Obesity: ethical dilemma and public health challenge
In spring 2013, faculty members from the University of Wisconsin School of Medicine and Public Health Department of Medical History and Bioethics orchestrated a gathering of national thought leaders who debated a wide arc of viewpoints related to obesity.
The school’s fifth-annual Bioethics Symposium, “Ethical Issues in Obesity,” raised many questions: Is obesity an epidemic? To whom does it matter if someone wears triple-extra-large clothing or orders super-size sugary beverages? When, if ever, should the government or health care providers get involved?
Norm Fost, MD, MPH, a professor in the Departments of Pediatrics and Medical History and Bioethics at the School of Medicine and Public Health, opened the symposium by reading “On Liberty” by John Stuart Mill.
“The principle crafted by Mill is one to which many Americans would subscribe, but the devil is in the details. Mill asserts that interfering with people’s liberty when they cause harm to others might be a sufficient basis for state intervention or even coercion.
"But what constitutes harm to others? And do economic harms constitute a sufficient reason for state action?” asks Fost, who founded and directed the UW-Madison Bioethics Program for more than 40 years.
How much those economic harms cost is debatable.
“Health care spending is at the heart of our bankruptcy problem in this country - it’s the most common cause of personal, small business and now governmental bankruptcy. Whether obesity-related conditions constitute 9 percent or 21 percent of health care costs, $150 billion or $300 billion, they’re big numbers. As the late Senator Everett Dirksen famously said, ‘A billion here, a billion there, pretty soon you’re talking real money,’” notes Fost.
Consistent with the symposium’s goals, presenters and participants from the School of Medicine and Public Health and across the country - several of whom are quoted in this article - discussed and debated myriad angles related to this topic. Soon after the symposium, the American Medical Association defined obesity as a disease.
Should the government work to reduce obesity?
Symposium speaker Peter Ubel, MD, believes it’s time for society to take a stand.
“Should onlookers care what other people are eating? Should it matter what someone eats if they happen to be on Medicare or if a child is overweight? It’s a general question of when freedom and well-being conflict,” notes Ubel, a professor of public policy and medicine at Duke University.
Obese people, he says, are sicker, less happy, make less money and live shorter lives. While he anticipates some people may debate these points, he poses an anecdotal retort: how many obese people ask their doctor to help them gain more weight?
“My compassion says that I don’t think they’re just saying ‘I want to lose weight’ and not really meaning it. I think (they’re saying) ‘I really want to lose weight,’ and it’s damn hard to do,” states Ubel.
He contests that it’s not always an aversion to sweat, but that biology, economics and advertising seem to be conspiring against those who are trying to shed pounds.
“Biology conspires against you to lose weight, likely due to evolutionary biological forces when people would go for long periods of time without food,” he explains. “Your body went into starvation mode and hoarded every calorie it had.”
Ubel also notes that when we get weak, we often go against our own preferences. This is especially true in low-income populations who are under significant stress - a population in which obesity rates tend to be higher.
One study that tracked the daily food intake among low-income individuals showed a marked decline in the amount eaten before the individuals’ monthly paychecks. After payday, they start eating to catch up. According to Ubel, this is an example of evolutionary calorie hoarding.
How much we eat, Ubel argues, often is influenced by forces beyond our awareness. Plate size and the number of people with whom you eat have studied effects, both correlating with intake. Even the way food tastes is unconsciously based on our perceptions of healthfulness and quality.
“The simplest thing the government can do is inform us about our eating choices more, so we can decide what we want to eat,” says Ubel, who notes that the government should start with the least burdensome policies like persuasion campaigns backed by research and evidence before taking other incremental steps in the battle against obesity.
The trouble with expanding public health's definition
What are the implications of defining public health so broadly that it impacts the size of the soda someone orders, as New York City Mayor Michael Bloomberg attempted? Jacob Sullum, a syndicated newspaper columnist and senior editor of Reason magazine who spoke at the School of Medicine and Public Health symposium, offers recent examples of things that have been defined as public health issues:
- In 2005, Senator Hillary Clinton likened violent video games to “a contagion” that threatened the “public health” of children.
- Michelle Obama, in 2010, said “obesity is nothing less than a health crisis.”
- Also in 2010, President Barack Obama said drug use is a “public health problem,” comparing it to smoking and not wearing a seatbelt.
What do using illegal drugs, not wearing a seatbelt, being overweight and playing violent video games have in common?
“You could say they are all damaging activities, and if you wanted to put it in a more even-handed way, you could say these are all things some people like to do that others disapprove of,” says Sullum. “This tendency to call every perceived problem that affects more than two people an epidemic obscures some important distinctions when you think about the classic targets of public health.”
The targets he cites are risks imposed on people from the outside, with communicable diseases being the example that New York State Supreme Court Justice Milton Tingling Jr. emphasized in his decision to overturn Bloomberg’s sugary drink ban. Yet, smoking, drug use and overeating are voluntary choices.
“Not all (risk-takers) are ignorant about the relevant statistics of their risk of injury. ... It’s still possible for someone with a certain set of tastes and preferences to say, ‘Let me enjoy myself now, and I’ll take my risks,’” says Sullum.
He notes that obesity has been shown to increase health care costs over a lifetime. The question is what to say when these habits or risks impose a burden on taxpayers?
“To me, the problem isn’t so much that people are doing risky things, but that other people are being forced to pay for the consequences,” says Sullum. “That’s inherent in the nature of having the government subsidize health care.”
A cultural and scholarly zeitgeist
Susan Lederer, PhD, chair of the Department of Medical History and Bioethics at the School of Medicine and Public Health, also shared her views at the symposium.
“The conventional wisdom is that we are in the midst of an epidemic of obesity. Not just an epidemic, but a pandemic. However, American physicians and health researchers have long warned that obesity was a major health problem,” she says.
While this concern has existed for decades, in 2001, the American government adopted new language and rhetoric to frame the problem. U.S. Surgeon General David Satcher, MD, PhD, issued the report, “The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity,” which applied the public health terminology of “epidemic” to describe body mass trends.
This change launched a cultural zeitgeist, and popular media ate up the fat debate. By 2002, more than 1,200 newspaper articles referred to the new obesity epidemic.
Between April and June 2003, more than 1,400 similar articles appeared. America’s growing awareness spawned books like Fast Food Nation and documentaries like “Super Size Me.” It also attracted considerable scholarly attention.
“It might be tempting to view books like 'The Obesity Myth' by Paul Campos as part of a lunatic fringe, but his book and others represent serious, sustained and informed critiques of what seemed to be, if not a public health obsession, a cultural conception in this broader frame,” says Lederer.
“Campos’ book mentions that obesity has become a 'moral panic' akin to the days of 'Reefer Madness,' when marijuana was touted as more dangerous than heroin. The compass we are using to direct our policy has become tilted in a profound way, analogous to the Red Scare in the 1950s,” she notes.
Educated critiques continue. Abigail Saguy, a postdoctoral fellow at the Robert Wood Johnson Program in Health Policy at the University of California, Los Angeles, claims that framing fatness as a health problem raises the stakes to life and death, and provides compelling rationales for more invasive treatments in her 2013 book, "What’s Wrong With Fat?"
“These critiques do not dispute the evidence: the number of obese people has roughly doubled in the U.S. since 1980, and obesity in its extreme form is correlated to illness and premature death, but there’s that other category of ‘overweight’ and whether or not that rises to the level of an epidemic. At this time, the evidence according to these critics does not support it,” explains Lederer.
Population health - lost in translation
Where we live, work and play is fundamentally different from what it was 50 years ago, as are the strategies food and beverage industries employ, explains Patrick Remington, MD, MPH, associate dean for public health at the School of Medicine and Public Health and professor in the Department of Population Health Sciences.
“Our genetics haven’t changed, but America’s average body weight certainly has,” Remington notes. “The trends from 1962 to present in the National Health and Nutrition Examination Survey show that obesity rates increased from about 10 percent to just over 30 percent of the population.”
He adds, “Rates of extreme obesity (a body mass index [BMI] of more than 40), which was virtually unmeasured in 1960, is now about 3 to 4 percent.”
“I think the reason there is a debate about the causes and consequences of obesity is because ‘epidemiology’ - the application of population health concepts to individuals - has been lost in the translation,” says Remington. “The relationship between body mass index and mortality is an example.
BMI was developed by insurance companies and survey researchers to have an easy way to classify populations, so you can compare the risk of various health outcomes by different levels of body mass index.”
Remington continues, “A well-studied, solid finding is that a population with a BMI greater than 30 is more likely to die prematurely. But notice I say a ‘population.’ Herein lies the problem: When you apply population findings to individuals, people say, what about me?
“Epidemiologists study populations, and we define risks by observing the distribution of attributes in populations. Most people, however, look at individuals, and when they see an exception to the rule, they begin to cast doubt about these associations.”