VIEWPOINT
Attacking Obesity
Lessons From Smoking
Arthur Garson, Jr, MD, MPH* and
Carolyn L. Engelhard, MPA
University of Virginia, Charlottesville, Virginia.
Manuscript received September 7, 2006;
revised manuscript received December 5, 2006,
accepted January 1, 2007.
* Reprint requests and correspondence: Dr. Arthur Garson, Jr., Dean’s Office, School of Medicine, University of Virginia, P.O. Box 800793, Charlottesville, Virginia 22908-0793. (Email: garson{at}virginia.edu).
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Abstract
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For the first time since the Civil War, American life expectancy is projected to decrease, owing to the diseases associated with obesity such as diabetes, ultimately causing cardiovascular death. In the past 30 years, the prevalence of obesity among U.S. adults has doubled, as has the incidence of type 2 diabetes. Enough data. The Surgeon General should attack obesity the same way as smoking in 1964, with: 1) Advisory Council creation of public statements; 2) warning labels and menu information in all restaurants; 3) legislation for tax incentives for industry to promote worksite health; and 4) consideration of taxation of fatty food; the cigarette tax is now 42%. It is abundantly clear that in short order, obesity will kill more people than smoking. The time has come for the country to get serious about obesity and take lessons from our nation’s campaign to reduce smoking. As patient advocates, scientists, and medical professionals, cardiologists should appropriately take the lead.
For the first time since the Civil War, American life expectancy is projected to decrease, owing to the diseases associated with obesity such as diabetes, ultimately causing cardiovascular death (1). In the past 30 years, the prevalence of obesity among U.S. adults has doubled, as has the incidence of type 2 diabetes (2). Enough data. We need to attack obesity.
The U.S. was faced with a similar problem 40 years ago: the dangers of smoking were graphically demonstrated in over 7,000 articles (3). Surgeon General Luther Terry convened an Advisory Committee that stated: "Cigarette smoking is a health hazard of sufficient importance in the United States to warrant appropriate remedial action" (3). In 1965, the U.S. Congress adopted the Federal Cigarette Labeling and Advertising Act, and in 1969 the Public Health Cigarette Smoking Act. These laws required a health warning on cigarette packages, banned cigarette advertising in the broadcast media, and called for annual reports on the health consequences of smoking. Since then, we have seen massive public information campaigns, bans on smoking in public places, exclusion of smokers from the workforce in certain corporations, nicotine patches, and cigarette taxes. For example, between 1970 and 2001, the federal tax on cigarettes increased from 8 cents to 34 cents/pack, and state cigarette taxes increased from 11 to 43 cents. Over the same period, the consumption decreased from 32 billion to 22 billion packs/year in the U.S. For every 10% increase in price, cigarette consumption decreases 4% (4). We can count this as partial success: nearly one-half of all living adults who ever smoked have now quit. However, 46 million Americans still smoke.
What lessons can we learn from smoking? The combination of warning labels, taxation, a public campaign, business participation, and legislation have been effective.
At the University of Virginia, we have initiated a program that could become a model for the U.S. In May 2004, we began to create "warning labels" on the 120 vending machines in the UVa Health System. Each snack and beverage was color-coded: red, yellow, or green. In consultation with our dieticians, we labeled red those items 201 calories or more (or 10.1% or more saturated fats), yellow were items 141 to 200 calories (or 5.1% to 10% saturated fat), and green items 140 calories or less (and <5% saturated fat). We also added a 5-cent "tax" (approximately 8%) to the cost of the red items and donated the proceeds to the UVa Children’s Fitness Program. Large signs explaining the program were placed next to each vending machine.
After one year, the red item sales decreased 5.3%, yellow increased 30.7%, and green increased 16.5%. We collected $6,700 in the nickel tax. Interestingly, total sales increased 8.3%. Although this was not a randomized trial, the results seemed worthy of further study. We are now planning to color-code each of the items in one of our two hospital cafeterias and compare sales between the two. After the initial data collection, a tax is planned. We have begun discussions with state officials to reproduce both the vending machine and cafeteria programs in schools throughout Virginia.
The surgeon general must attack obesity in much the same way that Luther Terry attacked smoking. In 2001 and in 2006, the surgeon general has issued statements and even a "Call to Action" (5). But these were not specific enough to result in action.
- 1 The surgeon general could convene a national Advisory Council and, mirroring the case for anti-smoking, issue a statement that "obesity is a health hazard of sufficient importance in the U.S. to warrant remedial action." This is tremendously important to focus public awareness on obesity as a disease, just like lung cancer.
- 2 On the basis of this call to action, enact laws to require "warning labels" just like for cigarettes. In this case, it would be to require nutritional information (at least calories) to be placed on vending machines and restaurant menus, as is currently the case for food stores and grocery stores. These labels should be color-coded, much as we have done at the University of Virginia. Because legislation is a lengthy process, hospitals, schools, and businesses could take the lead and voluntarily initiate labeling programs.
- 3 Legislation could also be developed to give tax benefits to corporations with wellness programs that demonstrate results, such as the reduction in the percent of smokers, reduction in the percent who are obese, and reduction in the percent with uncontrolled hypertension. Even in the absence of legislation, insurers could be convinced to pass along to the employers actuarial savings generated by preventive programs. Insurance rates could be increased for those who persist with an unhealthy lifestyle.
- 4 The most controversial is clearly taxation. We recommend adding "unhealthy food" to the list of "sin taxes." This is not a new idea; it has been proposed in a number of states (6). Having said that, the devil is in the details. For example, sales taxes are notably regressive, unduly penalizing the poor. Additionally, in many instances, high-calorie/high-fat food is less expensive: at the fast food restaurant, the cheeseburger is less expensive than the grilled chicken. Therefore, again, taxation would discriminate against the poor. Perhaps a progressive tax could be developed with a higher percent tax on steak than hamburger. Although taxation will help to shift demand, we should also develop ways to stimulate the food industry to create better tasting, healthier choices. The tax will clearly generate revenue. How could this work? Most certainly, "unhealthy" would need defining. Unlike cigarettes, we have to weave a fine line: clearly, we want to reduce unhealthy eating and not all eating. One approach could be, for example, to tax items with high saturated fat; the majority of food at any fast food restaurant has >3 g of saturated fat; and at "sit-down" restaurants, more than 50% of entrees have greater than one-half-day’s worth of calories for each (7). Very conservatively, let’s assume that one-half of the $512 billion spent in restaurants and vending machines could be classified as "unhealthy." A tax of 10% (remember, we are trying to make people pay attention to the tax) would generate $26 billion/year.
To give credit where credit is due, when the Master of Business Administration students at Rice University in Houston, Texas were investigating ways to pay for America’s uninsured, they proposed a "fast food tax." Most definitely, the "unhealthy food tax" builds on that idea. Recent studies have estimated that to cover the uninsured would require an additional $83 billion/year (8); the "unhealthy food tax" would get us one-third of the way there. If we went "all the way" and had an unhealthy food tax equal to the 42% cigarette tax, we could pay for all of the uninsured. Of course, the point is to reduce consumption of fatty food, but there might be collateral benefits.
What can cardiology do? We can advocate for the health of America and hopefully decrease the number of people who will die from cardiovascular disease. We can support the surgeon general if those initiatives are begun, advocate for their enactment, and work to operationalize the plans. We can be sure that we and every one of our patients know his or her body mass index (BMI). We don’t do very well right now: in 1 study of patients after myocardial infarction, the BMI was documented in only 14% of patients (9). We can work with our own local cafeterias and state school systems to put systems in place similar to the one at the University of Virginia. We can advocate for better exercise programs in schools and in the workplace. Finally, cardiologists can perform research not on the problems of obesity—we have enough data—but on solutions.
It is abundantly clear that, in short order, obesity will kill more people than smoking. The time has come for the country to get serious about obesity and take lessons from smoking. Cardiologists should appropriately take the lead.
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References
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- Olshansky SJ, Passaro DJ, Hershow RC. A potential decline in life expectancy in the United States in the 21st century N Engl J Med 2005;52:1138-1145.
- Fox C, Pencine MJ, Meigs JB. Trends in the incidence of type 2 diabetes mellitus from the 1970s to the 1990s: the Framingham study Circulation 2006;113:2914-2918.[Abstract/Free Full Text]
- Centers for Disease Control. History of the 1964 Surgeon General’s Report on Smoking and Health. Available at: http://www.cdc.gov/Tobacco/30yrsgen.htm. Accessed August 17, 2006.
- Campaign for Tobacco-Free Kids. Landmark National Cancer Institute report concludes cigarette tax increases and tobacco prevention programs reduce youth smoking. Available at: http://tobaccofreekids.org/Script/DisplayPressRelease.php3?Display=470. Accessed August 17, 2006.
- U.S. Department of Health and Human Services. The Surgeon General’s call to action to prevent and decrease overweight and obesity. Available at: http://www.surgeongeneral.gov/topics/obesity/calltoaction/CalltoAction.pdf. Accessed March 6, 2007.
- Bhatnager P. Burger, fries and fast food tax to go? Available at: http://64.233.161.104/search?q=cache:u94R_KL2KL8J:money.cnn.com/2005/05/09/news/. Accessed December 2, 2006.
- Center for Science in the Public Interest. New guide reveals calories and fat in restaurant food. Available at: http://www.cspinet.org/new/restaurant_guide.html. Accessed March 6, 2007.
- Hadley J, Holahan J. Covering the uninsured: how much would it cost? Health Affairs, web exclusive. Available at: http://content.healthaffairs.org/cgi/reprint/hlthaff.w3.250v1?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&author1=Hadley&andorexactfulltext=and&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT. Accessed March 6, 2007.
- Lopez-Jimenez F, Malinski M, Gutt M. Recognition, diagnosis and management of obesity after myocardial infarction Int J Obesity 2005;29:137-141.[CrossRef][ISI][Medline]
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