To the Editor: In his Shattuck Lecture on improving Americanhealth, Schroeder (Sept. 20 issue)1 argues that the low U.S.international ranking in health can be attributed primarilyto behaviors such as tobacco use and overeating. He suggeststhat expanding efforts to change these behaviors representsthe best hope for improving health. However, changing the policiesthat promote unhealthy behavior and lifestyles may be more effectivethan seeking to alter habits one person at a time.2 For example,each year, the tobacco, food, and alcohol industries spend billionsof dollars to persuade Americans to consume their products inways demonstrated to cause illness and premature death.3 Theautomobile, firearms, and pharmaceutical industries hire thousandsof lobbyists and contribute tens of millions of dollars to encouragelegislators to resist or weaken legislation that would imposemore stringent health safeguards on their products.4,5 Votersand physicians should insist that the government protect publichealth against the special interests that profit from the lethalbut legal products that impose such a heavy burden. Only thenwill the United States achieve the improvements in health thatSchroeder advocates.
Nicholas Freudenberg, Dr.P.H. Hunter College New York, NY 10010 nfreuden{at}hunter.cuny.edu
References
Schroeder SA. We can do better -- improving the health of the American people. N Engl J Med 2007;357:1221-1228. [Free Full Text]
Freudenberg N. Public health advocacy to change corporate practices: implications for health education practice and research. Health Educ Behav 2005;32:298-319. [Abstract]
Vladeck D, Weber G. Commercial speech and the public's health: regulating advertisements of tobacco, alcohol, high fat foods and other potentially hazardous products. J Law Med Ethics 2004;32:4 Suppl:32-34. [CrossRef][Web of Science][Medline]
Luke DA, Krauss M. Where there's smoke there's money: tobacco industry campaign contributions and U.S. Congressional voting. Am J Prev Med 2004;27:363-372. [Web of Science][Medline]
Relman AS, Angell M. America's other drug problem: how the drug industry distorts medicine and politics. New Repub 2002;227:27-41. [Web of Science][Medline]
To the Editor: Schroeder provides a timely reminder that beinga superpower does not necessarily translate into being a healthynation. He rightly points out that intervening in smoking andobesity will probably yield the most health gains. Similaritiesbetween the two are obvious, yet putting obesity among behavioralcauses of poor health can confuse the public health agenda.Factors associated with obesity are the product of lifestylechanges that are driving the behaviors of whole populations.These lifestyles are shaped by wider socioeconomic and developmentaltrends (e.g., food commercialism, urban development, and internationaltrade). As such, obesity from the etiologic and interventionalstandpoints belongs to the environmental sector of populationhealth. This has important implications for intervention, especiallyin light of the failure of most behavioral programs targetingobesity and the apparent inability of the health care systemto respond to such a colossal epidemic.1,2 Apparently, solutionswill ultimately lie in public health policies that will createenvironments in which healthy lifestyles will not only be themost rational but also the most affordable and profitable forpeople.
Wasim Maziak, M.D., Ph.D. University of Memphis Memphis, TN 38152 wmaziak{at}memphis.edu
References
Lake A, Townshend T. Obesogenic environments: exploring the built and food environments. J R Soc Health 2006;126:262-267. [CrossRef][Web of Science][Medline]
Maziak W, Ward KD, Stockton MB. Childhood obesity: are we missing the big picture? Obes Rev (in press).
To the Editor: Schroeder's assertion that injury from secondhandexposure should not be considered "a peril that attends obesity"is puzzling and contradicts the observation that persons whoobserve weight gain among their social contacts more readilyaccept weight gain themselves.1 It also affects us in other"secondhand" ways. For example, in the 2004 advisory circularof the Federal Aviation Administration (FAA) on aircraft weightand balance control,2 standard weight had to be increased by11 lb (5 kg) for men and by 18 lb (8 kg) for women. That thiswas not considered a trivial matter is evidenced by the FAA'sstatement that a recent airplane crash was, in part, attributedto overweight passenger load.2 Obesity was indicated as a contributingcause in the capsizing of a boat on Lake George that resultedin 20 deaths.3 The boat capacity was computed from an averageweight of 140 lb (64 kg) — a number left behind by mostAmericans many Twinkies ago. Obesity not only affects the bearerbut may cause injury from secondhand exposure as well.
Franz H. Messerli, M.D. Henry Greenberg, M.D. St. Luke's–Roosevelt Hospital Center New York, NY 10019
References
Christakis NA, Fowler JH. The spread of obesity in a large social network over 32 years. N Engl J Med 2007;357:370-379. [Free Full Text]
Federal Aviation Administration Flight Standards Service. Aircraft weight and balance control. Washington, DC: Department of Transportation, August 11, 2004.
Foderaro LW. No charges by sheriff in fatal capsizing on Lake George. New York Times. February 4, 2006.
To the Editor: Schroeder argues that "the pathways to betterhealth do not generally depend on better health care" and claimsthat improved public health "is more likely to come from behavioralchange than from technological innovation." In particular, hesuggests more aggressive measures in the fight against fat,including taxes, food-stamp restrictions, and mandated advertisingcampaigns against unhealthy diets.
Although no one disputes the untoward effects of a wideningwaistline, whether individual decisions about eating —as well as other forms of private, personal conduct —ought to be further medicalized and subject to additional governmentintervention is less obvious. Undoubtedly, important gains areto be had from optimized behaviors, but at what price? Is thecost of becoming "number one in health" best measured in dollarsor liberties? Does the doctor's practice stop at the officedoor or the refrigerator door?
Perhaps it is time for physicians to reconsider the boundariesof their profession. Yes, "we can do better," but should we?
Jason P. Lott, M.A. University of Pennsylvania Philadelphia, PA 19104 lottj{at}mail.med.upenn.edu
The author replies: My Shattuck Lecture contained three centralmessages: the United States lags behind other developed countriesin the health of its people; in order for improvement to occur,efforts must concentrate on the health of the poor; and thebest prospects for such improvement are combating smoking andobesity and physical inactivity. Though I received many responsesonline about the first two messages, the four letters commentonly on the third. Freudenberg argues that policies aimed atthe tobacco and food industries hold more promise than individualapproaches. In my lecture, I addressed policies that have workedin tobacco control and could potentially work for obesity. Iagree that the food and tobacco industries will oppose thesepolicies and that public health and clinical champions shouldsupport them.
Maziak contends that the causes of obesity are environmental,not behavioral, and calls for environmental solutions. The sameargument could be made for smoking, which is so heavily influencedby the $15 billion annual marketing efforts of the tobacco industry.Maximal improvement will come from coupling environmental strategieswith individual clinical efforts.
Messerli and Greenberg assert that tobacco use and obesity causesimilar collateral damage to others. I disagree. The SurgeonGeneral estimated that 50,000 of the 440,000 annual deaths fromtobacco use are caused by exposure to secondhand smoke.1 Whetheryou believe the Centers for Disease Control and Prevention'shigh estimate of deaths from obesity (365,000 per year)2 orits much lower estimate (112,000 deaths per year),3 neithercites any deaths from secondhand obesity. Furthermore, thereis no advocacy group against obesity comparable to Americansfor Nonsmokers' Rights.
Lott expresses the libertarian view that physicians and governmentsshould stay out of attempts to change individual behavior, evenif that behavior is harmful. The same argument could be madefor mandatory use of seat belts in automobiles and helmets formotorcycle riders, drunk-driving legislation, and the use offluoride to combat dental caries.4 In the case of tobacco useand obesity, I would be more sympathetic to Lott's argumentwere it not for the huge marketing efforts of the tobacco andfood industries, which, if unopposed, would be even more influentialthan they already are. Although I agree that clinical effortsshould avoid coercion and stigmatization, I come down on theside of urging clinicians to do all they can to improve thehealth of the public.
Steven A. Schroeder, M.D. University of California at San Francisco San Francisco, CA 94143 schroeder{at}medicine.ucsf.edu
References
Department of Health and Human Services. The health consequences of involuntary exposure to tobacco smoke: a report of the Surgeon General: 2006. Washington, DC: Government Printing Office, 2006.
Mokdad AH, Marks JS, Stroup JS, Gerberding JL. Actual causes of death in the United States, 2000. JAMA 2004;291:1238-1245. [Erratum, JAMA 2005;293:293-4.] [Free Full Text]
Flegal KM, Graubard BI, Williamson DF, Gail MH. Excess deaths associated with underweight, overweight, and obesity. JAMA 2005;293:1861-1867. [Free Full Text]
Isaacs SL, Schroeder SA. Where the public good prevailed: lessons from success stories in health. American Prospect 2001;12:26-30.
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