Alex Beam

Weight of public opinion

What’s wrong with subjecting obese Americans to the same stigmatization that smokers are?

By Alex Beam
Globe Columnist / July 15, 2011

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"Hey, fatty! Pull that doughnut out of your pie hole! You look like a pig, and you are costing me, and every other taxpayer, billions of dollars in unnecessary health care each year!’’

How do you like my new public service ad campaign, designed to stigmatize the overweight and the obese in the same way smokers have been made to feel the knout of social opprobrium for the past quarter-century?

I got the idea when I heard professor Daniel Callahan, the retired cofounder of the Hastings Center, a bioethics research institution, speak on a radio program about two weeks ago. Why aren’t overeaters subject to the same stigmatization as smokers?, he mused. Why not indeed? I phoned him, and he sent me a draft paper he had written on the subject: “Harnessing Stigma or Stigmatizing Stigma? The Case of Obesity.’’

Callahan makes a persuasive case: 67 percent of Americans are overweight, he writes. “Obesity is a leading cause of diabetes, heart disease, and kidney failure. There are some prima facie reasons for thinking about stigmatization as one more arrow in the quiver of possible solutions.

“It can hardly be said that obesity is beyond individual control,’’ he continues. “So, why not stigmatize [the obese], bringing social pressure to bear?’’

What could be more logical? No category of US citizens, with the possible exception of prisoners, has been subjected to more government-sponsored economic and social harassment than cigarette smokers. Last month every newspaper and TV station in the country gleefully reported the latest taxpayer-funded attack on smokers: graphic new cigarette warning labels, depicting coffin-nail addicts as losers with rotten teeth and, of course, dead.

Taxed up the wazoo, forced to pay hundreds of extra dollars for health insurance, tossed out in the rain and snow to sneak a few puffs of the dreaded cancer sticks - smokers are the deadbeat dads of the public health landscape. Here in Boston, there is a move afoot to ban smokers from public housing. In New York, Mayor Michael Bloomberg is ticketing cigarette smokers in public parks.

“The effort of smokers to invoke their civil rights gained no traction,’’ Callahan writes, “and the public health community made no moves to come to their aid.’’

I was looking forward to chatting with Callahan, because he sounded like a public health writer unfettered by modish jargon and the strictures of political correctness. He agreed to speak with me by phone from his vacation aerie on Little Cranberry Island, Maine. Practically the first words out of his mouth were: “I am switching sides. I don’t want to lead a crusade for stigmatizing men and women who have trouble controlling their weight. It would be enormously hurtful for a lot of people.’’

Who got to you, I asked?

Callahan showed his paper to other researchers before publication, and, predictably, they gave him some stiff criticism. He was particularly chastened by an articulate and forceful critique from Rebecca Puhl, a clinical psychologist who is also director of Research and Weight Stigma Initiatives at Yale’s Rudd Center for Food Policy & Obesity.

Puhl and I spoke, covering much of the territory she reviewed with Callahan. She repeated the mantra that I heard from other public health experts: “When we are talking about smoking, we are talking about behavior. When we are talking about obesity, we are talking about people.’’

Bollocks. In both cases we are talking about behavior that is harmful both to the individual and to society, and in both cases we are talking about people. It’s just that humiliating smokers is a societally approved parlor game - some joker at Harvard has been inveighing against “third-hand smoke’’- while state and local governments, and almost all corporations, observe a very different standard in handling fat people.

Puhl is the coauthor of a recent paper in the American Journal of Public Health that calls negative reinforcement “an unlikely motivator for weight loss.’’ After including the customary “more work is needed’’ disclaimer, Puhl and her coauthor conclude that “the available evidence challenges the assumption that weight stigma is a useful tool for changing health behaviors.’’

Puhl is talking about social stigmatization of fat people, which she says has been increasing along with the numbers of obese Americans. But government is loath to turn the spotlight on fat people the way it does on smokers. This year a Georgia campaign against childhood obesity did just that, featuring pictures of overweight children. There was an immediate backlash from the usual suspects - academics and activists, according to Callahan. “It is hard to imagine a picture of a child smoking that would draw a similar condemnation, much less characterize such children as beleaguered,’’ Callahan writes.

The government forces fast-food restaurants to publish nutrition information; people keep getting fatter. Michelle Obama enlists celebrities to dance around her Marie Antoinette-like veggie garden; kids keep getting fatter.

Maybe it’s time for a new approach.

Alex Beam is a Globe columnist. His e-dress is