Reading Nir’s thought-provoking post below sparked a couple of thoughts in my mind regarding fatness, ethics, and population health. The first is what I take to be the professional obligation to engage seriously with the epidemiologic uncertainty regarding the connections between fatness and health. With notable exceptions — see the Rudd Center, for example — most of the work in bioethics and law that discusses obesity problems does so by averring (1) that obesity is an enormous problem for public health; and then (2) proceeding to discuss a particular intervention intended to ameliorate it. But I generally perceive all too much haste with the first step.
There is a growing amount of scholarship in fields like fatness studies and critical obesity studies that engages the epidemiology regarding fatness and health on its own terms, and points out how much uncertainty there is regarding the connection. Just recently, the so-called ‘obesity paradox’ — that in some populations increased adiposity is actually protective of health — has made waves in the mass media and in the pages of major medical journals, but in point of fact the latest studies merely confirm the evidence on the subject that has been available for some time.
The single most rigorous investigation of the significant uncertainty in the fatness-health connection is Gard & Wright’s 2005 book, The Obesity Epidemic (ironically titled, of course), in which they examine over 1200 food science studies to demonstrate said uncertainty. There is nothing wrong with the latter — it inheres in epidemiology — but the question I have always been struck with centers on the significant disconnect between the extent of the uncertainty and the certitude with which public and even professional discourse on fatness and public health proceeds apace in the West. Gard and Wright argue convincingly that ideologies and constructions of fatness are critical to explaining the divergence.
In any event, what is the takeaway for bioethicists and health scholars working on fatness and obesity? First, I think the existence of significant epidemiologic uncertainty must be engaged. This is not to suggest that morbid obesity is good for population health — indeed, morbid anything is by definition bad for health. Rather, and given the rapidly moving goalposts of BMI, I would argue that we cannot evaluate the merits of any given intervention for remediating fatness without interrogating rigorously our evaluation of the extent to which it is high-priority problem. I am not prescribing what anyone’s answer here ought to be — merely that the uncertainty must be enjoined. The movements of fat acceptance and health at every size cannot blithely be dismissed as evidence-free grass-roots advocacy campaigns; there is decent epidemiologic evidence that buttresses the approaches, goals, and objectives of these social movements.
Second, and related, when the existence of fat bodies is treated primarily as a problem to be corrected, we run into significant and well–documented problem of fat stigma. It is of course possible to regard obesity as a significant health problem without resorting to the stigmatization of fat persons, but the history of health stigma shows how common it is for public health practices and programs to channel and execute stigmatizing attitudes, beliefs, and practices against those deemed to have spoiled identities. If it is at least possible that the scope and tone of national discourse on obesity and fatness incorporates stigmatizing social constructions on the subject, then ensuring we are sensitive to the complexities of the evidence is one responsible way of proceeding. Stigma is corrosive and IMO is rarely if ever justified in the name of public health (although there is disagreement on this, as Nir and I have discussed!), but in the case of fatness it also is demonstrably counterproductive (see Puhl & Heuer 2010).
There is a third point, one related to the social gradients of so-called risky health behaviors — that the fundamental causes of obesity-related diseases are much more likely to be the social and economic conditions that largely determine which groups are more likely to engage in such behaviors than others. But I’ll save this last point for the next post!