While smoking's popularity has been plummeting for decades
-- fewer than one in five people still smoke -- obesity has climbed to epidemic proportions and now affects more than one in three American adults.
These two trends are not unconnected. The average tobacco quitter
gains 11 or 12 pounds over the long run
. Although the benefits of not smoking are calculated to offset damage from the increased risk of obesity, the obesity tide is eroding some of the gains in life expectancy from reduced smoking.
Obviously, therefore, physicians are enthusiastically advising their heavier patients to lose weight
, hoping for the same success as they have achieved with smoking, right? Well, no. In fact, even when doctors inform patients that their body mass index (BMI) is too high, few offer constructive guidance about how to lose weight, citing barriers such as lack of time,
training and confidence.
Although physician advice can significantly boost
the success of weight-loss efforts, the proportion of people receiving such advice has fallen
. Even among patients consulting for obesity, physicians offer diet and nutrition education to only one in three.
Why is it that the public health approach applied so effectively to tobacco fails to translate to being overweight? Doctors have little hesitation about telling their smoking patients to quit, but a certain ambivalence seems to creep in when it comes to talking to patients about being overweight.
This is mirrored by official guidance. On smoking, the Surgeon General's advice to physicians is blunt: "Talk to your patients. Tell them that quitting smoking is the most important step they can take to improve their health. They will listen to you
In contrast, six pages of advice from the National Institutes of Health on talking to patients about weight loss describes obesity as a "sensitive topic," advises speaking "caringly," opening discussion "in a respectful way" and using the patient's preferred terms to describe being overweight.
Being overweight is less obviously a choice, and not a yes-no lifestyle issue where doctors can confidently say, "just stop." Moreover, official guidelines on diet and weight are notoriously inconsistent, and environmental influences on weight are far more widespread.
While stigmatizing smokers is almost de rigueur, there has been a considerable backlash against "fat shaming." One article in the Washington Post
by an emergency physician describing the difficulties of dealing with a morbidly obese patient
provoked one commentator to say she wanted to slap the doctor for his "smug and insincere pity."
Unlike smoking, a person's flab is very much a part of them. Saying "you're fat" comes to seem almost on a par with saying "you're ugly."
However, Donald Trump has recently bucked this trend
. The presidential candidate has talked publicly and disparagingly about the weight of Alicia Machado, a Miss Universe winner, and has previously called talk-show host Rosie O'Donnell a "pig."
The irony, not lost on many commentators, is that Donald Trump is not exactly slender himself. In fact, at 6 feet 3 inches and 236 pounds, according to his doctor,
his body mass index (BMI) is 29.5, putting him on the cusp of obese (a BMI of 30 or greater).
Unlike the yoga-posturing, vegetable-munching Hillary Clinton, Trump doesn't exercise. He eats buckets of fried chicken. He knows he should lose weight but his lifestyle gets in the way. He says he's always been overweight.
In other words, he's like an awful lot of Americans. So perhaps Trump is doing us a favour, making it fair game to talk about his size as a way to open discussions about obesity without upsetting those of a more sensitive disposition.
Perhaps fat-shaming Donald Trump
might even count as a public service.