Tommy Thompson, the Secretary of Health and Human
Services said “Rest assured, I don’t , and the Administration
doesn’t want to mandate anything. We’re not talking
about government regulating what you produce or how you sell it.”
5.
Nutrition curricula will be re-developed and re-emphasized in
schools
Students
will learn how to read food labels, how to construct healthy meals,
the consequences of obesity on their health, and will be encouraged
to demand healthier foods from their parents.
6.
Obesity treatment programs will spring up everywhere
But
like other health interventions, and most obesity treatment interventions
now, they will be available only to those who can pay out of pocket
at first. If effective obesity treatments that produce longer
term results emerge – there will be increasing pressure
on insurers to cover these treatments and they just might –
if they are practical and effective – save the insurers
money in the long run. Government will then commit to supporting
obesity treatment through Medicaid and Medicare and health care
costs will increase again because of this.
7.
Restaurants will be forced to list the nutritional content of
their food on their menus
This
will affect franchised chains first but will eventually become
the standard that people expect. Ruby Tuesdays – a chain
of about 600 restaurants nationally already does this and so does
TGI Fridays. What you see is truly terrifying - a slab of ribs
meal is 1450 calories, 90 grams of fat and 75 carbs. I don’t
know about you, but that looks a whole lot less appealing to me
with those numbers printed below the picture.
8.
The food industry will step up its efforts to keep the finger
pointed elsewhere
The
very powerful associations and lobbyists representing food growers,
importers, packagers, manufacturers, retailers, advertisers and
other who profit from food sales will step up their efforts at
health promotion – all directed at increasing exercise and
suggesting that people take more responsibility for “how
they eat.”
In
fact, the National Food Processors Association (NFPA) made the
following statement after the House passed the “Personal
Responsibility in Food Consumption Act” which the food industry
supported. They said “NFPA applauds the House of Representatives
for passing this important legislation, which will protect the
food industry from claims that food products are responsible for
causing weight gain and obesity in consumers. It is a timely and
needed response to those lawsuits seeking to pin the responsibility
for obesity in this country on the food industry.”
They
have adopted the slogan “Its not what you eat, its how you
eat!” Whatever that means!
9.
Health care disparities will increase as the usual misallocation
of resources will favor more affluent communities
Even
though obesity is much more prevalent in communities of color
and in low-income communities, resources for school based programs,
educational interventions, nutrition services, construction of
play-spaces and exercise spaces – will all be weighted heavily
to the more politically influential ( ie, wealthier) communities.
This will mean that the problem of obesity will stabilize and
begin to improve (hopefully) in those areas, while the epidemic
continues to worsen for some time in less affluent neighborhoods.
This will increase the disparities we see in the health and health
care outcomes of people of color and the poor compared to their
whiter and more affluent neighbors.
Across
America, as the problem of obesity continues to evolve, legislative
initiatives are already being proposed by state governing bodies.
At last count over 150 separate pieces of legislation are being
reviewed at this time by state legislators across the country.
Many of the proposals seek to deal with some of the issues I outlined
above.
But
making legislative change will not be easy. I predict this one
will be harder than anti-smoking and anti-drug and seatbelt legislation.
There will be a huge, well-financed outcry against government
intervention.
Do you remember the now-famous characters “Harry and Louise”
of the Clinton Health Plan era? This ad campaign was sponsored
by the Coalition for Health Insurance Choices (CHIC), a front
group for the Health Insurance Industry Association.
To derail the plan, CHIC sponsored a now-legendary TV spot called
"Harry and Louise," which featured a middle-class married
couple lamenting the complexity of Clinton's plan and the menace
of a new "billion-dollar bureaucracy." Harry and Louise
symbolized everything that went wrong with the great health care
struggle of 1994: A powerful advertising campaign, financed by
industry, that played on people's fears and helped derail progress."
I predict that Harry and Louise will re-emerge saying things like:
“Oh
Harry – can you believe the government is telling us what
we can and cannot eat?! I thought America was the land of the
free!”
“Yes, Louise.” Harry will answer. “Remember
the good old days when our refrigerator was filled with coca-cola
and ice cream?”
And Louise will respond, “Yes. Harry. Those were the good
old days before the government tried to tell us what we could
and couldn’t eat.”
American politics and most American politicians are controlled
by big business and food is very big business.
McDonalds
alone opens 2000 new restaurants annually. In the US, they employ
over one million people; they are the largest retail holder of
real estate in the country.
In
1998: