Discourses on environment, public health and values: the case of obesity

Michiel Korthals


The relationship between the environment and public health has many aspects. Pollution of water, air and soil harm public health severely. On the other hand, green areas, fresh air and water improve public health. Due to the fact that most humans now live in cities, the environment is often the physical environment; the way houses, infrastructure, green areas, industrial and commercial areas and public spaces are structured determine the public health of the majority. How-ever, the environment can also be the food and drinks offered. In particular, the relationship between the environment and public health in the case of food and agricultural production is more controversial than ever. Increasingly more people are obese; large companies are criticized by NGOs because of the low quality of their produced food and social environments are seen as encouraging obesity (Poston and Foreyt 1999; WHO 2003). An important factor of this environment is how food production, distribution and preparation are organized. Healthy or unhealthy food affects public health in opposing ways. In many developed countries, food production, distribution and preparation is done by specialized sectors: most consumers do not produce, share and prepare their own food, but large industries have taken over these activities, often by producing ‘fast food’ (Vandevijvere et al. 2015). This specialization has an enormous impact on the quality of the food that is finally eaten. Most industrially prepared food is too salty, sugary and fatty due to the fact that short-term profit rather than long-term public health is the main objective. This food system, together with the physical environment with its focus on driveways, elevators and escalators, doesn’t stimulate physical exercise, and shapes an obesogenic environment. When the environment is obesogenic (with an emphasis on driving cars and fast food), obesity flourishes.

This contribution consists of four sections, treating four ethical issues at stake. First, a controversial issue concerns the identification of what type of problem obesity is, where the problem is located and to what extent environmental factors, such as fast food and other environmental factors, are causing the problem. Second, responsibility for managing and increasing environmental health is in need of ethical attention. This means that fast food producers and land use planners should accept responsibility for obesity, because continuing in the same vein with producing fast food and obesogenic structures will aggravate the problem in the future. What should producers do to prevent negative impacts on the health of consumers and what are they permitted to do? Third, there is the ethics of doing research into the factors that produce environmental hazards. There are good reasons to believe that research paid for by the fast food industry is often one-sided (concentrating on the positive aspects of sweet and fatty foodstuffs) or even not done in an integral way. Fourth, the right to intervene to reduce unhealthy factors and the type of intervention in the behaviour of consumers and producers requires ethical analysis; not everything helps and not everything is permitted to prevent a person from becoming overweight. For example, nudging people towards healthy food choices and attitudes, and promoting urban design that facilitates physical activity, are acceptable only under certain ethical conditions.

In all these issues of the relationship between the environment and public health, normative values are intrinsically connected with research, decisions and activities. 1 will argue that studying and managing environmental risks require value decisions; the common definition of a risk (chance of a big future loss), enables us to quantify the risk, and presupposes value decisions about what type of problem the risk is.

The relationship between the environment and public health in the case of obesity

The benign or harmful effect of environmental factors on human health is a very complex question. As such it cannot be solved by scientific research alone. Therefore, the identification of these effects in itself raises ethical questions. Exposure to potentially hazardous substances and processes is often difficult to identify and document, not only because of the complexity of their interactions and their long-term risks, but also because individuals can experience differing susceptibilities to their harmful effects (Sharp 2001; Paulson 2006). Moreover, the environment is dynamic and consists of many interacting (micro-, meso-and macro-) levels. The widespread presence of obesity is a very negative public health problem, along with increased instances of concomitant diseases such as type-two diabetes, cancer of the intestines and cardiovascular diseases (Roth et al. 2004).

In general, one can discern three (inevitable normative) approaches to obesity: one that emphasizes the individual behaviour, one that emphasizes genetic factors and one that emphasizes the influence of environmental factors, like the building environment and the workplace, but also the easy access to unhealthy food. In some clinical cases it is proven that clients have a genetic disposal to being obese (Loos and Bouchard 2003). As a type of genetically caused disease, obesity starts in early childhood; the genetization of obesity can therefore not be generalized to the total population. However, many see obesity as the result of an individual’s choice and behaviour. This ethical position has important implications for the ascription of responsibility for this disease. Individualization means that obesity is

Discourses on environment, public health 19

Table 2.1 Different levels of interaction between genetic susceptibility and the environment

Levels of genetic susceptibility

Body size in a nomobesogenic environment

Body size in an obesogenic environment


High risk to become massively obese

High risk to become massively obese

Strong predisposition

Normal weight/overweight

High risk to become obese

Slight predisposition

Normal weight/overweight

High risk to become overweight/obese

Genetically resistant

Normal weight

Normal weight

only caused by individual characteristics, and no other social actor can be held accountable. For example, Coca Cola, one of the most powerful food companies, thinks and acts in this way (Jong 2013). On the other hand, obesity is clearly correlated with fast food, processed food and the urban environment, which is emphasized in the socialization approach. Therefore, many think that when on-street eateries such as McDonald’s, KFC, Fish’n’chips, and Ben and Jerry’s, are tolerated not only in cities but also in mass media advertising and sponsorship, it should not be surprising that the numbers of obese persons are greatly increasing (as they still are in Europe). Moreover, just as with most environmental risks to health, the risk of obesity is for the most part not equally distributed. Rich people tend to live in healthier, less obesogenic environments than poor people and are therefore less obese. One can assume that the three approaches, individual behaviour, genes and the environment, work together to determine an individual’s risk to obesity, as is shown in Table 2.1.

Only in an obesogenic environment (with fast and processed food dominantly present and little emphasis on the importance of physical exercise) can something like an epidemic of obesity occur, and one can say this is currently the case in many developed countries. This means that, ethically and scientifically, the influence of the fast food industry and the lack of physical exercise can be seen as important causal factors in determining the risks of obesity. With the previous considerations, we have delineated what type of problem obesity is, where the problem is located and which factors, such as fast food and environmental factors, are causing the problem.

Responsibilities for reducing obesity

When a causal relationship between certain environmental factors and obesity is established, the issue of responsibilities emerges. In addition, not only casual factors determine responsibilities, but also future possibilities of actors to change a harmful situation. Even when many causal factors can be discerned (ethicists, in these cases, speak of the problem of ‘many hands’; Van de Poel et al. 2012), some actors are able to do more to prevent unhealthy situations than others. In other words, at stake are the responsibilities different people and organizations

Main actors and their relationships in determining obesity

Figure 2.1 Main actors and their relationships in determining obesity

had in the past and have today and in the future, vis-à-vis adverse effects of the environment on human health (FEC 2005; Minkler 2000). To what extent can the actors involved be held accountable, and to what extent can they, from an ethical point of view, be prevented in one way or another from continuing similar actions that contribute to those adverse effects? As already alluded to, from an environmental point of view, many very different actors are involved, as can be seen in Figure 2.1.

These complicated problems in confused contexts, so characteristic of obesity, give rise to the issue of many hands, and that of the diffusion of responsibility: when too many people are involved, the individuals involved can easily deny their responsibility. However, even in the most complicated cases, one can always identify more powerful and less powerful people. It is said that children are more vulnerable than adults, implying that parents are solely responsible for their

Discourses on environment, public health 21 health. However, how can a parent be held responsible when children are directly addressed by unhealthy food marketing campaigns? Often, new technologies and practices (such as genomics) create new public responsibilities and new distribu-tions of responsibility, but also new types of responsibility for food professionals (Kraak et al. 2016). How can obese persons (adults, children and their caretakers) move on in this jungle of new responsibilities? Who is held responsible/accountable for the causes of obesity, and for its remedies? Is the current distribution of respon-sibilities adequate in the new circumstances created by the introduction of genomics?

Currently, most people blame the obese, in accordance with the individualiza-tion approach. The famous ethicist Peter Singer states: ‘Others just eat too much and should show more restraint. Along with the old-fashioned virtue of frugality, the idea that it is wrong to be a glutton is in urgent need of revival’ (Singer 2006). However, moralizing to the obese should be restricted by one important condition (Korthals 2004): individuals can only be held responsible for their own weight when they are adequately informed about their food and are able to act accordingly (Kant 1983). Otherwise, their choices are not autonomous, in the sense that they are not free but manipulated. Living in an obesogenic environment has this effect (COS 2008). It implies that obese persons do not have enough resources to rid themselves of their obesity; they can be seen as addicted to fast food (Lerma-Cabrera et al. 2016).

However, ethically and scientifically, the fast food industry and the physical environment with its lack of stimuli for physical exercise, are more important in changing the obesogenic environment than the goodwill of individuals. This means that fast food producers and land use planners should acknowledge responsibility for obesity, in particular towards children. Even when it can be shown that other causal factors play a role, the effects of consuming their products is a principal factor both in the present and in the future. Therefore they should take their responsibility and start to reduce the obesogenic effects on the population. What should producers and policy makers do to prevent negative impacts of the environment on the health of consumers and what are they permitted to do?

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