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Ethical Dilemmas In Obesity Prevention



Who, in the light of the obesity epidemic and its myriad consequences, could possibly object to public health messages and other measures that would target obesity?

Aren’t messages to increase physical activity and eat healthier, even if provided with a ‘nudge’ (fat tax, BMI report cards, etc.), a reasonable and necessary step in the interest of promoting public health and tackling obesity?

It turns out that things are less clear than you may think, especially if you consider the ‘ethics’ of such measures and their implications for those, who these measures seek to educate and change for the better.

Thus, a comprehensive analysis of the surprisingly problematic ethics of some of the public health approaches to obesity prevention, by the medical ethicist Inez de Beaufort and colleagues, from the University of Rotterdam, published in the latest issue of OBESITY REVIEWS, makes a most enlightening and thought-provoking read.

In their paper, the researchers look at 60 recently reported interventions or policy proposals targeting overweight or obesity and systematically evaluate their ethically relevant aspects.

As the authors point out, while efforts to counter the rise in overweight and obesity, such as taxes on certain foods and beverages, limits to commercial advertising, a ban on chocolate drink at schools or compulsory physical exercise for obese employees, may appear ‘ethical’ as they are aimed at improving individual and public health, enabling informed choice and diminishing societal costs, they also raise potential ethical objections against such efforts.

The long list of potentially ethically problematic aspects identified include:

  • Effects on physical health (of proposed interventions) are uncertain or unfavourable;
  • There are negative psychosocial consequences including uncertainty, fears and concerns, blaming and stigmatization and unjust discrimination;
  • Inequalities are aggravated;
  • Inadequate information is distributed;
  • The social and cultural value of eating is disregarded;
  • People’s privacy is disrespected;
  • The complexity of responsibilities regarding overweight is disregarded;
  • Interventions infringe upon personal freedom regarding lifestyle choices and raising children, regarding Freedom of private enterprise or regarding policy choices by schools and other organizations.

Whether or not the ‘ethical’ incentives to combat the obesity epidemic should ‘automatically’ override the potential ethical constraints, is less than clear.

The complexity of some of these ‘well meant’ initiatives can have unintended ethically problematic consequences: e.g. ‘demonizing’ candy, fast food, or chocolate milk can ostracize the child, who consumes these foods because of socioeconomic or other constraints. Oversimplistic and unrealistic messages about the benefits of diet and exercise can not only reenforce obesity bias and stigma but also lead to disengagement by the very individuals, for whom these messages are intended.

Blame, shame, and punish (tax) approaches to combatting obesity (implicit in many public health interventions) are ethically problematic not only because of lack of evidence of their effectiveness but also because such measures are unlikely to lead to positive and constructive solutions for the targeted individuals.

Thus, the authors recognise an urgent need to develop an ethical framework to support decision makers in balancing potential ethical problems against the need to do something.

Clearly, the need to kicking tires around the ethics of programmes to target obesity, is not only valuable from a moral perspective, but may also contribute to preventing overweight and obesity, as societal objections to a program may hamper its effectiveness.

As I have noted before, the principle of First Do No Harm, should apply as much to public health interventions as to individual care.

AMS
Edmonton, Alberta

ten Have M, de Beaufort ID, Teixeira PJ, Mackenbach JP, & van der Heide A (2011). Ethics and prevention of overweight and obesity: an inventory. Obesity reviews : an official journal of the International Association for the Study of Obesity, 12 (9), 669-79 PMID: 21545391

11 Comments

  1. And yet the Canadian Government does not have an issue sending a fatting message with the Canadian Good Food Guide.

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  2. It’s incredibly disappointing to me, as a fat (“obese,” if you really must) person, that many researchers apparently haven’t considered these points. Ethical analysis should be part and parcel of how we do research and public health.

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  3. You know how you get rid of the ethical dilemma? You stop targeting fat people and start promoting healthy habits for everyone. Health is not hard-wired to BMI, as you’ve noted in the past, so why are so many of these public health messages about weight? All it does is support size-based prejudice and discrimination.

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  4. Health policy should be about health and not address obesity, which, from individual to individual, has varying implications. If a measure is good for trim people as well as fat people, then officials may wish to considered including it in public health policy. Fat people, however, should not be singled out. Period. Not in marketing. Not for discriminatory laws. No public message should ever push for weight loss. Weight loss is complex and generally impermanent, and yo-yo weight cycling has health implications of its own. If an individual suspects obesity is creating personal health problems, then that individual should address the situation with her or his doctor, using the EOSS and not some simplistic measure such as BMI. Public health messages that encourage people to lose weight by eating less and moving more (I’m thinking here of the “Let’s Move” campaign in the states) are unhelpful. They do harm.

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  5. I think we also need to look at the messaging being pushed in schools. Yes, we need healthy offerings but some teachers and school districts without the proper education are becoming over zealous in the education they are providing to children. As a result of this my cousin’s, very slim, active grade 1 daughter, is coming home making comments aboout food along the lines of ‘if I eat too much I will get fat’ or ‘I better not eat that I will get fat’. Very bad messaging to be passing on.

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  6. Having run weight management centers for 10 years now, I’ve learned that messages that promote solutions without targeting size are the most effective at motivation. Eg; “An apple a day keeps the doctor, AND the trainer, away”. Overweight is something we all are, have been or can be. How do you want to motivated, with fear and loathing or education?

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  7. I agree with DeeLeigh and DebraSY: public policy should promote healthy behaviours, rather than directly targeting obesity, which ends up stigmatizing obese people as well as giving thin people the impression that they don’t need to engage in these behaviours unless they become overweight.

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  8. The edcaution programs are trying to present healthy weight inforation abound with the wrong kind of information–myself and everyone I know who is overweight have all this information–the few that don’t know this are really the exception. The knowledge that needs to be sent out is proper serving sizes; even what a sevring size looks like from a servving spoon.

    I have also found that as a persons weight goes up there desire to move more deminishes. A further problem is that exersize programs tend to be run by pencil thin women who can bounce at a rate that would severally injure feet and knees of there overweight clients who try to copy them– even if the music did not require airport grade hearing protection.

    As far as removing the chocolate milk from schools and or the chocolate bars is not so bad as these are usually an easily accessable products outside of the education setting. Furthere, keeping the student with behavior disorders away from the chocolate and hig suger candy is harder than one outside of the education system would think.

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  9. Healthy behaviours include healthy eating behaviours.

    Is there a “healthy eating behaviour” that an organization like the Canadian Obesity Network can provide?

    No point saying policy should promote healthy behaviours unless there is a behaviour specified to follow.

    (BTW, not the Canada Food Guide.
    The Canada Food Guide recommends too much food, too many carbs, is influenced by food sellers and so is to be taken with a large pinch of salt, and it says nothing about when food should be eaten. It might be fine for people with no tendency to gain weight, but people who do have to watch food carefully to avoid gaining weight need an eating behaviour guide designed scientifically specifically for them.

    The Canada Food Guide doesn’t provide specialized diets for diabetics or kidney disease patients, or people with allergies. Similarly, it also doesn’t provide a diet to treat obesity, or even to prevent obesity in people prone to gain weight.)

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  10. Dr. Sharma, i just wanted to put in a word of appreciation for your compassion and common sense. i may not have picked up many usable “tricks” to help combat my over-weight, but certainly have learned a lot about the subject in general. thanks!

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  11. I really dislike that its taken here as given that if a person is overweight (defined by BMI I’m assuming, a measure that’s been proven to be overly simplistic and ultimately not particularly useful) then theres something wrong with them. It’s an assumption. And its not true. There are plenty of overweight people who are healthy. There are plenty of normal and underweight people who are sick.

    Being overweight, being who you are, is ok, despite the constant messages to the contrary.

    The whole article, and the damn study, is incredibly offensive. What sort of person needs to be told that stigmatizing a group of people and forcing change on them is ridiculous and does harm?

    Health professionals apparently.

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