AMA Journal of Ethics^®

The researchers studied 4 sitcoms that feature African American characters and are popular with African American audiences—Moesha, The Parkers, Malcolm and Eddie, and The Jamie Foxx Show. They also examined 4 sitcoms without African American stars that are popular with general audiences—Friends, Frasier, Jesse and Stark Raving Mad. They concluded the following:

• 27 percent of the actors on the African American-oriented shows were overweight, compared to 2 percent on the general interest shows.
• 4.78 food commercials aired per half hour during the African American-oriented shows versus 2.89 during the other shows.
• 31 percent of commercials during the African American-oriented shows were for candy and 13 percent were for soda, compared to 11 percent for candy and 2 percent for soda in the general interest shows¹.

Dr. Anjali Jain, the University of Chicago pediatrician who headed the study, commented upon the disparity: "One could say this is an accurate reflection of African American reality, but on the other hand it might also be viewed as an ideal. It might help overweight people to feel less stigmatized, but . . . it might give them the message there aren't any adverse health consequences to being overweight"². This is not to suggest that overweight people should not star in television shows. On the contrary, people of all sizes and shapes should figure in programs that claim to offer viewers a "slice of life." What is at issue is the message conveyed when people who carry excess weight are portrayed almost invariably as happy individuals who have no health complications to worry about due to their weight. A similar phenomenon occurs in film, where characters often smoke but seldom experience the health consequences associated with the habit. Nor are the concerns here different from those raised by ad campaigns that showcase emaciated women as ideals of beauty that girls will want to emulate.

Food advertising specifically tailored to certain segments of the population is nothing new. Marketers of junk food have become quite sophisticated in targeting young children. This kind of advertising has become so pervasive that critics are calling for an outright ban of junk food advertising geared toward kids. Michael Jacobson, executive director of the Center for Science in the Public Interest, and Marion Nestle, chair of the New York University's Department of Nutrition and Food Studies, both argue that the government should ban junk food advertising on children's programs³. Although physicians have often blamed advertising for contributing to the obesity epidemic in this country, others cite a certain amount of peer pressure to gain weight. "People look at the rest of the country [and think,]: Everybody else is fat, why not me," says Michael Fumento, author of The Fat of the Land and senior fellow at the Hudson Institute. He states that being obese is no longer stigmatizing and is even something to be celebrated, citing the "fat and proud" movement. "You used to be proud because you did well in school, or your kids did well in school, or you earned a medal in a war," he says. "You're not supposed to be proud because you ate three sandwiches and the guy next to you ate one"⁴.

Attention to one's weight is often framed as a preoccupation with appearance, indication of poor body image, and source of social stigmatization, and these are valid considerations. It is not appropriate, however, to discuss weight only in terms of aesthetics when its implications for health are significant. The Department of Health and Human Services' Healthy People 2010 finds overweight people at increased risk for high blood pressure; type 2 diabetes; coronary heart disease; stroke; gallbladder disease; arthritis; sleep disturbance (apnea); respiratory problems; breast, prostate, and colon cancers; and depression.

In a country where more than 100 million adults are overweight [5] and obesity in younger children has been called an epidemic, it is time for the health consequences of obesity to be emphasized and addressed. Public education about nutrition and the importance of exercise is key to preventing and controlling problems of excess weight. To be involved in this public health initiative that has direct impact on patients' well-being, physicians need to have adequate knowledge in nutrition. Along with teachers and other community leaders, health care providers can play a significant role in helping people develop balanced diets and integrate exercise into their daily routine. As Former Surgeon General Dr. C. Everett Koop, founder of "Shape Up America!," notes, "While there are obviously some costs involved, the result in terms of reduced health care expenditures will far exceed the dollars spent"⁶.

Why has there not been more outreach in this public health area—with efforts similar to those extended in the battles against tobacco, alcohol, and violence? By using its resources to teach the principles of health-promoting lifestyles, the health sector could help reduce the number of overweight people and, in turn, reduce expenses associated with treating health complications of obesity.

Although excess weight is a problem across the population, studies report that it is more prevalent among certain groups—particularly low-income African American women who not only face financial and neighborhood safety barriers to shopping for products that promote healthy living habits but also tend to be more tolerant of obesity⁷. This observation brings us back to television programming and stereotypes. As Dr. Jain notes, "In some ways, the TV findings may just reflect reality, but I think it also plays a role in creating that reality. The chicken-and-egg argument is definitely there"⁸.

Along with ethnicity and culture, education influences consumption patterns. Younger and less educated viewers may be more influenced by what is pitched on the airwaves. Seeing healthy and happy obese characters and commercials for junk food may undermine educational efforts to improve dietary habits. Physicians have a responsibility to educate patients about nutrition and counter the plethora of images in the culture that promote poor dietary habits. Unfortunately, these images often target the most vulnerable members of our society: children, the poor, and people of color. Medical groups should devote resources to developing programs to combat obesity based on models of existing anti-tobacco and anti-alcohol campaigns. The real challenge for physicians and physician groups lies in designing educational campaigns that promote fitness and good eating habits without further marginalizing those who are seriously overweight.

Questions for Discussion

1. Is there a danger that well-intentioned advocacy for vulnerable populations might turn into a new form of old-fashioned paternalism?
2. What can we do to encourage marginalized populations to take more active roles in their own health?