Description
This is a continuation of the collective assignments we’ve been doing for the final research paper so the topic again is : Obesity
This week, you will find three scholarly, peer-reviewed research articles on your topic ( I will post the articles that you will be using below) . Remember that next week you will submit a paper on Cultural and/or Ethical perspectives of inquiry, so use this week’s assignment to prepare materials and collect information for that purpose.
Use articles that will help you explain and describe cultural and/or ethical, legal or regulatory issues related to your topic. You will analyze and evaluate these articles in your submission, which should include:
A brief introductory paragraph
Three separate paragraphs, one for each of the three articles, each presenting:
A brief 4 sentence summary of the article (use in-text citations)
An explanation as to what makes this source credible
An explanation of why the article will be useful in addressing your problem or issueobesity reviews
doi: 10.1111/obr.12043
Obesity and Media
Weight of tradition: culture as a rationale for obesity
in contemporary U.S. news coverage
H. A. Shugart
Department of Communication, University of
Summary
Utah, Salt Lake City, Utah, USA
In studies of mediated representations of obesity to date, the overwhelming
majority have found predominant a personal responsibility frame, specifically as
drawn against environmental frames, which are nonetheless gaining ground in
recent years. In this essay, I review that extant literature and seek to trouble the
binary by isolating national news coverage of obesity in two historically and
culturally specific regions of the United States that are regularly referenced in
relation to the issue: the South and the Midwest. I evaluate the key characterizations of obesity and obese individuals in these regions in mainstream national
news coverage between January 2009 and December 2012 in order to assess
whether, how, and to what extent personal responsibility or environmental frames
are invoked in this coverage. I argue that ‘culture’ appears to be gaining traction
as an emergent discourse for obesity, which may appear to offer a more complex
or nuanced explanation of the issue; however, this analysis suggests that it can be
taken up in ways that feature troubling implications and consequences.
Received 3 January 2013; revised 13 April
2013; accepted 13 April 2013
Address for correspondence: Dr HA Shugart,
Department of Communication, University of
Utah, LNCO 2400, 255 South Central Campus
Drive, Salt Lake City, UT 84105, USA.
E-mail: h.shugart@utah.edu
Keywords: Class, culture, obesity, race.
obesity reviews (2013) 14, 736–744
Introduction
In every culture, fat is much more than material: depending
on the historical, political, social and economic context in
which it occurs, it serves as a cultural signifier of such
disparate things as benevolence, greed, wealth, success,
power and failure. Mainstream mediated articulations of
obesity constitute both an index and purveyor of cultural
understandings of the issue in a given historical moment. In
studies of mediated representations of obesity to date, the
overwhelming majority have found predominant a personal responsibility frame, which sites the individual as
responsible for the condition, specifically as drawn against
environmental frames, which are nonetheless gaining
ground in recent years. In this essay, I describe that extant
literature and seek to trouble the binary by isolating
national news coverage of obesity in two historically and
culturally specific regions of the United States that are
736
14, 736–744, September 2013
regularly referenced in relation to the issue: the South and
the Midwest.
Health and culture
In the medical literature, culture has been assessed as a
variable in the incidence of obesity. Variously attributed to
issues of access to food, time, and/or opportunities for
physical exercise; food traditions; and differing cultural
perceptions of food, obesity, or both, most such studies
describe a correlation between obesity and class (1–6)
and/or race/ethnicity (5,7–11). In general, these studies find
that members of the working and poverty classes and
people of colour manifest relatively higher rates of obesity
than more prosperous or Caucasians.
Scholars in the social sciences and the humanities
document the wide variance of the cultural significance
of obesity, both historically (12–15) and across cultures
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(16–19). Specifically, this literature establishes that both the
valence and the very definition of obesity are typically a
reflection of the configuration of cultural, political and
environmental imperatives of a given historical moment,
especially as relevant to consumption, such that resonant
cultural values and/or anxieties are projected onto the
obese body, for instance as relevant to gender (20–22) and
class (12,15,23).
A number of critics have engaged the political and practical implications that follow from cultural significance
attributed to obesity. Challenging the current national
and global designation of obesity rates as ‘epidemic’, some
(22,24) document the socially acceptable discrimination
and ostracization of obese individuals. Others (25–29)
further address the political economic context that serves as
the backdrop for current anxieties around obesity, chronicling the many entities – corporate, health and government
– that literally profit from an obese populace and/or efforts
of redress.
The media, as a collective cultural institution, have
also been examined in relation to obesity (30,31). Clinical
researchers have generally apprehended this link in terms
of effects, as relevant to unhealthy practices while consuming media (32–35); sedentary behaviour necessitated or
encouraged by media use (30,36,36–38); and content that
encourages consumption of obesogenic foods (39–42).
Others have directed their attention to the content of
mediated representations of obesity, primarily via framing
studies that assess how obesity and/or obese individuals
are characterized, as well as what articulated cause(s) of or
redress to obesity. The undergirding assumption of framing
studies is that especially persistent and pervasive frames
influence if not direct audiences understandings and practices (43–45). With respect to health and medical information, in particular, surveys corroborate that the public
receives most of that information from the media, underscoring the importance of evaluating the content of those
messages (30,31,46).
Most framing studies of obesity have examined (primarily U.S.) news coverage, which has experienced a substantial uptick in the last decade. Overwhelmingly, the
prevalent frame apparent in this coverage is a ‘personal
responsibility’ model, wherein obesity is identified as a
consequence of poor individual practices, or ‘the product of
unhealthy choices’ (47–61). Studies of representations of
media fare (including, but not limited to framing studies)
other than news revealed a similar bias, specifically as
relevant to television programming (47,62–64), magazines
(65), advertising (66) and celebrity coverage (67). Although
the personal responsibility model remains prevalent in
mediated articulations of obesity, some studies have noted
the increasing emergence of an environmental frame,
wherein obesity is attributed to external conditions such as
availability and access (or lack thereof) to resources (56,60)
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Weight of tradition H. A. Shugart
737
or the demands of modern life in the developed world
(54,68,69).
These competing frames of obesity as available in the
media are clearly divergent in terms of their ideological
investments as well as their material implications; the fact
that they are in competition speaks to the highly volatile and
unstable nature of the subject of obesity. For this reason,
while I do not contest the extant literature, I suspect that the
binary articulated across these studies may be reductive,
especially as mediated discourse regarding obesity proliferates and evolves over time. My interest in undertaking this
analysis is to assess how contemporary mediated news
coverage of regions that are familiar to the broader culture
in terms of both historical context and with respect to
perceived character are represented in relation to obesity in
order to examine the degree to and ways in which context
and/or character are invoked in that coverage.
Regional characters
Despite its nominal ‘united’ status, the United States is an
extremely diverse nation. Because my goal in this essay is to
assess how the U.S. South and Midwest are, respectively,
characterized in contemporary mainstream news coverage
in relation to obesity, an understanding of their respective
ethos is warranted. Inevitably, these characterizations are
broad brushstrokes, rife with elisions. My intent is not to
perpetuate either the elisions or characterizations, but
rather to engage them as an index for understanding how
they are articulated with obesity in contemporary news
coverage.
Southern crosses
Although perceptions vary widely and often vehemently
with respect to which states comprise the U.S. South, the
U.S. Census Bureau includes in its designation the states
of Texas, Oklahoma, Arkansas, Louisiana, Mississippi,
Alabama, Florida, Georgia, South Carolina, North Carolina, Kentucky, Tennessee, Virginia, West Virginia, Maryland, Delaware and the District of Columbia (70). The
first human cultures to populate the region were Native
American; collectively, the various tribes that inhabited or
regularly traversed the region were referred to as ‘Mississippian’. European explorers entered the region in the 16th
century, and by the 17th century, it was appropriated as
multiple colonies of, variously, England, France and Spain;
while trade occurred initially between Native Americans
and immigrants, disease and violence – as immigrants
sought more land – all but eliminated original Native
American settlers. The predominant immigrant culture in
the region was English, divided among a small number
of wealthy, land-owning elite and a large number of
indentured servants who worked the land; these southern
14, 736–744, September 2013
738 Weight of tradition
colonies furnished England as well as other American colonies to the north with significant agricultural resources.
As the population and attendant demand for resources
increased, England began to procure slaves by raiding
the west coasts of Africa, a practice that continued and
increased beyond the American Revolution in 1776, which
secured U.S. independence from England. Although other
issues contributed to the eventual rift between newly established northern and southern states, arguably the major
factor was the issue of slavery. The distinction between
‘free’ and ‘slave’ states became more profound, politically
and culturally, especially as political power eventually
became concentrated in the northern states. This led to an
attempt by southern states to secede from the Union and
form their own confederacy, which in turn led to the Civil
War: the North – the Union – proved victorious and slavery
was abolished, but the history and legacy of the rift remains
culturally salient (71,72).
Although cursory, this overview of the historical context
of the U.S. South is perhaps sufficient to explain contemporary, pervasive perceptions of Southerners. They are
largely perceived as rebellious; rural; poor; lacking education, which is often construed as ignorance; unrefined or
uncouth; prone to violence; racist; and implicitly Caucasian
(73,74). Although these qualities are unflattering, some
Southerners embrace some of them, such as rebelliousness
(the ‘Rebel South’ remains a proud motto for many Southerners) and ‘redneckness’, which celebrates lack of refinement, education and poverty – and whiteness as configured
with these qualities (75). Notably, these perceptions are
pervasive in broader U.S. culture (76).
Midwestern roots
The region that is generally classified as the Midwest –
comprised of the states of Illinois, Indiana, Iowa, Kansas,
Michigan, Minnesota, Missouri, Nebraska, North Dakota,
Ohio, South Dakota and Wisconsin (70) – is generally
uncontested. Evidence suggests that the same assemblage of
native tribes that populated the South originally also populated the Midwest, along with Great Lakes Indians and the
Great Plains Indians. In the 17th century, France colonized
the region as part of a larger swath that extended across
much of North America, from what is now northern
Canada to Louisiana. French control of the region ended
with the conclusion of the French and Indian War in 1763,
at which point English settlements to the east began to
extend westward. Following the American Revolution,
European immigrants began to bypass the eastern coast to
settle in the Midwest, attracted by agricultural opportunities: the region features highly fertile soil, a temperate
climate, and three major waterways. For all human populations that have settled in the area, agriculture has been the
14, 736–744, September 2013
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H. A. Shugart
primary industry of the region. Accordingly, the Midwest
has been and continues to be known as the ‘nation’s breadbasket’ (77).
Slavery is also salient to the history and character of
the Midwest, albeit in ways opposite the South. The (at the
time) ‘Northwest Ordinance’ region, today the heart of the
Midwest, was the first to prohibit slavery in the United
States, and as such furnished the primary routes for the
Underground Railroad, which provided escaped slaves
with safe passage to free territories prior to the Civil War.
While escaped slaves had the most to lose, white Midwesterners who mobilized the Underground Railroad risked,
and sometimes lost, a great deal, for slavery had not yet
been prohibited in the South, and slaves were legally considered property of their owners (78).
The Midwestern ethos can be understood in terms of its
designation as the nation’s ‘heartland’, becauase of both its
geographical location in the country as well as its ‘breadbasket’ status. Accordingly, Midwesterners are likely to be
perceived as hard working, nurturing, and unsophisticated
– solid and traditional. The legacy of the Underground
Railroad, even if not consciously remembered, complements that perception, such that Midwesterners are typically perceived as honest and authentic, possessed of moral
integrity. If in subtler ways and for different reasons than
Southerners, the prototypical Midwesterner is also implicitly Caucasian per this characterization (79–81).
Again, these descriptions are inevitably general, superficial and selective; but stereotypes are at least these things
by definition, and my aim was to articulate the general
perceptions of these regions as apparent in broader U.S.
culture. Because the U.S. South and Midwest are regularly
presented as the most obese regions in the most obese
nation in the world (82,83), my interest in this essay is to
review and gauge whether, how, and to what extent these
cultural perceptions are in play in contemporary mainstream news coverage of obesity, particularly in relation
to prevalent ‘frames’ that have been documented in news
coverage of obesity more broadly.
Method
I analysed coverage of obesity in the South and the
Midwest from January 2009 to December 2012 in primary
national mainstream sources of news: the newspapers the
New York Times and USA Today; and television networks
ABC, CBS, CNN, and NBC. I targeted coverage over the
last four years in order to gauge recent patterns of coverage. Because environmental frames are only lately gaining
traction in the broader public sphere, I sought to evaluate
to what extent it might be articulated with or against the
predominant personal responsibility frame in recent coverage and/or what alternative frames might be emergent.
© 2013 The Author
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Weight of tradition H. A. Shugart
Table 1 Mainstream US news coverage of
regional obesity 2009–2012
NYT
USAT
ABC
CBS
CNN
NBC
Total
739
Southern
obesity
Midwestern
obesity
SO
in-depth
MWO
in-depth
11
16
13
12
14
12
78
5
10
9
7
10
8
49
3
5
2
4
4
3
21
4
1
1
3
2
2
13
MWO, Midwestern obesity; SO, Southern obesity.
Relevant papers and broadcasts were identified via
online searches of archives of the identified texts as well as
via LexisNexis searches of papers or transcripts, using
keyword searches for ‘obesity South’, ‘obesity Southern
states’, ‘obesity Midwest’, and ‘obesity Midwestern states’.
I identified a total of 127 papers and broadcasts that referenced obesity in the South and in the Midwest. Of these,
34, or 27%, offered sustained attention to the phenomenon
of obesity in those respective regions beyond mere reporting of relatively higher incidence: 13 newspaper stories
(NYT 7, USAT 6); and 21 televised news stories (ABC 3,
CBS 7, CNN 6, NBC 5; Table 1).
Although the resultant number of texts assessed is relatively small, I suggest that they are salient to the extent that
they feature a consistent and pervasive pattern that may
serve as a template for an apparently emergent, alternative
and ‘authorized’ (per presumption afforded mainstream
news sources) rationale for obesity.
My methodological approach is informed by interpretive
and cultural perspectives; I am interested in assessing the
‘construction of meanings related to health and medicine’
((84); also (85,86)). Upon identifying suitable texts, I
engaged in qualitative framing analysis, which entails
‘repeated and extensive engagement with text[s] and
looks holistically at the material to identify frames’ ((87);
also (88,89)). Procedurally, I identified both explicit and
implicit characterizations of obesity in the South and
Midwest: its causes, effects, solutions, as well as how individuals portrayed in relation to obesity were characterized.
Consistent patterns emerged across the texts that suggest
an emergent frame of obesity as a cultural phenomenon.
Context, character, obesity
Southern obesity
Across venues for the time period specified, 78 papers and
broadcasts addressed obesity in the U.S. South, and of
those, 21 engaged the issue to a degree greater than
merely reporting obesity statistics for Southern states.
Analysis revealed that obesity among Southerners is
© 2013 The Author
obesity reviews © 2013 International Association for the Study of Obesity
consistently attributed to three factors: defiance, impoverishment and race.
As noted, defiance, or rebelliousness, is a quality strongly
associated with the South; in contemporary coverage of
obesity in the South, it is prominently featured, articulated
further as self-destructive, even perversely so. Southerners
are depicted as consciously engaging in bad practices
despite knowing the consequences – often as a matter of
Southern identity and pride. Nutritional experts sent into
community centres throughout the South were reported to
find ‘resistance from cooks who say the healthier recipes
alter the taste of their dishes’. ‘The reputation of the Southern cook is at risk when you begin to modify [the cuisine]’
((90); also (91,92)). At the individual level, a number of
stories featured Southerners who would ‘ “rather have eggs
[than oatmeal]. And . . . some good gravy, biscuits, bacon.
I can’t help it, I love it”. . . . Last year, [his] sister Emmeline
died from diabetes complications . . . “She didn’t take care
of herself either,” he said. “Blind and everything else. Got
down so she couldn’t walk and stuff” ’ (93). This attitude
was characterized as endemic to the South, affecting even
those ostensibly addressing the problem: a Mississippi
superintendent of education, charged with reforming nutrition in state schools, was quoted as follows: ‘ “The important thing is that we model what good behavior looks like”.
. . . Bounds ate at a Jackson buffet that’s popular with state
legislators. The buffet included traditional, stick-to-yourribs Southern fare: fried chicken, grits, fried okra, turnip
greens.’ (94)
Poverty, often in tandem with lack of education, was also
regularly cited as directly relevant to obesity in the South,
often to balance or offset the characterization of the decadent Southerner (94–96). A few articles trace a straight line
between poverty and the traditional Southern diet, for
‘poor families stretch their budgets by buying cheaper,
processed foods that have higher fat content and lower
nutritional value . . . [and] poor people often fry their foods
[because] it’s an inexpensive way to increase the calories
and feed a family’ (94).
The third major pattern to emerge in this coverage
departed radically from conventional perceptions of
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740 Weight of tradition
Southerners as white and likely racist: that is, African
Americans were explicitly showcased in reports of obesity
in the South, per findings that African Americans in the
South feature the highest rates of obesity (97–99). One of
the ways in which they were explained was in tandem with
poverty (91,100–102). While the stereotype of the poor
Southern white was not necessarily unseated, the image of
the poor Southern Black was given primacy.
Another prevalent pattern of coverage in this vein was
the attribution of the Southern diet to Black Southerners.
This is novel: while ‘soul food’ has long been understood
as an African American subset of the broader Southern
diet, the two have historically not been understood as
interchangeable (103). Coverage assessed for this study,
however, conflated the two, moreover attributing it to
Black Southerners. Southern fare writ large was traced
to the historical, oppressive context of slavery, wherein
‘blacks made throw-away foods taste good. And . . . tons
of calories made sense’ ((104); also (94,105)). The
favoured cooking method of the South – deep frying –
was likewise attributed to slaves, who ‘didn’t have all day
to prepare meals; they had to get back into the fields to
work’ ((90); also (92,101)). The erasure of the distinction
between Southern food and soul food in contemporary
coverage of obesity surfaces an historically erased population per common perceptions of the South – but concomitantly lays the problem of Southern obesity at
its feet.
A final pattern that emerged within the broader focus on
Black Southerners in this coverage was relevant to (self)perception of obesity; specifically, Southerners were characterized as having an inaccurate or skewed apprehension
regarding what constitutes obesity, how to evaluate it,
and/or what constituted healthy or unhealthy practices
(98,100). In one report, a physician shared a personal
anecdote regarding unhealthy perceptions relevant to
eating practices of Black Southerners: ‘ “I will have – no
exaggeration – probably a plate with 4,000 calories on it.
And my relatives will say to me, ‘Aw, you’re not eating
much at all today. You should eat more than that’ . . . [i]f
you’re not on the big side, folks where I’m from down in
Perry County [AL] say you’re not healthy” ’ (98). Interestingly, the stereotype of Southern ignorance, typically associated with white Southerners, is associated with African–
American Southerners in this coverage, albeit as naiveté
rather than defiance.
These patterns showcase the instability attached to
public discourse around obesity. Poverty, lack of education,
rurality and historical events reflect environmental explanations, whereas defiance and ignorance reflect a personal
responsibility model. This coverage appears to advance
culture as an alternative, hybrid explanation that acknowledges historical and contemporary conditions as well as
individual choices and practices.
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H. A. Shugart
Midwestern obesity
Of 49 mentions across the venues and time frame specified,
13 news stories engaged the matter of obesity in the US
Midwest to a degree beyond simply reporting the high rate
of Midwestern obesity. Analysis of these stories revealed
three prominent patterns regarding obesity in that coverage: geography, abundant food, and diet.
While Southern obesity was linked to rurality in coverage
assessed, Midwestern obesity was linked to suburbia;
suburban ‘Midwestern sprawl’ was identified as a major
reason for the region’s high rates of obesity due to attendant impediments to physical activity (106,107). The sedentariness imposed by geographic distance was reported as
translating to dramatically minimized caloric expenditure
and, thus, a propensity for weight gain: ‘All other factors
being equal, each extra degree of sprawl meant extra
weight, less walking and a little more high blood pressure.
. . . Someone living in the most sprawling county – Geauga
County outside Cleveland – would weigh 6.3 pounds more
than if that same person lived in the most compact area,
Manhattan’ (108). Notably, the identification of suburbia
as a contributing factor to obesity locates the problem as it
occurs in the Midwest squarely in the middle class.
High rates of obesity in the Midwest were also attributed
to food abundance. Abundant food was reported to be a
traditional index of success among Midwesterners, a direct
result of their agricultural heritage: “In the Farm Belt states
of the Midwest . . . the tradition lingers that a family’s
success is best embodied by the bounteousness of its
table.” (107,109) Abundant food is further articulated with
kinship: ‘hearty’ meals – and eaters – are reported as signifying health not only of those around the table but of
the strength and vigour of family bonds (106,107,110).
Moreover, coverage reports that abundance must be made
visible in ways that enable if not encourage obesity, specifically via the Midwestern culinary practice of serving
dinners ‘family style’, or in large communal dishes
displayed on the dinner table from which diners serve
themselves (110,111). As with geographic explanations,
Midwestern obesogenic foodways and practices are implicitly articulated in this coverage with a middle-class imaginary of family and bounty.
The most prominent theme in news coverage of obesity
in the US Midwest, however, is traditional Midwestern
fare. The staunchly ‘meat-and-potatoes Midwest’ (107,
111) is emphatically and consistently invoked as a, if not
the, key variable responsible for the region’s high rates of
obesity. Midwesterners’ propensity for sweets and junk
food such as such as ‘Velveeta and Twinkie[s]’ (112) is
also noted in several reports (also (106,109,110)). But the
manner in which the Midwestern diet is portrayed is
perhaps most noteworthy: a pervasive tone of camp
humour infuses these depictions, rendering the Midwestern
© 2013 The Author
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diet as essentially, even if playfully, culinary kitsch. Midwestern restaurant fare is described as comprised of
‘mystery meat and puddles of beans’; school cafeteria fare
of ‘bagel dogs (yes, that’s an entree), yellowish meatloaf
and chicken tenders, which [an interviewee] likened to
“squirts of chicken foam” ’ (113). Not only is the food
itself subject to playful ridicule, but so is Midwesterners’
naiveté around food, for example not recognising lard as
meat based, perceiving vegetarianism as a dangerous whim
or thinking that ‘green is garnish’ ((114); also (111, 112)).
Midwesterners emerge in this coverage as traditional,
conservative, literal, and naïve products of their agricultural heritage. In framing terms, then, both individual and
environmental explanations for obesity are tendered. Thus,
as with coverage relevant to Southern obesity, a cultural
explanation for obesity is advanced, one that appears to
reimagine if not renounce the personal responsibility versus
environment binary that has tended to prevail in public
discourse about obesity.
Conclusion
The general finding of this analysis is that the explanatory
power of ‘culture’ appears have some traction as an emergent frame for obesity in contemporary news coverage
about the issue. Arguably, this frame represents a more
nuanced and complex characterization, an apparently
hybrid explanation that accounts for both individual and
environmental (deployed as historical legacies, in this case)
rationales identified in previous studies.
However, this frame is problematic for at least two
reasons. First, a cultural explanation, like a personal
responsibility model, continues to elide a role for governing
entities, for historical context cannot be changed, and the
invocation of agency in the cultural frame thus practically
(re)locates responsibility in the individual. In other words,
a culture frame may ultimately function materially as a
more diffuse version of the personal responsibility model.
This is similar to what Zoller identifies as the ‘lifestyle
theory of causation’, which describes health as an outcome
of one’s everyday circumstances and responses to them,
ostensibly tempering individual responsibility, but nonetheless ‘directing attention toward the individual and away
from political and social contexts’ (115). A cultural model
potentially even exacerbates this dynamic in that culture
privileges history, further obviating structural redress
insofar as attention is directed away from contemporary
contexts and solutions. Further, the presumption afforded
tradition potentially casts intervention as not only ineffective, but inappropriate.
A related problem with a cultural frame for obesity as
implied by this coverage is that culture is articulated as
problematic; it suggests that health is contingent upon
renouncing or transcending one’s culture, ethically trou© 2013 The Author
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Weight of tradition H. A. Shugart
741
bling in itself, and more so in that some cultures are represented as more or less threatening or more or less
egressible than others. This analysis suggests that the
elision of structural or regulatory efforts is accomplished in
ways that define citizenship in relation to culture – in this
case, along the axes of race and class – and furthermore
feature implications for material redress. Locating obesity
squarely in the cultural history and politics of race in the
South makes it a sensitive subject of critique and even
redress, for to do so would be insensitive or elitist at best,
racist at worst. The staunch (implicitly Caucasian) middleclassness apparent in characterizations of Midwestern
obesity renders it more accessible for critique; however, the
gentle ridicule via which it is articulated suggests that the
problem is contained – to the past and/or to a dwindling,
lovably naïve population – and is thus relatively harmless,
or at least will sort itself out as Midwesterners, or their
children, eventually come to consciousness, implicitly
referencing the middle-class axiom that children will
surpass their parents’ socioeconomic status. Accordingly,
the problem of obesity as it affects this population is
likewise dismissed, as is the spectre of intervention or
regulation.
These distinctions surface important divides around race
and class in the United States, which are not in themselves
necessarily surprising or unique, but they feature particular
implications for how obesity may be discursively and materially engaged – or not – for particular populations. Studies
of how obesity is engaged in relation to other regions and
populations are warranted in order to assess whether, where,
and to what degree a cultural frame has resonance. Studies
of audience reception as well as of production considerations could further illuminate whether and to what extent
particular frames have purchase with broader publics or
efforts of redress (46). This study, in the vein of framing
studies to date, suggests that said efforts must acknowledge
how the issue is understood and taken up discursively as well
as materially – as well as the political and social implications
of both those discourses and practices.
Conflict of Interest Statement
No conflict of interest was declared.
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obesity reviews
Other Review
obr_880
doi: 10.1111/j.1467-789X.2011.00880.x
669..679
Ethics and prevention of overweight and obesity:
an inventory
M. ten Have1,2, I. D. de Beaufort1, P. J. Teixeira3, J. P. Mackenbach2 and A. van der Heide2
1
Department of Medical Ethics, Erasmus
Summary
Medical Centre, Rotterdam, the Netherlands;
Efforts to counter the rise in overweight and obesity, such as taxes on certain
foods and beverages, limits to commercial advertising, a ban on chocolate drink
at schools or compulsory physical exercise for obese employees, sometimes raise
questions about what is considered ethically acceptable. There are obvious
ethical incentives to these initiatives, such as improving individual and public
health, enabling informed choice and diminishing societal costs. Whereas we
consider these positive arguments to put considerable effort in the prevention of
overweight indisputable, we focus on potential ethical objections against such an
effort. Our intention is to structure the ethical issues that may occur in programmes to prevent overweight and/or obesity in order to encourage further
debate. We selected 60 recently reported interventions or policy proposals targeting overweight or obesity and systematically evaluated their ethically relevant
aspects. Our evaluation was completed by discussing them in two expert meetings. We found that currently proposed interventions or policies to prevent overweight or obesity may (next to the benefits they strive for) include the following
potentially problematic aspects: effects on physical health are uncertain or
unfavourable; there are negative psychosocial consequences including uncertainty, fears and concerns, blaming and stigmatization and unjust discrimination;
inequalities are aggravated; inadequate information is distributed; the social and
cultural value of eating is disregarded; people’s privacy is disrespected; the complexity of responsibilities regarding overweight is disregarded; and interventions
infringe upon personal freedom regarding lifestyle choices and raising children,
regarding freedom of private enterprise or regarding policy choices by schools
and other organizations. The obvious ethical incentives to combat the overweight epidemic do not necessarily override the potential ethical constraints, and
further debate is needed. An ethical framework to support decision makers in
balancing potential ethical problems against the need to do something would be
helpful. Developing programmes that are sound from an ethical point of view is
not only valuable from a moral perspective, but may also contribute to preventing overweight and obesity, as societal objections to a programme may hamper
its effectiveness.
2
Department of Public Health, Erasmus
Medical Centre, Rotterdam, the Netherlands;
3
Faculty of Human Kinetics, Technical
University of Lisbon, Cruz Quebrada, Portugal
Received 1 October 2010; revised 7 February
2011; accepted 9 March 2011
Address for correspondence: M ten Have,
Department of Medical Ethics, Erasmus
Medical Centre, Dr. Molewaterplein 50,
Rotterdam, 3000 CA, Postbus 2040, the
Netherlands. E-mail:
m.tenhave@erasmusmc.nl
Keywords: Ethics, obesity, overweight, prevention.
obesity reviews (2011) 12, 669–679
© 2011 The Authors
obesity reviews © 2011 International Association for the Study of Obesity 12, 669–679
669
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Ethics and prevention of overweight
obesity reviews
M. ten Have et al.
Introduction
According to the World Health Organization, overweight is
among this century’s major health threats (1). The number
of people with serious overweight or obesity is increasing
steadily: in 1960–1962 an estimated 31.6% of US adults
were pre-obese (body mass index [BMI] of 25.0 to 29.9)
and 13.4% were obese (BMI of 30 or higher) (2). In
2007–2008, 68.0% of US adults were overweight, of
whom 33.8% were obese (3). The trends of overweight and
obesity among children and adolescents have increased in
parallel: in 2007–2008 almost 17% of school-aged children
and adolescents were obese (4). The prevalence of overweight is widely varying in different subgroups of the population: in developed countries it is notoriously high among
persons with a low educational level and a low income (3).
Obesity is an important risk factor for diabetes, cardiovascular disease and diseases of the locomotor system. Overweight is also related to psychological problems (1).
It is likely that many of these overweight-related health
problems can be prevented. Adopting a healthy lifestyle,
that is, a healthy diet and sufficient physical exercise, can
prevent overweight (1). According to the World Health
Organization, a healthy diet includes limiting the intake of
unhealthy fats, free sugars and salt and increasing the consumption of fruits, vegetables, legumes, whole grains and
nuts (5). Experts have advocated a combination of interventions to promote a healthy lifestyle: education (preferably education tailored to the target group or even to
individual persons), optimizing environmental opportunities to adopt a healthy lifestyle (e.g. with respect to the
infrastructure, building of houses, available means of
transport, schools, work, health care and supply of food)
and legal and other regulations (e.g. economic measures, or
putting restraints to the supply and commercial advertisement of fattening food products). It has been suggested that
extra attention is needed for special target groups in which
it is more likely that interventions can prevent health
problems, such as adolescents and children, or in which
overweight and obesity are more common, such as people
with a low socioeconomic status, and people from certain
migrant groups (6,7).
Most interventions that are aimed at preventing overweight or obesity have not (yet) been proven to be effective
or to have a favourable cost-effectiveness ratio. In spite of
a lack of comprehensive research on the effectiveness
of prevention strategies, authoritative agencies such as
the World Health Organization and, in the Netherlands,
the Health Council have suggested a ‘common sense’
approach, because of the size and the potential consequences of the obesity epidemic. Measures that are very
likely to be effective should be implemented as soon as
possible (6,8). However, lifestyle interventions, whether
they are evidence-based or not, frequently give rise to
ethical debate (9–14). The Dutch Council for Public Health
and Health Care has therefore pleaded for measures that
facilitate healthy choices, while suggesting reticence about
measures that more or less strongly force people to change
their lifestyle, because the potential social and ethical problems that may be associated with such coercive measures
should be analysed first (15).
In the present article, we have made an inventory of the
ethical aspects of measures aimed at the prevention of
overweight and obesity. There are obvious ethical incentives to combat the overweight epidemic, such as improving
individual and public health, enabling informed choice and
diminishing societal costs. Whereas we consider these positive arguments to put considerable effort in the prevention
of overweight indisputable, we focus on potential ethical
objections against such an effort. Our intention is to point
out how ethical issues may occur in programmes to prevent
overweight and/or obesity and to structure these issues in
order to encourage further debate. Our overview includes
interventions to prevent overweight as well as interventions
to prevent obesity, as both raise similar ethical issues.
Moreover, prevention programmes aimed at the population
at large are often unspecific about the exact target group.
However, the health risks of obesity (BMI of 30.0 or
higher) are higher than those of overweight (BMI of 25.0 to
29.9), which implies a distinct balancing of ethical arguments: the results of interventions aimed at obesity may
outweigh ethical objections more easily than the results of
interventions aimed at overweight.
Methods
We searched for interventions to prevent overweight on the
Internet, in the media and in scientific medical literature.
All interventions were proposed, implemented or studied
after 1980, in the Netherlands or elsewhere. We included
interventions that change the environment, interventions
that consist of providing information or educating people,
financial incentives, legal regulations and medical interventions. Our analysis was limited to 60 interventions, because
at that number we felt that adding additional interventions
would not provide new insights. A complete list of all
interventions included and the sources we used to identify
their characteristics can be found in Appendix S1. We performed a three-step systematic analysis of the potentially
ethically relevant aspects of interventions. By ‘potentially
ethically relevant aspect’ we refer to all aspects that may
lead to ethical objections. Issues in public health ethics
centre around ‘the trade-off that can arise between, on the
one hand, protecting and promoting the health of populations, and on the other, avoiding individual costs of various
kinds, including physical danger, moral harm and frustrated desires’ (16). First, we searched whether or not the
paper or website in which the intervention was presented
© 2011 The Authors
obesity reviews © 2011 International Association for the Study of Obesity 12, 669–679
obesity reviews
Ethics and prevention of overweight
included any explicit reference to potentially ethically problematic aspects. In a second step, ethical issues were identified directly by two of the authors (MtH and AvdH). In
the third step of our analysis, we discussed the results of
our inventory in two expert meetings. These expert meetings were attended by policymakers, physicians, representatives from health insurance companies, researchers,
ethicists and representatives of organizations of obese
people. The first meeting was focused on the extent to
which the problems we identified are exclusively related to
prevention of overweight and obesity; this meeting was
attended by 14 experts. The second meeting was focused
on prevention of overweight and obesity in children;
this meeting was also attended by 14 experts. Prior to the
meeting, the experts received our inventory of programmes.
During the meeting there was discussion on the basis of
statements that we presented (see Appendix S2).
Furthermore, certain programmes to prevent overweight
may have harmful side effects on physical health, and thus
threaten the value of well-being. Sometimes, health risks
are taken for granted because the risks of non-interfering
are even higher, for instance when the British government
recommends bariatric surgery and medication for exceptional cases of childhood obesity (20). Harm to health may
also occur because of prevention programmes that have a
negative and problem-based focus on overweight, according to O’Dea (21). Next to probably contributing to weight
concerns, unhealthy types of dieting and eating disorders,
they may discourage overweight people from visiting
health services or from practising physical activity (21).
The Singaporean Trim and Fit programme, for example,
was criticized for potentially contributing to eating disorders (22,23).
Finally, the intended effects of commercially financed
interventions may at least partly relate to providing the
producer with a positive and responsible image. Examples
are fast food chains that provide free pedometers (24), and
children’s summer camps for weight loss that are financially supported by a fast food company (25). In some
cases this so-called ‘image boosting’ ultimately may serve
the goal of increasing the turnover of overweight-inducing
products. The World Health Organization calls for controlling the promotion of dangerous and deliberately deceptive
approaches to weight loss or control, such as special weight
loss aids, ‘miracle-cures’ and certain drugs and treatments
often offered through unlicensed weight loss centres (1).
When the public are actually misled about a programme’s
aims, this conflicts with the ethical values of truthfulness
and transparency.
Results
The interventions that were included in our analysis are
presented in Table 1. We identified and analysed 58 concrete interventions and two policy proposals. Eighteen
interventions were aimed at promoting a healthy diet;
14 were aimed at physical exercise and 28 targeted both
behaviours. Interventions were aimed at the population at
large or at specific groups, such as employees, children or
their parents, people with a low socioeconomic position or
people from ethnic minority groups.
The following eight potentially problematic aspects were
identified. Table 1 provides an overview of them, including
examples of programmes for each aspect and the ethical
values at stake.
M. ten Have et al. 671
Psychosocial well-being
Physical health
A potential problem of programmes to prevent overweight
that was frequently identified is that their effects on physical health are not known or not favourable. Ineffective
programmes should of course not be implemented, and
should certainly not be financed by public means. But much
more often we deal with programmes that may have positive results, whereas this is not certain. Many publicly
financed programmes are not supported by evidence. Few
programmes have been evaluated, and for programmes that
have been evaluated, such as the ‘balance day-campaign’
(17), cost-effectiveness is often hard to prove or even
doubtful. Lack of scientific evidence frequently leads to
discussion about whether or not to continue a programme.
When government subsidy for a Dutch clinic for obese
children was stopped because of insufficient scientific evidence, opponents objected that practice showed positive
results, which could only be monitored if subsidy would be
carried on (18,19).
Overweight prevention can, in some cases, have various
negative psychosocial consequences, such as uncertainty,
fear and concerns about the health risks of overweight
and obesity, stigmatization and blaming, and unjust
discrimination.
Uncertainty, fear and weight concerns
The focus on the health risks of overweight and obesity has
drawn body weight into the medical sphere. The bodily
state of weight has more and more become an indicator
for health. Whereas overweight children have always been
bullied during gymnastics, today they are also being put on
a weighing scale and sent to a medical doctor. Informative
campaigns about the health risks of obesity confront
healthy people with health risks that they currently do not
experience and which they may not even encounter in the
future. For mothers-to-be who consult a doctor about pregnancy, body weight is examined as an indicator for the
future health of their child-to-be. This focus on health risks
© 2011 The Authors
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Table 1 Ethical issues, examples of programmes, values at stake
Ethical issue
Subissue
Examples of programmes
Ethical value at stake
Negative effects on
physical health
No evidence-based
cost-effectiveness
De Balansdag (27)
Heideheuvel clinic (22)
Well-being
Negative effects on
physical health
Stomach surgery and medication (32)
Trim and Fit (1)
Boosting the image
of the producer
Children’s summer camps for weight loss (41)
Free pedometer supplied with hamburger (11)
Uncertainty, fear and
worries
Website’s quote: ‘Overweight diminishes the chance to a long, healthy and
happy life’ (25)
Cholesterol test in supermarket (59)
Stigmatization and
blaming
Trailer Jamie’s school dinners (1)
Unjust discrimination
Firing stewardesses (34)
Firing police officers (35)
Higher insurance premiums (37)
Higher prices for overweight aeroplane passengers (38)
Grouping children at normal and overweight tables during recess (1)
Body mass index grade on school report card (46)
Withholding university diploma’s from overweight students (57)
Negative
psychosocial
consequences
Well-being
Privacy
Respect for persons
Truthfulness
Justice
Inadequate
information
De afvallers (8)
Promotion of products without fat but with a lot of sugar (general example)
Promotion of quick fixes for overweight in the form of slimming
products that discourage people from practising a healthy lifestyle
(general example)
Truthfulness and transparency
Autonomy and informed choice
Well-being
Cultural and social
value of eating
disregarded
Ban on birthday cakes in schools (39)
‘5 am Tag’ campaign (47)
Respect for cultures and value
pluralism
Well-being
Inequalities
aggravated
Fat tax (5)
Responsibility contract Medicaid (17)
Free swimming sessions (45)
Justice and fairness
Privacy disrespected
Weight grade on report cards (46)
Electronic child file (15)
Work-based programmes that focus on individual behaviours such as health
risk assessments (19)
Respect for the personal life
sphere: privacy
Individual
Responsibility contracts Medicaid (17)
Parents
Parents step up (14)
Intermediate
organizations such
as schools,
municipality or social
healthcare services
Compulsory cooking classes in the curriculum (48)
Balance between personal and
collective responsibility
Just division of responsibilities
between government, schools,
industry, civil society individual
Complexity of
responsibilities
disregarded
Liberty infringed
Industry
Labelling restaurant calories (6)
Regulation and laws
Ban on trans fats in restaurant menus (50)
Ban on soda and snack vending machines in schools (3)
Fat tax (5)
Foster care for obese child (55)
Changes in physical
environment that
close down options
Banning cars from city centres and around schools (42–44)
Slowing down the elevator in a company building (51)
Designing office building that encourages walking (52)
No fast food strip in business area in south-east Amsterdam (4)
Financial triggers
Fat tax (5)
Bonus for police officers who lose weight (36)
Financial bonus for townsmen who lose weight (54)
Higher insurance premiums on the basis of body mass index (37)
Tax on aeroplane tickets for overweight passengers (38)
Psychological
motivation
Caloric information on restaurant menu (6)
Social influence
Sneaky fitness (2)
Promoting practising sports by children by famous soccer players (28)
Offering employees weight loss drugs (53)
Respect for the personal life
sphere: autonomy and freedom of
choice
Freedom of action for
corporations
Value pluralism
Justice: being consequent
© 2011 The Authors
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Ethics and prevention of overweight
may create excessive and unwarranted fear and weight
concerns (26). A website’s quote: ‘Overweight diminishes
the chance to a long, healthy and happy life’ (27) aims to
motivate people to lose weight, but how will it affect people
who want to lose weight but do not succeed? Unsuccessful
efforts to change one’s lifestyle may result in feelings
of uncertainty and powerlessness. Slightly overweight
people may come to think that the health risks of severe
obesity also apply to them, and people may lose sight of
the line between the health consequences of occasionally
versus continuously snacking. As one example, when the
Dutch Heart Association organized cholesterol tests in
supermarkets, concerns were raised that this action was
ineffective, causing unjustified confidence and unnecessary
concern (28).
children at normal and overweight tables during recess
(22,23). Discrimination may undermine psychological
well-being, but it also involves ethical objections based on
the value of justice. An American high school includes on
its report cards a ‘Weight grade’ that indicates the child’s
BMI, evoking angry reactions from parents (40). And at an
American university, more than 20 students are in jeopardy
of not receiving diplomas because of their overweight (41).
Stigmatization and blaming
Being overweight is a highly stigmatized condition, which
means linking individuals to negative stereotypes. Overweight persons are the victim of childhood teasing and
bullying, avoidance by other people, discriminatory hiring
practices and misplaced humour (29,30). Overweight
persons are frequently presented as being unattractive and
they are associated with negative character traits such as
laziness and stupidity (31). Take for instance a television
spot for the promotion of Jamie Olivers’ programme to
prevent overweight, where Jamie Oliver is portrayed as an
obese person who drives to a snack bar and swallows a
bunch of hamburgers, and consequently breaks through his
motorcycle that buckles under his weight (32). On the
surface, the television spot is merely a funny way of getting
attention for a television programme to prevent overweight. However, it could also be interpreted as expressing
the implicit message that overweight persons are unattractive, lazy, silly and can only blame themselves for being
overweight. Another action to prevent overweight that
potentially blames the individual for being overweight is a
bill in Mississippi that makes it illegal for restaurants to
serve obese customers (33). Not only may stigmatization
and blaming messages contain subjective or even inadequate information, but also they are often extremely
hurtful and show a lack of respect.
Discrimination
Overweight persons are regularly treated differently from
normal weight persons. Overweight could for instance be
used as a criterion to fire people from certain professions,
which happened to stewardesses (34) and police officers
(35). Overweight persons may also have to pay higher
insurance premiums (36–38) or higher prices for airplane
tickets (39). This gives rise to the question of which
grounds and circumstances justify discrimination and
which do not. Some Singaporean schools that participated
in the before mentioned Trim and Fit programme grouped
M. ten Have et al. 673
Equality
In general, measures to prevent overweight have a tendency
to be less effective among lower educated people. In developed societies, a lower educational level is often associated
with a higher prevalence of overweight and obesity (42).
Although it is not a requirement for any single programme
to actively pursue the aim of reducing health inequalities, it
is generally considered to be a positive duty of public health
to diminish existing health inequalities (43,44). The presence of health inequalities conflicts with ideas about justice
and equality. Interventions that affect financial distribution
such as fat tax (45) or the responsibility contracts by Medicaid (46) are likely to hit harder among people with low
income. But inequalities may also be aggravated by campaigns with a positive and innocent character. For example,
offering free swimming sessions (47) will not reach women
from certain ethnic minorities, as long as the swimming
classes are mixed. If a campaign contains information that
is hard to grasp for lower educated people or people from
ethnic minorities and therefore does not succeed in changing their lifestyle, it may increase already existing health
inequalities (26).
Informed choice
In some cases, education about overweight and obesity
involves inadequate information, including unclear, overstated, oversimplified, subjective, incomplete or even false
messages. Corporations with their own agenda frequently
promote products ‘without fat’ that contain a lot of sugar,
and suggest that ‘quick’ fixes for overconsumption are
available in the form of slimming products that demotivate
people to practise a healthy lifestyle. In the rush of ‘having
to do something’ about the problem, messages to convince
people about the necessity of a healthy lifestyle are not
always in accordance with the facts. Suggesting that eating
healthy or, in turn, physical activity, are the solution for all
problems neglects other health determinants. A real-life
television programme about a competition between obese
families in losing weight was criticized by the Belgian
association for obese patients (Bold) because it would be
distributing inadequate information, by failing to acknowledge that obesity is a disease that requires long-term
medical treatment. Quote from their website (translated):
© 2011 The Authors
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‘This type of programs undermines the struggle against
obesity, which is recognized as a serious public health
problem by the OMS. Our leaders should urgently recognize that obesity is a disease, in order to avoid this type of
deviations where inadequate information is distributed
which is harmful for society as a whole.’ (48) Some interventions are justified on the basis of epidemiological information that is collected at an aggregate level, and cannot be
translated to individual cases without reserve. Evidence, for
example, that the population-wide adoption of a healthy
diet can prevent 25% of all deaths from cardiovascular
disease, does not indicate that adopting a healthy diet
reduces each individual person’s risk with 25%. Inadequate
information is problematic from an ethical point of view, as
it is in tension with the value of truthfulness and transparency (49). It hampers exercising freedom of choice and
autonomy and may have negative consequences on health.
information about the child’s health and development,
including potential overweight (53). The plan was criticized
for posing a threat to privacy (53). Having one’s child’s
BMI printed on his/her school report card (40), having to
provide information about one’s body weight and lifestyle
or being screened on overweight by company doctors also
involve intervening in the personal life sphere and may
thereby violate the right to privacy. Some features make
requiring disclosure of personal information extra sensitive
for ethical objections. Body weight, eating habits or styles
of feeding and rearing children all concern very personal
information. Physical contact in measuring someone’s
waist circumference is more personal than asking a selfreported BMI. Pressure to provide the information or
lack of consent can make an intervention problematic. It
also makes a difference which party collects the information (government, insurance company or employer) and
whether it has a legitimate justification to do so. Workbased programmes that focus on individual behaviours
such as health risk assessments may raise concerns regarding privacy issues (54,55). A final relevant distinction is
whether the person whose information is required has an
interest in providing it (for example to enable the general
practitioner to make a diagnosis) or not (for example when
information about an unhealthy weight has financial implications). In all cases, sufficient warrants must be made for
safeguarding the information.
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Ethics and prevention of overweight
Social and cultural values
Food and eating habits are related to important cultural
and social values. Food is for instance consumed to celebrate, to show hospitality or as a part of cultural traditions (50). However, many public health campaigns aimed
at changing people’s personal lifestyles focus exclusively on
the nutritional value of food, thus neglecting or interfering
with such values. They alter the practice of eating from a
natural and a social event into a practice that is only about
the value of health. Interventions that urge individuals to
make healthy choices, such as the British ‘5 a day’ campaign and the German ‘5 am Tag’ campaign, have been
criticized for presenting the healthy choice as the only
rational and valuable choice, which is thus easy to make.
Such campaigns could be ethically questionable as well as
ineffective if they fail to take into account the many other
values that food represents to people (51).
When collectively valued practices are violated and disappear, people may feel offended in their cultural identity.
This could explain the angry reactions of American parents
when the tradition of birthday cakes was banned from
American schools (52). Being hampered to participate in
culturally and socially valued practices may also lead to an
undermining of individual well-being, because these cultural traditions often are a source of pleasure and feelings
of community. Moderating participation in Christmas
dinner or the festivities after the Ramadan, or turning
down a colleagues’ birthday cake may lower calorie intake,
but may at the same time diminish positive feelings of
community.
Privacy
Starting in 2009, every child that was born in the Netherlands gets a digital file from youth health care, containing
Responsibility
Any preventive programme expresses ideas about who
must take action to prevent overweight or obesity: individual citizens, parents, schools, the government, the industry or a combination of these. Ethical objections arise if a
programme threatens the balance between individual and
collective responsibility, or if we lose sight of the fact that
the responsibility for the overweight epidemic cannot be
attributed to one single party. Overweight is the result of a
complex web of causal factors, many of which outside the
individuals’ control. It is partly the result of personal and
voluntary choices, and partly the result of social and environmental characteristics. An emphasis on people’s personal responsibility may disregard the influence of the
social and physical environment and of personal characteristics that are hard to modify or cannot be changed, such
as genetic characteristics, educational level and socioeconomic status, or vice versa (1,56–58). The state-funded US
healthcare insurance company, Medicaid, makes her clients
sign so-called ‘responsibility contracts’ (59). If clients do
not comply with promised health goals, they may for
instance lose their right to compensation for a diabetes
treatment (59). The campaign ‘Parents step up’ is also very
straightforward in blaming parents. Under the sound of
scary music, its website expresses slogans like ‘And don’t
© 2011 The Authors
obesity reviews © 2011 International Association for the Study of Obesity 12, 669–679
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Ethics and prevention of overweight
blame it on videogames. You are letting your child down as
a parent’ (60). Obviously, a distinction should be made
between attributing responsibility for the problem versus
attributing responsibility for resolving the problem.
However, attributing responsibility for a solution without
attributing accountability for the problem may also evoke
objections from stakeholders. The proposal to force
schools to adopt cooking classes in schools by the British
minister of health made head teachers complain that the
school curriculum was overdemanded (61,62). Restaurant
owners from New York were furious when they were
forced to label their menus with information about calories
(63,64). The weight of these objections partly depends
upon the positive results of the measure.
chosen to be informed about the menu’s caloric properties
(63,64), but once she/he is informed, it is hard to ignore
and still enjoy a desert like Sticky Toffee Pie. Another form
of infringing in personal liberties that is not immediately
apparent involves the use of social influence. This appears
in various ways, from a campaign for school children
where famous soccer players function as a role model for
healthy behaviour (75), to straightforward peer pressure in
the Sneaky fitness website that encourages employees to
guide their inactive colleagues towards healthy behaviour
by replacing the copying machine from their desk to
another room, or by faking that the elevator is out of order
(76). Programmes that are implemented in the working
atmosphere are extra likely to express pressure. When
employees are offered weight loss drugs by their employer
(72), they may find it hard to refuse, even if participation is
not required. Attempting to limit someone’s actions or to
require actions by someone for his or her own good is
called paternalism (77). Paternalistic programmes evoke
moral objections because not everyone equally values a
healthy lifestyle. Thus, promoting health may be in conflict
with pluralism of values. From a perspective of people who
work in health promotion, it may be self-evident that everyone strongly values health. But health is only one of the
valuable things in life and not all people consider health to
be the most important one (12). Furthermore, what people
consider a healthful life may vary considerably.
Programmes aimed at preventing childhood obesity often
raise the question to what extent parental autonomy may
be infringed (78,79). One of the most extreme examples
was the case of a 14-year-old obese boy weighing 555
pounds that was put into foster care, while his mother was
being arrested (80).
Liberty and autonomy
The solution for the obesity epidemic is frequently sought
in interventions that interfere with liberty and freedom of
choice regarding personal choices, commercial actions and
policy by schools and other organizations. Personal
autonomy and freedom of choice are important ethical
values in modern liberal societies, just as freedom of action
for corporations. Interventions to prevent overweight may
infringe upon these liberties in various ways. Regulations
or laws are the most far-reaching form of limiting choice
and include, for instance, prohibition of the use of trans
fats in restaurants (65,66), banning soda and snack
vending machines from schools (67,68), restricting the
amount of fast food selling points in a business area (69)
and banning cars from city centres (70,71). Personal choice
may be influenced or limited by interventions that change
the physical environment. American employers encourage
walking by locating the cafetaria far away from the office
or by slowing down the elevators in order to push its
employees to take the stairs (72). Some programmes
reward healthy behaviour or a healthy weight. Police officers from the Mexican city Aguascalientes receive a bonus of
100 pesos for every kilogram they lose, because they were
thought to be too slow in pursuing criminals (73). The
mayor of the Italian town Varallo offers cash money to
citizens who succeed in losing 3 to 4 kg in a month (74).
Other programmes punish unhealthy behaviour or an
unhealthy weight, for instance by imposing higher insurance premiums for persons with a high BMI (36,37), a fat
tax on products high in fat and sugar (45) or a tax on
aeroplane tickets for overweight passengers (39). Policy
that rewards certain behaviours and punishes others may
raise the objection that it is inconsequent, because only
some healthy or unhealthy behaviours are singled out while
others are overlooked (58). A less obvious, but not necessarily less strong form of exercising pressure is using psychological motivation. Personal choice includes the choice
‘not to know’: not every restaurant customer would have
M. ten Have et al. 675
Discussion
Lifestyle interventions, especially regarding the bodily condition of weight, affect personal characteristics and habits.
They touch upon people’s feelings and core convictions and
they give rise to strong ethical debate. Our analysis of 60
programmes to prevent overweight and obesity and comments in two expert meetings revealed eight types of potentially problematic ethical aspects. Four objections concern
negative consequences of a programme: its effects on physical health may be uncertain or unfavourable; it may have
negative consequences for psychosocial well-being, including uncertainty, fears and weight concerns, blaming and
stigmatization and unjust discrimination; it may distribute
inadequate information; and it may aggravate inequalities.
Four objections concern disrespect for certain ethical
values: the social and cultural value of eating may be disregarded; people’s privacy may be disrespected; the complexity of responsibilities regarding overweight may be
disregarded; and freedom regarding lifestyle, raising
© 2011 The Authors
obesity reviews © 2011 International Association for the Study of Obesity 12, 669–679
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children, private enterprise or policy choices may be
infringed. Obviously, disrespect for such ethical values may
also affect a programme’s effectiveness (43) or yield unintended consequences.
These potentially problematic ethical aspects arise out
of various origins. Firstly, some issues concern side effects
that are unforeseen and unwanted by the designers of the
intervention. They stem from a narrow focus on aiming
to reduce overweight, whereby other relevant issues are
lost out of sight. Think about campaigns that are essentially uncontroversial but that unintentionally contain
stigmatizing pictures that could easily have been replaced
if more attention had been paid to ethical issues. The
urgency to find solutions for overweight and obesity,
sometimes bordering on panic, does certainly not always
lead to solutions that are sensitive from an ethical
perspective.
A second category of ethical issues originates out of
conflicting interests. For instance, a campaign that informs
about the health risks of obesity protects some from
gaining weight, whereas at the same time it creates fear and
weight concerns among those who are already obese and
have great difficulties in losing weight.
A third category of ethical issues arises out of conflicting
beliefs and principles. People who feel that governments
must protect their citizens against unhealthy influences will
appreciate a ban on trans fats in restaurant kitchens
(65,66), whereas proponents of personal and commercial
liberties will object against such regulations.
In this paper we focused on potential objections against
programmes to prevent overweight or obesity. However,
our inventory does not show how frequently the issues
actually occur, as we did not conduct an empirical analysis.
Instead, we aimed to point out that programmes to prevent
overweight and/or obesity may yield ethical issues, to structure these issues, and to suggest that professionals who
develop and implement such programmes should pay
attention to them. Nor does our study show how serious
the ethical issues actually are. The fact that objections are
raised does not automatically imply that a programme
should not be implemented. In the first place, various and
sometimes contrary opinions exist about the validity of
ethical objections in specific situations. For instance,
depending on one’s beliefs about personal responsibility,
one will think differently about asking higher insurance
premiums from obese persons. The variety of moral convictions implies that programmes that involve ethical objections are not automatically ethically wrong. Ideas about
values and the good life are to a certain extent influenced by
ones cultural background and political convictions. This
is not to say that all moral opinions about overweight
prevention are equally valuable. As holds for all ethical
discussions, some arguments are simply more convincing
than others.
In the second place, ethical objections regularly refer to
programme characteristics that also have a positive side.
Banning cars from city centres (70,71) closes down options
for car drivers, but opens up possibilities for bicycle drivers.
Most programmes that give rise to ethical discussion are
motivated by the expectation that they will be effective in
preventing overweight and obesity. The message that
people feel better about themselves if they manage to lose
weight may be stigmatizing on the one hand, but motivating on the other hand. Fat tax poses a financial burden and
infringes upon personal choice, but at the same time may
provide an extra incentive for a healthy lifestyle (45). Oversimplified information is not according to the facts, but is
understandable to a broader audience than a nuanced and
detailed message would be. Bariatric surgery for obese children poses serious health risks, but may offer the only
solution to diminish the health risks posed by obesity (20).
Awareness of the fact that certain aspects of programmes
to prevent overweight and obesity may evoke ethical debate
is a first and crucial step for professionals who develop and
implement such programmes. The second step, which is
beyond the scope of this article, is to deal with these issues
and the debate they induce. This leads to the question how
a professional in overweight prevention should react to
ethical objections: which arguments must be taken seriously and how should burdens be weighed against benefits?
Further thinking about an ethical framework for such consideration and decision making would enable professionals
from overweight prevention practice and policy to be prepared for ethical objections, and if possible and desirable to
prevent them. Developing programmes that are sound from
an ethical point of view is not only valuable from a moral
perspective, but may also contribute to preventing overweight, as ethical analysis will make public health work
more effective (43).
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Ethics and prevention of overweight
Conclusion
Programmes to prevent overweight or obesity involve a
number of potential ethical objections. Obvious ethical
incentives to combat the overweight epidemic do not necessarily override these potential ethical constraints. Therefore, further debate is needed. An ethical framework would
be useful for helping professionals in overweight prevention to map the ethical issues, structure the relevant arguments and make a decision about the extent to which a
programme is ethically acceptable. This inventory of potential ethical issues provides a first step towards creating such
a framework.
Conflict of Interest Statement
No conflict of interest was declared.
© 2011 The Authors
obesity reviews © 2011 International Association for the Study of Obesity 12, 669–679
obesity reviews
Acknowledgements
This study is part of a PhD project about the ethical aspects
of prevention of overweight and obesity, which was funded
by ZONmw. Furthermore, in drafting this study we
benefited greatly from our participation in the workshops of the international and interdisciplinary project
‘EUROBESE’ (FP6 SAS6-CT-2005-016646), which was
funded by the European Union. We thank all its participants
for the inspiring discussions. Finally, we thank the participants in the expert meetings for their valuable contribution.
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![Description
This is a continuation of the collective assignments we’ve been doing for the final research paper so the topic again is : Obesity
This week, you will find three scholarly, peer-reviewed research articles on your topic ( I will post the articles that you will be using below) . Remember that next week you will submit a paper on Cultural and/or Ethical perspectives of inquiry, so use this week’s assignment to prepare materials and collect information for that purpose.
Use articles that will help you explain and describe cultural and/or ethical, legal or regulatory issues related to your topic. You will analyze and evaluate these articles in your submission, which should include:
A brief introductory paragraph
Three separate paragraphs, one for each of the three articles, each presenting:
A brief 4 sentence summary of the article (use in-text citations)
An explanation as to what makes this source credible
An explanation of why the article will be useful in addressing your problem or issueobesity reviews
doi: 10.1111/obr.12043
Obesity and Media
Weight of tradition: culture as a rationale for obesity
in contemporary U.S. news coverage
H. A. Shugart
Department of Communication, University of
Summary
Utah, Salt Lake City, Utah, USA
In studies of mediated representations of obesity to date, the overwhelming
majority have found predominant a personal responsibility frame, specifically as
drawn against environmental frames, which are nonetheless gaining ground in
recent years. In this essay, I review that extant literature and seek to trouble the
binary by isolating national news coverage of obesity in two historically and
culturally specific regions of the United States that are regularly referenced in
relation to the issue: the South and the Midwest. I evaluate the key characterizations of obesity and obese individuals in these regions in mainstream national
news coverage between January 2009 and December 2012 in order to assess
whether, how, and to what extent personal responsibility or environmental frames
are invoked in this coverage. I argue that ‘culture’ appears to be gaining traction
as an emergent discourse for obesity, which may appear to offer a more complex
or nuanced explanation of the issue; however, this analysis suggests that it can be
taken up in ways that feature troubling implications and consequences.
Received 3 January 2013; revised 13 April
2013; accepted 13 April 2013
Address for correspondence: Dr HA Shugart,
Department of Communication, University of
Utah, LNCO 2400, 255 South Central Campus
Drive, Salt Lake City, UT 84105, USA.
E-mail: h.shugart@utah.edu
Keywords: Class, culture, obesity, race.
obesity reviews (2013) 14, 736–744
Introduction
In every culture, fat is much more than material: depending
on the historical, political, social and economic context in
which it occurs, it serves as a cultural signifier of such
disparate things as benevolence, greed, wealth, success,
power and failure. Mainstream mediated articulations of
obesity constitute both an index and purveyor of cultural
understandings of the issue in a given historical moment. In
studies of mediated representations of obesity to date, the
overwhelming majority have found predominant a personal responsibility frame, which sites the individual as
responsible for the condition, specifically as drawn against
environmental frames, which are nonetheless gaining
ground in recent years. In this essay, I describe that extant
literature and seek to trouble the binary by isolating
national news coverage of obesity in two historically and
culturally specific regions of the United States that are
736
14, 736–744, September 2013
regularly referenced in relation to the issue: the South and
the Midwest.
Health and culture
In the medical literature, culture has been assessed as a
variable in the incidence of obesity. Variously attributed to
issues of access to food, time, and/or opportunities for
physical exercise; food traditions; and differing cultural
perceptions of food, obesity, or both, most such studies
describe a correlation between obesity and class (1–6)
and/or race/ethnicity (5,7–11). In general, these studies find
that members of the working and poverty classes and
people of colour manifest relatively higher rates of obesity
than more prosperous or Caucasians.
Scholars in the social sciences and the humanities
document the wide variance of the cultural significance
of obesity, both historically (12–15) and across cultures
© 2013 The Author
obesity reviews © 2013 International Association for the Study of Obesity
obesity reviews
(16–19). Specifically, this literature establishes that both the
valence and the very definition of obesity are typically a
reflection of the configuration of cultural, political and
environmental imperatives of a given historical moment,
especially as relevant to consumption, such that resonant
cultural values and/or anxieties are projected onto the
obese body, for instance as relevant to gender (20–22) and
class (12,15,23).
A number of critics have engaged the political and practical implications that follow from cultural significance
attributed to obesity. Challenging the current national
and global designation of obesity rates as ‘epidemic’, some
(22,24) document the socially acceptable discrimination
and ostracization of obese individuals. Others (25–29)
further address the political economic context that serves as
the backdrop for current anxieties around obesity, chronicling the many entities – corporate, health and government
– that literally profit from an obese populace and/or efforts
of redress.
The media, as a collective cultural institution, have
also been examined in relation to obesity (30,31). Clinical
researchers have generally apprehended this link in terms
of effects, as relevant to unhealthy practices while consuming media (32–35); sedentary behaviour necessitated or
encouraged by media use (30,36,36–38); and content that
encourages consumption of obesogenic foods (39–42).
Others have directed their attention to the content of
mediated representations of obesity, primarily via framing
studies that assess how obesity and/or obese individuals
are characterized, as well as what articulated cause(s) of or
redress to obesity. The undergirding assumption of framing
studies is that especially persistent and pervasive frames
influence if not direct audiences understandings and practices (43–45). With respect to health and medical information, in particular, surveys corroborate that the public
receives most of that information from the media, underscoring the importance of evaluating the content of those
messages (30,31,46).
Most framing studies of obesity have examined (primarily U.S.) news coverage, which has experienced a substantial uptick in the last decade. Overwhelmingly, the
prevalent frame apparent in this coverage is a ‘personal
responsibility’ model, wherein obesity is identified as a
consequence of poor individual practices, or ‘the product of
unhealthy choices’ (47–61). Studies of representations of
media fare (including, but not limited to framing studies)
other than news revealed a similar bias, specifically as
relevant to television programming (47,62–64), magazines
(65), advertising (66) and celebrity coverage (67). Although
the personal responsibility model remains prevalent in
mediated articulations of obesity, some studies have noted
the increasing emergence of an environmental frame,
wherein obesity is attributed to external conditions such as
availability and access (or lack thereof) to resources (56,60)
© 2013 The Author
obesity reviews © 2013 International Association for the Study of Obesity
Weight of tradition H. A. Shugart
737
or the demands of modern life in the developed world
(54,68,69).
These competing frames of obesity as available in the
media are clearly divergent in terms of their ideological
investments as well as their material implications; the fact
that they are in competition speaks to the highly volatile and
unstable nature of the subject of obesity. For this reason,
while I do not contest the extant literature, I suspect that the
binary articulated across these studies may be reductive,
especially as mediated discourse regarding obesity proliferates and evolves over time. My interest in undertaking this
analysis is to assess how contemporary mediated news
coverage of regions that are familiar to the broader culture
in terms of both historical context and with respect to
perceived character are represented in relation to obesity in
order to examine the degree to and ways in which context
and/or character are invoked in that coverage.
Regional characters
Despite its nominal ‘united’ status, the United States is an
extremely diverse nation. Because my goal in this essay is to
assess how the U.S. South and Midwest are, respectively,
characterized in contemporary mainstream news coverage
in relation to obesity, an understanding of their respective
ethos is warranted. Inevitably, these characterizations are
broad brushstrokes, rife with elisions. My intent is not to
perpetuate either the elisions or characterizations, but
rather to engage them as an index for understanding how
they are articulated with obesity in contemporary news
coverage.
Southern crosses
Although perceptions vary widely and often vehemently
with respect to which states comprise the U.S. South, the
U.S. Census Bureau includes in its designation the states
of Texas, Oklahoma, Arkansas, Louisiana, Mississippi,
Alabama, Florida, Georgia, South Carolina, North Carolina, Kentucky, Tennessee, Virginia, West Virginia, Maryland, Delaware and the District of Columbia (70). The
first human cultures to populate the region were Native
American; collectively, the various tribes that inhabited or
regularly traversed the region were referred to as ‘Mississippian’. European explorers entered the region in the 16th
century, and by the 17th century, it was appropriated as
multiple colonies of, variously, England, France and Spain;
while trade occurred initially between Native Americans
and immigrants, disease and violence – as immigrants
sought more land – all but eliminated original Native
American settlers. The predominant immigrant culture in
the region was English, divided among a small number
of wealthy, land-owning elite and a large number of
indentured servants who worked the land; these southern
14, 736–744, September 2013
738 Weight of tradition
colonies furnished England as well as other American colonies to the north with significant agricultural resources.
As the population and attendant demand for resources
increased, England began to procure slaves by raiding
the west coasts of Africa, a practice that continued and
increased beyond the American Revolution in 1776, which
secured U.S. independence from England. Although other
issues contributed to the eventual rift between newly established northern and southern states, arguably the major
factor was the issue of slavery. The distinction between
‘free’ and ‘slave’ states became more profound, politically
and culturally, especially as political power eventually
became concentrated in the northern states. This led to an
attempt by southern states to secede from the Union and
form their own confederacy, which in turn led to the Civil
War: the North – the Union – proved victorious and slavery
was abolished, but the history and legacy of the rift remains
culturally salient (71,72).
Although cursory, this overview of the historical context
of the U.S. South is perhaps sufficient to explain contemporary, pervasive perceptions of Southerners. They are
largely perceived as rebellious; rural; poor; lacking education, which is often construed as ignorance; unrefined or
uncouth; prone to violence; racist; and implicitly Caucasian
(73,74). Although these qualities are unflattering, some
Southerners embrace some of them, such as rebelliousness
(the ‘Rebel South’ remains a proud motto for many Southerners) and ‘redneckness’, which celebrates lack of refinement, education and poverty – and whiteness as configured
with these qualities (75). Notably, these perceptions are
pervasive in broader U.S. culture (76).
Midwestern roots
The region that is generally classified as the Midwest –
comprised of the states of Illinois, Indiana, Iowa, Kansas,
Michigan, Minnesota, Missouri, Nebraska, North Dakota,
Ohio, South Dakota and Wisconsin (70) – is generally
uncontested. Evidence suggests that the same assemblage of
native tribes that populated the South originally also populated the Midwest, along with Great Lakes Indians and the
Great Plains Indians. In the 17th century, France colonized
the region as part of a larger swath that extended across
much of North America, from what is now northern
Canada to Louisiana. French control of the region ended
with the conclusion of the French and Indian War in 1763,
at which point English settlements to the east began to
extend westward. Following the American Revolution,
European immigrants began to bypass the eastern coast to
settle in the Midwest, attracted by agricultural opportunities: the region features highly fertile soil, a temperate
climate, and three major waterways. For all human populations that have settled in the area, agriculture has been the
14, 736–744, September 2013
obesity reviews
H. A. Shugart
primary industry of the region. Accordingly, the Midwest
has been and continues to be known as the ‘nation’s breadbasket’ (77).
Slavery is also salient to the history and character of
the Midwest, albeit in ways opposite the South. The (at the
time) ‘Northwest Ordinance’ region, today the heart of the
Midwest, was the first to prohibit slavery in the United
States, and as such furnished the primary routes for the
Underground Railroad, which provided escaped slaves
with safe passage to free territories prior to the Civil War.
While escaped slaves had the most to lose, white Midwesterners who mobilized the Underground Railroad risked,
and sometimes lost, a great deal, for slavery had not yet
been prohibited in the South, and slaves were legally considered property of their owners (78).
The Midwestern ethos can be understood in terms of its
designation as the nation’s ‘heartland’, becauase of both its
geographical location in the country as well as its ‘breadbasket’ status. Accordingly, Midwesterners are likely to be
perceived as hard working, nurturing, and unsophisticated
– solid and traditional. The legacy of the Underground
Railroad, even if not consciously remembered, complements that perception, such that Midwesterners are typically perceived as honest and authentic, possessed of moral
integrity. If in subtler ways and for different reasons than
Southerners, the prototypical Midwesterner is also implicitly Caucasian per this characterization (79–81).
Again, these descriptions are inevitably general, superficial and selective; but stereotypes are at least these things
by definition, and my aim was to articulate the general
perceptions of these regions as apparent in broader U.S.
culture. Because the U.S. South and Midwest are regularly
presented as the most obese regions in the most obese
nation in the world (82,83), my interest in this essay is to
review and gauge whether, how, and to what extent these
cultural perceptions are in play in contemporary mainstream news coverage of obesity, particularly in relation
to prevalent ‘frames’ that have been documented in news
coverage of obesity more broadly.
Method
I analysed coverage of obesity in the South and the
Midwest from January 2009 to December 2012 in primary
national mainstream sources of news: the newspapers the
New York Times and USA Today; and television networks
ABC, CBS, CNN, and NBC. I targeted coverage over the
last four years in order to gauge recent patterns of coverage. Because environmental frames are only lately gaining
traction in the broader public sphere, I sought to evaluate
to what extent it might be articulated with or against the
predominant personal responsibility frame in recent coverage and/or what alternative frames might be emergent.
© 2013 The Author
obesity reviews © 2013 International Association for the Study of Obesity
obesity reviews
Weight of tradition H. A. Shugart
Table 1 Mainstream US news coverage of
regional obesity 2009–2012
NYT
USAT
ABC
CBS
CNN
NBC
Total
739
Southern
obesity
Midwestern
obesity
SO
in-depth
MWO
in-depth
11
16
13
12
14
12
78
5
10
9
7
10
8
49
3
5
2
4
4
3
21
4
1
1
3
2
2
13
MWO, Midwestern obesity; SO, Southern obesity.
Relevant papers and broadcasts were identified via
online searches of archives of the identified texts as well as
via LexisNexis searches of papers or transcripts, using
keyword searches for ‘obesity South’, ‘obesity Southern
states’, ‘obesity Midwest’, and ‘obesity Midwestern states’.
I identified a total of 127 papers and broadcasts that referenced obesity in the South and in the Midwest. Of these,
34, or 27%, offered sustained attention to the phenomenon
of obesity in those respective regions beyond mere reporting of relatively higher incidence: 13 newspaper stories
(NYT 7, USAT 6); and 21 televised news stories (ABC 3,
CBS 7, CNN 6, NBC 5; Table 1).
Although the resultant number of texts assessed is relatively small, I suggest that they are salient to the extent that
they feature a consistent and pervasive pattern that may
serve as a template for an apparently emergent, alternative
and ‘authorized’ (per presumption afforded mainstream
news sources) rationale for obesity.
My methodological approach is informed by interpretive
and cultural perspectives; I am interested in assessing the
‘construction of meanings related to health and medicine’
((84); also (85,86)). Upon identifying suitable texts, I
engaged in qualitative framing analysis, which entails
‘repeated and extensive engagement with text[s] and
looks holistically at the material to identify frames’ ((87);
also (88,89)). Procedurally, I identified both explicit and
implicit characterizations of obesity in the South and
Midwest: its causes, effects, solutions, as well as how individuals portrayed in relation to obesity were characterized.
Consistent patterns emerged across the texts that suggest
an emergent frame of obesity as a cultural phenomenon.
Context, character, obesity
Southern obesity
Across venues for the time period specified, 78 papers and
broadcasts addressed obesity in the U.S. South, and of
those, 21 engaged the issue to a degree greater than
merely reporting obesity statistics for Southern states.
Analysis revealed that obesity among Southerners is
© 2013 The Author
obesity reviews © 2013 International Association for the Study of Obesity
consistently attributed to three factors: defiance, impoverishment and race.
As noted, defiance, or rebelliousness, is a quality strongly
associated with the South; in contemporary coverage of
obesity in the South, it is prominently featured, articulated
further as self-destructive, even perversely so. Southerners
are depicted as consciously engaging in bad practices
despite knowing the consequences – often as a matter of
Southern identity and pride. Nutritional experts sent into
community centres throughout the South were reported to
find ‘resistance from cooks who say the healthier recipes
alter the taste of their dishes’. ‘The reputation of the Southern cook is at risk when you begin to modify [the cuisine]’
((90); also (91,92)). At the individual level, a number of
stories featured Southerners who would ‘ “rather have eggs
[than oatmeal]. And . . . some good gravy, biscuits, bacon.
I can’t help it, I love it”. . . . Last year, [his] sister Emmeline
died from diabetes complications . . . “She didn’t take care
of herself either,” he said. “Blind and everything else. Got
down so she couldn’t walk and stuff” ’ (93). This attitude
was characterized as endemic to the South, affecting even
those ostensibly addressing the problem: a Mississippi
superintendent of education, charged with reforming nutrition in state schools, was quoted as follows: ‘ “The important thing is that we model what good behavior looks like”.
. . . Bounds ate at a Jackson buffet that’s popular with state
legislators. The buffet included traditional, stick-to-yourribs Southern fare: fried chicken, grits, fried okra, turnip
greens.’ (94)
Poverty, often in tandem with lack of education, was also
regularly cited as directly relevant to obesity in the South,
often to balance or offset the characterization of the decadent Southerner (94–96). A few articles trace a straight line
between poverty and the traditional Southern diet, for
‘poor families stretch their budgets by buying cheaper,
processed foods that have higher fat content and lower
nutritional value . . . [and] poor people often fry their foods
[because] it’s an inexpensive way to increase the calories
and feed a family’ (94).
The third major pattern to emerge in this coverage
departed radically from conventional perceptions of
14, 736–744, September 2013
740 Weight of tradition
Southerners as white and likely racist: that is, African
Americans were explicitly showcased in reports of obesity
in the South, per findings that African Americans in the
South feature the highest rates of obesity (97–99). One of
the ways in which they were explained was in tandem with
poverty (91,100–102). While the stereotype of the poor
Southern white was not necessarily unseated, the image of
the poor Southern Black was given primacy.
Another prevalent pattern of coverage in this vein was
the attribution of the Southern diet to Black Southerners.
This is novel: while ‘soul food’ has long been understood
as an African American subset of the broader Southern
diet, the two have historically not been understood as
interchangeable (103). Coverage assessed for this study,
however, conflated the two, moreover attributing it to
Black Southerners. Southern fare writ large was traced
to the historical, oppressive context of slavery, wherein
‘blacks made throw-away foods taste good. And . . . tons
of calories made sense’ ((104); also (94,105)). The
favoured cooking method of the South – deep frying –
was likewise attributed to slaves, who ‘didn’t have all day
to prepare meals; they had to get back into the fields to
work’ ((90); also (92,101)). The erasure of the distinction
between Southern food and soul food in contemporary
coverage of obesity surfaces an historically erased population per common perceptions of the South – but concomitantly lays the problem of Southern obesity at
its feet.
A final pattern that emerged within the broader focus on
Black Southerners in this coverage was relevant to (self)perception of obesity; specifically, Southerners were characterized as having an inaccurate or skewed apprehension
regarding what constitutes obesity, how to evaluate it,
and/or what constituted healthy or unhealthy practices
(98,100). In one report, a physician shared a personal
anecdote regarding unhealthy perceptions relevant to
eating practices of Black Southerners: ‘ “I will have – no
exaggeration – probably a plate with 4,000 calories on it.
And my relatives will say to me, ‘Aw, you’re not eating
much at all today. You should eat more than that’ . . . [i]f
you’re not on the big side, folks where I’m from down in
Perry County [AL] say you’re not healthy” ’ (98). Interestingly, the stereotype of Southern ignorance, typically associated with white Southerners, is associated with African–
American Southerners in this coverage, albeit as naiveté
rather than defiance.
These patterns showcase the instability attached to
public discourse around obesity. Poverty, lack of education,
rurality and historical events reflect environmental explanations, whereas defiance and ignorance reflect a personal
responsibility model. This coverage appears to advance
culture as an alternative, hybrid explanation that acknowledges historical and contemporary conditions as well as
individual choices and practices.
14, 736–744, September 2013
obesity reviews
H. A. Shugart
Midwestern obesity
Of 49 mentions across the venues and time frame specified,
13 news stories engaged the matter of obesity in the US
Midwest to a degree beyond simply reporting the high rate
of Midwestern obesity. Analysis of these stories revealed
three prominent patterns regarding obesity in that coverage: geography, abundant food, and diet.
While Southern obesity was linked to rurality in coverage
assessed, Midwestern obesity was linked to suburbia;
suburban ‘Midwestern sprawl’ was identified as a major
reason for the region’s high rates of obesity due to attendant impediments to physical activity (106,107). The sedentariness imposed by geographic distance was reported as
translating to dramatically minimized caloric expenditure
and, thus, a propensity for weight gain: ‘All other factors
being equal, each extra degree of sprawl meant extra
weight, less walking and a little more high blood pressure.
. . . Someone living in the most sprawling county – Geauga
County outside Cleveland – would weigh 6.3 pounds more
than if that same person lived in the most compact area,
Manhattan’ (108). Notably, the identification of suburbia
as a contributing factor to obesity locates the problem as it
occurs in the Midwest squarely in the middle class.
High rates of obesity in the Midwest were also attributed
to food abundance. Abundant food was reported to be a
traditional index of success among Midwesterners, a direct
result of their agricultural heritage: “In the Farm Belt states
of the Midwest . . . the tradition lingers that a family’s
success is best embodied by the bounteousness of its
table.” (107,109) Abundant food is further articulated with
kinship: ‘hearty’ meals – and eaters – are reported as signifying health not only of those around the table but of
the strength and vigour of family bonds (106,107,110).
Moreover, coverage reports that abundance must be made
visible in ways that enable if not encourage obesity, specifically via the Midwestern culinary practice of serving
dinners ‘family style’, or in large communal dishes
displayed on the dinner table from which diners serve
themselves (110,111). As with geographic explanations,
Midwestern obesogenic foodways and practices are implicitly articulated in this coverage with a middle-class imaginary of family and bounty.
The most prominent theme in news coverage of obesity
in the US Midwest, however, is traditional Midwestern
fare. The staunchly ‘meat-and-potatoes Midwest’ (107,
111) is emphatically and consistently invoked as a, if not
the, key variable responsible for the region’s high rates of
obesity. Midwesterners’ propensity for sweets and junk
food such as such as ‘Velveeta and Twinkie[s]’ (112) is
also noted in several reports (also (106,109,110)). But the
manner in which the Midwestern diet is portrayed is
perhaps most noteworthy: a pervasive tone of camp
humour infuses these depictions, rendering the Midwestern
© 2013 The Author
obesity reviews © 2013 International Association for the Study of Obesity
obesity reviews
diet as essentially, even if playfully, culinary kitsch. Midwestern restaurant fare is described as comprised of
‘mystery meat and puddles of beans’; school cafeteria fare
of ‘bagel dogs (yes, that’s an entree), yellowish meatloaf
and chicken tenders, which [an interviewee] likened to
“squirts of chicken foam” ’ (113). Not only is the food
itself subject to playful ridicule, but so is Midwesterners’
naiveté around food, for example not recognising lard as
meat based, perceiving vegetarianism as a dangerous whim
or thinking that ‘green is garnish’ ((114); also (111, 112)).
Midwesterners emerge in this coverage as traditional,
conservative, literal, and naïve products of their agricultural heritage. In framing terms, then, both individual and
environmental explanations for obesity are tendered. Thus,
as with coverage relevant to Southern obesity, a cultural
explanation for obesity is advanced, one that appears to
reimagine if not renounce the personal responsibility versus
environment binary that has tended to prevail in public
discourse about obesity.
Conclusion
The general finding of this analysis is that the explanatory
power of ‘culture’ appears have some traction as an emergent frame for obesity in contemporary news coverage
about the issue. Arguably, this frame represents a more
nuanced and complex characterization, an apparently
hybrid explanation that accounts for both individual and
environmental (deployed as historical legacies, in this case)
rationales identified in previous studies.
However, this frame is problematic for at least two
reasons. First, a cultural explanation, like a personal
responsibility model, continues to elide a role for governing
entities, for historical context cannot be changed, and the
invocation of agency in the cultural frame thus practically
(re)locates responsibility in the individual. In other words,
a culture frame may ultimately function materially as a
more diffuse version of the personal responsibility model.
This is similar to what Zoller identifies as the ‘lifestyle
theory of causation’, which describes health as an outcome
of one’s everyday circumstances and responses to them,
ostensibly tempering individual responsibility, but nonetheless ‘directing attention toward the individual and away
from political and social contexts’ (115). A cultural model
potentially even exacerbates this dynamic in that culture
privileges history, further obviating structural redress
insofar as attention is directed away from contemporary
contexts and solutions. Further, the presumption afforded
tradition potentially casts intervention as not only ineffective, but inappropriate.
A related problem with a cultural frame for obesity as
implied by this coverage is that culture is articulated as
problematic; it suggests that health is contingent upon
renouncing or transcending one’s culture, ethically trou© 2013 The Author
obesity reviews © 2013 International Association for the Study of Obesity
Weight of tradition H. A. Shugart
741
bling in itself, and more so in that some cultures are represented as more or less threatening or more or less
egressible than others. This analysis suggests that the
elision of structural or regulatory efforts is accomplished in
ways that define citizenship in relation to culture – in this
case, along the axes of race and class – and furthermore
feature implications for material redress. Locating obesity
squarely in the cultural history and politics of race in the
South makes it a sensitive subject of critique and even
redress, for to do so would be insensitive or elitist at best,
racist at worst. The staunch (implicitly Caucasian) middleclassness apparent in characterizations of Midwestern
obesity renders it more accessible for critique; however, the
gentle ridicule via which it is articulated suggests that the
problem is contained – to the past and/or to a dwindling,
lovably naïve population – and is thus relatively harmless,
or at least will sort itself out as Midwesterners, or their
children, eventually come to consciousness, implicitly
referencing the middle-class axiom that children will
surpass their parents’ socioeconomic status. Accordingly,
the problem of obesity as it affects this population is
likewise dismissed, as is the spectre of intervention or
regulation.
These distinctions surface important divides around race
and class in the United States, which are not in themselves
necessarily surprising or unique, but they feature particular
implications for how obesity may be discursively and materially engaged – or not – for particular populations. Studies
of how obesity is engaged in relation to other regions and
populations are warranted in order to assess whether, where,
and to what degree a cultural frame has resonance. Studies
of audience reception as well as of production considerations could further illuminate whether and to what extent
particular frames have purchase with broader publics or
efforts of redress (46). This study, in the vein of framing
studies to date, suggests that said efforts must acknowledge
how the issue is understood and taken up discursively as well
as materially – as well as the political and social implications
of both those discourses and practices.
Conflict of Interest Statement
No conflict of interest was declared.
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obesity reviews
Other Review
obr_880
doi: 10.1111/j.1467-789X.2011.00880.x
669..679
Ethics and prevention of overweight and obesity:
an inventory
M. ten Have1,2, I. D. de Beaufort1, P. J. Teixeira3, J. P. Mackenbach2 and A. van der Heide2
1
Department of Medical Ethics, Erasmus
Summary
Medical Centre, Rotterdam, the Netherlands;
Efforts to counter the rise in overweight and obesity, such as taxes on certain
foods and beverages, limits to commercial advertising, a ban on chocolate drink
at schools or compulsory physical exercise for obese employees, sometimes raise
questions about what is considered ethically acceptable. There are obvious
ethical incentives to these initiatives, such as improving individual and public
health, enabling informed choice and diminishing societal costs. Whereas we
consider these positive arguments to put considerable effort in the prevention of
overweight indisputable, we focus on potential ethical objections against such an
effort. Our intention is to structure the ethical issues that may occur in programmes to prevent overweight and/or obesity in order to encourage further
debate. We selected 60 recently reported interventions or policy proposals targeting overweight or obesity and systematically evaluated their ethically relevant
aspects. Our evaluation was completed by discussing them in two expert meetings. We found that currently proposed interventions or policies to prevent overweight or obesity may (next to the benefits they strive for) include the following
potentially problematic aspects: effects on physical health are uncertain or
unfavourable; there are negative psychosocial consequences including uncertainty, fears and concerns, blaming and stigmatization and unjust discrimination;
inequalities are aggravated; inadequate information is distributed; the social and
cultural value of eating is disregarded; people’s privacy is disrespected; the complexity of responsibilities regarding overweight is disregarded; and interventions
infringe upon personal freedom regarding lifestyle choices and raising children,
regarding freedom of private enterprise or regarding policy choices by schools
and other organizations. The obvious ethical incentives to combat the overweight epidemic do not necessarily override the potential ethical constraints, and
further debate is needed. An ethical framework to support decision makers in
balancing potential ethical problems against the need to do something would be
helpful. Developing programmes that are sound from an ethical point of view is
not only valuable from a moral perspective, but may also contribute to preventing overweight and obesity, as societal objections to a programme may hamper
its effectiveness.
2
Department of Public Health, Erasmus
Medical Centre, Rotterdam, the Netherlands;
3
Faculty of Human Kinetics, Technical
University of Lisbon, Cruz Quebrada, Portugal
Received 1 October 2010; revised 7 February
2011; accepted 9 March 2011
Address for correspondence: M ten Have,
Department of Medical Ethics, Erasmus
Medical Centre, Dr. Molewaterplein 50,
Rotterdam, 3000 CA, Postbus 2040, the
Netherlands. E-mail:
m.tenhave@erasmusmc.nl
Keywords: Ethics, obesity, overweight, prevention.
obesity reviews (2011) 12, 669–679
© 2011 The Authors
obesity reviews © 2011 International Association for the Study of Obesity 12, 669–679
669
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Ethics and prevention of overweight
obesity reviews
M. ten Have et al.
Introduction
According to the World Health Organization, overweight is
among this century’s major health threats (1). The number
of people with serious overweight or obesity is increasing
steadily: in 1960–1962 an estimated 31.6% of US adults
were pre-obese (body mass index [BMI] of 25.0 to 29.9)
and 13.4% were obese (BMI of 30 or higher) (2). In
2007–2008, 68.0% of US adults were overweight, of
whom 33.8% were obese (3). The trends of overweight and
obesity among children and adolescents have increased in
parallel: in 2007–2008 almost 17% of school-aged children
and adolescents were obese (4). The prevalence of overweight is widely varying in different subgroups of the population: in developed countries it is notoriously high among
persons with a low educational level and a low income (3).
Obesity is an important risk factor for diabetes, cardiovascular disease and diseases of the locomotor system. Overweight is also related to psychological problems (1).
It is likely that many of these overweight-related health
problems can be prevented. Adopting a healthy lifestyle,
that is, a healthy diet and sufficient physical exercise, can
prevent overweight (1). According to the World Health
Organization, a healthy diet includes limiting the intake of
unhealthy fats, free sugars and salt and increasing the consumption of fruits, vegetables, legumes, whole grains and
nuts (5). Experts have advocated a combination of interventions to promote a healthy lifestyle: education (preferably education tailored to the target group or even to
individual persons), optimizing environmental opportunities to adopt a healthy lifestyle (e.g. with respect to the
infrastructure, building of houses, available means of
transport, schools, work, health care and supply of food)
and legal and other regulations (e.g. economic measures, or
putting restraints to the supply and commercial advertisement of fattening food products). It has been suggested that
extra attention is needed for special target groups in which
it is more likely that interventions can prevent health
problems, such as adolescents and children, or in which
overweight and obesity are more common, such as people
with a low socioeconomic status, and people from certain
migrant groups (6,7).
Most interventions that are aimed at preventing overweight or obesity have not (yet) been proven to be effective
or to have a favourable cost-effectiveness ratio. In spite of
a lack of comprehensive research on the effectiveness
of prevention strategies, authoritative agencies such as
the World Health Organization and, in the Netherlands,
the Health Council have suggested a ‘common sense’
approach, because of the size and the potential consequences of the obesity epidemic. Measures that are very
likely to be effective should be implemented as soon as
possible (6,8). However, lifestyle interventions, whether
they are evidence-based or not, frequently give rise to
ethical debate (9–14). The Dutch Council for Public Health
and Health Care has therefore pleaded for measures that
facilitate healthy choices, while suggesting reticence about
measures that more or less strongly force people to change
their lifestyle, because the potential social and ethical problems that may be associated with such coercive measures
should be analysed first (15).
In the present article, we have made an inventory of the
ethical aspects of measures aimed at the prevention of
overweight and obesity. There are obvious ethical incentives to combat the overweight epidemic, such as improving
individual and public health, enabling informed choice and
diminishing societal costs. Whereas we consider these positive arguments to put considerable effort in the prevention
of overweight indisputable, we focus on potential ethical
objections against such an effort. Our intention is to point
out how ethical issues may occur in programmes to prevent
overweight and/or obesity and to structure these issues in
order to encourage further debate. Our overview includes
interventions to prevent overweight as well as interventions
to prevent obesity, as both raise similar ethical issues.
Moreover, prevention programmes aimed at the population
at large are often unspecific about the exact target group.
However, the health risks of obesity (BMI of 30.0 or
higher) are higher than those of overweight (BMI of 25.0 to
29.9), which implies a distinct balancing of ethical arguments: the results of interventions aimed at obesity may
outweigh ethical objections more easily than the results of
interventions aimed at overweight.
Methods
We searched for interventions to prevent overweight on the
Internet, in the media and in scientific medical literature.
All interventions were proposed, implemented or studied
after 1980, in the Netherlands or elsewhere. We included
interventions that change the environment, interventions
that consist of providing information or educating people,
financial incentives, legal regulations and medical interventions. Our analysis was limited to 60 interventions, because
at that number we felt that adding additional interventions
would not provide new insights. A complete list of all
interventions included and the sources we used to identify
their characteristics can be found in Appendix S1. We performed a three-step systematic analysis of the potentially
ethically relevant aspects of interventions. By ‘potentially
ethically relevant aspect’ we refer to all aspects that may
lead to ethical objections. Issues in public health ethics
centre around ‘the trade-off that can arise between, on the
one hand, protecting and promoting the health of populations, and on the other, avoiding individual costs of various
kinds, including physical danger, moral harm and frustrated desires’ (16). First, we searched whether or not the
paper or website in which the intervention was presented
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included any explicit reference to potentially ethically problematic aspects. In a second step, ethical issues were identified directly by two of the authors (MtH and AvdH). In
the third step of our analysis, we discussed the results of
our inventory in two expert meetings. These expert meetings were attended by policymakers, physicians, representatives from health insurance companies, researchers,
ethicists and representatives of organizations of obese
people. The first meeting was focused on the extent to
which the problems we identified are exclusively related to
prevention of overweight and obesity; this meeting was
attended by 14 experts. The second meeting was focused
on prevention of overweight and obesity in children;
this meeting was also attended by 14 experts. Prior to the
meeting, the experts received our inventory of programmes.
During the meeting there was discussion on the basis of
statements that we presented (see Appendix S2).
Furthermore, certain programmes to prevent overweight
may have harmful side effects on physical health, and thus
threaten the value of well-being. Sometimes, health risks
are taken for granted because the risks of non-interfering
are even higher, for instance when the British government
recommends bariatric surgery and medication for exceptional cases of childhood obesity (20). Harm to health may
also occur because of prevention programmes that have a
negative and problem-based focus on overweight, according to O’Dea (21). Next to probably contributing to weight
concerns, unhealthy types of dieting and eating disorders,
they may discourage overweight people from visiting
health services or from practising physical activity (21).
The Singaporean Trim and Fit programme, for example,
was criticized for potentially contributing to eating disorders (22,23).
Finally, the intended effects of commercially financed
interventions may at least partly relate to providing the
producer with a positive and responsible image. Examples
are fast food chains that provide free pedometers (24), and
children’s summer camps for weight loss that are financially supported by a fast food company (25). In some
cases this so-called ‘image boosting’ ultimately may serve
the goal of increasing the turnover of overweight-inducing
products. The World Health Organization calls for controlling the promotion of dangerous and deliberately deceptive
approaches to weight loss or control, such as special weight
loss aids, ‘miracle-cures’ and certain drugs and treatments
often offered through unlicensed weight loss centres (1).
When the public are actually misled about a programme’s
aims, this conflicts with the ethical values of truthfulness
and transparency.
Results
The interventions that were included in our analysis are
presented in Table 1. We identified and analysed 58 concrete interventions and two policy proposals. Eighteen
interventions were aimed at promoting a healthy diet;
14 were aimed at physical exercise and 28 targeted both
behaviours. Interventions were aimed at the population at
large or at specific groups, such as employees, children or
their parents, people with a low socioeconomic position or
people from ethnic minority groups.
The following eight potentially problematic aspects were
identified. Table 1 provides an overview of them, including
examples of programmes for each aspect and the ethical
values at stake.
M. ten Have et al. 671
Psychosocial well-being
Physical health
A potential problem of programmes to prevent overweight
that was frequently identified is that their effects on physical health are not known or not favourable. Ineffective
programmes should of course not be implemented, and
should certainly not be financed by public means. But much
more often we deal with programmes that may have positive results, whereas this is not certain. Many publicly
financed programmes are not supported by evidence. Few
programmes have been evaluated, and for programmes that
have been evaluated, such as the ‘balance day-campaign’
(17), cost-effectiveness is often hard to prove or even
doubtful. Lack of scientific evidence frequently leads to
discussion about whether or not to continue a programme.
When government subsidy for a Dutch clinic for obese
children was stopped because of insufficient scientific evidence, opponents objected that practice showed positive
results, which could only be monitored if subsidy would be
carried on (18,19).
Overweight prevention can, in some cases, have various
negative psychosocial consequences, such as uncertainty,
fear and concerns about the health risks of overweight
and obesity, stigmatization and blaming, and unjust
discrimination.
Uncertainty, fear and weight concerns
The focus on the health risks of overweight and obesity has
drawn body weight into the medical sphere. The bodily
state of weight has more and more become an indicator
for health. Whereas overweight children have always been
bullied during gymnastics, today they are also being put on
a weighing scale and sent to a medical doctor. Informative
campaigns about the health risks of obesity confront
healthy people with health risks that they currently do not
experience and which they may not even encounter in the
future. For mothers-to-be who consult a doctor about pregnancy, body weight is examined as an indicator for the
future health of their child-to-be. This focus on health risks
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Table 1 Ethical issues, examples of programmes, values at stake
Ethical issue
Subissue
Examples of programmes
Ethical value at stake
Negative effects on
physical health
No evidence-based
cost-effectiveness
De Balansdag (27)
Heideheuvel clinic (22)
Well-being
Negative effects on
physical health
Stomach surgery and medication (32)
Trim and Fit (1)
Boosting the image
of the producer
Children’s summer camps for weight loss (41)
Free pedometer supplied with hamburger (11)
Uncertainty, fear and
worries
Website’s quote: ‘Overweight diminishes the chance to a long, healthy and
happy life’ (25)
Cholesterol test in supermarket (59)
Stigmatization and
blaming
Trailer Jamie’s school dinners (1)
Unjust discrimination
Firing stewardesses (34)
Firing police officers (35)
Higher insurance premiums (37)
Higher prices for overweight aeroplane passengers (38)
Grouping children at normal and overweight tables during recess (1)
Body mass index grade on school report card (46)
Withholding university diploma’s from overweight students (57)
Negative
psychosocial
consequences
Well-being
Privacy
Respect for persons
Truthfulness
Justice
Inadequate
information
De afvallers (8)
Promotion of products without fat but with a lot of sugar (general example)
Promotion of quick fixes for overweight in the form of slimming
products that discourage people from practising a healthy lifestyle
(general example)
Truthfulness and transparency
Autonomy and informed choice
Well-being
Cultural and social
value of eating
disregarded
Ban on birthday cakes in schools (39)
‘5 am Tag’ campaign (47)
Respect for cultures and value
pluralism
Well-being
Inequalities
aggravated
Fat tax (5)
Responsibility contract Medicaid (17)
Free swimming sessions (45)
Justice and fairness
Privacy disrespected
Weight grade on report cards (46)
Electronic child file (15)
Work-based programmes that focus on individual behaviours such as health
risk assessments (19)
Respect for the personal life
sphere: privacy
Individual
Responsibility contracts Medicaid (17)
Parents
Parents step up (14)
Intermediate
organizations such
as schools,
municipality or social
healthcare services
Compulsory cooking classes in the curriculum (48)
Balance between personal and
collective responsibility
Just division of responsibilities
between government, schools,
industry, civil society individual
Complexity of
responsibilities
disregarded
Liberty infringed
Industry
Labelling restaurant calories (6)
Regulation and laws
Ban on trans fats in restaurant menus (50)
Ban on soda and snack vending machines in schools (3)
Fat tax (5)
Foster care for obese child (55)
Changes in physical
environment that
close down options
Banning cars from city centres and around schools (42–44)
Slowing down the elevator in a company building (51)
Designing office building that encourages walking (52)
No fast food strip in business area in south-east Amsterdam (4)
Financial triggers
Fat tax (5)
Bonus for police officers who lose weight (36)
Financial bonus for townsmen who lose weight (54)
Higher insurance premiums on the basis of body mass index (37)
Tax on aeroplane tickets for overweight passengers (38)
Psychological
motivation
Caloric information on restaurant menu (6)
Social influence
Sneaky fitness (2)
Promoting practising sports by children by famous soccer players (28)
Offering employees weight loss drugs (53)
Respect for the personal life
sphere: autonomy and freedom of
choice
Freedom of action for
corporations
Value pluralism
Justice: being consequent
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may create excessive and unwarranted fear and weight
concerns (26). A website’s quote: ‘Overweight diminishes
the chance to a long, healthy and happy life’ (27) aims to
motivate people to lose weight, but how will it affect people
who want to lose weight but do not succeed? Unsuccessful
efforts to change one’s lifestyle may result in feelings
of uncertainty and powerlessness. Slightly overweight
people may come to think that the health risks of severe
obesity also apply to them, and people may lose sight of
the line between the health consequences of occasionally
versus continuously snacking. As one example, when the
Dutch Heart Association organized cholesterol tests in
supermarkets, concerns were raised that this action was
ineffective, causing unjustified confidence and unnecessary
concern (28).
children at normal and overweight tables during recess
(22,23). Discrimination may undermine psychological
well-being, but it also involves ethical objections based on
the value of justice. An American high school includes on
its report cards a ‘Weight grade’ that indicates the child’s
BMI, evoking angry reactions from parents (40). And at an
American university, more than 20 students are in jeopardy
of not receiving diplomas because of their overweight (41).
Stigmatization and blaming
Being overweight is a highly stigmatized condition, which
means linking individuals to negative stereotypes. Overweight persons are the victim of childhood teasing and
bullying, avoidance by other people, discriminatory hiring
practices and misplaced humour (29,30). Overweight
persons are frequently presented as being unattractive and
they are associated with negative character traits such as
laziness and stupidity (31). Take for instance a television
spot for the promotion of Jamie Olivers’ programme to
prevent overweight, where Jamie Oliver is portrayed as an
obese person who drives to a snack bar and swallows a
bunch of hamburgers, and consequently breaks through his
motorcycle that buckles under his weight (32). On the
surface, the television spot is merely a funny way of getting
attention for a television programme to prevent overweight. However, it could also be interpreted as expressing
the implicit message that overweight persons are unattractive, lazy, silly and can only blame themselves for being
overweight. Another action to prevent overweight that
potentially blames the individual for being overweight is a
bill in Mississippi that makes it illegal for restaurants to
serve obese customers (33). Not only may stigmatization
and blaming messages contain subjective or even inadequate information, but also they are often extremely
hurtful and show a lack of respect.
Discrimination
Overweight persons are regularly treated differently from
normal weight persons. Overweight could for instance be
used as a criterion to fire people from certain professions,
which happened to stewardesses (34) and police officers
(35). Overweight persons may also have to pay higher
insurance premiums (36–38) or higher prices for airplane
tickets (39). This gives rise to the question of which
grounds and circumstances justify discrimination and
which do not. Some Singaporean schools that participated
in the before mentioned Trim and Fit programme grouped
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Equality
In general, measures to prevent overweight have a tendency
to be less effective among lower educated people. In developed societies, a lower educational level is often associated
with a higher prevalence of overweight and obesity (42).
Although it is not a requirement for any single programme
to actively pursue the aim of reducing health inequalities, it
is generally considered to be a positive duty of public health
to diminish existing health inequalities (43,44). The presence of health inequalities conflicts with ideas about justice
and equality. Interventions that affect financial distribution
such as fat tax (45) or the responsibility contracts by Medicaid (46) are likely to hit harder among people with low
income. But inequalities may also be aggravated by campaigns with a positive and innocent character. For example,
offering free swimming sessions (47) will not reach women
from certain ethnic minorities, as long as the swimming
classes are mixed. If a campaign contains information that
is hard to grasp for lower educated people or people from
ethnic minorities and therefore does not succeed in changing their lifestyle, it may increase already existing health
inequalities (26).
Informed choice
In some cases, education about overweight and obesity
involves inadequate information, including unclear, overstated, oversimplified, subjective, incomplete or even false
messages. Corporations with their own agenda frequently
promote products ‘without fat’ that contain a lot of sugar,
and suggest that ‘quick’ fixes for overconsumption are
available in the form of slimming products that demotivate
people to practise a healthy lifestyle. In the rush of ‘having
to do something’ about the problem, messages to convince
people about the necessity of a healthy lifestyle are not
always in accordance with the facts. Suggesting that eating
healthy or, in turn, physical activity, are the solution for all
problems neglects other health determinants. A real-life
television programme about a competition between obese
families in losing weight was criticized by the Belgian
association for obese patients (Bold) because it would be
distributing inadequate information, by failing to acknowledge that obesity is a disease that requires long-term
medical treatment. Quote from their website (translated):
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‘This type of programs undermines the struggle against
obesity, which is recognized as a serious public health
problem by the OMS. Our leaders should urgently recognize that obesity is a disease, in order to avoid this type of
deviations where inadequate information is distributed
which is harmful for society as a whole.’ (48) Some interventions are justified on the basis of epidemiological information that is collected at an aggregate level, and cannot be
translated to individual cases without reserve. Evidence, for
example, that the population-wide adoption of a healthy
diet can prevent 25% of all deaths from cardiovascular
disease, does not indicate that adopting a healthy diet
reduces each individual person’s risk with 25%. Inadequate
information is problematic from an ethical point of view, as
it is in tension with the value of truthfulness and transparency (49). It hampers exercising freedom of choice and
autonomy and may have negative consequences on health.
information about the child’s health and development,
including potential overweight (53). The plan was criticized
for posing a threat to privacy (53). Having one’s child’s
BMI printed on his/her school report card (40), having to
provide information about one’s body weight and lifestyle
or being screened on overweight by company doctors also
involve intervening in the personal life sphere and may
thereby violate the right to privacy. Some features make
requiring disclosure of personal information extra sensitive
for ethical objections. Body weight, eating habits or styles
of feeding and rearing children all concern very personal
information. Physical contact in measuring someone’s
waist circumference is more personal than asking a selfreported BMI. Pressure to provide the information or
lack of consent can make an intervention problematic. It
also makes a difference which party collects the information (government, insurance company or employer) and
whether it has a legitimate justification to do so. Workbased programmes that focus on individual behaviours
such as health risk assessments may raise concerns regarding privacy issues (54,55). A final relevant distinction is
whether the person whose information is required has an
interest in providing it (for example to enable the general
practitioner to make a diagnosis) or not (for example when
information about an unhealthy weight has financial implications). In all cases, sufficient warrants must be made for
safeguarding the information.
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Ethics and prevention of overweight
Social and cultural values
Food and eating habits are related to important cultural
and social values. Food is for instance consumed to celebrate, to show hospitality or as a part of cultural traditions (50). However, many public health campaigns aimed
at changing people’s personal lifestyles focus exclusively on
the nutritional value of food, thus neglecting or interfering
with such values. They alter the practice of eating from a
natural and a social event into a practice that is only about
the value of health. Interventions that urge individuals to
make healthy choices, such as the British ‘5 a day’ campaign and the German ‘5 am Tag’ campaign, have been
criticized for presenting the healthy choice as the only
rational and valuable choice, which is thus easy to make.
Such campaigns could be ethically questionable as well as
ineffective if they fail to take into account the many other
values that food represents to people (51).
When collectively valued practices are violated and disappear, people may feel offended in their cultural identity.
This could explain the angry reactions of American parents
when the tradition of birthday cakes was banned from
American schools (52). Being hampered to participate in
culturally and socially valued practices may also lead to an
undermining of individual well-being, because these cultural traditions often are a source of pleasure and feelings
of community. Moderating participation in Christmas
dinner or the festivities after the Ramadan, or turning
down a colleagues’ birthday cake may lower calorie intake,
but may at the same time diminish positive feelings of
community.
Privacy
Starting in 2009, every child that was born in the Netherlands gets a digital file from youth health care, containing
Responsibility
Any preventive programme expresses ideas about who
must take action to prevent overweight or obesity: individual citizens, parents, schools, the government, the industry or a combination of these. Ethical objections arise if a
programme threatens the balance between individual and
collective responsibility, or if we lose sight of the fact that
the responsibility for the overweight epidemic cannot be
attributed to one single party. Overweight is the result of a
complex web of causal factors, many of which outside the
individuals’ control. It is partly the result of personal and
voluntary choices, and partly the result of social and environmental characteristics. An emphasis on people’s personal responsibility may disregard the influence of the
social and physical environment and of personal characteristics that are hard to modify or cannot be changed, such
as genetic characteristics, educational level and socioeconomic status, or vice versa (1,56–58). The state-funded US
healthcare insurance company, Medicaid, makes her clients
sign so-called ‘responsibility contracts’ (59). If clients do
not comply with promised health goals, they may for
instance lose their right to compensation for a diabetes
treatment (59). The campaign ‘Parents step up’ is also very
straightforward in blaming parents. Under the sound of
scary music, its website expresses slogans like ‘And don’t
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Ethics and prevention of overweight
blame it on videogames. You are letting your child down as
a parent’ (60). Obviously, a distinction should be made
between attributing responsibility for the problem versus
attributing responsibility for resolving the problem.
However, attributing responsibility for a solution without
attributing accountability for the problem may also evoke
objections from stakeholders. The proposal to force
schools to adopt cooking classes in schools by the British
minister of health made head teachers complain that the
school curriculum was overdemanded (61,62). Restaurant
owners from New York were furious when they were
forced to label their menus with information about calories
(63,64). The weight of these objections partly depends
upon the positive results of the measure.
chosen to be informed about the menu’s caloric properties
(63,64), but once she/he is informed, it is hard to ignore
and still enjoy a desert like Sticky Toffee Pie. Another form
of infringing in personal liberties that is not immediately
apparent involves the use of social influence. This appears
in various ways, from a campaign for school children
where famous soccer players function as a role model for
healthy behaviour (75), to straightforward peer pressure in
the Sneaky fitness website that encourages employees to
guide their inactive colleagues towards healthy behaviour
by replacing the copying machine from their desk to
another room, or by faking that the elevator is out of order
(76). Programmes that are implemented in the working
atmosphere are extra likely to express pressure. When
employees are offered weight loss drugs by their employer
(72), they may find it hard to refuse, even if participation is
not required. Attempting to limit someone’s actions or to
require actions by someone for his or her own good is
called paternalism (77). Paternalistic programmes evoke
moral objections because not everyone equally values a
healthy lifestyle. Thus, promoting health may be in conflict
with pluralism of values. From a perspective of people who
work in health promotion, it may be self-evident that everyone strongly values health. But health is only one of the
valuable things in life and not all people consider health to
be the most important one (12). Furthermore, what people
consider a healthful life may vary considerably.
Programmes aimed at preventing childhood obesity often
raise the question to what extent parental autonomy may
be infringed (78,79). One of the most extreme examples
was the case of a 14-year-old obese boy weighing 555
pounds that was put into foster care, while his mother was
being arrested (80).
Liberty and autonomy
The solution for the obesity epidemic is frequently sought
in interventions that interfere with liberty and freedom of
choice regarding personal choices, commercial actions and
policy by schools and other organizations. Personal
autonomy and freedom of choice are important ethical
values in modern liberal societies, just as freedom of action
for corporations. Interventions to prevent overweight may
infringe upon these liberties in various ways. Regulations
or laws are the most far-reaching form of limiting choice
and include, for instance, prohibition of the use of trans
fats in restaurants (65,66), banning soda and snack
vending machines from schools (67,68), restricting the
amount of fast food selling points in a business area (69)
and banning cars from city centres (70,71). Personal choice
may be influenced or limited by interventions that change
the physical environment. American employers encourage
walking by locating the cafetaria far away from the office
or by slowing down the elevators in order to push its
employees to take the stairs (72). Some programmes
reward healthy behaviour or a healthy weight. Police officers from the Mexican city Aguascalientes receive a bonus of
100 pesos for every kilogram they lose, because they were
thought to be too slow in pursuing criminals (73). The
mayor of the Italian town Varallo offers cash money to
citizens who succeed in losing 3 to 4 kg in a month (74).
Other programmes punish unhealthy behaviour or an
unhealthy weight, for instance by imposing higher insurance premiums for persons with a high BMI (36,37), a fat
tax on products high in fat and sugar (45) or a tax on
aeroplane tickets for overweight passengers (39). Policy
that rewards certain behaviours and punishes others may
raise the objection that it is inconsequent, because only
some healthy or unhealthy behaviours are singled out while
others are overlooked (58). A less obvious, but not necessarily less strong form of exercising pressure is using psychological motivation. Personal choice includes the choice
‘not to know’: not every restaurant customer would have
M. ten Have et al. 675
Discussion
Lifestyle interventions, especially regarding the bodily condition of weight, affect personal characteristics and habits.
They touch upon people’s feelings and core convictions and
they give rise to strong ethical debate. Our analysis of 60
programmes to prevent overweight and obesity and comments in two expert meetings revealed eight types of potentially problematic ethical aspects. Four objections concern
negative consequences of a programme: its effects on physical health may be uncertain or unfavourable; it may have
negative consequences for psychosocial well-being, including uncertainty, fears and weight concerns, blaming and
stigmatization and unjust discrimination; it may distribute
inadequate information; and it may aggravate inequalities.
Four objections concern disrespect for certain ethical
values: the social and cultural value of eating may be disregarded; people’s privacy may be disrespected; the complexity of responsibilities regarding overweight may be
disregarded; and freedom regarding lifestyle, raising
© 2011 The Authors
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children, private enterprise or policy choices may be
infringed. Obviously, disrespect for such ethical values may
also affect a programme’s effectiveness (43) or yield unintended consequences.
These potentially problematic ethical aspects arise out
of various origins. Firstly, some issues concern side effects
that are unforeseen and unwanted by the designers of the
intervention. They stem from a narrow focus on aiming
to reduce overweight, whereby other relevant issues are
lost out of sight. Think about campaigns that are essentially uncontroversial but that unintentionally contain
stigmatizing pictures that could easily have been replaced
if more attention had been paid to ethical issues. The
urgency to find solutions for overweight and obesity,
sometimes bordering on panic, does certainly not always
lead to solutions that are sensitive from an ethical
perspective.
A second category of ethical issues originates out of
conflicting interests. For instance, a campaign that informs
about the health risks of obesity protects some from
gaining weight, whereas at the same time it creates fear and
weight concerns among those who are already obese and
have great difficulties in losing weight.
A third category of ethical issues arises out of conflicting
beliefs and principles. People who feel that governments
must protect their citizens against unhealthy influences will
appreciate a ban on trans fats in restaurant kitchens
(65,66), whereas proponents of personal and commercial
liberties will object against such regulations.
In this paper we focused on potential objections against
programmes to prevent overweight or obesity. However,
our inventory does not show how frequently the issues
actually occur, as we did not conduct an empirical analysis.
Instead, we aimed to point out that programmes to prevent
overweight and/or obesity may yield ethical issues, to structure these issues, and to suggest that professionals who
develop and implement such programmes should pay
attention to them. Nor does our study show how serious
the ethical issues actually are. The fact that objections are
raised does not automatically imply that a programme
should not be implemented. In the first place, various and
sometimes contrary opinions exist about the validity of
ethical objections in specific situations. For instance,
depending on one’s beliefs about personal responsibility,
one will think differently about asking higher insurance
premiums from obese persons. The variety of moral convictions implies that programmes that involve ethical objections are not automatically ethically wrong. Ideas about
values and the good life are to a certain extent influenced by
ones cultural background and political convictions. This
is not to say that all moral opinions about overweight
prevention are equally valuable. As holds for all ethical
discussions, some arguments are simply more convincing
than others.
In the second place, ethical objections regularly refer to
programme characteristics that also have a positive side.
Banning cars from city centres (70,71) closes down options
for car drivers, but opens up possibilities for bicycle drivers.
Most programmes that give rise to ethical discussion are
motivated by the expectation that they will be effective in
preventing overweight and obesity. The message that
people feel better about themselves if they manage to lose
weight may be stigmatizing on the one hand, but motivating on the other hand. Fat tax poses a financial burden and
infringes upon personal choice, but at the same time may
provide an extra incentive for a healthy lifestyle (45). Oversimplified information is not according to the facts, but is
understandable to a broader audience than a nuanced and
detailed message would be. Bariatric surgery for obese children poses serious health risks, but may offer the only
solution to diminish the health risks posed by obesity (20).
Awareness of the fact that certain aspects of programmes
to prevent overweight and obesity may evoke ethical debate
is a first and crucial step for professionals who develop and
implement such programmes. The second step, which is
beyond the scope of this article, is to deal with these issues
and the debate they induce. This leads to the question how
a professional in overweight prevention should react to
ethical objections: which arguments must be taken seriously and how should burdens be weighed against benefits?
Further thinking about an ethical framework for such consideration and decision making would enable professionals
from overweight prevention practice and policy to be prepared for ethical objections, and if possible and desirable to
prevent them. Developing programmes that are sound from
an ethical point of view is not only valuable from a moral
perspective, but may also contribute to preventing overweight, as ethical analysis will make public health work
more effective (43).
676
Ethics and prevention of overweight
Conclusion
Programmes to prevent overweight or obesity involve a
number of potential ethical objections. Obvious ethical
incentives to combat the overweight epidemic do not necessarily override these potential ethical constraints. Therefore, further debate is needed. An ethical framework would
be useful for helping professionals in overweight prevention to map the ethical issues, structure the relevant arguments and make a decision about the extent to which a
programme is ethically acceptable. This inventory of potential ethical issues provides a first step towards creating such
a framework.
Conflict of Interest Statement
No conflict of interest was declared.
© 2011 The Authors
obesity reviews © 2011 International Association for the Study of Obesity 12, 669–679
obesity reviews
Acknowledgements
This study is part of a PhD project about the ethical aspects
of prevention of overweight and obesity, which was funded
by ZONmw. Furthermore, in drafting this study we
benefited greatly from our participation in the workshops of the international and interdisciplinary project
‘EUROBESE’ (FP6 SAS6-CT-2005-016646), which was
funded by the European Union. We thank all its participants
for the inspiring discussions. Finally, we thank the participants in the expert meetings for their valuable contribution.
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)
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