The ethics of
promoting weight loss

by Steven R. Hawks, EdD, CHES, and Julie A. Gast, PhD, CHES

   Health-based educational efforts to reduce body weight have been largely unsuccessful in terms of reducing the prevalence of obesity, increasing the levels of activity, or altering the amount of fat in the American diet. Instead, they unwittingly may have contributed to unhealthy weight cycling, the culture of thinness, self-deprivation, eating disorders, low self-esteem, and profiteering at the expense of the consumer.
   Because of these and other concerns, serious debates have been taking place in the health profession as to what message (if any) should be sent to the public in relation to weight control.1
   There is a need to carefully consider the ramifications of weight control paradigms and resulting programs. Specifically, the following ethical issues need to be addressed in weight loss education: (a) the emphaisis on individual responsibiity; (b) the lack of attention to social environment; (c) indirect support for the culture of thinness; (d) poor understanding of true health risk factors; (e) questionable motives of weight loss promoters; and (f) the inadvertent promotion of discrimination against the obese.2

Individual responsibility
   Even though it has been proposed that humn genetics and social environment may be the most important determinants of obesity at the macro level,3 most weight control programs hold the individual primarily responsible for body size. The consequences of "blaming" the individual for their body size could include: (a) increased rates of yo-yo dieting; (b) false expectations; (c) a legacy of failure and low self-esteem; (d) disgust associated with self-reflections; (e) eating disorders; (f) exercise disorders; and (g) a lack of attention to societal, genetic, and other causes of obesity.
   There is a need to explicitly acknowledge the multiple factors that contribute to obesity (many of which are beyond the control of the individual) and modify the heavy emphasis on personal responsibility.

Social environment
   It may be profitable to focus more research efforts and attention on understanding the contribution of the social environment to the prevalence of obesity. In an effort to reduce the prevalence of tobacco use, several changes were brought about in the social environment: bans on tobacco advertising, restrictions on tobacco use in public areas, and a significant reduction in the number of tobacco vending machines.
   Although the Nutrition Labeling and Education Act of 1991 helped raise consumer awareness and control questionable health claims in relation to food products, little effort has been made to understand or control other forms of negative nutritional advertising. For example, do we need to attend to the type and amount of food-related ads during Saturday morning cartoons or ensure more nutritious fast food choices in schools and malls?
   Further, there has been little effort to evaluate the relationship between environmental supports for exercise (e.g., safe walking trails, bicycle routes, parks, recreation centers, employee fitness centers) and the activity levels of community members. It does not seem ethically justifiable to blame the individual while failing to fully evaluate the influence of the social environment in determining obesity, or taking appropriate steps to create a less toxic environment.4

Promoting the culture of thinness
   Large people who are fit have a lower risk of mortality than thin people who are sedentary.5 Yet the high levels of concern over weight control found among health professionals may serve to add fuel to the media contention that people must be thin to be healthy or socially acceptable.
   There also seems to be a divergence between the goals of the weight loss educator, to enhance physical health through weight loss, and the goals of the participant, to lose weight in response to the cultural pressure to be thin.
   Appropriate concern for the concept of "holistic health" -- the importance of strong social support, the value of spiritual well-being, and the positive effects of good emotional health -- runs the risk of being overshadowed by an excess concern for promoting thinness. Rather than equate "thin" with "healthy," there is a need for health educators to  publicize the concept that body size may be less important for holistic health than activity level, diet composition, social ties, spiritual well-being, or emotional health.

Understanding valid risk factors
   If obesity (body size) is defined as a chronic disease and an independent risk factor for morbidity and mortality, then VLCDs, diet pills, herbal rememdies, stomach stapling, and lifelong drug prescriptions become justifiable methods for reducing body size. If the true health risk factors are instad defined in terms of personal diet composition and activity levels, then the appropriate remedy may be individual behavior change. But if the social environment also exerts a major influence on activity levels and diet composition, then restrictions on food advertising, limitations on the availability of nutritionally harmful foods, and more school- and community-based activity programs may be necessary.
   It is important to view the correlation between body size and health status from a broad perspective to appreciate the complexity of the relationship and to come up with the most appropriate solutions.

Questionable motives of weight loss promoters
   Because of the intense cultural pressure to achieve thinness, the public is susceptible to new weight loss approaches, especially if they promise quick, painless results -- and especially if they can be tied to the legitimate medical establishment. As such, a plethora of profit-motivated companies wait eagerly for hints of medical advances in weight control, and then quickly market unproven remedies to a vulnerable public -- such as ineffectual thigh creams, food supplements (chromium picolonate), herbal remedies (some dangerously high in ephedrine and caffeine), as in the case of VLCDs, occasionally is tainted by lucrative efforts that turn out to be ultimately ineffective or even harmful.6 Those involved with the promotion of weight loss should take extra precaution to avoid unproven interventions and strategies that might exploit a vulnerable and trusting public.

Discrimination
   Weight loss programs that target the individual as being primarily responsible for body size may inadvertently set the stage for employers to discriminate against obese people in terms of hiring practices, and for insurance companies to discriminate by charging higher health insurance premiums. Given that the causal factors for obesity are complex, intertwined, and not completely understood, such discrimination is insuportable.7

Appropriate health goals
   An individual's body size is determined by numerous complex factors, many of which are not within personal control. Once activity level and diet composition are accounted for, the relationship between body size and physical health is rather weak.
   Ideal weight should be redefined as the natural weight the body adopts given a healthy diet and meaningful levels of physical activity.
   In light of these conclusions, the promotion of weight loss as a health education goal presents a number of ethical challenges, espeically in a society where body size is wrongly equated with personal worth and social acceptability. Given these ethical challenges, it makes sense to ask, "Should weight loss be dropped as a public health goal in favor of nutrition and activity goals that are more likely to result in positive health outcomes and that are less likely to cause harm?"

Steven R. Hawks, EdD, CHES, and Julie A. Gast, PhD, CHES, are both associate professors in the Department of Health, Physical Education, and Recreation at Utah State University.
 

References
1.  Brownell KD, Rodin J. The dieting maelstrom: is it possible and advisable to lose weight? Am Psychol 1994;49:781-791.
2.  McLeory KT, Bibeau DL, McConnell TC. Ethical issues in health education and health promotion: challenges for the profession. J Health Educ 1993;24:313-318.
3.  Bray GA, York B, Delany J. A survey of the opinions of obesity experts on the causes and treatments of obesity. Am J Clin Nutr 1992;55:151S-154S.
4.  Jeffery RW. Public health approaches to the management of obesity. In:Brownell KD, Fairburn CG, eds. Eating disorders and obesity. New York: Guilford Press, 1995:558-563.
5.  Blair SN, Kampert JB, Kohl HW, III, et al. Influences of cardiorespiratory fitness and other precursors on cardiovascular disease and all-cause mortality in men and women. JAMA 1996;276:205-210.
6.  Flynn TJ. Letters to the edtior: very low calorie diets. JAMA 1990;263:2885.
7.  Wadden TA, Wingate BJ. Compassionate treatment of the obese individual. In: Brownell KD, Fairburn CG, eds. Eating disorders and obesity. New York: Guilford Press, 1995:564-571.