New Government Position, "Fat Police," aimed at putting veterans back to work, Former Sargent to show up unexpected and Force these fat lazy mothatfuckers into aerobics and a mile run!

The Politics Of Obesity: Seven Steps To Government Action Rogan Kersh and James Morone Abstract Concern is rapidly growing about obesity rates in the United States. This paper analyzes the political consequences. Despite myths about individualism and self-reliance, the U.S. government has a long tradition of regulating ostensibly private behavior. We draw on the historical experience in four other private realms (alcohol, illegal drugs, tobacco, and sexuality) to identify seven "triggers" that prompt government to intervene in citizens’ private habits. We suggest which of those triggers have been tripped—or are in play—in the case of obesity and food consumption. Finally, we review what government now does in this field and what it might do in the future. Surgeon General David Satcher’s 2001 "Call to Action" on obesity begins dramatically: "Overweight and obesity have reached...epidemic proportions." Academics, federal officials, medical experts, journalists, and public interest groups have begun to echo the alarm.1 Unlike most public health problems, however, obesity arises in large part from private behavior: from people’s consumption of food and drink. In the United States, with its strong culture of individualism, such private activity is often viewed as off-limits to governmental intervention. "The government should stay out of personal choices I make," writes Washington University professor Russell Roberts. "My eating habits or yours don’t justify the government’s involvement in the kitchen."2 Public officials have not yet responded forcefully to the growing concern about an obesity "epidemic." However, the issue—which first met with scornful gibes about "Big Chocolate"—has moved onto the U.S. political agenda with remarkable speed. Congress, the White House, and bureaucratic agencies have begun to respond. Will the government eventually regulate fat in the food we eat?3 In this paper we suggest that it might very well do so. For despite the enduring myths about American self-reliance, the U.S. government has a long tradition of intervening in what seems to be purely private behavior. From alcohol restrictions in the early Republic to the tobacco wars of recent years, personal behavior has regularly become subject to governmental intervention, regulation, and prohibition. We begin with the historical record. A distinctive set of political conditions generally precedes governmental intervention in the private sphere. We identify seven steps traditionally leading to political action and evaluate which of those steps public health activists have already taken in the obesity case. We then turn directly to government food policy: What is the government actually doing today? What kind of actions might it undertake in the future? Controlling ‘Private’ Behavior What inspires U.S. public officials to regulate personal behavior? In this section we describe seven "triggers" to action. We developed the triggers by doing our own historical analysis of individual reform movements and then identifying what they shared in common: The following seven conditions repeatedly characterized public intervention in the private sphere. These triggers do not always operate in a precise cycle; the order and the intensity of each vary with the case. But the politics of public action in at least four ostensibly private areas—drink, drugs, tobacco, and sexuality/family planning—generally includes all seven factors.4 Social disapproval. The agitation generally begins in society. Observers back to Alexis de Tocqueville have commented on the formidable power of social norms and public opinion in the United States. Long before the government stirs, private groups condemn a popular activity. In response to heavy drinking among workers, early-nineteenth-century mill owners and urban elites began to worry about the disruptive effects of alcoholism and preached temperance. In the late nineteenth century men believed that sexual continence was dangerous to their health; large red-light districts flourished in every major city. Victorian feminists rebelled, organized a purity campaign, and set out to close the brothels and change expectations about male behavior. In these cases, as well as those of illegal drug and tobacco use, the first step to action involves social groups’ attacking widely accepted practices. Sometimes the condemnation wins broad support. At other times the criticism is bitterly contested across class, race, gender, or geographic lines. But challenges to private behavior first arise with shifting societal norms. Obesity has been the subject of powerful public disapproval for more than a century. The criticism developed, quite suddenly, at the end of the nineteenth century. What had long been a mark of prosperity became, as one popular magazine put it in 1914, "an indiscretion, and almost a crime." That view of fat grew stronger over the years (diminishing only during the Depression and world wars).5 The rise of the diet industry—for which total spending is now estimated at more than $36 billion annually—is one testament to Americans’ concern with their weight.6 A steady stream of reports chronicle widespread antipathy toward overweight people, affecting everything from personal esteem to college admissions and hiring decisions.7 The first trigger for political regulation of private behavior—social disapproval—has long been tripped in the case of obesity. Medical science. Public health crusades are typically built on a scientific base. Medical knowledge can rapidly transform society by challenging long-accepted social activities. Early-eighteenth-century Americans, for example, preferred rum and fermented cider to water, which was widely (and often rightly) thought to be unhealthy. As physicians began to issue warnings about alcohol use in the 1830s, Americans’ consumption of rum plummeted, falling 75 percent in three decades.8 In our own time, medical findings about the dangers of tobacco led to concerted pressure against use—and radically transformed consumption habits in little more than a generation. The science does not need to be accurate to have an impact. The findings are sometimes reliable: Tobacco really is harmful. They may be partially true: Liquor contributes to health problems, but it is not poison, as prohibitionists insisted. Or the science can be entirely fictitious, as when Victorian physicians warned men that self-abuse or too much sex could maim, blind, or kill them. In any event, medical knowledge in itself is rarely enough to stimulate a political response. Rather, the key to its impact lies in the policy entrepreneurs who spread the medical findings. A string of U.S. surgeons general played a crucial role in publicizing tobacco risks. The nation’s early industrialists took the lead in spreading the new view of drinking and sobriety, fearing the effects of workers’ heavy drinking in the mills. Although social disapproval of obesity set in during the 1890s, sustained medical concern did not develop for another half-century.9 This second trigger for government action did not get tripped till the 1950s. Once a medical consensus emerged, the findings spread rapidly. Even so, it took more than two decades for government actors to respond to the health warnings. Public officials did not begin to devote federal resources to publicizing obesity’s danger until the 1970s, a development we describe below. Self-help. In the wake of social sanctions and medical warnings, self-help movements frequently spring up to encourage people to live more healthy lives. This urge, too, is deeply rooted in American history. Urban workingmen in the 1830s founded Washington Temperance Societies to help one another swear off liquor; women formed Martha Washington Societies, the first female temperance groups. The heirs to these early self-help movements are ubiquitous in modern America. Alcoholics Anonymous is the best-known of thousands of groups, with online "virtual self-help communities" as the latest innovation in this old Yankee tradition.10 Obesity organizations stand out in the present-day panoply of self-help. Most such groups target personal behavior—specifically, diet and consumption habits. Some, like Overeaters Anonymous, take on a quasi-religious spirit; others, like Weight Watchers, offer a kind of communal diet program. In short, the third trigger for public action has been activated in the realm of food and obesity since the 1960s, when the first wave of self-help groups for overweight people appeared. Social disapproval, medical research, and self-help movements are all rooted in the private sector. But together they raise the political salience of health issues. Reformers frustrated by offenders’ resistance to their message of uplift and self-improvement urge government sanctions. In the antialcohol example, middle-class temperance activists insisted that if people would only take the dry pledge, the mounting troubles facing American cities would become more manageable. In the most enthusiastic dry sermons, urban problems would evaporate entirely. But even with salvation at hand, the incorrigibles refused to take the pledge. They harmed themselves and endangered society.11 This view of the poor as recalcitrant is no less evident in the present day. And it animates the most troubling trigger (and one of the most powerful) to government regulation of personal behavior. The demon user. Reformers in all of our cases—drink, drugs, tobacco, and sexual transgressions—urged users to take the pledge, to improve themselves. These misbegotten souls were often people on the social and economic margins: foreigners, racial minorities, the urban masses, and the lower classes. That gave the sermons a racial or class-based edge. Periodically, reformers’ disapproval burst into intense social prejudice or demonization. The history of U.S. drug wars, to take one example, unfolds as successive episodes of racial and ethnic fears. Official prohibitions on smoking opium were inspired by fears of Chinese immigrants, beginning in the 1870s.12 Cocaine panics of the 1910s were rooted in fantasies about drug-crazed black men. "Bullets fired into vital parts that would drop a sane man in his tracks," reported the New York Times, would not even slow down the "Negro cocaine fiend."13 Congress eventually responded to this racial phantasm with the Harrison Narcotics Act of 1914. During the Great Depression, West Coast alarmists fixed on Mexican Americans smoking marijuana and flying into "delirious rage." Prohibition of marijuana followed (in 1937) despite protests from the American Medical Association (AMA) that the drug might have medicinal value.14 Demonizing users—especially poor people and minority groups who drink, take drugs, or harbor sexually transmitted diseases—has been one of the most powerful spurs to government action in U.S. history. There is nothing quite like the fear of sinister others to overcome the stalemate of American policy making. Although overweight Americans have faced popular prejudice for more than a century, critiques of gluttony have not translated into demonization. Antiobesity activists do not portray overweight people as dangerous to society—like drug addicts or smokers polluting the air with secondhand toxins. In part this may be because more than half of U.S. adults are overweight, and nearly one in five is obese.15 Still, each of the other cases challenged a commonplace activity or condition. In 1965, for example, an estimated 43 percent of American adults were habitual smokers—a figure that has plummeted with changes in social mores, regulatory efforts, and disapproval bordering on the demonization of smokers.16 One common thread in past demonization episodes is at least latent in the obesity case. Poor people and members of minority groups tend to be more obese than other Americans are.17 Given the historical patterns of other ostensibly private consumption practices, the opportunity for demonization may well be present. But, to date, this has not been taken up by those calling for action against obesity. Demon industry. In all four of our comparative cases, activists attack the producers or suppliers. They charge corporate villains with seeking profits by peddling poison. Worse, the greedy industry lures children into destructive habits. The contemporary tobacco case is typical—a ruthless industry unleashes Joe Camel to ensnare America’s youth. Similarly, Prohibition gathered force by attacking the liquor trust. To gain advantage amid fierce competition, nineteenth-century breweries opened saloons and slashed the price of beer. Opponents including the Anti-Saloon League (ASL) effectively promoted Prohibition by demonizing the saloon as a terrible danger to American industry and morals. When the AMA organized a campaign against abortion in the 1870s, they targeted the commercial industry rather than the local midwife. The most celebrated case—and the end of legal abortion in the nineteenth century—involved a woman who owned and operated clinics in Philadelphia, New York, and Boston. Similarly, the drug peddler lurking near the schoolyard offers a classic twentieth-century icon of malice. Together, demon users and malevolent industries have been powerful triggers to political action across U.S. history. For unhealthy foods and obesity, this trigger emerged into political play in, roughly, 1999. The fast-food industry has become the most visible target. Eric Schlosser’s surprise best-seller, Fast Food Nation, featured some familiar demonization arguments: A cynical industry targets children, reshapes their eating habits (it is hugely "profitable to increase the size and the fat content of their portions"), and literally sponsors an epidemic ("no other nation in history has gotten so fat so fast"). Schlosser further blames the industry for a long list of harms: It has trashed the American countryside, widened the gap between rich and poor, reconstructed the entire meat-packing industry (his details of working conditions are as horrifying as anything in Upton Sinclair’s The Jungle), and cynically fed an obesity epidemic. The result is "emotional pain," "low self-esteem," and widespread illness and death.18 Until Schlosser’s book achieved best-selling status, critics of any segment of the food industry had not found a wide audience, either in the general public or among policymakers. But a growing literature slams fast foods, junk foods, and soft drinks. One marker of the change is the Wall Street Journal’s recent front-page story, "Food Makers Get Defensive about Gains in U.S. Obesity."19 With this trigger in cultural play, obesity begins to shift from being a private health matter to being a political issue. Scientific findings never carry the same political weight as does a villain threatening American youth. If critics successfully cast portions of the industry in this way, far-reaching political interventions are possible, even likely. When an industry becomes demonized, plausible counterarguments (privacy, civil liberties, property rights, and the observation that "everyone does it") begin to totter. In any case, obesity politics now centers on this trigger. Critics have begun the attack (and have launched what is likely to be a substantial flock of related lawsuits). Two additional triggers will help to determine how far the critics get. Mass movement. Identify a looming evil, and Americans often organize movements demanding a response. Activists, grouped en masse, can cut through barriers to political action by seizing the attention of policymakers. When small numbers of women knelt in prayer outside saloons in the 1870s, they met with derision. When the Women’s Christian Temperance Union (WCTU) got 200,000 women fighting liquor—the first women’s mass movement in the United States—they were welcomed into meetings with political leaders.20 Mass movements trigger political action. They overwhelm entrenched industry power (tobacco, breweries) and overcome the inertia built into American politics. Obesity politics has never stirred popular awareness on the order of WCTU marches against alcohol or the "Just Say No" antidrug crusades. When the New Republic published a supportive profile of a prominent advocate of government-sponsored antiobesity regulation, Yale psychologist Kelly Brownell, it emphasized the lack of popular agitation: "Brownell is not out leading a mass movement on the streets of New Haven and has no plans to do so."21 However, demonization generally precedes mobilization: The politics of the preceding trigger will affect the prospects for this one. If super-sizing a soft drink and fries begins to seem as dangerous as lighting up a cigarette, a movement may very well spring up. For now, at least, the sixth trigger remains untripped. Interest-group action. Cultural images ("Big Tobacco," "Just Say No") and mass movements win political attention. Interest groups translate popular energy into specific complaints and detailed policy proposals. In the antialcohol struggle, the WCTU got the attention. Its successor, the ASL, got Prohibition through Congress. Instead of mobilizing grassroots supporters, the ASL hired lawyers and lobbyists; instead of demonstrations, it sponsored legislation. The league’s methods illustrate how social disapproval gets turned into government action. Interest groups distill popular unrest and translate it for the narrow give-and-take of legislative politics. The importance of interest groups has grown over time, as have their number and their arsenal of strategies. In the tobacco case, for example, public health groups relied on class-action lawsuits along with more traditional pressure-group tactics. A coalition of antismoking groups, trial lawyers, and state attorneys general provided a crucial spur to legislative action.22 On the obesity front, public health groups such as the American Heart Association (AHA) and the National Cancer Institute (NCI) have advocated efforts to improve dietary habits since 1952, when the AHA identified obesity as a major cardiac risk factor and promoted low-fat, low-cholesterol diets and increased exercise as a response.23 More recently, critics of the food industry, such as the Center for Science in the Public Interest (CSPI), have mounted antiobesity campaigns in and beyond Washington. One of the nation’s largest health care philanthropies, the Robert Wood Johnson Foundation, recently joined the fray in defining lifestyle (including tobacco use and obesity) as one of its major concerns. Sustained pressure from these advocates has not shifted national politics toward regulatory control, in part owing to strong and savvy lobbying by the food industry and its supporters.24 The first lawsuits in the fatty-foods arena are beginning to appear. "The courts may be the next battleground," declared the New York Times in May 2002. "The stage is set to declare foods that contribute to the [obesity] problem a threat." Two months later a suit was filed against four fast-food companies charging that they sold Caesar Barber the food that made him obese and should be held accountable for "wrecking his life." The case has drawn extensive (and mostly critical) media coverage. Most observers make the obvious parallel to the tobacco wars. The proliferation of lawsuits is a modern variation of interest-group pressure—it focuses broad agitation into political action.25 Although social scientists often depict the U.S. government as relatively weak, it has been far more ready than most Western regimes have been to regulate (or prohibit) private behavior. The politics of social control generally feature the seven triggers discussed here. Of course, political history does not permit causal claims, but we believe that these descriptive analogies across time and issue areas offer a useful policy guide. Context also matters: In every example of state intervention, political action becomes possible when a "window of opportunity" opens. Even when all seven triggers are in place, policy efforts may fail—without propitious circumstances, luck, timing, or a political plan primed to go when opportunity strikes. The Clinton health care reform proposal of 1993–94 offers a cautionary tale of reformers who faltered at the final stages. Political Responses To Obesity With three triggers for governmental action satisfied and others arguably in play, political efforts to curb obesity will likely generate considerable debate, and perhaps action, in the future. For the present, however, governmental food policies tilt in a very different direction. Public regulation of high-fat foods has been limited to ensuring purity and, more recently, promoting nutrition. On the other hand, both local and national governments have actively encouraged the production and consumption of high-fat foods, especially meat and dairy products. The next sections review governmental activity in this realm over the past century. Purity. Although an antifat culture had begun to stir in the 1890s, the central political issue was food purity. Sinclair’s The Jungle generated enough public outrage to overcome industry opposition, and after several false starts Congress passed a Pure Food and Drug Act along with a permanent federal appropriation for meat inspection (both in 1906). For the next decade Progressive reformers pushed additional purity legislation. They also targeted fraudulent advertising by legislating formal guidelines for net weights and measures (in 1913). As early as 1895, Congress directed the agriculture secretary to "investigate and report upon the nutritive value of...human food, with special suggestion of full, wholesome and edible rations," but no legislative action developed as a result of the secretary’s report.26 Today governmental action remains more focused on purity and accuracy than on nutritional value. In 1999 a consortium of governmental, academic, and commercial weight-loss organizations developed new consumer-information guidelines about commercial diet programs. The Federal Trade Commission (FTC) has also been investigating fraudulent or misleading diet claims. Although critics are not yet satisfied with food inspection standards, federal attention to purity and fair market practices far exceeds attention to obesity and unhealthy foods. And compared with governmental control of alcohol, drugs, and tobacco, the response to food consumption has been feeble. Advertising fat’s dangers. Although medical science lagged behind Americans’ antifat persuasion, by the mid-twentieth century the link between diet and health outcomes had become well established. Physicians and nutritional scientists identified several risk factors contributing to obesity and definitively linked being overweight to cardiovascular disease, diabetes, and other life-threatening illnesses. This medical consensus about the dangers of being overweight had little political effect. The federal government did not officially acknowledge the connection between diet and the risk of chronic disease until 1969, when a White House conference was held on food, nutrition, and health. Subsequent action has focused primarily on collecting information, disseminating findings, and sponsoring further research. While these are not normally controversial activities, in food politics they have generated much heat. Take the apparently innocuous topic of food labeling. It was authorized by Congress in 1906 (as part of the Pure Food and Drug Act) and strongly recommended in a 1938 statute, the Food, Drug, and Cosmetic Act. The Food and Drug Administration (FDA) launched a voluntary labeling program in 1973. Prodded by the states, especially California and New York, Congress finally mandated labeling in 1990—although implementation delays dragged on until 1994. The debate about precisely what must be labeled still goes on: A New York Times editorial in 2002 charged that the FDA "continues to dither" on labeling of trans fatty acids in food.27 Government officials have also begun to publicize nutrition warnings long voiced by physicians, insurance companies, and public-interest groups (as noted in our discussion of the medical and interest-group triggers). In 1977 the federal government began promulgating dietary guidelines with a high-profile publicity campaign.28 This development apparently had important effects: Econometric analysis indicates that official warnings linking cancer and heart disease to fat consumption resulted in diminished consumption of saturated and other fats between 1977 and 1985.29 Despite generally positive results, federal enthusiasm, measured in budgetary allocations, for this approach remains limited. U.S. Secretary of Agriculture Dan Glickman publicly lamented in 2000 that "we haven’t communicated the [dietary] guidelines well. We’d like the resources to do that."30 Laura Sims, in her balanced scholarly study of U.S. nutritional policy, suggests that "the content of [government] nutrition messages may have been compromised so much by input from various organized interests that the messages are too generic and non-directive to consumers to help them make health-promoting food choices."31 Regulation. Federal and state actors have been deeply involved in the production, distribution, and consumption of food. The U.S. Department of Agriculture (USDA) was established during Lincoln’s presidency, with nutritional issues today overseen by it and myriad agencies and departments, including the FTC; the U.S. Department of Commerce; and a number of units within the U.S. Department of Health and Human Services (HHS), including the FDA, the National Institutes of Health (NIH), and many others. Yet no regulations exist to control the production or consumption of low-nutrition, high-fat foods, even within government programs. Consider, for example, the National School Lunch Program (NSLP) for undernourished children. Studies in the 1990s showed that dietary fat in government-approved school lunches far exceeded recommended guidelines; calls for reform have not resulted in action.32 Regulating high-fat, low-nutrition foods—again, partial culprits behind rising obesity rates—seems particularly difficult, given the complexity of the food regime. However, perhaps as a result of increasing attention to obesity and the first signs of industry demonization, a regulatory regime has begun to emerge. Before reviewing that development, we look at government action that appears to sustain, and even encourage, rising American obesity rates. Aiding and abetting. Instead of controlling high-fat foods, government policy actively supports them—sometimes at the expense of low-fat alternatives. The three primary sources of fat in the typical American diet are red meat, plant oils, and dairy products. Producers of all three are subsidized or otherwise aided by federal, state, and local authorities. At times the state goes further and promotes fatty foods. Surplus high-fat dairy products, for example, have long been a mainstay of federal nutrition assistance programs, including the NSLP. The USDA pursues what Sims tags a "schizophrenic mission." The agency supports beef producers "while issuing dietary guidance about meat consumption." Official policy choices may only inadvertently encourage fatty American diets, but this contribution is rarely acknowledged. "The ‘politics of fat,’ " concludes Sims, "has been conspicuously absent from debates over agricultural policy."33 What Could Government Do? If the federal government were to mobilize against obesity, what might it do? Governmental policies toward alcohol, tobacco, and drugs include at least four regulatory strategies: controlling the conditions of sale through direct restrictions or limits (especially aimed at youth); raising prices through "sin taxes"; government litigation against producers of unhealthy substances with damage awards earmarked for health care or healthy alternatives; and regulating marketing and advertising. As we noted above, federal officials already promote alternatives to unhealthy eating, via education programs warning consumers about health risks; stronger education measures might include government-funded cessation programs addressing compulsive behavior, or direct subsidies for healthy alternatives. A combination of these policies—now in place at state and federal levels for tobacco, alcohol, and drugs—could be applied to unhealthful, low-nutrition foods.34 The first glimmerings of a movement toward federal regulatory policy are becoming apparent. Fueled by muckraking investigations into the fast-food industry, recent actions include congressional legislation designed to combat childhood obesity (S. 2821), Senate subcommittee hearings on the "obesity epidemic" (in May 2002), a new $4.1 million USDA "Team Nutrition" program to teach children about healthful eating, and a White House "Health and Fitness Initiative" emphasizing physical activity (announced in June 2002). The initial commentary by lawmakers firmly denied coercive government action. Sen. Bill Frist (R-TN), the first physician elected to the U.S. Senate since 1928, declared that he was "enlisting as a soldier" in "the war against fat" when he announced his sponsorship of the Improved Nutrition and Physical Activity Act. Frist emphasized that his bill "is not going to have ‘sin’ taxes or ‘fat’ taxes. It’s not going to be punitive in any way."35 Arguably, these early signs of action are more significant than is their precise form—Senator Frist so firmly rejects "fat taxes" and "punitive" regulations because they have already emerged as policy options. The political triggers to action have started tripping—in particular, the demonization of the industry and the rise of lobbying groups. More decisive regulatory policies await further politics. If American history is any guide, rising social disapprobation, conclusive medical knowledge, and further criticism of industry (perhaps alongside attacks on obese individuals) may fan the flame of interest-group activity—including litigation—and result in far more government regulation of fatty foods. Such sanctions would represent a nightmare for libertarians and the food industry. To many public health advocates, they constitute necessary protection against what one writer terms "North Americans’ sedentary suicide." For now, the political battle has been joined.36