In 2003, a prestigious researcher, Jeffrey M. Friedman, called for a ‘War on Obesity, not the Obese.” A war on obesity, not the obese. [Science. 2003] – PubMed Result We seem, six years later, not able to make the distinction.
Elsewhere we have addressed various attacks on persons with obesity, rather than obesity itself. Medical experts, it seems, appear particularly unable to tell what is a war on obesity and what is a war on persons with obesity.
A ‘War on Obesity’ includes the same elements that have guided other, successful, approaches to health care problems, whether infectious diseases or chronic conditions. The elements are straight-forward: (1) educate the public and health professionals, (2) focus research on finding both the causes and effective interventions, (3) promote prevention, when possible, (4) intervene and treat those affected, (5) if relevant, strongly combat stigmatization and discrimination, as they are impediments to effectively treating and preventing the disease, and (6) consumer protection to stop the exploitation of worried people and their diversion into unproductive avenues of recourse. With obesity, in general, the federal government has only focused on educating the public and promoting prevention (although we still lack proven prevention strategies). All the other strategies have been not totally, but largely, neglected.
Identifying a “War on the Obese” requires a little work. It requires work because stigmatizing overweight/obese people is so ingrained in our culture. It starts early and does not stop. Shunning, embarrassing, ridiculing and penalizing persons with obesity is so ingrained in our society, we take it for granted. How do we recognize it?
Lets take Dr. Toby Cosgrove, CEO of the Cleveland Clinic, statements about hiring obese persons.
1. On August 12, 2009, David Leonhardt of the New York Times, wrote, “Cosgrove says if it were up to him, if there weren’t legal issues, he would not only stop hiring smokers. He would also stop hiring obese people. When he mentioned this to me during a recent conversation, I told him many people might consider it unfair. He was unapologetic.”
2. On September 6, 2009, Dr. Cosgrove was interviewed by Guy Raz on NPR:
RAZ: And you have argued that you would not hire people who are obese. Is that fair?
Dr. COSGROVE: No, I think that that was a quote that was taken out of an hour-and-a-half interview. And what I said was that we are concerned about the obesity problem, not about people who are obese.
3. September 9, 2009, Cleveland .com carried the story, “Clinics Dr. Delos ‘Toby’ Cosgrove defends remarks about not wanting to hire obese people.” Asked at an obesity summit at the Cleveland Clinic, organized by the clinic’s bariatric surgery program by Walt Lindstrom, founder of the Obesity Law and Advocacy Center in California, if he wished ‘he hadn’t said it.” The Dr. Cosgrove demurred and said his comment was meant “to stimulate discussion on the growing costs of obesity.” He said, “I think a lot of people misunderstood what the point was…I never considered not hiring obese people, but I think we have to do something bold to address the problem.” The article goes on, “Cosgrove opened his remarks at the Obesity Summit by highlighting the Clinics health and wellness initiatives. On the obesity front, the hospital has eliminated fried foods, removed soda and candy from vending machines and subsidized Weight Watchers and fitness programs for its 40,000 employees, he said. “In nine months, we’ve lost 110,000 pounds across the organization, which I think is an amazing tribute to the program.”
4. September 12, 2009: On a Wall St. Journal Health Blog, Dr. Cosgrove said, “it would be illegal to apply a similar standard (not hiring smokers) to people who are obese, because they’re protected by the Americans with Disabilities Act (ADA). He said, “I can’t decide that I’m not going to hire somebody because they are 400 pounds. We don’t hire smokers and that’s perfectly legal.” According to the blog entry, “Cosgrove questioned that rule, suggesting it could hinder efforts to lower the nation’s obesity rate. Dr. Cosgrove said, “We are protecting people who are overweight rather then giving people a social stigma.” The blog reports that the Department of Justice said that only morbid obesity can be protected by the ADA but only “if it substantially limits a major life activity in the past or is regarded as substantially limiting.”
5. On September 13, 2009, Connie Schultz, a Cleveland Plain-Dealer Pulitzer-prize winning columnist for her focus on blue-collar families and economics, wrote, “Apparently, it is now fashionable to bash the obese. For the sake of health care, you understand. Nothing personal.” Quoting Dr. Cosgrove remorse that “We are protecting people who are overweight rather than giving people a social stigma” Schultz states, “What, Oh, he must mean all those obese people bragging about the compliments from strangers, the big, welcoming grins on the faces of fellow airline passengers. Not to mention the parade of size-20 models on fashion runways. Yup, obesity is really popular in America. Who wouldn’t want to be called fat. Punishing obesity compounds the problem.”
6. September 14, 2009, Dr. Cosgrove apologized to employees of the Cleveland Clinic for any “hurtful” comments, stating, “My objective was to spark discussion about premature causes of death, but some of my comments were hurtful to our community. That was certainly not my intent, and for that I apologize.”
In Cleveland, 70% of adults are over their recommended weight. Obesity is more prevalent among women than men, greater among black adults and higher among older persons than younger ones as well as more prevalent among lower income persons.
The picture of obese persons in Cleveland is intriguing. According to the Center for Health Promotion Research, “Obese and non-obese Clevelanders did not differ in the reporting of adequate fruit and vegetable consumption.” The difference appears to be in physical activity with obese persons reporting less adequate moderate or vigorous physical activity. More than half of all Clevelanders reported not getting adequate weekly amounts of moderate physical activity. BUT, as the report notes, “Clevelanders who were obese were more than twice as likely to report having diabetes (17% vs. 7%) and nearly twice as likely to report having asthma (15% to 8%).” They also report more hypertension and high cholesterol that non-obese Clevelanders. Therefore, the reports notes, lower levels of physical activity were related to diabetes, hypertension, high cholesterol and heart attacks.
The report goes on to note that obese Clevelanders reported more use of nutrition classes and organized health promotion activities compared to non-obese residents. Fully 75% of obese Clevelanders are trying to lose weight. Of the 76% of Clevelanders who reported seeing a doctor in the past 12 months, only 16% were given advice about their weight! Obese Clevelanders reported using both diet and exercise compared to those who were not obese. And more obese persons used a diet- only approach, “a possible reflection of the mobility issues related to obesity, and the additional need for diet modification.” http://www.case.edu/affil/healthpromotion/Publications/Publications/Steps%20BRFSS%20Data%20Brief%20OBESITY%203.27.08%20FINAL.pdf
Dr. Cosgrove has apologized to his current employees saying he only wanted to talk about premature deaths due to obesity. If he is concerned about premature deaths due to obesity, he might address why does his health plan for employees cover bariatric surgery after a two year waiting period (http://www.clevelandclinic.org/healthplan/plan-cchs-caremanagement.htm#MedBenefitsCoverClarification), one of the longest in the country, and, for which, there is no medical justification?
Even though Dr. Cosgrove has apologized to his employees, does anyone in the hiring process at Cleveland Clinic not understand the boss doesn’t want to see so many fat people on staff? Would you hire an obese Clevelander and take them to meet the boss for the ‘Welcome aboard’ gesture? Not likely.
At the end of the day, there is no evidence that stigmatizing obese persons reverses or resolves the problem. Stigma and discrimination does not work and only increases the sum of human unhappiness. We need new therapies and we need physicians who want to help their patients, and, Dr. Cosgrove, we need positive leadership.