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Why Target National Obesity Rates?

In a recent article in the Hastings Center Report, Daniel Callahan argues that obesity is a serious public health problem facing the U.S. and suggests a variety of strategies for combating this problem. The article has provoked a great deal of public attention on blogs and web news sites since its publication in January. Much of this attention has been critical of Callahan’s third strategy for combating the obesity epidemic, namely, “stigmatization lite.”  Like these commentators, I agree that Callahan is wrong to propose social stigmatization as a means of combating obesity, but I also challenge Callahan on other grounds.

One problem with the article that has been overlooked by critics concerns the goal that Callahan takes for granted: reducing overall national obesity. Callahan makes passing reference to two kinds of reasons for reducing national obesity rates, but neither seems compelling.

The first might be considered intervening for the purpose of preventing the overweight and obese from further harming themselves. Callahan hints at this reason for interventions when he mentions the “health impacts of obesity” and the fact that it “shortens lives.” Rising obesity rates mean that more people are committing self-harm and justifies more severe interventions.  Is this a good reason for mounting a large-scale intervention?

Many people will balk at this paternalist reasoning. Even if it is better to be of a normal weight, coercing someone solely for his or her own benefit is objectionable.

But even if we were sympathetic to paternalist lines of reasoning, it is not clear that decreasing someone’s overall weight is definitely for his or her good. While extreme forms of obesity are highly correlated with increased mortality, recent highly publicized evidence has indicated that both overweight and grade 1 obese persons enjoy decreased all causes of mortality relative to those of a normal or average weight.

The second kind of reason Callahan references might be considered intervention for the purpose of preventing harm to others. Callahan mentions here the “cost” of obesity. But while obesity can undeniably lead to expensive medical charges, studies have shown that obesity is actually cheaper in the long run than is healthiness, as Callahan himself admits. The study Callahan cites shows that lifetime medical costs in the study group of Dutch patients were highest for those who were of an average weight and did not smoke; lower for those who were obese but did not smoke; and lowest of all for those who smoke.

While this result will seem counter-intuitive to many people, its explanation is not particularly complicated. Good health does not prevent illness or death, it merely delays them. Those who are obese and/or smoke will, sadly, contract illness and die at a younger age. Consequently, the obese use fewer lifetime medical resources.

If we look at wider social costs, the same holds true or is even exacerbated. People who lead healthy lifestyles spend their productive years paying taxes or insurance fees, and then spend a relatively longer period of retirement reclaiming their prior contribution to these systems. Those leading unhealthy lifestyles often make it through the bulk of their productive life (i.e. prior to retirement), but spend a relatively shorter period of time receiving Medicare, social security, or other social benefits.

Where does this leave us?  While we may join Callahan in regretting that the nation is becoming progressively fatter, it isn’t clear that this necessitates anything like the massive coordinated response suggested by Callahan. Directly referring to the good of the overweight and/or obese when designing interventions is morally problematic. But even if it weren’t, data showing that some overweight or obese persons may live longer calls into question whether it is even plausible to defend the proposed interventions by referring to the good of those they target. Referring to the costs to others, while acceptable in principle, would be similarly problematic if it turns out that the most severely obese persons have the lowest lifetime medical costs and impose the fewest costs on society.

Stigmatization is a drastic means for treating any social problem. But before considering such a drastic means, we’d do well to contemplate carefully whether there is a problem that definitely needs to be fixed.

D. Robert MacDougall is a postdoctoral fellow at Dalhousie University in Halifax.

Posted by Susan Gilbert at 03/11/2013 10:40:21 AM |

Published on: March 11, 2013
Published in: Health and Health Care, Health Care Reform & Policy

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