This week in the New York Times, Aaron E. Carroll questioned why paying people for quitting smoking and losing weight is unpalatable to many Americans, even though significant evidence shows that financial incentives improve health outcomes. Carroll concludes that financial incentives tend to be least palatable for behaviors we know are harmful to begin with, as “[p]aying people to quit using harmful drugs or smoking can seem too close to rewarding people for adopting such habits in the first place.”obesity word cloud

Carroll’s piece got me thinking. If we didn’t see obesity largely as the result of individual irresponsibility, what would obesity policy look like?

Obesity and individual blame

As a society, we tend to cast obesity as the result of individual irresponsibility: laziness, lack of willpower, poor dietary choices, and questionable parenting. While people no doubt have some personal responsibility for their health, research on the determinants of smoking, exercising, and eating behavior reveals “that these are not simply free and independent choices by individuals, but rather are influenced by powerful environmental factors.”
In their recent piece in The Lancet, Roberto and colleagues discuss a series of environmental factors “exploiting biological, physiological, social, and economic vulnerabilities of people in ways that undermine their ability to act in their long-term self-interest.” Yet, our inherent prejudice against people who are overweight and obese essentially ignores these powerful environmental factors, like highly-appetizing processed foods packed with sugar, fat, salt, and calories, which make it harder for the body to regulate intake and weight. Similarly, we tend to disregard important biological barriers to losing excess weight, including changes in metabolism and hunger during weight loss attempts.
Obesity policy based on scientific evidence, rather than blame and stigma
Our tendency to blame obesity on the individual not only causes stigma and discrimination, it deprives society of comprehensive population level policies and laws we need to prevent and treat this chronic health condition.
As Carroll’s piece suggests, if we neutralized blame and stigmatization, we would likely see more research and policies utilizing financial incentives for healthy eating and weight loss among the overweight and obese. Such incentives would no longer be seen as rewarding slothful and gluttonous behavior, but as evidence-based, cost-effective means of achieving sustainable health outcomes.
Perhaps we would also see more public funding and insurance coverage for the full range of treatments for overweight and obesity, including nutritional counseling, prescription weight-loss medications, and weight-loss surgery. If we remove blame and stigmatization, we remove the basis for the argument that public funds should be reserved for the treatment of more “deserving” patients. As Ben Brooks writes, since neither obesity nor overweight “has the terrifying arbitrariness of cancer, nor the abruptness of a sudden heart attack – neither seems to warrant the same commitment to prevention.
Most importantly, perhaps, we would see more regulatory focus on the powerful environmental and social factors that undermine individual decision-making. Effective policies like taxes on sugar-sweetened beverages, portion size limits, and legislatively mandated restrictions on the salt content of processed foods would be commonplace. Most of us would reject industry claims of “personal responsibility” and the intrusive “nanny state,” which are deployed to undermine strong public health regulations. Policy-makers, no longer hamstrung by these industry tactics, would reject the its calls for self-regulation, voluntary schemes, and consumer education information as the answer to the obesity epidemic. Instead, compulsory regulations focused on manufacturers and society-level issues like marketing and availability would rule the day, complimented by genuinely informative labeling and nutrition information.
Today, non-communicable diseases (NCDs) are by far the leading cause of death in the world. Many NCDs are caused by tobacco use, alcohol consumption, and unhealthy diets, which, driven by the industries promoting them, evoke notions of individual irresponsibility and blame. As we make policies and laws to address NCDs and their risk factors, we should recognize that societal perceptions of disease influence research, funding, policies, and regulation. Our tendency towards individual blame not only causes stigma and discrimination—it deprives us of effective policies and laws to prevent, treat, and support people with serious chronic health conditions.