Obesity: a wicked public health problem

Obesity - good or bad?Cl

Updated version here



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Most people view obesity as an unequivocal bad -- both for the person and the public. 

Lines are being drawn in the battle against "big food" just like big tobacco before. The marketers of food are critiqued for over-sized portions, and ironically, similarly critiqued for offering smaller portions.

However, while media and public health and popular views may appear to be generally fairly united in terms of their perception of obesity as the problem, the problem is far more complex than many seem to realise.

What is the problem in the first instance? Obesity is not always viewed as a problem. Some suggest that obesity may be a positive social signal (Mankar et al. 2008), a sign of wealth and status (Wells 2006). Even today in the West, no-one is likely to show concern about babies that are well above the norms for their age in terms of weight.

But the prevalence of obesity is growing rapidly. This is agreed, but the reason why is far from clear. Is it the energy input - e.g., junk food, carbohydrates, highly processed foods, sugars, etc? Or the energy output - e.g., lazy leisure (television, video-games, smart-phones), motorised transport, reduced background exercise (more elevators, more remote controls, more computer-based work, etc)?

And perhaps more significantly, what is the problem posed by increased obesity? The public health view often portrays obesity as a dire condition, but a systematic review (Flagel et al. 2013) suggest that the obesity-mortality relationship is not as strong as some might fear. Others have pointed out that obesity is relatively benign metabolically (Hughes 2008) and that talk of an obesity epidemic has been “overblown” (Gibbs 2005). Obesity may even be apparently protective in some circumstances (e.g., the so-called "fat paradox").

And even if it is decided to be harmful for the individual, on what basis is it right for public health to proscribe individual choices, preferences, pleasures? The claim that obesity costs the public health system does not appear to bear up when life-time health costs are examined (Van Baal et al. 2008).

But let's assume that obesity does harm the public good, and further assume that it is okay for public health and policy makers to direct what may be marketed and what consumers may consume. Are we now not allowing these authorities to promote a leaner body image? How is this acceptable when marketers have been so soundly critiqued for promoting overly-idealistic body images (while being simultaneously critiqued for promoting obesity)?

Perhaps the biggest problem is that dogmatism prevents a real examination of the complex nature of the issue. There are two forms of philosophical scepticism that need to be applied. The first is epistemic, the second is ethical. Dogmatism fails to acknowledge the two forms of uncertainty. In the first instance, judgments are made about what is true (even while evidence is conflicting). In the second, judgments are made by public health and policy makers on what constitutes "good" behaviour and thereby impinge on what is ultimately a very personal decision - how we choose to take on energy and how we choose to expend it.

Obesity and the public health approach to the issue are problematic. The dogmatism adopted both conceals the uncertainties (epistemological and ethical) and confounds the problem.

Free-riders - leave them be

The concern that some are getting something without having paid their due seems indubitably true. That is, both that some get something without paying their share, and that some are concerned about it.  

But is there anything we can do about it? And perhaps more importantly, is there anything we should do about it?

Sure, there are people who get to share the benefit that accrues to a whole while contributing less than their part. But isn't that essentially the heart - and I mean "heart" - of welfare? 

Perhaps the difference is that those with a bigger share of the cake gift some of theirs to others. Free-riding is mooching, the others are not happy about the free-loader taking more than their share.

But rewards often poorly reflect share of the work done as we see in the story of how science advances. One or two people may get the credit, but in reality, a scientific advance or breakthrough is the product of the work of many. Watson and Crick get most of the credit for discovering the structure of the DNA molecule, but many feel that Rosalind Franklin is much overlooked for her part in the discovery. This is perhaps reflected in some of the better known multiple independent discoveries in science, e.g., calculus (Newton and Leibniz); natural selection: (Darwin and Wallace). 

So, we tend to roundly condemn those who take the fruits of the labour of others and deprive those others of the benefit. We condemn those that steal cars, computers or other goods. However, while we still see it as stealing, we seem to think less poorly of those who pilfer from large organisations, and/or if the items are trivial items (e.g., pens, paper, paper-clips). 

If we think the large organisation suffers, we are less concerned with condemning the free-riders, the many who illegally download of music, videos, books. In this instance, we seem disinclined to be very concerned (how much does it really cost me?), or may even participate if only from time to time (swings and roundabouts).

But we get quite agitated about "social loafing", the way that one or more members in a work-group sits back and lets others do the work and shares the reward.

Yes this is to some extent how we all succeed. Perhaps the more honest among us acknowledge how we have succeeded by the contribution of others. As Newton famously observed: "If I have seen further, it is by standing on the shoulders of giants."

So why do we get so agitated about free-riders? Importantly, are we justified in doing so?

Take the notion of those that choose not to vaccinate their children. People get quite incensed about the problem of the consciously unvaccinated as free-riders even labeling them as "public health parasites". 

Some claim that their behavior endangers our own presumably vaccinated children. However, for this to be true, then we must have a concern about vaccination failure. It is true that vaccines do not protect perfectly. Nor are they perfectly safe. But the risks on both sides are small.

"Small?" you might ask when a child's life it as at risk? 

True, but remember, there is in fact a risk on both sides - vaccination-failure, and therefore risk of the disease, and therefore risk of an awful outcome; and on the other side, vaccination reaction, and some other awful outcome. Again, to be clear, both "awful outcomes" are unlikely, and no-one wants to see a baby die or be damaged for life, and this is true of both sides.

So, the "free-rider's" behavior creates a risk, and the insistence that everyone vaccination also creates a risk, then the argument for why free-riding in this instance is wrong must fall to something else.

Is it that we are incensed that one gets the benefit without any of the cost? That is, the vaccinators do understand that there is a small risk of a vaccination reaction, and they have taken the gamble and are incensed that others have not. This is reasonable, but so is the growth in the number unvaccinated as herd immunity grows.

This does seem to get to the heart of how at least some feel about free-riders. It is less about the cost that we  personally experience, and more about a feeling that it is "unfair". I see this in students who insist that free-riders in their group assignments are "punished" by a lowered grade even though the grade to the rest of the group remains unchanged.

Now, the problem is when someone suggests that those who do not register as organ-donors, the free-riders, should have reduced priority for organ-donations.

This seems reasonable. We provide an incentive for people to be willing as organ donors, and penalize the unwilling in the event that willing donors get priority. We would not deprive the free-rider from access to donor organs, we would not let a living patient die on the table for want of an available organ because they chose not to register for organ donation.

So, perhaps the real ethical lesson is for the rest of us to find some compassion, to give without expecting something in return - a little like welfare. To favour those that help over those that do not, or in the negative, to return a disservice with disservice, an version of the famous tit-for-tat strategy that encourages cooperative behavior.

It is probably a little sad that hitchhiking disappeared from the world for this was an example of giving without expecting in return. The free-riders created a smile. Today, it still exists, but now perhaps more safely mediated by the internet in concepts such as the couchsurfing which offers free accommodation to travellers around the world. 

The rideshare websites that have replaced hitchhiking are celebrated as saving resources. In effect, encouraging "free-riding" (or nominal fee for a ride) may be for the common good!

Business has also recognized that, especially in the age of the internet, many want something for free. Fortunately, there are a few willing to pay for a "premium" version which in effect subsides the "long tail" of free-riders .

Yes, it is frustrating that some people get something for nothing, and perhaps even at a cost that is borne by others. It doesn't seem fair, and perhaps it isn't. But life isn't fair. No promises of fairness and equity were ever offered. And if they were, then we privileged Westerners owe those with the misfortune of being born in the developing world a LOT.

But if our frustration seeks to impose punitive measures against the free-riders, are we not committing a greater wrong than the wrong we are seeking to punish?

Sure, free-riding creates a cost, but when that cost is to the common good, it is probably fairly insignificant. So is the response to the free-rider designed to motivate behavior change or meting out retribution? 

Does a person who is unconsciously free-riding deserve to be punished? Or what of those who are slacking off here because they have contributed elsewhere?

We may feel a frustration at those that free-ride, and especially those that who are unapologetic for "cheating" and at worst, do not even acknowledge their indebtedness to others, but to what extent is it right to try and eliminate this wrong.

Perhaps the answer lies in a proportionality to cost. Dole-bludgers, over-eager welfare recipients, the unvaccinated, and other free-loaders may incense us as individuals, but the cost is not enormous (and almost certainly not greater than the gravy train ridden by top executives and politicians at the public's expense).

And in any case, rather than punish their wrong-doing, real good is to over-come our own over-zealous attachment to our perception of their wrong-doing. Let it ride.

Marketing to children - a learning opportunity

Are children at risk of being unduly influenced by advertising? Yes.

Does it follow that we should therefore regulate marketing to children to prevent the nefarious advertisers from taking advantage of children's  vulnerabilities?

 

In general, my view is no!

That children are especially vulnerable to the temptations offered by sellers of sugar frosties seems indisputable. However, I do dispute the arguments that this implies we ought to block marketing to children. Let me explain why.

 

One of the most common arguments for supporting restriction and regulation of marketing to children runs along the lines that children are exposed to enormous amounts of advertising. Advertisers spend billions of dollars in marketing stuff aimed at children (http://www.care2.com/greenliving/and-they-are-marketing-to-children-too-imagine-that.html). Betsy Moore (2014, "Should marketers be persuading our children" in Marketing and the Common Good) tells us that children are exposed to 25,000 to 30,000 television advertisements each year.

So? 

They are also exposed to thousands, perhaps millions of instances of the letter 't' each year as well. Exposure does not equal influence. The letter 't' is the central brand of the various Christian churches, that is the cross. But no-one is likely to argue that this enormous exposure in some way influences our children to take up the Christian religion.

(It may be noted that the intentionality of the advertiser is irrelevant. It is no matter whether the advertiser - commercial or religious - intends to influence the audience. Vast exposures does not equal influence).

No, the strongest argument is that children are vulnerable, but isn't this part and parcel of being young? Moore (2014, ibid) observes that children "may learn to be unduly materialistic and impulsive". What! Outrageous! Just like vast swathes of the Western consumer landscape, just like us, just like their parents. Oh!

Yes, children need to learn to distinguish messages with persuasive intent from persuasive intent - but this should be broader than simply training them to distinguish commercial from non-commercial messages. Marketers are just one of multiple sources that engage in communications with persuasive intent. Others include politicians, public servants, priests, police, public interest groups, teachers - and parents! 

Of all of the various persuasive messages that people are exposed to, the persuasive intent of marketers is the least disguised. There is no secret that marketers are trying to get people to buy their stuff. Children of course, may not understand that. But that is what learning is all about. Children need to learn that marketers make things look attractive because they want them to buy what they're selling. And of course, this is the first step on a path whereby children develop an understanding that others who are less open about their intent are trying to "sell" them stuff too. Even their parents. 

There is a tendency here to equate the marketer's intent to make a sale as inherently evil. This seems to be unlikely. We are against marketers, only those that deceive or dupe their customers to make their sale. For this reason, we are especially tuned to the vulnerability of the young. However, just because someone is vulnerable does not mean that they are exploited.

Are marketers exploiting children and their vulnerabilities? The literature seems to be surprising quiet on this issue. I suspect that the reason for this is that companies that do dupe and exploit are quickly revealed. No-one likes those kinds of marketers - whether they prey on the young, the elderly, or even we supposedly more wise and careful consumers of the middle-age.

However, this kind of thinking does lead us to consider something important. We appear to be putting up barriers, rules, regulations, when there is no apparent crime. It is like putting up cast iron grills on our window even though we may be living in a safe, well-to-do neighborhood where crime is absent.

However, this analogy highlights another difference. The rules to prevent crime, breaking and entering are in place in all neighbourhoods, but in those neighborhoods where the risk of such crime is high, the residents put up the grills.

Aha! Yes, children are vulnerable, but we really should be helping them erect grills and grates to block the entry of the unscrupulous intruders who cannot be blocked with rules and regulations. All the rules in the world will not block those who are immoral. And arguably, blocking children from exposure to advertising simply deprives them from important learning experiences.

Children of age 2-7 are arguably not much able to buy things for themselves. Their decisions have to be mediated by a parent. And isn't it one of the important roles of a parent to help the child negotiate the real world Persuasive messages - from both commercial and non-commercial sources - are an important part of life. And the child needs to learn to identify persuasive intent, and needs to learn to make decisions for him or herself.

Without such training, then children would grow up to become adults who are themselves vulnerable to the offers of highly processed, sugar-laden foods - and other forms of snake-oil.

Rules - numerous & ineffective

Regulation endeavours to create justice, but must inevitably fail.

It would seem that morality cannot be mandated.

People will do dreadful things to others, and we cannot possibly comprehend why.

Creating rules may stop some marginal cheating, but it will also manifestly fail to stop others. "Cheats" existed before the rules, and continue to exist after the rules are created. It may even create new cheats, and even some that may prosper (just look at the trade in illegal drugs as an example).

So perhaps rules create a little "more" justice, but it is no more than a pap? Ought we not to accept that it is impossible to eliminate injustice because self-interest ensures that some will want more than their share!