AMA Journal of Ethics®

Illuminating the art of medicine

Journal of Ethics Header

AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. April 2010, Volume 12, Number 4: 327-330.

Op-Ed

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A Call for Collaborative Action against America’s Greatest Health Threat

In order to enact policies that will curb the rising rate of obesity in the U.S., Americans must emphasize scientific findings over special-interest politics.

Richard H. Carmona, MD, MPH

During my term as surgeon general of the United States, it was clear to me that the obesity epidemic in the United States was a significant and growing source of preventable disease and economic burden. Today, the evidence is even more compelling. Obesity is the major risk factor for type 2 diabetes, acts as a cause or accelerator of chronic diseases, and impacts national security by diminishing the viable workforce that qualifies for uniformed service. As a nation, we have an imperative to immediately and expeditiously address the complex variables that contribute to the health, economic, and ethical dilemmas imposed by our nation’s obesity epidemic, which we are also exporting to the world.

Learning Objective Understand why policymakers must emphasize scientific findings over special-interest politics to curb the rising rate of obesity in the U.S.

While our nation fights two wars, attempts to avert global economic implosion, and simultaneously addresses many other national and global challenges, it has been difficult to gain traction and appropriate national attention for efforts to address obesity. Regardless of the perspective from which it is viewed—prevention, policy, health reform, diagnosis, clinical care, ethics, or potential regulation—obesity has proven to be an elusive and sometimes deadly adversary.

It has taken since the 1960s for our nation to make progress in overcoming the use of tobacco. We are on the verge of negating the health and economic gains from reduced tobacco use by supplanting one health problem with another. We may, in fact, be raising the first generation of American children who will have shorter lifespans than their parents, in great part due to the chronic diseases so closely associated with overweight and obesity.

Well-informed professionals are divided on to how to approach the crisis effectively and efficiently. To resolve differences in approach that initially appear to be irreconcilable, and to balance individual freedoms and the needs of society, will require diplomacy and sensitivity.

In our democratic political system, public health issues such as obesity, stem cell research, emergency contraception, and abortion become currency for polarized political platforms. In that charged political atmosphere, true science is lost, marginalized, or ignored, with the result that the public remains health illiterate and less able to make informed health decisions for themselves and their families. We, as health professionals, must resist all attempts to politicize obesity and stay focused on using the best science available in making recommendations to our patients, our communities, and policymakers.

Pursuing Solutions to the Obesity Crisis

In sharp contrast to the many special-interest interpretations of the obesity problem are two large nonpartisan, national groups that I have the privilege to chair: the Strategies To Overcome and Prevent (STOP) Obesity Alliance and the Partnership to Fight Chronic Disease (PFCD). Both organizations comprise public, private, academic, business, and government thought leaders and are directly and indirectly addressing obesity in an ethical manner on the clinical, community, and policy levels. The STOP and PFCD coalitions are clearly demonstrating the momentum and impact that can be generated with a collaborative approach and shared goals.

All of us who are pursuing solutions to the obesity epidemic face clinical, ethical, and regulatory challenges. First among them is the significant role of individual lifestyle and behavior choices in causing obesity. When you are able to choose where to live and what to eat, your individual and family decisions are different from those of the millions of Americans who are pushed down the ladder of good health by social and economic realities. There is no simple solution to the incongruities and variables that stratify our society along cultural, language, geographic, and educational lines.

Given these stratifying differences, what is the correct approach for addressing obesity? Do we reward healthful behavior or penalize behavior that puts health at risk? Should we tax “bad” foods? How do we define bad foods, and how would such a tax process be enforced? Would we need “food police”? Would infractions be misdemeanors or possibly felonies if significantly egregious? Society and health care payors certainly feel they have a right to control costs by preventing obesity and reducing the instance of chronic diseases like type 2 diabetes, heart disease, and cancer. Whose job should it be to regulate what foods can be bought and sold? If the market fails to address the needs of those who have few or no choices in what they eat, whose responsibility is it to ensure access to fresh healthy foods and to create areas where people can exercise safely?

Next, what is the role of industry in the obesity debate? Are businesses ethically or legally bound to advertise foods that promote health and to disclose all food content? Some groups want to restrict the advertising and promotion to children of foods and drinks that are high in fat, salt, and sugar. This issue is critical because food purchasing and eating habits are ingrained at an early age and contribute significantly to adverse health behaviors and choices in adult life.

Third, what part should government play in fighting the obesity epidemic? Should government ensure that all children have appropriate health education by seeing that schools teach diet, nutrition, and the benefits of physical activity? If so, what is the parent’s role in providing a home environment that is consistent with the health curricula being taught in schools? Should there be federal tax and mandated warnings on non-nutritious food as there are on cigarettes and alcohol?

Looking further at government’s role, the U.S. Farm Bill has been declared by some to be a major contributor to the obesity epidemic because it subsidizes crops such as sugar and corn. Can we therefore consider the U.S. government partially responsible for contributing to the obesity epidemic? Inasmuch as the government has been made aware of the deleterious health effects of the Farm Bill, does it have an ethical and legal obligation to help eradicate the associated variables that are contributing to the nation’s obesity?

Finally, how can health professionals do a better job of identifying and managing obesity? In August 2009, the STOP Obesity Alliance, assisted by researchers from George Washington University, conducted a roundtable and follow-up interviews with physicians and other health care professionals to identify innovative approaches for obesity treatment. They identified three: monitoring health and explaining standard health measures to patients, goal setting and patient motivation, and care coordination and system integration.

Numerous issues and questions lie within those three areas. Is there acceptance and use of the incremental definitions of success in weight loss that result in improved health? Is it feasible to track weight and health indicators over time to help patients understand how weight impacts health? Can health care practices, small and large, be positioned within integrated systems where care is coordinated for optimal outcomes? How do we ensure that the stigma of obesity does not find footing in medical settings or treatment protocols?

Efforts to achieve solutions to the obesity epidemic must be widespread and in-depth. At every turn, the potential for unintended consequences of policies in any sector is exacerbated by the multifactorial nature of a health condition that is often misunderstood by those who suffer from it and treat it. Inaccurate media portrayals and stereotypes add to the confusion. Any other health threat of a similar magnitude and consequence would be deemed a national emergency.

Achieving sustainable solutions to the widespread obesity in our country will require cooperation on the part of all sectors of society—individuals, families, communities, businesses, industry, health professionals, faith-based organizations, and all levels of government. The good news is that, through decades of research, observation and learning, we have deciphered many of the contributors to the epidemic.

We must now turn our collective attention to initiating and sustaining an intergenerational undertaking that will demand an unprecedented coordination of resources at all levels. We must all become engaged in and committed to the process of transforming our nation’s health culture. We must begin by delivering care and services that are sensitive to cultural differences. Information must be presented, not just in plain language, but in a manner that will convey to those with low health literacy the importance of making the desired behavioral changes.

Policy formation, in particular, is an extremely complex process that involves balancing myriad inputs with timing and opportunity. To succeed in this far-reaching endeavor we must subordinate our own interests to creating a seamless, integrated, and holistic approach that benefits society at large, not merely one group—no matter how loud or demanding the constituents of that group may be.

By engaging in a new straightforward, results-oriented process of change, we will improve our nation’s health and economic viability for the long-term. We must collectively move beyond the divisiveness that exhausts our limited resources and, without reservation, engage all Americans in a best effort to make our great nation a healthier nation.


Richard H. Carmona, MD, MPH, was the 17th surgeon general of the United States (2002-2006). He is currently a distinguished professor at the University of Arizona’s Zuckerman College of Public Health. His professional interests include protecting, promoting, and advancing the health, safety, and security of the United States. As surgeons general say, “Once a surgeon general, always a surgeon general."

Acknowledgment

Editing support provided by Janice McIntire, Canyon Ranch Institute.

A Rationale for Policy Intervention in Reducing Obesity, April 2010

What’s Wrong with the U.S. Approach to Obesity? April 2010

The viewpoints expressed on this site are those of the authors and do not necessarily reflect the views and policies of the AMA.