By Margie Nichols, Ph.D.

There’s an interesting piece by Gina Kolata in the Times today  about how funds used to combat smoking in teens is now diverting into obesity prevention in children.  The question is:  if you have to choose, which is more important to prevent?  Obesity or smoking?  Clearly we shouldn’t HAVE to choose….but if we did?

The answer isn’t obvious.  Kolata discusses some of the pros and cons.  For example, anti-smoking campaigns aimed at teens appear to have been partially successful- teen smoking has gone down, although since rates of smoking have gone down in all age groups, it’s a little hard to attribute that purely to prevention efforts.  And, the truth is that we know of nothing that prevents obesity.  As Kolata says, “..no interventions, when tested in large studies, have caused a big difference in children’s or teenager’s weights.”

So all the ‘common sense’ about preventing obesity – promoting healthier choices, more activity, soda taxes – might be about as effective as, say, the D.A.R.E. program was in keeping kids away from drugs (i.e., zero percent)  My guess is that many of these measures may prevent obesity in a small percentage of what I call ‘accidentally’ obese kids – those who really aren’t inclined to overeat and would be fine if Mom didn’t shove so much McDonald’s at them.

Another argument against targeting obesity in kids is that even could we find effective prevention methods, we aren’t absolutely sure that the problems associated with obesity would go away.  One doctor commented , “Maybe someone with a genetic predisposition to be fat and get high blood pressure would get high blood pressure even if obesity were prevented.”   But we DO know the benefits of not smoking, and they are dramatic even when people smoke into adulthood and THEN stop.

Which brings me to my decision should I be forced into a Solomonic position of choosing:  as a psychologist, I come down heavily on the side of obesity prevention, with the caveat that we have to pour a lot of money into research to see what works.  People DO stop smoking as adults.  The smoking rate among teens is just under 20%, same as for adults – down from 42% in 1964!  And as our culture increasingly grows intolerant of smoking, more and more adults quit.

And that is part of the point.  People CAN quit smoking.  Studies show that most people who want to quit smoking eventually do, even if it takes several “tries.”  But not so for obesity.  Long-term success rates for ALL methods of weight-loss save one are abysmal – well under 10%.  The one exception is bariatric surgery.   It is nearly impossible to lose and keep off significant weight as an adult, while it is almost always possible to eventually be successful in smoking cessation.  If we can actually find something that prevents obesity – we will have accomplished a miraculous stride in medicine.

One other factor influences me as a psychologist.  Kids are not ostracized, ridiculed, bullied for smoking, but they surely are for being obese.  Even adults who smoke, while they may increasingly feel like pariahs, are not really ‘shunned’ – they just have to smoke outside.  The myth of the ‘happy fat person’ is not true for children, and it is not true for obese adults.  Obese adults often face more discrimination than women, people of color, or gays, and it is still socially acceptable to do so openly.  To be obese is to suffer a lifetime of battling low-self-esteem and very real discrimination.  The psychological cost of being obese has to be factored into all the health statistics.  If they are, obesity may pull ahead of smoking as Public Health Hazard number one.


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