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"Race, Poverty, and New Strategies to Control the Obesity Epidemic,"

by Anthony Robbins, Wendy E. Parmet & Richard Daynard May/June 2003 issue of Poverty & Race

Obesity, and perhaps some efforts taken in the name of combating it, constitute serious dangers to poor and minority populations in this country. Obesity has reached epidemic levels in the United States. This epidemic poses a first-order health threat to the population, particularly young people. The prevalence of obesity and its gravity continue to increase. Obesity contributes to severe health impairments—heart disease, type 2 diabetes, osteoarthritis, hypertension, plus colon and post-menopausal breast cancer—and death. For many of these problems, economically disadvantaged and minority populations suffer most heavily. Obesity’s direct and indirect health care costs are approaching $100 billion a year, the same order of magnitude as tobacco-caused health expenditures.

Overweight and obesity by age: United States, 1960-99

A Cause of the Epidemic

Overweight results from consuming more food energy than activity expends. Overweight and obesity are the natural response of a population to the environment that features inexpensive, tasty, convenient and highly caloric foods. Many elements of that environment have their greatest impact on poor and minority populations. Food industry processing and marketing practices have encouraged excessive food consumption. In a country with an overabundance of food and where the raw materials that go into processed foods are very inexpensive, food companies increase their return on investment by selling products where the “value” they add through marketing, processing and packaging is a large part of the final price. Foods that encourage greater consumption not only capture a larger share of the market but induce individuals to eat more than they need to maintain an appropriate weight. How is this done? Super-sized portions offered at small price increments over regular-sized portions attract people to buy more at a lower unit price. Convenience—food that takes little time or effort to prepare—is attractive. Tastes, such a sweetness, fattiness and saltiness, produce satisfying effects. And the food industry’s marketing targets the young, attempting to establish profitable eating habits early in the naïve population of children. Schools, starved for resources, are now complicit, through their contracts with food companies, in teaching children to eat and drink high-calorie processed foods.

Assigning responsibility for obesity to the food industry conflicts with our nation’s strong tendency to attribute “life style” choices to individuals. Even the 2001 Surgeon General’s analysis of obesity cit focused on how to help people change their own behaviors or habits. Members of disadvantaged groups understand that poverty constrains choices, including “life style” choices about what to eat. Limits of time and money, and habits learned at an early age, condemn many poor Americans to an excessively generous diet of processed and fast food. Perhaps “comfort food” is not misnamed. The distribution of obesity by income is similar to the distribution of tobacco use in the population—greater prevalence with lower income, as well as racial disparities.

Age-adjusted Prevalence of Overweight or Obesity in Selected Groups (NHANES III, 1988-1994

Legal Strategies

Just as lawyers successfully challenged the tobacco industry for selling a product that manufacturers knew to be deadly, litigators have recently filed lawsuits on behalf of obese people who believe they are victims of food industry marketing that encouraged over-consumption. And, like the early tobacco litigation, it is hard to predict the outcome until the lawyers learn what the food marketers knew about causing obesity and when they knew it. Although the recent suit filed against McDonalds did not succeed the first time in court, a careful reading of Judge Sweet’s decision for the federal district court for Southern NY (available at http://banzhaf.net/docs/sweet1) reveals a roadmap for how these and other plaintiffs might sue fast food companies successfully.

We have little doubt that many food processors and restaurants have very extensive knowledge about what makes their products attractive, what encourages more consumption. Although food manufacturers and sellers will portray eating habits as matters of personal choice, these personal choices have been shaped and influenced by the marketing tactics of the food industry. Have these marketing practices been deceptive or misleading—and perhaps deliberately so? For example, does labeling a product “low fat” encourage over-consumption by people who fail to realize that the product, although low in fats, may still be highly caloric? We expect that legal discovery will pierce the secrecy to disclose just how much the food industry knew and when they knew it, just as that process led to finding clear evidence in the tobacco litigation.

Some Cautionary Words

If this is true, some lawsuits will successfully hold food producers and sellers at least partly responsible for obesity and its health consequences. But will the outcome of litigation be good for public health, for others in the population beyond the plaintiffs? There are reasons to be concerned. The few plaintiffs who receive large payments are unlikely to regain their good health. But the critical question relates to protecting the rest of the population who can still avoid the consequences of overeating. Will the industry be asked to change its practices, and how?

For tobacco, the desirable public health goal was always to reduce cigarette smoking to the greatest possible extent—an addiction dangerous at all times. For food, the goal is not elimination of food, but limited consumption to eliminate obesity. It is not too soon to begin strategic planning to assure a good public health outcome, as we cannot expect the plaintiffs’ attorneys to represent the interest of the population at large. We must:

  • Define the public health objectives so that any judgment or settlement can be assessed by its effect on the obesity epidemic and its health consequences. Having a measurable objective is important because the industry will certainly argue that voluntary changes in marketing will suffice.
  • Explore ways to extend legislation and regulation of foods from the immediate safety of the products to the health consequences of the entire food production, processing and marketing system.
  • Study the disproportionate effect of food marketing on children and vulnerable populations in order to prevent further damage from any changes proposed by litigation, regulation, legislation or the industry itself.

The goal must be to change corporate behavior and thus a population of individual behaviors.

The Other Edge of the Sword

A less than well coordinated attack on the corporate behavior that contributes to overweight and obesity can have a downside. The obesity epidemic may provide a new opportunity for the Bush Administration to cut assistance to poor people. Food stamps and school lunches are the immediate targets. Conservatives have hit on the idea that food programs encourage recipients to overeat. The New York Times (Feb. 23, 2003) quotes Douglas J. Besharov, director of the American Enterprise Institute’s Project on Social and Individual Responsibility: “We are feeding the poor as if they are starving, when anyone can see that the real problems for them, like other Americans, is expanding girth.”

As a start, House-passed legislation would allow up to five states to do as they wish with the federal food stamp program, frozen at the current funding level. The Administration also proposes to enforce income rules more strictly in the school lunch program that now provides 28 million students with $7 billion worth of food per year. “In recent pilot programs in which families were asked to document household income, approval for free lunches fell by 21% and by 8.8% for reduced-price lunches,” reported in the same day’s New York Times.

Now is the time for two populations of advocates to come together: public health professionals who know that overweight and eating habits are not principally a matter of individual choice and advocates for disadvantaged populations who can keep the public health community from inadvertently harming poor people and minorities.

Notes:

Anthony Robbins (anthony.robbins@tufts.edu) is Professor of Public Health at the Tufts University School of Medicine; Wendy E. Parmet (w.parmet@neu.edu) and Richard Daynard (r.daynard@neu.edu) both serve on the faculty of Northeastern University School of Law. All three are principals in the Public Health Advocacy Institute (phaionline.org). The Institute’s First Annual Conf. on Legal Approaches to the Obesity Epidemic will be held June 20-22 in Boston; inf. from their website.

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