Bioethics and Obesity: Toward a Syndemic, Broad Policy Approach
Bioethics must recognize a syndemics approach to ethical solutions to the obesity epidemic in the US. The line between public health and personal health is artificial. Economic, political, and social structures influence the body in the doctor’s office. Public health approaches obesity various ways—usually by recommendations of exercise and lifestyles that are unattainable. Public programs to encourage eating vegetables and exercising exist at all levels, community to federal. Yet an anticipated 50 percent of the population will have obesity by 2030. Attacking the problem at the individual or behavioral level is unlikely to solve it but remains the prevailing theme.
Some aim to address obesity at the “systems level”, recognizing that obesity does not reflect a linear cause-and-effect relationship. Yet the WHO key factors to protect against obesity focus on personal habits. Scholarly articles recommending important steps like nutrition labeling mix personal behavior into policy. That is, the recommended policies often target individual behavior calling for change rather than corporate or government policy that would open the opportunity to change. I am a huge proponent of labeling, but the obesity epidemic tends to reflect pricing, not labeling. Another example is the New York City ban on sodas over a certain size or the concept of a soda tax. Both aim to control individual purchasing habits. Yet they do not control why soda is cheap to make – agriculture subsidies.
Huge economic structures, federal policies, the global food trade, and food politics influence obesity. Completely eliminating personal responsibility is not the answer. But the most ethical approach to the obesity that results from diet and lifestyle must identify the non-personal and non-genetic causes of obesity and eliminate them. The bioethics community fails people experiencing obesity by applying a myopic set of principles validating actions that encourage those experiencing obesity to change habits. Even in calling for approaches that shore up food sources, remedy food deserts, increase farmer’s markets, and place vegetables in bodegas, the bioethics community seems to focus more on government and nonprofit programs than on political market distortions like subsidies, or on the lobbying that allows corporate interests to impact health. The other bioethics obsession (and my passion admittedly) is freedom, yet that also keeps the bioethics at the bodily level and distracts from the issue of how much corporate freedom exists and how to balance that when it infringes individual’s ability to be free from something.
At the federal level, competing priorities have downstream effects. Corporate lobbying influences federal decisions and dollars. The Farm Bill includes SNAP and policies that favor some crops over others (“staples”), leading to growing foods that tend to then be processed. The subsidies for commodity crops act as an insurance program for those unhealthy crops. A farmer, or Big Ag, has incentive to grow corn and soy knowing that if they face a crop failure (weather, pest, or environmental) or a market failure (e.g., lower commodity prices when there is too much supply), the government will pay the difference. The corn contributes to corn syrup, a contributing cause of obesity, and the policies keep soda cheap. The Farm Bureau, an insurance and lobbying group, represents farmers, but its lobbying efforts reflect its relationships with Big Food rather than small family farms. The Farm Bill directed incentives to transition to organics, but fruits, nuts, and vegetables remain “specialty crops” and are not eligible for subsidies.
Food corporations took on major lobbying efforts ahead of the 2020-2025 Dietary Guidelines. HHS and the USDA oversee and rewrite the guidelines every five years incorporating nutrition science and epidemiology, yet the lobbying muddies the waters. I personally find it comical that Secretary of Agriculture Sonny Perdue and a Big Pharma exec (Alex Azar, Secretary of HHS) have the power to comment on what anyone eats, yet their letter introducing the new guidelines asks Congress to make policy that makes it easier for individuals to “make food and beverage choices that are rich in nutrition.” Historically, Perdue projected stances that would make it more difficult for people to afford healthy foods and he wanted to impose a work requirement for SNAP.
I am skeptical of any role of government in what we eat. Public health and the US Congress operate under the assumption that the government should convey to the people some outline for eating. If they continue to do so, it would only be appropriate to have their policies make those eating choices easier. Better education, wages, and opportunities correlate to better food choices. As seen in the map above, our poorest states have the highest percentage of people with obesity. Addressing poverty would be better than telling those in poverty to eat more vegetables.
A framework to analyze the ethical problem must look to the downstream effects of a broad swath of policy initiatives. The Farm Bill, school lunch programs, and food-related policies are not the entirety of the problem. Exploring families and their experiences would show the lived experience of putting food on the table: Where are they shopping? How much does their food cost? Are they cooking? How much is fresh versus processed or packaged? Public policy makes unhealthy food cheap. Low wages make people rely on cheap food.
In the middle, many people are not educated about health and nutrition. I do not recommend they solely rely on the federal government among the many sources of information although the federal government, NIH, CDC, etc. do have largescale epidemiology and PubMed puts much of it in one place. I would use caution knowing the federal government’s conflict of interest due to its openness to the food lobby. The scrambling of industry to influence the guidelines and then to create processed foods that conform to the macro-nutrient dietary outline undermines the guidelines. Eating is cultural and personal, and perhaps best kept that way.
A framework to address the ethical issues surrounding obesity should avoid discussions of bariatric surgery for kids or the size of a soda, and look at poverty, wages, and subsidies with an eye to the lived experience of those with obesity.
