Is Obesity a Choice?
By Fiorenzo Conte
Obesity is on an upward trend and it has doubled worldwide since 1980; second newsflash, this rise is taking place in both high-income, middle-income and low-income countries. As obesity and being overweight are major risk factors for a series of chronic disease such as diabetes, policy makers around the world are coming up with ideas to stabilize or reverse the overweight epidemic. The latest proposal has been put forth by NYC mayor Michael Bloomberg: impose higher tax on soft drinks with high sugar content. The proposition stirred up much debate: on one side Bloomberg’s attempt to discourage the consumption of soft drinks was considered an enlightened initiative to improve public health; from another side his attempt was brandished as a new form of baby authoritarianism in which the state arrogates on itself the power to know (and impose) what is best for its citizens.
The positions are very different: on one side it is claimed that there is conclusive evidence that soft drinks cause obesity and that taxing soft drinks can go a long way into constraining people to make healthier choices; public health after all is about discipline and constriction. On the other side it is argued that the evidence supporting the soft drinks/obesity link is at best not conclusive and that public health interventions which constrain people are bound to fail: public health is not about constriction and any such attempt is based on the assumption that somebody (the government) knows best than the others. Despite these differences, the two sides however have two things in common.
Disease of Choice? One side claims that people are obese because they make bad choices: the role of the government is to eliminate the possibility of making such bad choices and taxing soft drinks fits into the approach of punishing bad choices. The other side claims that the attempt of the government to limit the free choice of the individuals is misplaced because people get what they want and at the moment they want soft drinks. If you increase the price of soft drinks they will cut back on other expenses and keep choosing to buy sodas. Both sides therefore rest on one fundamental assumption: obesity is a disease of choice; people get obese as a result of their free choices. But is this really the case?
Imagine you are a kid growing up in the US and you come from a poor family which struggles to make ends meet. You will probably start drinking sugary drinks as soon as you begin eating solid food. When you go to pre-school you will not find water in your lunch box, you will find juice products filled with extra sugar products. In a sense you are very likely to become addicted to sugary products just because you have always eaten and drunk that way. It is just they way it is for you, so when you become a teenager you will keep buying sodas or drinks high in sugar. On the top of that it might just be easier for you to find sodas in your corner shops rather than water; and even when you can find both maybe the former has the same price of the latter so why not going for the tasty one? If you get into this habit of buying soft drinks when you are a kid you are very likely to stick to this habit when you become an adult.But how much was this the result of your free choice?
Well, very little. First of all, one does not really chose the kind of food available. Think about this: of the 600,000 food items currently available in the US 80% are laced with added sugar. As a result, the sugar consumption per day of Americans went up from 75 grams in 1977 to 110 grams in 1994. This increase in sugar content has very little to with the choice of individuals and more with the interest of the farming sector to convert excess crops into high fructose corn syrup. So even when one thinks to eat healthy (e.g. apples) the odds to eating sugar are very high. Second of all, eating and drinking a lot of sugars depends as much from one person’s choice as it does from the external environment and social norms one grows up in. And one does not get to chose the social norms. If it is easier to find a soda in your corner shop that it is to find water how much of it is one person’s free choice?
Side Effects of the Disease-as- Free-Choice Paradigm: the problem with defining obesity as a disease of choice is that with choice comes responsibility and blame. Two conclusions follow suit: firstly, if people get sick because of their choices the money of the community should not be wasted on their treatment; secondly, being obese impose a cost on the society (e.g. health care costs) therefore people obese should be made pay to offset this cost. Hence, if one is obese he or she should take care of themselves without relying on the society. There is another disease which had the same mix of choice and blame: HIV/AIDS. And the story of HIV/AIDS tells us what are the risks associated with the disease-as-free-choice paradigm.
People with HIV, it was said, chose to assume the risky behaviors (e.g. not using condoms) and therefore they should pay for the costs they impose on the society (i.e. higher prevalence and therefore higher risk to get infected). Similarly, the society should not pay for the cost of their care: after all they chose their sickness. This paradigm, however, has different pitfalls: firstly, it stigmatizes those who are infected and this is unlikely to be to anyone’s advantage in society; people who are stigmatized deny their diseases and this makes both prevention and treatment more difficult. Secondly, it conflates those who made the choice and those who did not have a choice: if a prostitute needs the money to sustain her family and she gets paid more for not using condoms can it be really said that she chose not to use condoms? If a kid “chooses” to buy a soda because it was always in the lunch box is it really his/her choice? By conflating those who chose and those who do not, the victim is always to be blamed.
Any public health intervention must reach a fine balance between persuasion and constriction while taking into consideration how much of the individual’s choices are shaped by the structural environment. Choices are not made in a vacuum and, therefore, are rarely free. When a disease is defined as a disease of choice, the paradigm is tilted in favor of constriction while sidelining the surrounding environment. With this it comes the tendency to blame the person: the history of people living with HIV shows that it is not the way to go.
HT to Jessica and Keondra for the info about obesity in the US