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date: 25 May 2020

Obesity Prevention and Promotion of Good Nutrition: Public Health Ethics Issues

Abstract and Keywords

This chapter provides a brief introduction to obesity prevention and discusses some ethical concerns with obesity prevention efforts, as well as some ethical arguments for them. A first set of ethical issues centers on justice and the perceived inequity or unfairness of obesity prevention efforts, as well as justice-based arguments for obesity prevention efforts targeted at disadvantaged groups. A second set of ethical issues concerns stigma, responsibility, and moral blame, and whether obesity discourse and efforts inappropriately stigmatize or assign responsibility to individuals. A third set of ethical concerns focuses on choice, and whether government regulation of the marketplace is problematically paternalistic. After providing a brief overview of these ethical concerns with obesity prevention, the chapter ends by arguing that the ethical conversation would be enriched by more fully incorporating a discussion of the value of eating.

Keywords: obesity prevention, paternalism, choice, justice, fairness, responsibility, stigma, public health ethics

(p. 585) Introduction

Recent decades have seen sharp increases in overweight and obesity worldwide (Ng et al., 2014). According to public health organizations and experts, these high rates of overweight and obesity have significant consequences for public health, increasing the risk for diet-related disease and causing an estimated 3.4 million deaths worldwide in 2010 (Lim et al., 2013). Along with the human cost—in terms of illness and early death—obesity and diet-related disease have significant financial costs (Finkelstein et al., 2009). To many researchers and policymakers, this “obesity epidemic” demands a comprehensive response by public health and the global community more generally (IOM and CAPOP, 2012; WHO, 2013). Yet some aspects of the public health response to obesity have generated ethical controversy. This chapter introduces obesity prevention and then discusses some ethical concerns with efforts to foster healthy eating. Though obesity prevention encompasses both efforts to increase physical activity and to promote healthy eating, this chapter focuses on the latter efforts because they have generated more controversy.

(p. 586) Explanations of Unhealthy Eating and Obesity

Researchers have created complex models of eating behavior (e.g., Afshin et al.’s (2014) “barriers and opportunities for healthy eating,” or Story et al.’s (2008) “ecological framework depicting the multiple influences on what people eat”) that identify a wide variety of influences on eating behavior. These influences include facets of the individual, aspects of the community environment, social and cultural influences, policies, and basic structural features of societies. According to many such models and frameworks, individual behavior should be understood in the context of local food environments, which are situated within larger systems. These larger systems include national and international policies and rules, as well as structural features of societies, such as economic systems or health care systems.

Some features of local food environments identified as influencing eating include pervasive and low-cost packaged food and fast food; aggressive marketing that makes these foods desirable and socially normative; and the lesser availability and higher cost of healthier foods such as fruits, vegetables, and whole grains (Afshin et al., 2014; Story et al., 2008; Schwartz and Brownell, 2007). For example, Schwartz and Brownell (2007, 79–80) give a vivid description of the food environment as a “toxic environment”:

Driving down the highway, we see dozens of drive through windows at fast food restaurants, billboards with advertisements for inexpensive snacks, and soft drinks at drugstores, and when we stop for gas, shelf after shelf of high-fat and high-sugar snacks at gas station mini marts …. A variety of good tasting snacks and meals are now highly visible and accessible for most Americans, and there is also evidence that since the 1970’s, portion sizes have gotten larger, and far exceed federal guidelines. These foods are also extremely convenient compared with home made meals, fast food and packaged foods are easier to obtain and ready to eat immediately, as they require little preparation …. Another layer of the toxic environment that promotes the consumption of unhealthful foods is their heavy promotion by the food industry.

This “toxic environment” interacts with human biology and psychology to create obesity, according to Schwartz and Brownell.

Moving out from the local environment, there are broader systems, policies, and social forces cited as creating local food environments and causing obesity. These include rising incomes in developing countries, which lead to dietary shifts toward energy-dense and less healthy foods in those countries, also known as the “nutrition transition” (Popkin, Adair, and Ng, 2012); lifestyles that discourage physical activity, encouraged by technological advances and transportation and zoning policy, such as policies that encourage commuting by car rather than public transportation or bicycle (Lang and Rayner, 2007); agricultural policies, such as subsidies for corn and soy that have led to an excess of cheap corn and soy, which are used in sugary and high-fat processed foods; (p. 587) technological advances in food processing and distribution that have increased the availability of convenient, high-calorie foods (Finkelstein and Zuckerman, 2008); and so on. Some scholars offer even “bigger picture” explanations of obesity, arguing that neoliberalism—the political economic system emphasizing free market capitalism and a minimal state—contributes to increasing rates of obesity, in part because it encourages seeing consumer choice as a right, and thus seeing government regulation of the food marketplace as illegitimate (Guthman and DuPuis, 2006; Wilkerson, 2010).

Obesity Prevention Efforts

As the previous chapter, “Malnutrition, Public Health, and Ethics,” discussed, there are multiple influences on unhealthy eating and obesity that occur at multiple levels. Accordingly, efforts to promote healthy diets target these multiple levels. A contrast is sometimes drawn between individual-focused approaches and environment-focused approaches (Roberto et al., 2015; Brownell et al., 2010; Kirkland, 2011), but in fact multiple kinds of obesity efforts can be distinguished, including efforts focused on changing how individuals interact with their environments, such as individual weight-loss interventions; policies that directly change local food environments, such as opening more grocery stores in underserved neighborhoods; policies affecting the food supply and food marketplace, such as agricultural subsidies, or regulations limiting the amount of sodium or trans-fat packaged foods; and policies addressing broader social and economic factors that influence health, such as policies that increase access to health care, improve public transportation, and reduce poverty.

Although these approaches are distinct, they are not mutually exclusive and could be pursued simultaneously. Indeed, given the complexity of obesity, it is likely that complementary approaches are required. For example, the World Cancer Research Fund International’s NOURISHING framework identifies ten focal policy areas for healthy eating and the prevention of diet-related disease (WCRF, 2016). These include policies focused on behavior change; policies focused on changing the food environment, such as restrictions on advertising, as well as subsidies and taxes to change consumer choices; and policies focused on food system change, such as incentivizing the production of healthier foods.

Given the limited effectiveness of individual-focused efforts, such as nutrition education or weight-loss interventions, researchers and advocates commonly claim that such efforts are not sufficient and need to be supplemented or replaced with environment-focused interventions, as the NOURISHING framework does (Story et al., 2008; Schwartz and Brownell, 2007; Roberto et al., 2015). But some scholars go farther, arguing that, given the limited effectiveness of obesity prevention efforts in general, the public policy focus should be on policies addressing broader social and economic factors that influence health, policies accomplishing multiple goals at once, and not policies focusing on obesity prevention per se (Williams, 2015). For example, Garrath Williams (2015) (p. 588) points to the mixed and disappointing evidence on community-level obesity prevention efforts. He suggests that the public policy focus should not be on wider implementation of community-level efforts, but rather on public policies that address broader social and economic factors that influence health. Julie Guthman (2011) and Anna Kirkland (2011) also call for a shift in attention from efforts to change the food environment to broader social policies, such as policies that increase access to health care and transportation.

Despite these critical voices, expert recommendations remain focused on addressing obesity directly. They typically highlight the need to change food environments and the composition of products available in the marketplace, as well as encouraging individual behavior change (WHO, 2013; IOM and CAPOP, 2012; Roberto et al., 2015).

Ethical Concerns with Obesity Efforts

Obesity prevention and healthy eating efforts raise a range of ethical issues. For example, ten Have et al. (2013, 305) identify eight potential ethical pitfalls with obesity prevention efforts: these efforts may negatively affect “physical health, psychosocial well-being, equality, informed choice, social and cultural values, privacy and the attribution of responsibilities and liberty.”

The remainder of this chapter discusses a few of these ethical pitfalls. Along the way, some ethical arguments for obesity prevention are also discussed.

Justice, Equality, and Fairness

One set of ethical concerns centers on justice, equity, and fairness. First, consider high-income countries. Some argue that the higher rate of overweight/obesity and diet-related diseases among some racial/ethnic minority groups and lower-income populations is an equity and justice issue, and that there is thus a justice-based ethical reason to focus preventive efforts on these groups (Kumanyika, 2005). Obesity prevention efforts that provide resources or increase food access—such as efforts to increase food access for low-income populations and in underserved areas—address multiple justice-based concerns. Not only do these efforts address health disparities, they also address disparities in food access that are seen as a separate and important justice issue. Access to healthy, culturally appropriate food is seen as an important resource; inadequate access is seen as a failure of distributive justice; and increased food access is a central goal of the food justice movement (Alkon and Agyeman, 2011; Szende, 2015). Inadequate food access is also seen as the result of other injustices, such as institutional racism (Szende, 2015).

When society turns to obesity efforts that restrict or disincentivize options, or that penalize certain behaviors, quite different justice-based and fairness-based arguments (p. 589) are made. Financial disincentives, such as taxes on sugary drinks, or higher health insurance premiums for employees who do not participate in employer wellness programs to promote healthy eating and physical activity, are objected to as regressive (that is, they take a larger percentage of the income of low-income people), and as unfair or inequitable for that reason (Barry, Niederdeppe, and Gollust, 2013). Some object to the perceived inequity of “targeting” low-income and minority groups with efforts that may not be welcome and that smack of “micromanaging” their personal choices (Kirkland, 2011; Barnhill and King, 2013). In response, others argue that disadvantaged groups have the most to gain from taxes on sugary drinks, because they have higher rates of obesity. Thus, far from being regressive and unfair, these efforts can disproportionately benefit disadvantaged groups (Barry, Niederdeppe, and Gollust, 2013).

Turning to low- and middle-income countries, there is a complex relationship between disadvantage and diet-related disease. Some, but not all, risk factors and diet-related diseases are more prevalent in lower-income populations (Di Cesare et al., 2013). This raises a distinct equity question: As increasing attention is put on reducing the global burden of diet-related illness, will this burden be reduced in an equitable way (Di Cesare et al., 2013; Schmidt and Barnhill, 2015)? Will scarce resources in low- and middle-income countries be spent disproportionately on prevention and treatment for better-off, middle-class populations that have more political power? Some have argued that there is an ethical demand to focus prevention on the most disadvantaged populations in these countries (Schmidt and Barnhill, 2015).

Stigma and Moral Blame

A second set of ethical pitfalls with obesity efforts concerns stigma, responsibility, and moral blame. Scholars and activists have criticized the public conversation about obesity as characterized by negative moral judgments of overweight people, including the view that they are lazy or lack self-control (Puhl and Heuer, 2010); the “belittling” view that overweight people are victims of their environments and do not exercise their agency (Guthman, 2007; Kirkland, 2011); and the inappropriate attribution of responsibility and moral blame to overweight people for being overweight, when in fact overweight has environmental and social causes, and thus is not something individuals cause and not something that individuals should be morally blamed for or held liable for. Some discussions of obesity and responsibility combine distinct kinds of responsibility that, as a matter of ethical reasoning, ought to be distinguished, such as causal responsibility (e.g., whether individuals caused their overweight, or whether it was caused by external factors), role responsibility (e.g., whether it is the individual’s role to ensure healthy eating, or whether this is society’s job, or both), blameworthiness (e.g., whether people deserves moral blame for their eating habits or body weight, and whether the food industry deserves moral blame for its actions), and liability (e.g., whether people should be held liable for the higher costs associated with eating behavior or weight, for example by paying taxes on junk food or paying higher health (p. 590) insurance premiums if they are overweight). Wikler (1987) offers a helpful discussion of distinct notions of responsibility at play in discussions of health.

Some scholars question whether public concern with obesity and diet-related disease derives primarily from concern for public health, or whether it instead reflects something else, such as bias against overweight and obese people, moral judgments about people who are overweight or obese, or an aesthetic preference for thinness. A related argument is that public concern with obesity is an instance of “moral panic,” in which groups or behaviors seen as deviant come to be seen as a threat to society, typically involving an exaggeration of risks. (Campos, 2006; Guthman, 2007).

Some specific obesity prevention efforts have also been called stigmatizing, such as public information campaigns meant to evoke guilt, shame, scorn, and other negative emotions (Kliff, 2012; Abu-Odeh, 2014; Fairchild, Bayer, and Colgrove, 2015). Researchers have argued that stigmatization is counterproductive in reducing obesity (Goldberg and Puhl, 2013). Stigma increases stress and unhealthy eating, reduces the quality of care provided to overweight people, and reduces their utilization of health care (Puhl and Heuer, 2010). Stigmatizing obesity efforts also runs the risk of exacerbating background discrimination against people who are overweight and obese. The consensus among ethicists is that the stigmatization of overweight and obesity is counterproductive and ethically inappropriate, though there may be some vagueness about what stigma in fact is. “Stigma” and “stigmatization” are used by some authors to refer to a specific kind of social sanction that is severe and all-encompassing, involving a loss of status, shame, and self-punishment. But other authors and researchers use these terms more loosely so that they refer to public disapproval, social marginalization, self-directed shame, and other related phenomena (Bayer, 2008a; Bayer, 2008b; Burris, 2008). A useful definition comes from Andrew Courtwright (2013, 78), who states that “for an institution to stigmatize a health related characteristic or behavior involves changing norms about the desirability of the activity, marking the bearers of the trait, and excluding them from the broader community, a process that can, but does not necessarily, create a spoiled social identity.”

Choice, Paternalism, and Regulation of the Marketplace

A third set of ethical concerns with healthy eating and obesity efforts focuses on choice, paternalism, and government regulation of the marketplace. Recommended obesity policies typically include increased regulation of the food industry, such as reformulating, taxing, or banning products and placing restrictions on food marketing. These regulations are sometimes framed as protecting consumers from a food industry that not only imperils health but also undermines consumer autonomy by misleading, deceiving, manipulating, or exploiting consumers (Nestle and Ludwig, 2010; Frieden, 2013; Roberto et al., 2015; Farley, 2015). Public resistance to these aggressive regulations is sometimes explained as the result of industry influence, with the industry working behind the scenes to shape public opinion (Nestle, 2007; Frieden, 2013; Farley, 2015; (p. 591) Aaron and Siegel, 2017; Kearns, Schmidt, and Glantz, 2016). But this resistance should not be dismissed without careful examination, because it reflects long-standing ethical objections to government paternalism.

Governmental efforts to promote healthier eating are sometimes derided as instances of the “nanny state.” This complaint reveals philosophical objections to paternalistic policies that interfere with individuals’ choices or actions in an effort to improve those individuals’ welfare, such as policies banning the sale of certain products like large sugary drinks or food made with trans fats (Dworkin, 2017). Paternalistic policies are objected to as counterproductive—since individuals are better placed than the government to know and to promote their own welfare—and as violating individual autonomy (Feinberg, 1986; Dworkin, 1972; Mill, 2002), though theorists disagree about when paternalistic interference amounts to a problematic violation of individual autonomy, and when it is ethically inappropriate, all things considered (Feinberg, 1986; Conly, 2013). Paternalism is also objected to as degrading, demeaning, failing to treat people as equals, or assuming that people value health more than they actually do (Conly, 2013; Noë, 2012; Pugh, 2014).

In the context of obesity efforts, increasing evidence from behavioral economics that humans are prone to cognitive biases and are “systematically irrational” casts doubt on a human ability to make food choices that promote welfare (Sunstein, 2014; Thaler and Sunstein, 2008). In response to the autonomy objection, Sarah Conly (2013, 2014) has argued that paternalistic policies that prevent irrational eating, such as limits on portion sizes in restaurants, can be ethically justifiable even though they violate autonomy; such policies respect the person by helping one accomplish long-term goals of staying healthy and living a long life—goals that virtually everyone has, according to Conly.

Some theorists argue that autonomy and self-determination must be distinguished from unfettered choice, and that unfettered choice is not necessary for autonomy or self-determination, and in fact can undermine them (such as when people choose unhealthy lifestyles). Being able to exercise control over our lives and determine the shape of our lives requires some level of health; thus, choice-limiting public health policies may promote long-term autonomy or self-determination (Conly, 2013).

Taking a step back, some argue that obesity efforts that limit choice should not even be seen as paternalistic policies, because their ultimate aim is not just to increase individual welfare, but also to reduce the social costs of poor health and advance the common good (Bayer and Moreno, 1986; Gostin and Gostin, 2009). Illness has social costs, and some ethicists have argued that healthy eating policies should be seen not as policies aimed at improving each citizen’s health in order to increase that citizen’s own welfare, but as policies aiming to improve each citizen’s health in order to reduce the social costs of illness and advance the common good (Gostin and Gostin, 2009). Relatedly, the health costs associated with diet-related illnesses are sometimes framed as externalities that are unfairly imposed on others by those whose eating behavior is unhealthy; on this line of thought, healthy eating efforts are seen as ways to reduce these unfair burdens, not just as efforts to help the targeted individuals themselves.

(p. 592) As an alternative to choice-limiting policies and efforts, Richard Thaler and Cass Sunstein (2008) propose libertarian paternalism, or efforts to change people’s behavior in ways that will improve their welfare, but without blocking any choices or attaching significant costs to any choices. Examples include “nudges” like putting healthy food first in a cafeteria line, since people are more likely to choose the food that comes first (Thaler and Sunstein, 2008). Though libertarian paternalism does not limit choice, it has still faced many of the same objections made to choice-limiting paternalistic policies. For example, criticisms include that the government will not succeed in making people better off by using nudges, since the government is not well placed to know what is good for us (Sunstein, 2014). Nudging has also been criticized as being demeaning or disrespectful, or as not respecting autonomy, because it does not treat people as rational agents capable of making good decisions for themselves (Hausman and Welch, 2010; Waldron, 2014). Nudging has also been criticized as overly controlling or manipulative (Saghai, 2013; Waldron, 2014).

Conclusion

The existing ethical conversation captures many ethical dimensions of obesity prevention efforts, including the fairness of policies, their stigmatizing potential, and the ethics of limiting choice. Are these efforts fair? Do they make the distribution of food, health, and opportunities to be healthy more equitable and more just, or less equitable and less just? Do these efforts stigmatize people in counterproductive or unethical ways? Is “obesity epidemic” discourse problematic because of the assumptions or moral judgments latent in it? Do some obesity efforts limit individual choice in ethically inappropriate ways, or is this choice limitation ethically justifiable as a way to protect individuals from industry influence and help them achieve their own ends?

This ethical conversation would be enriched it if more fully incorporated a discussion of the value of eating (Barnhill et al., 2014). Food provides sustenance, comfort, hedonic pleasure, and aesthetic pleasure to individuals. Sharing food is a foundational experience in virtually all kinds of human relationships and social groups. Patterns of eating express personal and group identities (Anderson, 2014; Rozin and Siegal, 2003; Guptill, Copelton, and Lucal, 2013). In short, eating—even unhealthy eating—has social meaning and value for individuals and groups (Resnik, 2010; Barnhill et al., 2014).

Conversely, healthy eating can have disvalue. Efforts to adopt healthier eating patterns can have a range of costs for individuals and families, include psychological costs (e.g., stress, discouragement), social costs (e.g., changing dietary patterns can cause tension with family members who don’t like the changes), and economic costs (e.g., spending more money on food, or spending more time cooking) (Devine and Barnhill, 2017). A vivid portrayal of these costs comes from a study of mothers’ experiences making home-cooked meals, with 150 mothers of different incomes levels and racial/ethnic backgrounds (Bowen, Elliott, and Brenton, 2014). For these mothers, making home-cooked meals (p. 593) could take time away from other valuable experiences, such as helping a child with her homework. It also required a predictable work schedule, which not all have, and it required foresight and planning. Making home-cooked meals also had discernible personal and social costs: “We rarely observed a meal in which at least one family member didn’t complain about the food they were served,” the researchers reported (Bowen, Elliott, and Brenton, 2014, 24).

A discussion of value is already included, in a limited way, in discussions of healthy eating efforts. Commentators have noted that these efforts promote health—a valuable state—at the expense of pleasure and convenience, which are ways that some consumers find unhealthy foods valuable. But a broader examination of the ways in which eating has value and disvalue would enrich the ethical conversation, clarifying what is really at stake for individuals and groups when public health experts try to change their eating habits.

A more detailed understanding of the value of unhealthy eating could also help us design healthy eating efforts that preserve the social and personal value of unhealthy eating experiences while making these experiences healthier. An example would be a policy that incrementally changes how children’s birthdays are celebrated at school, replacing sweets with healthier foods as the means of celebration (Barnhill et al., 2014). If we understand what people find valuable and disvaluable about unhealthy eating, we’ll have more luck designing policies that improve unhealthy eating experiences while retaining their value. Such policies may be more likely to be successful at changing behavior, more likely to garner public support, and less likely to trigger ethical complaints.

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