Chapter 8
Political, Legal, and Social Issues of Overweight and Obesity

The politics of obesity demand that we revisit campaign contribution laws and advocate for a government agency—independent of industry—with clear responsibility for matters pertaining to food, nutrition, and health.

—Marion Nestle, professor and chair of the Department of Nutrition, Food Studies, and Public Health at New York University, in "The Ironic Politics of Obesity," Science, vol. 299, no. 781, February 7, 2003

THE GLOBAL POLITICS OF OBESITY

At the international level, the World Health Organization (WHO) has developed an aggressive plan to combat an escalating global epidemic of overweight and obesity—"globesity"—throughout the world. The WHO guidelines on diet and exercise, The Expert Consultation on Diet, Nutrition and the Prevention of Chronic Disease, released in 2003, advocate such actions as lowering intakes of sugar, salt, and saturated fats. They also recommend sharply limiting the marketing of food to children, and using tax and pricing policies to influence food consumption. The WHO asserts that these measures are necessary to reverse rising rates of the obesity-related illnesses—heart disease, diabetes, and cancer—forecast to account for nearly three-quarters of deaths worldwide by 2020.

The WHO plan was developed by an international team of experts using the latest scientific evidence available and has been commended by public health officials throughout the world. It is not, however, favored by some food manufacturers because among its proposals are restrictions on advertising unhealthy foods to children and the imposition of taxes and farm subsidy changes aimed at increasing prices of sugary and high-fat foods. For example, the International Sugar Research Organization strenuously objects to the recommendation that sugar amount to no more than 10% of food and drink calories consumed per day, calling instead for a 25% cap. Table 8.1 shows how total U.S. consumption of caloric sweeteners increased from 1966 to peak in 1999. After remaining fairly constant through 2002, use of caloric sweeteners declined slightly in 2003 but increased again in 2004.

On January 15, 2004, the United States expressed its opposition to the WHO plan and demanded significant changes to the initiative. Director of the Office of Global Health Affairs and Special Assistant to the Secretary for International Affairs at the U.S. Department of Health and Human Services (HHS) William R. Steiger questioned the validity of some of the dietary recommendations. In a twenty-eight-page critique of the WHO plan, Steiger wrote, "There is also an unsubstantiated focus on good and bad foods, and a conclusion that specific foods are linked to non-communicable diseases." Steiger put forth the U.S. position that all foods can be part of a healthy and balanced diet and called for "greater personal responsibility in battling obesity." According to WHO spokesperson David Porter, Steiger was the only member of the international scientific community to contest the proposed population nutrient intake goals.

U.S. opposition to the WHO proposal has been criticized as a clear effort to appease U.S. food and sugar suppliers. Some WHO scientists and consumer advocacy groups say the U.S. objections—specifically those about the recommendations to limit sugar consumption and reconsider food advertising aimed at young children—aim to protect industries that have recently been under attack rather than to improve public health. However, the food industry itself has publicly pledged to support the WHO plan. The Grocery Manufacturers of America, the world's largest association of food and drink companies, which includes PepsiCo Inc. and Hershey Foods Corp., said it was committed to working with WHO to combat obesity.

Kelly Brownell of the Yale Center for Eating and Weight Disorders, and Marion Nestle, chair of the Department of Nutrition and Food Studies at New York University, compared the food industry's self-serving attempts to delay action on the WHO proposal to efforts made by the tobacco industry to defend the harmless-ness of cigarettes. In "The Sweet and Lowdown on Sugar" (New York Times, January 23, 2004), the nutrition experts asserted that "By making its position on the WHO indistinguishable from that of the food industry, the Bush administration undermines the efforts of more forward-thinking food companies and threatens public health. Its action underscores the need for government to create a wall between itself and the food industry when establishing nutrition and public health policy. Recommendations to cut back on sugars may not please food companies, but it's time to stop trading calories for dollars."

The WHO global strategy did not become official until it was endorsed by member states at the U.N. summit in May 2004. While the plan is not binding, it is considered a guiding document for public health efforts on the issue worldwide. Although the draft gained broad international support, in January 2004 the WHO agreed to U.S. demands for additional time to comment on the final resolution. Nutritionists, public health agencies, and medical professional associations responded with shock and dismay that the United States had succeeded in stalling the global obesity-control plan. Despite U.S. efforts to delay its adoption, at the 57th World Health Assembly, the WHO Global Strategy on Diet, Physical Activity and Health was endorsed by resolution WHA57.17 on May 22, 2004.

The strategy provides member states with a range of policy options to address two of the major risks responsible for the heavy and growing burden of chronic diseases attributable to unhealthy diet and physical inactivity. It explains how healthier diet, nutrition, and physical activity can help to prevent and control these diseases. The document describes roles for WHO member states, UN agencies, civil society, educators, and the private sector in helping to reduce the occurrence obesity. It recommends obesity-prevention measures, including effective food and agriculture policies, fiscal policies, surveillance systems, consumer education, and nutrition labeling. The strategy urges limiting intake of sugars, fats, and salt in foods, and increasing the consumption of fruits, vegetables, legumes, whole grains, and nuts. It also emphasizes the need for countries to develop national strategies with a long-term, sustainable perspective to make the healthy choices the preferred alternatives at both the individual and community level.

Is Sugar the New Tobacco?

The WHO named sugar as the principal culprit in the current epidemic of obesity and obesity-related diseases, diabetes, and cardiovascular heart disease. The WHO approach to food is not, however, comparable to its strategy to combat tobacco use. The food strategy aims to provide member states and other interested stakeholders with a range of recommendations and policy options to promote healthier diets and more physical activity. It will be up to member states to decide how these should be further developed and implemented at the national level. Since the strategy was endorsed at the World Health Assembly, member states are responsible for determining which specific policy options are appropriate to their circumstances. WHO will then provide technical support for the implementation of programs, as requested by member states.

Americans crave sugar. Though the United States is just 5% of the world population, it accounts for a 33% of total global sugar consumption, more than ten million tons annually. Table 8.2 shows monthly estimates of U.S. sugar supply and use during fiscal year 2006. Sugar is the most subsidized U.S. crop. At a rate of nearly $500 per acre annually, U.S. sugar producers receive $1.4 billion in federal subsidies each year. U.S. sugar prices are artificially inflated because of import restrictions that protect producers from competition. Americans pay as much as four times more for domestic sugar than they would if foreign competitors were permitted to market sugar in the United States. Critics of these subsidies observe that the sugar industry makes generous contributions to senators and members of congress of both parties.

Sugar—sucrose, dextrose, fructose, corn syrup, or maltodextrin—is a key ingredient of many processed food products. Table 8.3 lists the names of added sugars that may be principal ingredients of processed foods. A can of soda may contain the equivalent of eight teaspoons of refined sugar. The Center for Science in the Public Interest (CSPI) reports that Americans' sugar consumption has been steadily increasing since the mid-1980s. The average American consumes at least sixty-four pounds of sugar per year, and the average teenage boy at least 109 pounds (http://www.cspinet.org/reports/sugar/addedsugar.html). American adults get 16% of their calories from added sugars, and children aged six to eleven get 18% of their calories from added sugars. Adolescents aged twelve to nineteen get 20% of their calories from added sugars. CSPI also observes that people with diets high in added sugars consume lower levels of fiber, fewer vitamins, and less folate, magnesium, and calcium, among other nutrients. By displacing vital nutrients and foods in the diet, added sugars may increase the risk of osteoporosis, cancer, high blood pressure, heart disease, and other health problems.

Although the health food industry has been warning the public about the perils of over-consumption of refined sugars for more than thirty years, mainstream nutritionists and public health professionals have joined the ranks of those calling for reduced sugar consumption. Along with ending sugar subsidies, they want to sharply limit advertising of sugary products to children, ban the sale of soft drinks in schools, and conduct widespread community public health education programs to inform Americans about the health risks of consuming excessive amounts of refined sugars.

THE U.S. WAR ON OBESITY GAINS MOMENTUM

In addition to generating international debate, the issue of obesity is receiving considerable attention from lawmakers, public health officials, and politicians throughout the United States. Some legislators and policy makers have chastised the administration of President George W. Bush for allegedly yielding to the food industry and trying to dilute the WHO antiobesity plan. Among the many legislative initiatives being considered are proposals to mandate nutrition information on restaurant menus, improving school lunch programs, and the imposition of taxes on high-calorie, low-nutrition food items.

Along with Brownell and Nestle, some of the combatants on the frontlines and in the news are Richard

Daynard, president of the Public Health Advocacy Institute, California state senator Deborah Ortiz (D-Sacramento), federal regulator John Graham, nutritionist Margo Wootan and executive director Michael Jacobson, both of the Center for Science in the Public Interest, law professor Richard Banzhaf, and Richard Berman, executive director of the Center for Consumer Freedom, an advocacy group supported by restaurant and food companies.

Skirmishes in the war on obesity do not center on whether there is a problem, but rather on how best to address it. Participants on one side characterize the food industry, advertisers, and the media as complicit—coercing consumers with seductive advertising and sugary, high-calorie treats. Their opponents believe that consumers should exercise personal responsibility and make their own choices about food and exercise.

In "The Ironic Politics of Obesity" (Science, vol. 299, no. 5,608, February 7, 2003), Nestle asserted that the war on obesity is unlikely to be won because healthful eating is not in the best interest of U.S. industry, and government agencies are beset by conflicts of interest. Nestle has condemned the lack of government leadership, observing that the U.S. Department of Agriculture (USDA) offers confusing and conflicting advice to consumers. To fulfill its mission to promote U.S. agricultural products, the USDA simultaneously exhorts consumers to eat more, while issuing sadvice about diet, which for many overweight Americans means "eat less." This conflict of interest has produced vague federal dietary guidelines that advise Americans to "aim for a healthy weight, [and] choose beverages and foods to moderate your intake of sugars." Nestle has called for "small taxes on junk foods and soft drinks (to raise funds for antiobesity campaigns); restrictions on food marketing to children, especially in schools and on television; calorie labels on fast foods; and changes in farm subsidies to promote the consumption of fruits and vegetables."

In contrast, the WHO strategy does not stipulate any specific tax or subsidy. However, it observes that several countries have adopted fiscal measures to promote availability of and access to various foods, and to increase or decrease consumption of certain types of food. The strategy notes that public policies can influence prices through such measures as tax policies and subsidies. The strategy acknowledges that decisions on policy options are the responsibility of individual member states, depending on their particular circumstances.

The Public Health Advocacy Institute (PHAI) contends that food industry processing and marketing practices have encouraged excessive food consumption. The PHAI Law and Obesity Project considers the existing state of regulation, legislation, and litigation related to the food industry's contribution to obesity, and the potential for new legal strategies to effectively reduce that contribution. PHAI board member Richard Daynard has suggested that every fast-food receipt should include not only item costs, but also calorie and fat content information.

California state senator Ortiz spearheaded a legislative victory that prohibits the state's public elementary and middle schools from selling soda from vending machines. On September 15, 2005, California Governor Arnold Schwarzenegger signed legislation to ban the sale of soda in the state's public high schools. John Graham, a Harvard University professor of public health who serves as administrator of the Office of Information and Regulatory Affairs, Office of Management and Budget, campaigned to require food manufacturers to disclose the trans-fat content of their products on nutrition labels. (Trans-fats are formed by the partial hydrogenation of vegetable oil—the process used to make vegetable oil more solid. Trans fats raise LDL cholesterol levels and may lower HDL cholesterol.) The campaign was successful. As of January 1, 2006, the U.S. Food and Drug Administration (FDA) requires disclosure of the trans-fat contents of food to be sold in the U.S. market.

Richard Banzhaf, who campaigned forcefully against tobacco, advocates using the legal system to create change in Americans' diets. He exhorts attorneys to bring lawsuits against fast-food purveyors and manufacturers of junk food to increase consumer awareness of the role the food industry has played in promoting obesity.

Richard Berman, whose organization represents major corporations such as RJR Nabisco, has marshaled lawyers, publicists, and lobbyists to respond to antiobesity crusaders. The Center for Consumer Freedom identifies itself as a nonprofit coalition that stands for "common sense and personal choice." Its Web site derides lawsuits and legislation aimed at limiting consumers' rights to choose the foods they want to consume, and it pokes fun at CSPI mandates to offer consumers nutritional data, and the self-appointed "food police"—legislators, public health officials, and others—intent on modifying Americans' diets (http://www.consumerfreedom.com/). The organization is credited with helping to defeat a measure introduced by Ortiz in 2003 that would have required chain restaurants to offer nutritional data about their products. It also endorsed Florida Republican Representative Ric Keller's Personal Responsibility in Food Consumption Act (H.R. 339), aimed at protecting restaurants from obesity-related lawsuits. On January 28, 2004, the U.S. House Judiciary Committee approved H.R. 339; however, a companion bill introduced in the Senate, the Common Sense Consumption Act (S. 1428) did not make it out of Committee. In October 2005 the Center for Consumer Freedom was protesting legislative efforts to institute a fast-food restaurant and food service tax in Michigan.

The American Obesity Association Action Plan

In 2002 the American Obesity Association Action Plan put forth an agenda for the government that enumerated specific funding priorities, programs, and services to prevent, treat, and educate Americans. The plan called for:

• A national commitment to combating obesity comparable in scope and funding to those for cancer, HIV/AIDS, and smoking
• Full implementation of the National Institutes of Health Guidelines for the treatment of obesity in federal health programs including Medicare, Medicaid, federal employee health plans, the Indian Health Service, and plans for the military and veterans
• Allocation by Congress of at least $750 million to fund a comprehensive research program on obesity
• Accelerated HHS-funded research specifically aimed at preventing and treating childhood and adolescent obesity
• Assumption of a key leadership role by the education community to address the rise of obesity among students at all levels
• A Medicare prescription benefit to enable older adults and disabled people to gain access to antiobesity medications
• Support for consumer protection agencies' efforts to identify and eliminate frauds and deceptive practices directed against people with obesity
• Collaboration between the federal government and private organizations to initiate a campaign to better inform employers of the issues of workplace discrimination and denial of access to obesity treatment

• Enacting legislation introduced by Senators Patrick Leahy (D-VT) and Richard Lugar (R-IN) to allow the Secretary of Agriculture to more effectively restrict the sale of soft drinks and other foods of minimal nutritional value in schools that participate in the federal school-lunch program
• Concerted efforts of the HHS and the Department of Education to encourage states to screen students for diabetes and hypertension

By the close of 2005 at least one key AOA objective had been realized. In July 2004 the AOA celebrated the decision by the Centers for Medicare and Medicaid Services to eliminate language from its policy that said obesity is not a disease.

During 2005 AOA advocacy efforts centered on investigating and reversing insurers' decisions to eliminate coverage of bariatric surgery for people with clinically severe obesity. OPERATE (Obese People Entitled to Receive Appropriate Treatment Equitably) is a AOA project developed to reverse the January 1, 2005, decision by Blue Cross Blue Shield of Florida to drop bariatric surgery as a covered benefit for its members and to promote access to treatment for people with obesity. The AOA is focusing on the Florida insurer because it is concerned that if its decision is not overturned then other insurance companies may also opt to exclude or eliminate benefits. The OPERATE coalition includes "health professionals, businesses, hospitals, the general public, and any person or group who has a shared commitment to improve the lives of people with morbid obesity" (http://www.obesity.org/subs/advocacy/operate.shtml).

OVERWEIGHT, OBESITY, AND THE LAW

In 2005 a few states considered taxing foods and beverages with minimal nutritional value and using the revenues to finance school facilities or childhood obesity prevention initiatives. A bill introduced in Nebraska would impose a sales tax on snack foods to create a fund for school facilities, and Texas would impose a statewide sales tax on items listed as a "sweet" or "snack" (in the National Nutrient Database for Standard Reference by the USDA) and use the resulting revenues to fund childhood obesity prevention programs.

The states continue to debate the benefits of requiring insurers to provide coverage for surgical treatment of clinically severe obesity. In 1999 Georgia was the first state to mandate coverage, and in 2000 Indiana and Virginia followed suit. Legislation to provide or strengthen private insurance coverage for obesity prevention or treatment, especially for people with clinically severe obese was considered or enacted in 2005 by Alaska, California, Connecticut, Georgia, Indiana, Maryland, Missouri, Mississippi, Tennessee, and Virginia. Maryland currently requires insurers to cover obesity treatment including surgery, while Georgia, Indiana, and Virginia require private insurers to offer general coverage for clinically severe obesity as an option.

Legislators Target School Programs

The National Conference of State Legislatures reported that during 2005, legislatures were actively considering policy options to address the obesity epidemic. Aiming to start early to prevent the onset of chronic conditions, legislators proposed a variety of policy approaches to create opportunities for a healthier diet and more exercise beginning in childhood. State legislatures in thirty-eight states considered or enacted legislation aimed at improving the nutritional quality of school foods and beverages. This includes twenty-one states in which such legislation was under consideration in 2005, fifteen states in which legislation was enacted, one state in which legislation passed both chambers of the legislature and was sent to the lieutenant governor, and one state in which the legislation was vetoed.

The seventeen states that enacted school nutrition legislation in 2005 are Arizona, Arkansas, California, Colorado, Illinois, Kansas, Kentucky, Louisiana, Maine, Maryland, New Mexico, North Carolina, Oklahoma, Rhode Island, South Carolina, Texas, and West Virginia. Legislation was sent to the lieutenant governor in Utah. In Texas, legislators modified school nutrition requirements already in place through the state's Department of Agriculture. The Texas Public School Nutrition Policy became effective August 1, 2004, under the auspices of the state's Agriculture Commissioner, who was authorized by the governor to administer the state's National School Lunch Program, School Breakfast Program, and After School Snack Program. New Jersey also implemented comprehensive school nutrition standards through its Department of Agriculture under the governor's direction in 2005, effective for the 2007–08 school year.

In Connecticut, a comprehensive school nutrition and physical activity bill passed the legislature but was vetoed by the governor. The bill would have required a daily minimum period of physical activity for students, established committees to monitor and implement nutrition and physical activity policies, and limited the types of beverages available to students. Nineteen other state legislatures considered school nutrition legislation in 2005—Alabama, Alaska, Hawaii, Indiana, Iowa, Massachusetts, Missouri, Mississippi, Montana, Nebraska, New Hampshire, New Jersey, New York, North Dakota, Ohio, Oregon, Pennsylvania, Tennessee, and Virginia.

During 2005 Colorado, Kentucky, Maine, and West Virginia enacted obesity initiatives that provide nutrition content information for foods on school menus or all foods and beverages served in schools to enable students and parents to make healthy choices. Many states also considered legislation to require nutrition labeling or menu information for food and drink items in all restaurants or retail food establishments. While many states have school health education requirements, in recent years legislators have considered or enacted bills specifically requiring nutrition education aimed at preventing childhood obesity as a key component of school health curricula. California, Colorado, Illinois, Kansas, Maine, South Carolina, Texas, and West Virginia were among the states that required some form of nutrition education in 2005.

The federal Child Nutrition and WIC Reauthorization Act of 2004 (P.L. 108-265) requires each school district participating in the National School Lunch and/or Breakfast Program to establish a local wellness policy by the beginning of the 2006–07 school year. Statewide legislation for wellness policies was considered or enacted in 2005 independently or in response to the federal requirement in California, Colorado, Illinois, Ohio, Rhode Island and Tennessee.

In 2005 thirteen states considered or enacted legislation related to student body mass index (BMI). Tennessee and West Virginia mandated monitoring BMI as part of comprehensive antiobesity legislation. Other states that considered BMI legislation in 2005 include Alaska, Connecticut, Georgia, Iowa, Maine, New Jersey, New York, North Carolina, Oregon, South Carolina, and Texas. In Arkansas, the first state to enact BMI legislation in 2003, legislation was introduced in 2005 to repeal the state's requirement for confidential reporting of student BMI information to parents, but it did not pass. Tennessee legislation requires reporting student BMI to parents as part of a confidential health report card; providing parents with basic information about what BMI means and what they can do with this information; and encourages schools where BMI data suggest high rates of overweight to expand or implement school-based nutrition and physical activity programs. In West Virginia, the legislation establishes physical activity requirements in public schools using BMI as an indicator of progress and includes BMI measurement in kindergarten screening procedures. West Virginia students in grades four through eight and those in high school physical education will undergo BMI measurement in required fitness testing procedures. The legislation protects student confidentiality and requires that all BMI data be reported in aggregate to the governor, the State Board of Education, the Healthy Lifestyles Coalition, and the Legislative Oversight Commission on Health and Human Resource Accountability.

Forty-eight states continue to require physical education in schools, but the nature and extent of the requirement varies. In 2005 thirty-five states considered legislation governing physical activity or physical education in schools and at least eight of those states enacted legislation including Arizona, Colorado, Kansas, Kentucky, Louisiana, Montana, South Carolina, and Texas. States have focused on increasing physical education requirements or encouraging positive physical activity programs for students during and after school. Some states and school districts cite the cost of physical education programs and an emphasis on academics as obstacles to increasing physical education programs.

States with legislative proposals to create childhood obesity task forces, commissions or studies in 2005 included Kansas, New Mexico, North Carolina, Virginia, and West Virginia. California and Illinois enacted legislation to raise public awareness of childhood obesity and to address the problem with wellness, nutrition, and physical activity initiatives.

RESTOCKING VENDING MACHINES IN SCHOOLS

The CDC School Health Policies and Programs Study (SHPPS) 2000 survey found that 43% of elementary schools, 89.4% of middle/junior high and 98.2% of senior high schools had either a vending machine or a school store, canteen, or snack bar where students could purchase competitive foods or beverages (food of the same types available in grocery and convenience stores, as opposed to school lunch foods that must adhere to federal nutrition guidelines).

Since 2000 many states have undertaken efforts designed to improve the nutritional value of the products available in food and beverage vending machines in elementary, middle/junior, and high schools. Some states have introduced and enacted legislation to replace existing food and drinks of minimal nutritional value with healthier options or to restrict student access to the machines. This is not exclusively state issue; some cities and local schools districts have established policies banning or replacing specific foods and beverages in vending machines or restricting student access to the machines.

In 2003 two states enacted laws regarding vending machines in schools. Arkansas banned access by elementary school students to vending machines offering food and soda. California banned vending machine sales of carbonated beverages to elementary, middle, and junior high school students and replaced them with milk, water, and juice. It also limited vending machine access in middle and junior high schools from one-half hour before the start of the school day to one-half hour after the end of the school day. In the 2004 session four states—Colorado, Louisiana, Tennessee, and Washington—enacted laws regarding vending machines in schools. In 2005 state legislation specific to vending machines in schools was introduced in Arizona, California, Connecticut, Florida, Hawaii, Illinois, Indiana, Iowa, Kansas, Kentucky, Maryland, Michigan, Mississippi, Montana, Nebraska, New Jersey, New Mexico, New York, North Dakota, Oklahoma, Oregon, Pennsylvania, Rhode Island, Tennessee, West Virginia, and Virginia.

Lawsuits Attack Food Service Industry

An increasing number of individuals and advocacy groups are bringing lawsuits against the food service industry. Some claim they deserve compensation for the damage that fattening foods have done to their health. Others focus on advertising and marketing that they feel is deceptive and misleads people into eating unhealthy products. Many attorneys and public health professionals endorse such lawsuits because they can serve as vehicles by which to reverse the obesity epidemic, in part because the media attention generated by such lawsuits motivates food companies to produce healthier products and to reconsider marketing and advertising practices.

The first class-action suit was the widely publicized case of Caesar Barber, a fifty-six-year-old New Yorker weighing 270 pounds, who claimed that four fast-food restaurants—McDonald's, Burger King, Wendy's, and KFC—jeopardized his health by promoting high-calorie, high-fat, and salty menu items. In "Whopper of a Lawsuit: Fast-Food Chains Blamed for Obesity, Illnesses" (ABCNews.com, July 26, 2002), Geraldine Sealey reported that Barber filed the lawsuit in the New York State Supreme Court "on behalf of an unspecified number of other obese and ill New Yorkers who also feast on fast food." According to Sealey, Barber's suit alleged that the fast-food restaurants, where he ate "four or five times a week even after suffering a heart attack, did not properly disclose the ingredients of their food and the risks of eating too much." Although Barber's suit was dismissed by two judges and he was barred from filing a third time, legal scholars assert that more cases like his will be heard by the courts.

The legal community did not have long to wait. In January 2005 an appeals court ordered McDonald's to defend a 2004 lawsuit by New York teenagers Ashley Pelman and Jazlen Bradley, who claim the company hid the health risks of Chicken McNuggets and other foods that made them obese. Samuel Hirsch, the lawyer who represented Caesar Barber, represents the teenagers. The suit is the first complaint accusing a fast-food chain of hiding health risks of their food to be considered by a judge. The teenagers said they ate at McDonald's restaurants three to five times a week over a fifteen-year period. Their suit claims the company hid the health risks of Big Macs, Chicken McNuggets, and other foods high in fat and cholesterol in its 1987 advertisements in the United States and in brochures circulated in Great Britain. McDonald's defended the accuracy of its ads and asserted that there was no evidence that the teenage plaintiffs, one of whom was born in 1988, ever saw the ads.

Prior to the teens' and Barber's suits, there were at least three narrower lawsuits alleging negligent or misleading practices in the fast-food industry. In 2003 McDonald's settled a $12 million lawsuit and apologized for engaging in deceptive advertising. The company conceded that it failed to adequately disclose additives and processing methods that made its food less healthful, and wrongly described its French fries, which are cooked using beef-flavored soybean oil, as vegetarian. A similar lawsuit was filed against Pizza Hut for allegedly using beef fat as an ingredient in its Veggie Lovers' Pizza. Another 2002 class-action lawsuit alleged that the makers of the corn and rice puff snack food "Pirates' Booty" fraudulently misrepresented the food's fat content, underreporting it by more than 340%.

PHYSICIANS GROUP SUES DAIRY INDUSTRY

In July 2005 the Physicians Committee for Responsible Medicine filed a class action lawsuit against the dairy industry and several food companies for falsely claiming that dairy consumption can help people lose weight. The suit was prompted by television and print advertisements sponsored by the dairy industry that claimed consuming twenty-four ounces of fat-free or low-fat dairy per day can help the body burn fat. The physicians committee contends that most scientific evidence shows people will either gain weight or remain the same weight with increased dairy consumption. According to the committee, the industry claims rely almost exclusively on research conducted by Michael B. Zemel, a University of Tennessee nutritionist whose work is funded by the dairy industry. Zemel responded to these charges by saying that the funding he has received from General Mills and the National Dairy Council has not affected his findings.

The physicians committee is not alone in their lawsuit. Co-plaintiff Catherine Holmes is also suing for $236, the amount she spent on dairy products in a failed attempt to lose weight. Holmes claims that she gained two pounds rather than losing weight when she increased her dairy consumption by eating yogurt and cottage cheese.

One of the defendants in the case is the International Dairy Foods Association (IDFA), a trade group that represents food manufacturers that use dairy products. A spokesperson for the IDFA asserted that the claims were valid and were reviewed by the USDA. Two other defendants in the case are the National Dairy Council, Dairy Management Inc., General Mills, Kraft Foods, Dannon Co., Lifeway Foods, and McNeil PPC (Frederic J. Frommer, "Group to Sue Dairy over Weight-Loss Claim" Associated Press, June 27, 2005).

Legislation Protects Food Industry Interests

The food industry and others argue that Americans choose what they eat, and should not be able to blame the food industry if their personal choices have unhealthy consequences. State and federal legislators that agree with this viewpoint have enacted or attempted to enact laws that protect the food industry from weight-related lawsuits.

On October 19, 2005, the House of Representatives passed a bill that would prevent most obesity or weight-related claims against the food industry and make it harder than ever before for consumers to sue restaurants and food retailers for serving fattening fare. By a vote of 307 to 119, lawmakers endorsed the "Personal Responsibility in Food Consumption Act," which informs consumers that if they gain weight as a result of eating high-fat, high-calorie, and sugar-laden food, they have only themselves to blame. The legislation, however, did not receive a vote in the Senate and did not become law.

The restaurant and food-processing industries have also championed state measures such as the Idaho Commonsense Consumption Act, signed into law on April 2, 2004, which bans civil lawsuits for obesity and obesity-related health problems. The same month, Arizona enacted legislation affirming, "that there is no duty to warn a consumer that a non-defective food product may cause health problems if consumed excessively and provides an affirmative defense."

In 2005 Wyoming enacted a bill that limits an individual's ability to sue food and beverage companies. Specifically, Wyoming's Commonsense Consumption Act, H.B. 170, prohibits an individual from suing a manufacturer, seller, trade association, agricultural producer, wholesaler, broker, or retailer of a qualified product for injury or death based on the individual's weight gain, obesity, or a health condition related to weight gain or obesity. South Dakota and Utah had passed comparable legislation in March 2004, followed by Colorado, Florida, Georgia, Missouri, and Tennessee in May 2004, Louisiana in June, Illinois in July, and Michigan in October. In addition to Wyoming, Kansas, Kentucky, Maine, North Dakota, Ohio, Oregon, and Texas introduced and enacted legislation limiting obesity-related lawsuits in 2005.

At the close of 2005, Minnesota, Nebraska, New Jersey, New York, Oklahoma, Pennsylvania, Rhode Island, South Carolina, and Wisconsin were considering variants of this type of legislation. Alabama, California, Connecticut, Iowa, Maryland, Mississippi, Montana, Nevada, New Hampshire, New Mexico, North Carolina, Pennsylvania, Virginia, and Wisconsin tabled or defeated such legislation in 2004–05. Although lawmakers in many states agreed that lawsuits against restaurants for obesity claims are frivolous, several did not consider it necessary to pass legislation to prevent such lawsuits. In Wisconsin, Governor Jim Doyle vetoed an obesity lawsuit bill, indicating that courts are capable of distinguishing frivolous lawsuits from those with merit.

THE FOOD INDUSTRY RESPONDS TO PUBLIC OUTCRY

Mounting pressure on the food industry to change its marketing practices and offer healthier products has had some success. For example, in 2003 Coca-Cola withdrew from exclusive vending-machine contracts in schools, and acquired Odwalla, an organic fruit-juice company, to enable the company to offer healthy beverages. Kraft announced intentions to eliminate in-school marketing to children, introduce smaller portions, and develop more nutritious products. Applebee's International began to offer Weight Watchers selections on its restaurant menus. McDonald's reduced the use of trans fats for cooking its French fries and has introduced a line of salads as well as leaner versions of its Chicken McNuggets. On January 6, 2004, McDonald's restaurants in New York, New Jersey, and Connecticut launched McDonald's "Real Life Choices," a program to help consumers stick to their diets while eating fast foods. The program teaches consumers how to choose food items based on the calorie, fat, or carbohydrate content. For example, breakfast choices include an "Egg McMuffin," which, when prepared without butter or margarine, is less than 300 calories, a snack-size fruit and yogurt parfait that contains less than 8 grams of fat, or a double order of scrambled eggs with fewer than 5 grams of carbohydrates.

In March 2004 McDonald's responded to growing attention to the relationship between portion size and obesity by announcing that the corporation would discontinue its "supersize" products—French fries and soft drinks—in an effort to simplify its menu and appeal to consumers' heightened awareness about obesity. McDonald's also piloted a new "Go Active" meal for adults that included a salad, a pedometer to count steps, and a bottle of water in several test markets throughout the country. Industry observers applauded these moves, citing the corporation's shift from the "value" aspect of fast food—providing more food for less money—to a more health-conscious purveyor of salads and reasonable portion sizes that emphasize nutrition rather than value. They also expressed the hope that other fast-food chains would follow suit and offer more nutritional information and low-calorie fare.

In another effort to counter charges that its food is unhealthy and contributes to obesity, McDonald's announced that it will display nutrition facts on the packaging for most of its menu items beginning in 2006. Customers of the world's largest restaurant company will be able to learn the amount of calories and fat, among other information, in a McDonald's product by looking at the wrapper instead of having to go to its Web site or ask for nutrition information at the counter.

In 2005 Kraft, the country's largest packaged food company, launched a variety of healthier foods, including whole-grain Wheat Thins, a whole-grain version of macaroni and cheese, and whole-grain Chips Ahoy and Fig Newtons. A three-cookie serving of the new Chips Ahoy has 8 grams of fat and 150 calories, ten fewer than the original; in addition, there is one more gram of fiber, two per serving instead of one. Kelly Brownell, director of the Rudd Center for Food Policy and Obesity at Yale University lauded Kraft for its new products but cautioned that consumers might be lulled into overeating by the healthy whole-grain foods and forget that while the new products are more nutritious, they are not low in calories (Melanie Warner, "Kraft Introduces Two Somewhat Healthier Cookies Made of Whole Grains," New York Times, September 16, 2005).

WEIGHT-BASED DISCRIMINATION

Nearly everyone who is overweight or obese has suffered some form of bias, from disapproving glances and unsolicited advice about how to lose weight to the seemingly unending stream of "fat jokes" and the unflattering and even humiliating portrayal of overweight people in the media. Despite the pervasive anti-fat bias in American culture, until recently there were anecdotal reports, but little evidence, demonstrating that negative attitudes toward obese individuals resulted in stigmatization and clear instances of discrimination.

In "Bias, Discrimination, and Obesity" (Obesity Research, vol. 9, no. 12, December 2001), Rebecca Puhl and Kelly Brownell reviewed data revealing that systematic discrimination against obese individuals occurs in at least three areas—education, employment, and health care. They also acknowledged that evidence points to discrimination in adoption proceedings, jury selection, and housing.

The authors described obese people as "the last acceptable targets of discrimination" and named rejection—teasing, taunts, derogatory comments, and derision—by peers as the first of many challenges overweight or obese youngsters will face. Some studies have found distinct anti-fat bias in children as young as age three, and increasingly negative stereotypic attitudes with age. Puhl and Brownell point to a landmark study conducted during the 1960s in which children were shown pictures of six children with various physical characteristics and disabilities, including use of crutches or wheelchair, amputations, or facial disfigurements, and were asked to rank them in order of whom they would be most likely to befriend. The majority of subjects ranked the picture of the obese child last. When this study was performed again in 2001, children in the fifth and sixth grade displayed the strongest bias against the obese child and expressed even more prejudice than their counterparts had forty years earlier. Teachers also revealed considerable bias, with nearly 30% in one survey describing becoming obese as "the worst possible thing that can happen to a person."

The authors observed that along with the psychological and social consequences of prejudice and exclusion, obese students suffered lower rates of college acceptance, with obese women gaining college admission less frequently (31%) than obese male applicants (42%). They also found that normal-weight college students received more financial support from their families than overweight students, and overweight women were least likely to receive financial support.

Overweight and obese job applicants and workers may be subjected to weight-based discrimination in employment. Numerous studies have documented discrimination in hiring practices, especially when the positions sought involved public contact, such as sales or direct customer service. Obese workers face inequities in wages, benefits, and promotions, and several studies have confirmed that the economic penalties are greater for women than for men. Overweight women earn less doing the same work as their normal-weight counterparts and have dimmer prospects for promotion. The courts have considered cases in which workers contended that their job terminations were weight-related. The outcomes of these cases indicate that termination can occur because of employer prejudice and arbitrary weight standards.

Research conducted by Dalton Conley, director of the New York University Center for Advanced Social Science Research and Rebecca Glauber found that while overweight women did not fare as well as their normal-weight peers in terms of income, overweight men were as successful, economically and in terms of job status, as normal-weight men. The researchers showed that increased BMI significantly decreased women's family income as well as their "occupational prestige," a measure of the social status afforded to different jobs. A 1% increase in a woman's BMI reduced her family income by 0.6% and a 0.4% decrease in occupational prestige. Along with lower pay and less-prestigious jobs, heavier women's poorer socioeconomic outcomes were attributable to three factors:

• Overweight women tend to have lower chances of getting married.
• When they do marry their spouses tend to have less earning power.
• Overweight women have a higher risk for divorce.

Consistent with past research, men experience no negative effects of body mass on economic outcomes. Overweight men are not less likely to marry, nor are they at increased risk for divorce, separation, or widowhood (Dalton Conley and Rebecca Glauber, "Gender, Body Mass and Economic Status," Working Paper No. 11343, National Bureau of Economic Research, May 2005).

Weight Bias among Health Professionals

Anti-fat bias among health-care professionals may discourage obese people from seeking medical care and compromise the care they receive. Although research has indicated that obese patients often delay or cancel medical appointments for a variety of reasons, including fear about being weighed or undressing in front of health professionals, speculation exists that presumed or real prejudice on the part of health professionals also may deter them from seeking medical care. When researchers asked more than 400 physicians to name patient characteristics that provoked feelings of discomfort, reluctance, or dislike, one-third of the subjects mentioned obesity, making it the fourth most-common condition named after drug addiction, alcoholism, and mental illness. The subjects also linked obesity to negative qualities such as poor hygiene, hostility, dishonesty, and noncompliance with prescribed treatment. Another survey of family physicians found that two-thirds said their obese patients lacked self-control, and nearly 40% characterized their obese patients as lazy. Nurses expressed similar attitudes—nearly half reported that they were uncomfortable caring for obese patients, and 31% told surveyors they would prefer not to care for obese patients at all.

Puhl and Brownell found documented evidence that deeply held negative stereotypes adversely affected the clinical judgment of health professionals, including diagnosis and the quality of care delivered to obese patients. A survey of more than 1,200 physicians revealed that most were ambivalent about caring for overweight and obese patients, and did not intervene or treat them with the same determination they displayed toward normal-weight patients. Just 18% said they would refer an overweight patient to a weight-loss program, and less than half (42%) would refer a mildly obese patient to a weight-loss program.

Even health professionals who specialize in the medical treatment of obesity are not immune from anti-fat bias. Marlene Schwartz and her colleagues administered a standardized test that measured bias to 389 health professionals (198 women and 191 men)—physicians, researchers, dieticians, nurses, psychologists, and others—who attended an international obesity conference in Quebec in 2001. The researchers reported the test results in "Weight Bias among Health Professionals Specializing in Obesity" (Obesity Research, vol. 11, no. 9, September 2003). Bias was assessed using the Implicit Associations Test (IAT), a timed test that analyzes the automatic associations respondents make about particular attributes. For example, the IAT helps to identify whether or not test-takers hold negative attitudes and stereotypical views about obese people, such as considering them to be lazy, unmotivated, sluggish, or worthless.

The researchers found that the health professionals they tested—one-third of whom provided direct clinical care to obese patients—exhibited significant anti-fat bias. They linked the stereotypes lazy, stupid, and worthless with obese people, with younger health professionals displaying more anti-fat bias than older health-care workers did. The researchers hypothesized that younger health professionals may have been more strongly imprinted with societal pressures to be thin, which have intensified in recent decades. Another explanation may be that older health professionals, who have more maturity and experience, may have overcome some of their negative attitudes about obese patients. Despite the presence of bias, the researchers conceded that while it is intuitively appealing to assume that bias has an influence on treatment, their research did not demonstrate that bias resulted in poorer treatment of obese patients.

OBESE AMERICANS RECEIVE FEWER PREVENTIVE HEALTH SERVICES

Ironically, people who are obese and usually receive more medical care for chronic diseases related to obesity, also may receive fewer preventive services. Does bias contribute to this disparity in preventive care? Researchers Truls Østbye and his colleagues at the Department of Community and Family Medicine, Duke University Medical Center in Durham, North Carolina, examined the association between BMI and receipt of screening mammography and Papanicolaou tests (screening for cervical cancer) among middle-aged women and the association between BMI and receipt of influenza vaccination among older adults (Truls Østbye et al., "Associations between Obesity and Receipt of Screening Mammography, Papanicolaou Tests, and Influenza Vaccination: Results from the Health and Retirement Study [HRS] and the Asset and Health Dynamics Among the Oldest Old [AHEAD] Study," American Journal of Public Health, vol. 95, no. 9, September 1, 2005). The investigators analyzed data from the Health and Retirement Study (4,439 women aged fifty-sixty-one years) and the Asset and Health Dynamics Among the Oldest Old (AHEAD) Study (4,045 women and 2154 men aged seventy years or older).

They found significant differences in how often obese women were given mammograms and Pap smears to screen for cancer. They also found that obese men and women were also less likely to receive flu shots. Seventy-one percent of the obese women studied reported having mammograms, compared with 78% of those who were not obese. Similarly, 54% of the obese women reported having Pap smears, compared with 73% of the non-obese women. In addition, 57% of the obese men and women whose records were reviewed reported receiving flu shots, compared with 78% of the people who were of normal weight. The investigators posed several potential explanations for the disparity in preventive services—obese patients' reluctance to undress for cancer screening tests, practitioners' difficulties in performing screening tests on obese women, and the observation that obese patients may require so many medical care services for chronic diseases that preventive care may be overlooked.

Airlines Weigh Their Options

In June 2002 Southwest Airlines became the center of a fiery debate when the airline decided to strengthen its enforcement of a policy established in 1980 of requesting and requiring passengers who, because of excessive girth, must occupy two airplane seats to purchase both seats. The policy allows passengers to be reimbursed for the additional seat if their flight is not full. The National Association to Advance Fat Acceptance (NAAFA), an advocacy group, and other consumer groups termed the move discriminatory. Southwest Airlines is not the only airline with this policy; Continental, Northwest, and other commercial carriers also require large-sized passengers to pay for two seats.

In 2003 the Federal Aviation Administration (FAA) proposed requiring all passengers on small airlines to be weighed in along with their luggage. The FAA asserted that before take-off, the pilot must calculate the weight of the aircraft as well as that of its passengers, luggage, and crew to determine which seats passengers should occupy to ensure proper balance. For this reason it is vital to know exact passenger and luggage weights on small planes, where several people with a few extra pounds can tilt the plane away from its center of gravity. Although operators of smaller commuter airlines acknowledged the safety issue, they were reluctant to support the FAA recommendation because they feared that weighing people would discourage them from using commuter airlines, many of which are already strapped financially.

In May 2003 the FAA ruled that airlines must assume that passengers weigh 190 or 195 pounds depending on the season. At the same time, checked bags on domestic flights were adjusted from an estimated twenty-five pounds to thirty pounds. The thirty-pound estimate for checked bags on international flights remained unchanged. The requirement followed shortly after the crash of a commuter plane that killed all twenty-one people aboard. Investigators suspect the propeller plane was slightly above its maximum weight on takeoff, with most of the weight toward the tail. The weight distribution problem was compounded by a maintenance error that made it difficult to lower the nose with the control column. After the nineteen-seat plane rose above the ground, its nose pointed dangerously skyward; the pilots were unable to level it off, and the plane spun into the ground.

In October 2004 research conducted by Andrew Dannenberg and his colleagues at the CDC revealed that the average American gained ten pounds during the 1990s. The extra weight required an additional 350 million gallons of fuel used by airlines in 2000. The extra weight translated into about $275 million in excess costs in 2000 alone—and that calculation was made when jet fuel cost less than half of 2006 prices. The extra fuel represented 2.4% of the total volume of jet fuel used domestically that year, and along with the monetary cost, there was the environmental impact of burning all that extra jet fuel to transport what the CDC termed "this additional adiposity." Jack Evans, spokesperson for the Air Transport Association of America, which represents major U.S. airlines, agreed that weight is a real issue, "Every bit of added weight increases the amount of fuel you're going to be burning." He explained further that weight considerations and fuel prices have prompted airlines to replace metal forks and spoons with plastic utensils and to forgo bulky magazines.

Obese Female Shoppers Face Discrimination

In April 2005 investigator Eden King and her colleagues at Rice University in Houston, Texas, reported the results of a study that revealed widespread rude behavior and discrimination against obese female shoppers. The investigators discovered that when women aged nineteen to twenty-eight wore prosthetic suits designed to make them appear obese, they were treated more rudely, and received less eye contact and fewer smiles from sales clerks at a Houston shopping mall than when they shopped without the fat suit. Although nearly three-quarters of the sales clerks were women, they tended to interact less with the obese female shoppers, ending interactions abruptly and assuming more negative tones of voice with them.

Treatment of the obese shoppers was worse when they were dressed casually than when they wore professional attire, and interestingly, their treatment improved when they shopped sipping diet soda and volunteered that they were trying to lose weight. A survey of shoppers conducted as part of this study found that survey respondents who were obese reported being subjected to more rude treatment from sales clerks, which prompted them to spend less time and money in the stores where they experienced discrimination. King and her colleagues were optimistic that the financial and ethical implications of this study would provide powerful incentives for retailers to address size discrimination with employees (Society for Industrial and Organizational Psychology, Los Angeles, California, April 15-17, 2005).

San Francisco Bans Weight-Based Discrimination and Hears Landmark Cases

On July 26, 2000, the San Francisco Human Rights Commission unanimously approved historic guidelines for implementing a height/weight anti-discrimination law, and the city became the first jurisdiction in the United States to offer guidelines on how to prevent discrimination based on weight or height (Compliance Guidelines to Prohibit Weight and Height Discrimination, San Francisco Administrative Code Chapters 12A, 12B, and 12C and San Francisco Municipal/Police Code Article 33). Santa Cruz, California, Seattle, Washington, Washington, D.C., and the state of Michigan have similar laws banning discrimination based on height or weight.

The strength of the ordinance was tested two years later when Jennifer Portnick, a 240-pound aerobics instructor, was refused a job at Jazzercise, Inc., an international dance-fitness organization based in Carlsbad, California, and brought her case before the San Francisco Human Rights Commission. She later reached an agreement with the company to drop a requirement about the appearance of instructors. It was the first case settled under the San Francisco ordinance, which has become known as the "fat and short law."

Patricia Leigh Brown, in "240 Pounds, Persistent and Jazzercise's Equal" (New York Times, May 7, 2002), reported that Portnick's attorney, Sondra Solovay, the author of Tipping the Scales of Justice: Fighting Weight-Based Discrimination, said Portnick was "geographically lucky" to have filed her case in one of just four jurisdictions in the country that outlawed weight-based discrimination.

Some observers did not celebrate Portnick's victory. In "Fat Law Should Be Repealed" (Ifeminists.com, May 14, 2002), George Getz, press secretary for the Libertarian Party, described Portnick's case and the San Francisco ordinance as "a case of political correctness run amok," and "just one example of the sizable side effects of government regulation." Libertarian Party executive director Steve Dasbach characterized the ordinance as "another wacky anti-discrimination law," and an outgrowth of the 1990 Americans with Disabilities Act (ADA), which was intended to protect people with disabilities from discrimination but has been used to protect and defend workers with controversial "disabilities" such as a dentist fired for fondling his patients, because he had a sexual addiction, and a worker fired for falsifying records, because he had an impulse disorder that prompted him to wrongdoing. (Obesity itself is not considered a disability under the ADA; however, people with obesity-related disabilities are protected by the landmark legislation. Because the ADA does not specifically include or exclude obese people, the extent of its protection will be determined in litigation.) Dasbach declared that Portnick's win, forcing an aerobics company to employ an overweight instructor, could pave the way for more implausible hiring practices, such as schools forced to hire illiterate teachers.

SHOULD BALLET SCHOOLS DISCRIMINATE?

Another complaint filed under the San Francisco ordinance alleged that the prestigious San Francisco Ballet School demonstrated size-bias in its rejection of eight-year-old Fredrika Keefer. The aspiring ballerina's mother, Krissy Keefer, said the school discouraged Fredrika from auditioning because she did not have the "physical attributes that the school looks for." When Fredrika was not accepted to the school, her mother was told that Fredrika's height (3 feet, 9 inches) and weight (64 pounds) were an issue—she did not fit the school's published criteria requiring applicants to have "a well-proportioned, slender body."

The school is subject to the San Francisco ordinance because it receives $550,000 annually from the city's "Grants for the Arts" program. Still, the school denied it had any specific written height or weight requirements for students, and said physical appearance is never the sole determining factor when auditioning applicants. In a published interview, the school's attorney, Emily Flynn, said "It is axiomatic to say that ballet training requires certain physical attributes, and the school's admissions process is inherently selective" ("San Francisco Ballet School Faces Allegations of Size Bias," CNN.com, January 2, 2001).

The case provoked heated debate among feminists, advocates of affirmative action, and members of the professional dance community. In "Counterpunch: Critic's Argument for Heftier Dancers Is Thin" (Los Angeles Times, April 16, 2001), Toni Bentley, a former dancer with the New York City Ballet, asked rhetorically, "Should music students be admitted to the Juilliard School who are tone deaf and to medical schools with C and D grade averages? Should short guys be hired by the NBA? Should round little girls be admitted to professional ballet schools, thereby being subjected to a competitive discipline for which they are at a disadvantage?" Bentley asserted that "if the arts or sports are to be subjected to affirmative action and lack of discrimination against the untalented and physically inappropriate, then they will cease to exist."

The Web site of the San Francisco Human Rights Commission reported in April 2002 that the case was being settled without an investigation (http://www.sfgov.org/site/sfhumanrights_page.asp?id=16789). Fredrika Keefer continued dancing and appeared in the production Einstein's Daughters at the Cowell Theater in San Francisco in 2003. As of March 2006 Krissy Keefer was a voting member of the San Francisco Arts Task Force, an organization charged with making recommendations regarding program funding in support of the arts.

The Origins of Stigma and Bias

Rebecca Puhl and Kelly Brownell have written extensively about the pervasiveness and strength of weight stigma in the United States. In "Psychosocial Origins of Obesity Stigma: Toward Changing a Powerful and Pervasive Bias" (Obesity Reviews, vol. 4, no. 4, 2003), they observed that many people intensely dread the possibility of becoming obese. In one survey, about one-quarter of women and 17% of men said they would sacrifice three or more years of their lives to be thin. There are reports of women who choose not to become pregnant because they fear gaining weight and becoming fat. Others smoke cigarettes in an effort to remain thin or reject the advice that they quit smoking because they fear they will gain weight should they quit. This powerful fear of fat, coupled with widespread perceptions that overweight people lack competence, self-control, ambition, intelligence, and attractiveness, create a culture in which it is socially acceptable to hold negative stereotypes bout obese individuals and to discriminate against them.

One explanation of the origin of weight stigma is that traditionally Americans believe in self-determination and individualism—people get what they deserve and are responsible for their circumstances. In this context, when overweight is viewed as resulting from controllable behaviors, it is easy to understand that if an individual believes overweight people are to blame for their weight, then they should be stigmatized. Other research find-ings—that many Americans view life as predictable, with effort and ability inevitably producing the desired outcomes, and the finding that attractive people are deemed good and believed to embody many positive qualities—support this theory. Interestingly, researchers have found that in other countries, the best predictors of anti-fat attitudes were cultural values that held both negative views about fatness and the belief that people are responsible for their life outcomes.

Several other theories about the origins of weight stigma have been proposed. "Conflict theory" suggests that prejudice arises from conflicts of interest between groups and struggles to acquire or retain resources or power. "Social identity theory" posits that groups develop their social identities by comparing themselves to other groups, and designating other groups as inferior. "Integrated threat theory" proposes that stigmatized groups are perceived as a threat. Proponents of this theory suggest that overweight and obese people threaten deeply held cultural values of self-discipline, self-control, moderation, and thinness. Another theory, "evolved dispositions theory," proposes that members of a group will be stigmatized if they threaten or undermine group functioning. This evolutionary adaptation may predispose people to shun obese individuals since they are at increased health risk, and may not be able to make sufficient contributions to the group's welfare because of weight-related illness or disability.

Reducing Weight Bias and Stigma

Bethany Teachman and her colleagues wondered if anti-fat bias would be reduced when people were told that an individual's obesity resulted largely from genetic factors rather than as the result of overeating and lack of exercise. The investigators assigned study participants to one of three groups. The first group received no information about the cause of obesity; the second group was given an article asserting that the principal cause of obesity was genetic; and the third group was given an article that attributed the majority of obesity to overeating and lack of physical activity. As the researchers anticipated, the group told that obesity was controllable—resulting from overeating and inactivity—revealed the greatest amount of bias. However, to their surprise, the investigators found that the group informed that obesity was primarily genetic in origin did not have significantly lower levels of bias than either the control group that had received no prior information or the group informed that obesity was caused by overeating and inactivity ("Demonstrations of Implicit Anti-Fat Bias: The Impact of Providing Causal Information and Evoking Empathy," Health Psychology, vol. 22, no. 1, January 2003).

The investigators also wanted to find out whether eliciting empathy for obese people would significantly reduce negative attitudes. Teachman and her colleagues hypothesized that by sharing written stories about weight-based discrimination with study participants they would feel empathy with the subjects in the stories, which they would then generalize to the entire population of obese people. While some study participants in the group that read the stories displayed lower bias, the majority did not have lower bias than a control group that had not read the stories of discrimination. The investigators speculated that the stories describing negative evaluations of an obese person might actually have served to reinforce rather than diminish bias.

Puhl and Brownell observe that the increasing prevalence of obesity has not acted to reduce weight bias. They also refute the notion that stigma is necessary to motivate overweight and obese people to lose weight. They reiterated that dieting is not associated with long-term weight loss, regardless of the individual's motivation. Further, stigma has led to discrimination and exerts a harmful influence on health and quality of life. These obesity experts contend that unless stigma is reduced, obese people will continue to contend with prejudice and discrimination.

Although few studies have evaluated the effectiveness of strategies to reduce weight stigma, a variety of initiatives have produced varying degrees of attitudinal change. These approaches include:

• Educating participants about external uncontrollable causes such as the biological and genetic factors that contribute to obesity
• Teaching and encouraging young children to practice size acceptance

• Improving attitudes by combining efforts to elicit empathy with education about the uncontrollable causes of obesity
• Encouraging direct personal contact with overweight and obese individuals to dispel negative stereotypes
• Changing individuals' beliefs by exposing them to opposing attitudes and values held by a group that they consider important. This approach is known as "social consensus theory," and relies on the observation that after learning that a group does not share the individuals' beliefs, they are more likely to modify their beliefs to be similar to those expressed by the group they respect or wish to join.

In "Psychosocial Origins of Obesity Stigma: Toward Changing a Powerful and Pervasive Bias," Puhl and Brownell described the results of their experiments using social consensus theory to modify attitudes toward obese people. They conducted experiments with university students in which participants reported their attitudes toward obese people before and after the researchers offered them varying consensus opinions of other students. In one experiment, participants who were told that other students held more favorable attitudes about obese people reported significantly fewer negative attitudes and more positive attitudes about obese people than they had before they learned about the opinions of other students. Further, they also changed their ideas about the causes of obesity, favoring the uncontrollable causes after they were told the other students believed obesity was attributable to these causes.

A second experiment confirmed that the power to alter the participants' beliefs depended on whether the source of the opposing beliefs was an "in-group" or "out-group." Not surprisingly, participants' attitudes toward obese people were more likely to change when the information they were given came from a source they valued—an "in-group." In a third experiment the researchers compared attitudinal change produced by social consensus with other methods to reduce stigma, including one in which participants were given written material about the uncontrollable or controllable causes of obesity. They found that social consensus was as effective as or more effective than any of the other methods they applied. The researchers stated that social consensus theory also offers an explanation about why obese individuals themselves express negative stereotypes—they want to belong to the valued social group, and choose to accept negative stereotypes in order to align with current culture. Further, by accepting prevailing cultural values and beliefs they not only resemble the in-group more closely but also distance themselves from the out-group, where identity and membership are defined by being overweight or obese.

Although Puhl and Brownell consider social consensus a promising approach to reducing weight bias and stigma, they caution that there are many unanswered questions about its widespread utility and effectiveness. They concluded that "an ideal and comprehensive theory of obesity stigma would identify the origins of weight bias, explain why stigma is elicited by obese body types, account for the association between certain negative traits and obesity, and suggest methods for reducing bias. Existing theories do not yet meet all these criteria."

Advocacy Groups Promote Size and Weight Acceptance

People get so many conflicting messages about what is healthy and what is attractive. The same thin celebrities who were being glamorized in recent years are now being airbrushed to look even thinner on magazine covers. That sends a terrible message, both to the celebrities and to the public. Love your body, it's the only one you have. You have to take care of yourself—and that starts with self-esteem.

—Allen Steadham, director of the International Size Acceptance Association, in a press release dated July 18, 2003

There is a growing consumer movement that advocates size and weight acceptance with the overarching goal of assisting people to have positive body images at any weight and to achieve health at any size. Nearly all organizations that champion size acceptance characterize preoccupation with dieting and weight loss as unhealthy and unproductive, citing statistics about diet failures, the dangers of "yo-yo dieting"—slowed metabolism, increased fat storage, and regained weight—as well as frustration and low self-esteem. The size acceptance movement proposes that it is possible to be fit and fat and that health and beauty are attainable at all weights. It also works to reduce "fat phobia," anti-fat bias, and weight-based discrimination.

In July 2003 the International Size Acceptance Association (ISAA), an organization that promotes size acceptance and aims to end size discrimination throughout the world by means of advocacy and visible, lawful actions, launched the Respect Fitness Health Initiative and Healthy Body Esteem campaigns to provide an alternative to the "diet-of-the-day" pressures and gloom-and-doom predictions about size and weight that assault people every day. The ISAA asserts that people of all sizes can become more fit, and the organization is committed to helping people of all sizes strive for higher levels of fitness and improvements in their overall quality of life. Similarly, the organization observes that everyone could benefit from healthier food choices and is committed to helping inform the public about healthy nutrition.

In May 2005 the ISAA issued its first "Size Friendly Business Award" to the McDonald's Corporation, to commend the corporation's introduction of healthier food choices into its menus, installation of "size appropriate seating" in the restaurants, and longstanding tradition of having indoor and outdoor playground equipment to encourage physical activity in children. ISAA director Allen Steadham explained that, "ISAA's core concept is 'Respect-Fitness-Health' and we want to recognize businesses that implement this concept. We believe that the McDonald's Corporation has committed to promoting health and responsibility in creating a positive environment for consumers of all sizes" ("Size Acceptance Organization Awards McDonald's Corporation," International Size Acceptance Association, http://www.size-acceptance.org/isaa_awards_mcdonalds.html, May 20, 2005).

Another group, the Council on Size & Weight Discrimination, Inc., a not-for-profit consumer advocacy organization working to end "sizism," bigotry, and discrimination against people who are heavier than average, focuses its advocacy efforts on affecting changes in medical treatment, job discrimination, and media images. The Council's basic principles were derived from "Tenets of the Nondiet Approach" (Karin Kratina, Dayle Hayes, and Nancy King, Moving Away from Diets: Healing Eating Problems and Exercise Resistance, 2nd edition, [Lake Dallas, TX: Helm Publishing, 2003]) and focus on:

• Total health enhancement and well being, rather than weight loss or achieving a specific "ideal weight"
• Self-acceptance and respect for the diversity of bodies that come in a wide variety of shapes and sizes, rather than the pursuit of an idealized weight at all costs
• The pleasure of eating well, based on internal cues of hunger and satiety, rather than on external food plan or diets
• The joy of movement, encouraging all physical activities rather than prescribing a specific routine of regimented exercise

The National Association to Advance Fat Acceptance (NAAFA) is a nonprofit human rights organization dedicated to eliminating discrimination based on body size and providing people with the "tools for self-empowerment through public education, advocacy, and member support." NAAFA has assumed a proactive role in protesting social prejudice, bias, and discrimination, as well as working with the Federal Trade Commission to stop diet fraud. The organization also seeks to improve legal protection for people who are overweight and obese by educating lawmakers and serving as a national legal clearinghouse for attorneys challenging size discrimination.

One of the main themes of the August 2005 annual NAAFA convention was "fat fitness." Workshop instructors advised the predominantly female attendees from throughout the United States and Great Britain that fitness was important at any body size and that being healthy and in good shape does not necessarily mean being thin. The lack of men at the convention was, according to the few men present, a clear indication of how society unfairly discriminates with regard to size.