Obesity, one of the prominent and predictable risk factors for severe COVID-19, was not highlighted as much as it should have been from the early pandemic on. It, and arguably other comorbidities and chronic health problems associated with it, seemed to be played down compared to other issues. Most importantly, in discussing obesity, there was no urgency. It was viewed as a static situation, accepted as fact in the background playing a role in risk, but not in solutions. In the time it took to develop and distribute a vaccine, people could have decreased some risk factors for severe COVID-19. The bioethics narratives surrounding risk factors often properly centered on socioeconomic and racial disparity, but they were not forward thinking and failed to offer short-term recommendations like weight loss as an emergency measure. While recommending even more serious isolation for some at-risk people, there was not a largescale public health movement to inspire dietary and exercise changes in the short term. Get-healthy-style messaging was not prevalent. To study this as an ethical lapse requires examining the roots of public pandemic messaging.
Public Health, Public Policy, & Obesity
Health can improve somewhat quickly. Fast weight loss is possible and can resolve other issues like high blood pressure. Government prioritizes health in some ways and funds many programs to encourage weight loss. Yet there are, of course, many explanations for the failure to significantly decrease rates of obesity, many of which concern government, corporate lobbying power, and low wages. Food deserts remain in many areas. Hours worked may preclude cooking using fresh ingredients. Food production has become globalized and lost its local roots. Government subsidizes corn used for corn syrup. The public health discussion surrounding food is fraught with conflicts of interest and hurdles to success. Arguably the biggest barrier to public health initiatives is other public policies.
Items go from idea to grocery store shelf without an impact statement on obesity. Those in poverty are “the most prone to obesity” in the US. At the policy level, conflicts of interest and the role of agricultural policy, minimum wage, and the many social, political, and financial determinants of health must be openly discussed.
Incentives and punishments have been explored as ways to promote healthy behaviors. The scope of ideas ranges from financial incentives by government entities or insurers to condemnation of those carrying extra risk, the costs of which may be distributed throughout the population due to government services like Medicaid or other pooled risk like insurance. Depending on how one measures success, many programs are successful at local levels and may be keeping rates from rising steeply even if they are not demonstrating largescale decreases in obesity across the country. Obesity is unlikely to subside if the conflicts of interest dictating affordable food supply coupled with income inequality remain the status quo.
And we may want to consider obesity contagious— having a close friend who has obesity increases one’s risk of developing obesity by 71 percent. Obviously, it is not contagious in the traditional way. But there is a group effect.
Yet my question has to do with the narrative. Was there a responsibility in the bioethics arena to have devoted more of the pandemic-related news, social media posts, and interviews to diet and exercise?
COVID-19 & Obesity
Data from September 2020 in “Obesity Reviews, an international team of researchers pooled data from scores of peer-reviewed papers capturing 399,000 patients. They found that people with obesity who contracted SARS-CoV-2 were 113% more likely than people of healthy weight to land in the hospital, 74% more likely to be admitted to an ICU, and 48% more likely to die.” Had obesity been addressed based on its relationship to H1N1 deaths through public campaigns, people may have known more about the links between inflammation and severe respiratory viruses. People with obesity make up 40 percent of the US population. An April 2021 study reported that 78 percent of people hospitalized for COVID-19 were overweight and 50 percent were obese. The highest COVID death rates were in countries with the most obesity. We have not explored whether depicting obesity as an emergency rather than as chronic would have saved some lives.
Fear of a Blame Narrative May Lead to Dangerous Quiet
Shame as a strategy that calls for social pressure to change may be misplaced, and fails to recognize the many causes of obesity, but a failure to use public health messaging to express the urgency is an ethical lapse. When bioethics views obesity through the psychology lens that confirms the detrimental effects of shaming, some ethicists may overcorrect by tiptoeing around transparent discussions at the expense of delivering life-saving information with the urgency it requires. (For one exception, see highly criticized Daniel Callahan’s article and viewpoint.) In particular, the bioethics community tends to be shy about anything that people could perceive as blaming or shaming individuals. Preparation for future pandemics should clearly include decreasing the occurrence of obesity in the population as a strategy using the logic that obesity and its correlates pose(d) a vulnerability to many past and present viruses. Just compare the urgency of the vaccine messaging (certainly rightfully urgent) to weight loss messaging during the pandemic and the outsized role of bioethics in the vaccine conversation compared to the obesity one.
The Role of Specialists
Possibly the role of experts is part of the problem. Within public health, the pandemic was relegated to infectious disease specialists. Then, many focused on a vaccine, an important use of public funds and attention. The behavior side focused on masks and social distancing, and at first, on hand washing, rather than on diet and exercise. Most comorbidities were listed rather than discussed. If obesity had been center stage as a curable severe risk factor, it is possible (probable even) that some people would have recovered from obesity during the past 18 months thereby decreasing their potential for severe COVID-19.
Adding to the bioethical lapse, a new tension arrived between people who promote vaccination and people who promote nutritional supplements, a healthy diet, and active or lower stress lifestyle, even if they too promote vaccination, although especially if they do not, like Dr. Joseph Mercola. In the climate of cancel culture and political polarization, the search for objective data and the questioning of mainstream medicine is being incorrectly aligned with an anti-vaccination or anti-science culture. The doctors promoting a constant message of health may effectively lead their social media followers or patients to understand and maintain healthy habits. Yet there is a danger if doctors call for people to remain unvaccinated, something to which those who blindly follow might fall prey. But is it possible that someone who opposes vaccination may be correct about something else, like diet and exercise?
The New Politicized Attack on Supplements
An observation is that the media, the bioethics community, and the public health apparatus condemn people “hawking” supplements, but have only to look at the opioid epidemic to see why people might prefer supplements to pharmaceuticals. Political beliefs have little to do with that. The same condemnation does not extend to those “hawking” pharmaceuticals, as every mainstream media outlet engages in heavy pharmaceutical advertising. A divided media has led to aligning supplements with right-wing talk show hosts who advertise them, properly condemning false claims. To negate a credibility or trust issue, as with medicines, people should research herbs and even food, question the integrity of salespeople and manufacturers, and do their due diligence.
(There is a proof issue that feeds supplement skepticism — it likely arises from an education that may value placebo-controlled trials over epidemiology or other types of evidence, and that crowds out funding for herbal remedies. It can be a healthy skepticism and help people avoid supplements that do not work, while choosing ones that do.) In general, advertising is not a useful source of objective data whether through a talk show host or by a pharmaceutical company.
While supplements are not likely to outweigh the importance of diet and exercise, they have a useful role in treating certain conditions. Doctors like Mark Hyman recommend both medicines and supplements depending on the health issue. As a result of the politicization of the issue, people may overlook diet, lifestyle, and natural supplements, further straining the healthcare infrastructure. The condemnation of all supplement use, even for distinct health problems, seems to me a pharmaceutical win. Nonetheless, I have concerns about doctors who sell their own lines of supplements.
Healthy Distrust & Critical Thinking
Tribalism and polarization can negate thinking. An unwillingness to question authority, or the blind following of experts, as a tribal position, may be a new development. That is, there may be a trend toward this illogical view: If some far right-wing people and talk show hosts who have misconceptions about the value of the COVID-19 vaccines question authority, then no one else (outside of that tribe) should question authority. The notion that the “smart” people follow orders is simply wrong and can lead to blindly following public health advice that later proves incorrect. I would argue free and intelligent people question, do their own research, read primary sources, and compare viewpoints. I find that true regardless of political affiliation. The counter to too much skepticism should not be the absence of any skepticism. It should be fostering public trust through accountability.
Any media-driven tug-of-war between supplements on one side and beliefs in vaccine efficacy on the other is detrimental to health. And pitting natural solutions against pharmaceutical ones has no benefit to the field of bioethics and may be detrimental to credibility as well as long-term health.
Some people argue that a neoliberal sociopolitical structure places too much responsibility on individuals. While in the healthcare context, shirking a duty to provide care is an ethical lapse, and the lapse relevant here concerns conflicts of interest, public policy failures, and the absence or deemphasis of a helpful, truthful narrative, I would also argue that respect for individuality, individual rights, and freedom calls for transparent, difficult discussions about obesity, diet, and lifestyle. The narrative also should include public policy beyond health policy. That is, there is definitely a role for bioethics here in explaining the urgency as a matter of moral priority. Polarization or a fear of failed or negative narratives that shame or blame should not be an excuse to quiet an empowering narrative about overcoming obesity.
Considerations, Hypotheses, and Open Questions
- Broad public policy—maybe we have made it so difficult to achieve health that the public health infrastructure has relented and decided to focus on cures while it is not effective at prevention.
- The counterargument is that the emergency aspect called for the focus on medicine and vaccination–was there no time to focus on health as well?
- The conflict of interest of the food lobby in federal, state, and local policy has a cost in health. It would be valuable to explore the data and the ethics.
- Too much stock in experts—Obesity experts may help some clients but have not succeeded in broadly solving the public health problem. It could be that people cannot follow the advice, the advice is unattainable–the food is too expensive or too far from their food desert where they rely on liquor stores for packaged food –, or the advice is incorrect and overly influenced by lobbyists.
- Some people do not have access to diet and nutrition experts, especially holistic ones trained in affordable organic and natural solutions.
- Apps and other sources of accountability that are affordable may become more useful than nutritionists and doctors.
- Nutrition science – is it possible that the calorie is not the best measure of how food will affect body weight, body mass, and health?
- While unworkable for most people, moving may be a viable way to improve health for those with the means. Examining moving as a weight loss tool could lead to a better examination of geographical health trends and enable communities to replicate good examples.