1. THE NATIONAL UNIVERSITY OF IRELAND
ROYAL COLLEGE OF SURGEONS IN IRELAND
MEDICAL UNIVERSITY BAHRAIN
THE OBESITY EPIDEMIC
BY
Galiena Verton Steggerda
`` Obesity is one of the few medical problems that can be
reversed very, very quickly´´
Sir Liam Donaldson
Chief Medical Officer for England
A dissertation submitted in partial fulfilment of the requirement for the Masters in
Health Care Ethics and Law
Date of Submission:
Supervisor: Meaven Royston
Student Number: 9038451

2. Word Count: 2463
Declaration
This thesis is submitted in partial fulfilment of the requirements of the MSc in Health
Care Ethics and Law in the Royal College of Surgeons in Ireland Medical University of
Bahrain and has not been submitted to any other university. I confirm that this thesis is
my own work. Assistance has been acknowledged. Permission is given to the Library of
the Royal College of Surgeons in Ireland Medical University of Bahrain to lend or copy
this thesis.
Name: Galiena Verton Steggerda
Date: 15 February of 2012
2

3. Acknowledgment
I am extremely thankful to Jaap Verton, my husband who has always supported me in my
personal development, and to my children, Dragan and Tyrza, who have been very
patient over the past two years.
And I’m heartily thankful to my friend Sandra Thompson, for always standing by my
side to help, and for all the guidance she has given, the endless support, and the
encouragement.
I am thankful to my supervisor Meave Royston and my Professor David Smith, that I
was able to undertake this Master Thesis in Ethics Health and Law.
Lastly, I offer my regards and blessings to all of those who supported me in any respect
during the completion of this project.
Galiena Verton Steggerda
3

4. Abstract
There is currently a global obesity epidemic, with obesity being the most significant
contributor to health problems. This presents a threat to society due to the risk to
individuals and therefore to the whole of society, and the way this impact on public
services.
Major contributors to obesity levels are eating habits and taking less exercise. Lifestyles
have radically changed over time, and it is true to say that for the most people in the
developed world, life is more sedentary than fifty years ago. Obesity has been shown to
be associated with low socio-economic status in industrialised, developed nations.
The law can help combat the obesity epidemic. Given the threat that obesity poses, a
certain level of paternalism can be justified to control the obese epidemic.
Globally the cost of obesity is considerable. Obesity is estimated to account for between
0.7% and 2.8% of a country´s total health care expenditure; 9.1% for overweight and
obesity. Obese individuals are estimated to have medical costs 30% higher than their
peers who are not obese.
A paternalistic approach is described as the attempt to induce individuals in ways that
will benefit them, or to not act in ways that will harm them. Paternalism is motivated by
a beneficial concern for the welfare of individuals, and of society, through the use of
means other than reasoned persuasion. Paternalism is opposed by many on the grounds
that it restricts personal autonomy; that is, ‘the opportunity to regulate one’s own life
according to one’s own judgment, even when one’s judgment is bad’. Autonomy is an
important right in democratic society, because it represents liberty. However, there are
examples of the use of legal paternalism where the intention has been to safeguard the
health of the society as a whole.
4

5. Abbreviations
BMI Body Mass Index
BSE Bovine Spongiform Encephalopathy
DEXA Dual Energy X-ray Absorptiometry
ENSP European Network for Smoking and Tobacco Prevention
EU European Union
FCTC Framework Convention on Tobacco Control
GP General Practitioner
HSC Health Survey for England
HSE Health Survey England
IOTF International Obesity Task Force
KFC Kentucky Fried Chicken
Kg Kilograms
M2 Meters Squared
NCMP National Child Measurement Programme
NHS National Health Service
PCT Primary Care Trust
SPD Supplementary Planning Document
TCS Tobacco Control Scale
UK United Kingdom
WHO World Health Organization
WHO FCTC World Health Organization Framework Convention on Tobacco Control
5

6. Contents
Page
Introduction 11
Chapter 1 Obesity and Ethics 14
1.0 Obesity and Ethics 14
1.1 Obesity – The Size of the Problem 14
1.2 Obesity as an issue 14
1.3 Ethics and medicine 15
1.4 Areas for discussion and debate 15
1.5 Can we be too overprotective? 16
1.6 Obesity and stigmatization 17
1.7 Choice and responsibility 17
1.8 Stigmatization 20
1.9 Who is responsible 20
1.10 Intervention 20
1.11 Paternalism 21
Chapter 2 Obesity – The Size of the Problem 24
2.0 Obesity – The Size of the Problem 24
2.1 What is obesity? 24
2.2 How is obesity measured? 24
2.3 Body Mass Index 25
2.4 What is BMI? 26
6

7. 2.5 Why use BMI? 26
2.6 What are the problems with its use? 27
2.7 How should be interpret different BMI levels? 27
2.8 Is BMI interpreted the same way for children as it is for adults? 28
2.9 What other measures of fatness are available? 29
2.10 So what should we conclude 30
2.11 In what sense is obesity a problem? 31
2.12 Key facts 32
2.13 Facts about overweight and obesity 32
2.14 What causes obesity and overweight 33
2.15 Facing a double burden of disease 33
2.16 How can overweight and obesity be reduced? 34
2.17 The World Health Organization 2008-2013 Action Plan 35
2.18 Can intervention be justified in the case of obesity? 36
Chapter 3 Obesity – A Global Health Problem for Children and Adults 37
3.0 Obesity – A Global Health Problem for Children and Adults 37
3.1 Obesity and health 38
3.2 What does obesity do to your health? 39
3.3 Obesity, cancer and other illnesses 40
3.4 Childhood obesity 41
3.5 Why the focus should be on children 42
3.6 The medical condition of childhood obesity 42
3.7 Tackling the issue 43
3.8 Paternalistic measures to combat childhood obesity 44
Chapter 4 Why Are People Obese? 46
4.0 Why Are People Obese? 46
4.1 Obesity and diet in history 46
7

8. 4.2 Changes in the modern world and contemporary society 47
4.3 What are the factors that cause obesity? 48
4.4 Genetic factors 48
4.5 Environmental and social factors 49
4.6 Cultural factors 50
4.7 Other causes of obesity 51
4.8 Illnesses 51
4.9 Drugs and medication 52
4.10 Insufficient sleep 52
4.11 Endocrine disruptors (foods that interfere with lipid metabolism) 52
4.12 Smoking 53
4.13 Medication that causes a person to put on weight 53
4.14 Choices and responsibility 54
Chapter 5 Socio Economic Issues and Obesity 56
5.0 Socio Economic Issues and Obesity 56
5.1 What are socioeconomics 56
5.2 Do social economic factors play a role in obesity 56
5.3 Adult obesity and socioeconomic status 57
5.4 Child obesity and socioeconomic status 57
5.5 Socioeconomic relationship and residential environment and physical
activity
59
5.6 Socio-economic and safety 59
5.7 Socio-economics and residential environments 60
5.8 Children and adolescents 61
5.9 Socially disadvantaged groups 62
5.10 The level of education and obesity 62
5.11 Can the case be proven? The links between socioeconomic status and
obesity 63
8

9. Chapter 6 Control Through Legislation 68
6.0 Control Through Legislation 68
6.1 John Stuart Mill’s Harm Principle 69
6.2 Paternalism and the role of the law 70
6.3 The case with tobacco 71
6.4 The effects upon health of smoke free legislation
73
6.5 The case with alcohol 73
6.6 The ‘Responsibility Deal’ and alcohol 75
6.7 Fluoridation of water: a case of direct intervention 76
6.8 Paternalism and self-harm 78
6.9 The case for paternalism 79
7.0 Obesity Management 81
7.0 Obesity Management 81
7.1 Primary and secondary care and the management of obesity 81
7.2 Primary care 82
7.3 Secondary care
83
7.4 Financial implications of obesity 84
7.5 The financial cost and economic burden of obesity 85
7.6 Paternalistic measures in action 86
8.0 Conclusion 89
References and Bibliography 92
9

10. List of Tables
Page
Figure 1: The measurement of supplemental fat using a pair of 25
Calipers (source Google images)
Figure 2: Graph to show the calculation of BMI (height versus 30
weight) (source National Institutes of Health)
Figure 3: Table to calculated BMI plotting height against weight 31
Figure 4: Estimated costs of obesity according to four research studies 84-5
(source: information from National Obesity Observatory)
10

11. ‘Obesity is one of the few medical problems that can be reversed very, very quickly’
Sir Liam Donaldson
Chief Medical Officer of England
Introduction
11

12. The world is currently in the grip of an obesity epidemic.i.
The World Health
Organization predicts that by 2015, about 2.3 billion adults will be overweight and over
700 million people will be classified as obese.ii.
Worldwide, WHO estimates that more than 22 million children under the age of 5 years
are obese. Childhood obesity leads to a higher risk of disability and premature death in
adulthood. Rates of obesity among children are estimated to have tripled during the last
20 years. Fifty per cent of all children in the United Kingdom are predicted to be
classified as obese by 2020.iii.
Obesity has consequences at a personal and social level; it is disabling and life
threatening. It places a great burden on national health services, and for society as a
whole in terms of the percentage of healthcare expenses that are used to treat obesity
comorbidities. Obesity is estimated to account for 0.7% to 2.8% of a country´s total
healthcare expenditure, 9.1% for overweight and obesity.iv.
Paternalism can involve measures that are coercive, forcing individuals to act in a certain
way. Paternalistic measures can be justified to protect both the public from an
individual’s behaviour (such as the legislation on smoking in public place), and to protect
the individual from the consequences of their own behaviour. Autonomy is an important
right in democratic society, because it represents liberty. There are, however, examples
of the use of paternalism where the intention has been wider than the prevention of harm
to others, for example restrictions on smoking in public places, or the compulsory use of
seatbelts. In terms of obesity, the debate is whether individuals should be allowed to
make their own decision regarding lifestyle which can lead to obesity, or whether health
care providers or the government should taking an active role in combating what has
become a disease prevalent on an epidemic scale.
Government intervention is necessary to reverse the current obesity trend. Governments
and health organisation have recognised the problem of obesity and are developing
strategies to implement preventative measures. In the UK in 2007, foods that are high in
12

13. fat, salt and sugar (so called ‘junk food’) were banned from advertising on television
before the 9 o’clock watershed, ie during the time young children were likely to be
watching television. Many Local Education Authorities implemented guidelines for
schools banning the use of vending machines selling snacks such as crisps, chocolate and
sugary drinks. Local guidelines have enforced healthy eating options being available in
school dining rooms, and a number of local authorities have taken a lead from Waltham
Forest by banning the opening of new take-away restaurants within 400 yards of a school,
youth club or park.
In the UK, the NHS is implementing a clear clinical pathway for children and adults to
tackle obesity. The NICE clinical pathway is developed to provide the best care for the
population through a step by step programme assisting in diagnosing and treating obesity.
Globally, more radical, paternalistic approaches are now being introduced. The
Government of Denmark has introduced a so called “fat-tax” in an attempt to discourage
the consumption of saturated fats.
Obesity control measures are frequently opposed on paternalistic grounds, claiming the
autonomy of the individual is affected. But a paternalistic approach to obesity control
can be justified by regulating the food industry rather than dictating what individuals
should, or not should eat. The law could facilitate an approach to obesity control using a
soft rather than hard paternalistic approach. This is an approach that is more likely to
receive support from the public and government. However the use of hard paternalistic
measures has been recently justified relating to measures directed at children. Children
are particularly vulnerable and therefore in need of additional protection. Maybe hard
paternalistic approach in obesity management could be seen as too extreme for the adult
obese population. However autonomy also means that people have the right to make their
own decisions, so does this mean they can be obese? Does society have a view on the
rights of the individual, and is there a conflict with the greater good of society?
13

14. i. International Association for the study of obesity www.iotf.org
ii. World Health Organisation WHO www.euro.who.int/en/what-we-do/health-topics/disease-
prevention/nutrition/facts-and-figures
iii. World Health Organisation WHO www.euro.who.int/en/what-we-do/health-topics/disease-
prevention/nutrition/facts-and-figures
iv. Foresight. Government Office for Science. Tackling Obesities: Future Choices Project Report (2nd
Ed); 2007
Chapter 1
Obesity and Ethics
Obesity - The Size of the Problem
14

15. In the year 2000, the number of people in the world classified as obese became greater
than the number of people suffering from malnutrition. Obesity is replacing infectious
diseases and under-nutrition as the single most significant contributor to ill health within
populations worldwide. This extraordinary fact illustrates the extent of the problem, and
the reason governments around the world accept that obesity presents complex areas for
concern that need to be addressed as a component of public health care. Obesity is no
longer regarded as simply being a cosmetic problem affecting certain individuals, but an
epidemic threatening global well being.
Obesity as an issue
Obesity can be defined as the accumulation of excess fat in the body that arises as the
result of an imbalance between energy intake and energy expenditure, over a prolonged
period of time.
Obesity is not a disorder with a single root cause. Body weight itself is determined by an
interaction between genetic, environmental and psychosocial factors that all impact on
energy intake and expenditure. Although genetic differences are undoubtedly important,
the vast rise in the level of obesity is best explained by the behavioural and
environmental changes that have resulted from technological advances.
Is obesity a problem for anyone other than the obese individual? The clear and
resounding answer worldwide is ‘Yes’, as governments take action within society in
order to impact on the problem. The burden on the individual and to the wider economy
is potentially immense due to costs associated with long-term diseases and reduced
productivity in the work place. Managing the ‘obesity epidemic’ means working towards
the prevention of obesity, together with the treatment of those who are already obese and
in danger of suffering life-shortening illnesses.
Ethics and medicine
15

16. Ethics is the branch of philosophy that addresses questions of morality, such as good and
evil, right and wrong, and virtue and vice. Medical ethics specifically governs moral
principles that apply values and judgments to the practice of medicine, including how
these are applied in a clinical setting. The six values that are most commonly applied to
medical ethics are those of autonomy, beneficence, non-maleficence, justice, dignity, and
honesty, involving the concept of informed consent.i.
In the real world, ethics acts as an aid to decision making with regard to behaviour.
Where dilemmas exist, ethics works to arrive at a considered response. An individual
should be responsible for their own actions, yet a person’s behaviour must be judged in
relation to their social situation, and in terms of legal context. In the field of medical
ethics, the principal participants are governments, doctors, primary healthcare facilitators,
and the individual. Whilst a key ethical value is that of autonomy, or the right of an
individual to self-determination, society also takes a responsible role in promoting the
common good, just as a parent has an obligation of care to their child.ii.
Areas for discussion and debate
Discussion with regard to the ethics of intervention and the issue of obesity raises two
basic ethical problems. The first is with regard to the patient who does not want
intervention in their lifestyle choices (it is their autonomy to do what they want). Can it
be justifiable to intervene on the grounds of promoting a person’s health or well being. Is
paternalism justified in this situation?
The second ethical dilemma involves economic gain. This is not usually considered to be
sufficient reason alone to claim that intervention can be justified. Can it be justified to
negatively affect a person or persons’ well being in order to benefit others or to promote
the common good?
Can we be too overprotective?
16

17. What does Paternalism mean: the system, principle, or practice of managing or
governing individuals, businesses, nations, etc, in the manner of a father dealing
benevolently and often intrusively with his children.
The Finnish Philosopher Heta Hayry made a distinction between three different forms of
paternalism and maternalism.iii.
1. Hard paternalism involves direct coercion
2. Soft paternalism involves giving unwanted information or foreclosing some
options for action and maternalism
3. Maternalism involves control by inducing a guilty conscienceiv.
Within the world of healthcare, hard paternalism is where a patient who has lung cancer
is that that he must stop smoking immediately, otherwise treatment will not take place.
Soft paternalism, or maternalism, can be explained as with the situation of a pregnant
woman, who is told that, by drinking alcohol, there is the chance that she could be
harming her unborn baby.
The case of tobacco consumption is interesting. A pure form of paternalism is
exemplified with the message on a packet of cigarettes ‘SMOKING KILLS’, whereas the
smoking ban in public places, which exists now in many countries around the world, is an
example of soft paternalism, but only if laws are implemented on the grounds of the
health and welfare of smokers. A ban on smoking in public places can be described as
hard paternalism if the raison d’être is in terms of protecting non-smokers. The debate on
the question of paternalism asks whether it is legitimate to interfere with people’s
choices, or does this constitute an infringement on a person’s autonomy. Should all
choices be respected?
In the context of food consumption, providing information on food packaging detailing
nutritional values allows people to make an informed choice. There is no guarantee that
17

18. people will make optimal choices with regard to nutrition, but this would not form an
argument against supplying the information in the first place. Autonomy is an essential
ideal in society, despite the risk that individuals will choose unhealthy options.
Obesity and stigmatization
Identifying individuals as being at risk can cause social stigmatization, and thus a change
in self-perception. Being obese puts a person into a high-risk group, easily identified and
in danger of being stigmatized. High-risk groups are very often targeted out of cost
effectiveness, but this focus can cause problems of justice. Aristotle outlined the basic
principal of justice, stating that all individuals should be treated equally, but focusing
attention and resources on high risk groups, such as those who are obese, is counter to the
concept of equality. To be just, health promotion should be targeted to the whole
population, and to effect a change in behaviour, every member of society should be given
the same information and encouragement to live a healthy lifestyle. This strategy may in
fact constitute a more effective use of resources, as the prevalence of obesity, including
levels predicted in the future, could be cut.
Choice and responsibility
If autonomy is to be an ideal, it must follow that individuals must be responsible for the
predictable consequences of their choices and actions. Those people who are obese must
take responsibility for their physical condition. There are, however, a number of
complications in claiming personal responsibility, because life style choices may be
driven by a number of factors. Socialization and social structure are powerful influences
on the way people live their lives, and it may be difficult to change the life style a person
is born into. Socioeconomic factors dictate here, and the fact is that life style can
significantly contribute to a person’s sense of well being, even if that life style is
questionable and the consequences are negative. Is good health always synonymous with
well being? Who can objectively judge whether the vegetarian, fitness enthusiast has a
better quality of life that the burger eating, alcohol drinking, smoker? If we assert that a
18

19. person’s obesity is their own responsibility, are they accountable for their own health and
the consequences of being obese? Should the obese be treated differently because they
may be judged to be responsible for their condition? If obese individuals are treated
differently because they are judged to have made poor life style choices, would claims
that they are being discriminated against and treated unjustly be defensible.
The justification for interfering with a person’s autonomy is clear with addictive
substances such as alcohol and tobacco. The addictive properties of nicotine, for
example, make the concept of informed choice and personal responsibility redundant. A
recent study by the University of Oregon shows a change in the sensitivity of the brain
where a person’s regular diet is high in fat and sugar. Their conclusion is that ‘junk food’
can be as addictive as cocaine or heroin.v.
Does this therefore mean that there is an
argument for legal restrictions on foods that are known to contribute to obesity? How
does this fit with an individual’s autonomous right to make choices and decisions for
themselves?
Conflict exists between the notion of personal choice and responsibility, and the
justification for large scale interventions that may affect the non-obese in a negative way.
An example of this would be the recent ‘fat tax’ as implemented by the Danish
Government in 2011. In an effort to combat the problem of obesity, reducing
cardiovascular disease and diabetes, laws have gone into effect specifically targeting
saturated fats – the fats found most commonly in animal products like butter, cream and
meat. This is the first tax of its kind in the world, and imposed a price increase based on
the formula of 16 krone per kilo of saturated fat on any food that contains more than
2.3%.vi.
Given current Danish consumption, and the fact that they eat a lot of butter and
sausage, it is estimated that approximately 82 million kilos of fat is subject to the tax. At
the political level, there was a high degree of consensus for the implementation of this
law, in conjunction with a wide agreement to improve the health of the Danish people. In
fact the tax was approved by nearly 90% of the Danish parliament.
19

20. This is not the first time that the Danish government has taken the regulation route to
govern foods that are considered as being ‘less than healthy’. Sugar has long been
subject to higher tariffs, though when originally introduced it was intended that this tax
should be a revenue earner rather than a method of improving public health. In 2004,
Denmark became the first country in the world to ban transfats, the solid fats commonly
used in snack foods and industrially baked goods, and experts believe that the ban has
played a significant role in reducing rates of cardiovascular disease by over 30% in
Denmark over the past seven years.
The introduction of the ‘fat tax’ is Denmark is not without its critics, particularly in the
food industry. The major objection has not been the introduction of the tax, but its
method of implementation. As a national whose farming industry is based on dairy
products, farmers have been affected significantly by diminished revenues due to the
price rises, and those who have found it hardest to absorb the price increase have been
organic producers. In terms of encouraging healthy eating, producers of organic food
have been encouraged through government measures and incentives, but in this case there
appears to be a direct contradiction. Should the dairy industry be penalized for people’s
independent choices in consumption when they are producing a good and healthy product
when eaten in moderation?
The ethical issue as to whether it is possible to implement government policies whilst
maintaining choice and responsibility is difficult. While personal responsibility may be
the ideal, does society also have a part to play? Is it legitimate to expect members of
society to take responsibility for their health, if governments are not upholding their
responsibility for health education? One method would be for governments to take an
authoritarian position by prohibiting specific marketing strategies on specific kinds of
food. This in turn may result in a loss of revenue, with diminished tax earned from a
decreased demand for specific food products. The financial implications are significant,
and represent an issue society must face.
Stigmatization
20

21. The contemporary media promotes specific body images, which gives rise to certain
issues. It is alleged that promoting images of ‘waif’ like figures has led to an increase in
different kinds of eating disorders, such a bulimia and anorexia. There is a risk of
stigmatizing those whose body shapes are not deemed as being ideal, particularly in a
world which increasingly recognizes the dangers of obesity. A balance between food
consumption, physical activity and education is a example of soft paternalism, where
personal awareness and a sense of self-responsibility is encouraged. This may be ideal,
but it in effective in real life?
Who is responsible?
In the pursuit of a range of strategies to combat the global problem of obesity, it should
first be determined who to target, i.e. who will take responsibility. The health care
organizations and government institutions are primary in this field, but the worldwide
food industry, and individuals themselves also have a role. The question is, is this role
equal? Is any one of these component parts wholly, or even mostly, responsible for the
obesity epidemic? The nature of responsibility must be addressed in order to successfully
implement programmes to combat obesity.
Intervention
It is generally accepted that obesity can often be traced to early childhood, or possibly
even the intrauterine environment. An intervention strategy based on intensive dietary
advice to parents, and the intensive monitoring of weight and body shape off all children
could prove effective and direct. With such a programme, intervention could be quickly
put into practice as an extension of current antenatal and child development health
initiatives. Agreement and compliance are essential in such health care strategies, and a
joint approach between parents and health care providers is vital. Though parents have
an ethical and legal obligation to promote ‘the best interest of the child’, the law also
21

22. states that the child’s interests are paramount, so society, and government, must also take
a responsible role.
‘The best interest of the child’ will depend on the social environment a child is brought
up in, and to a large degree, society must allow parents to act on their concept of what the
best interest of the child is. Naturally, the context will change from family to family, and
in different moments in time. Financial and social stresses and obligations will dictate
decisions made within the family situation, and this would form a powerful argument for
society, through government, to take a responsible position and augment paternalistic
policies to assist.
Paternalism
Paternalism and individual autonomy may be considered to be opposite extremes, and in
academic debate, this may be so. In a practical, real world situation, there must be some
interplay between the individual and those in power making decisions. Perhaps the key
area for debate is how far individuals want to hand over responsibility for their situation
to others, or how far they wish to take part in the decision making process. In the case of
obesity, it is not simply the doctor or health care provider who may take a paternalistic
rôle, it is also the government, who is in a strong position to affect an individual’s health
through both hard and soft paternalistic policies. Conflict exists when these actions
impinge on a person’s autonomy.
Whether it is the case with a person who is already obese, or society as a whole, attitudes
will vary. Some people will seek the advice of doctors or skilled professionals and allow
them to take the lead in decision making with regard to the best perceived course of
action. The will be done on a basis of trust. Other patients will have strong views and
wish to decide on the course of action they choose for themselves. They recognize
ownership of their own body, and believe that experts can assist them by providing
enough information for them to make decisions for themselves. Although the days seem
to be past where doctors totally disregarded a patient’s views, with no explanation and no
22

23. discussion, it is not helpful to be in the opposite extreme of positions, where the doctor
takes no leadership at all, leaving all decisions to their patients. A patient cannot take
important decisions without guidance.
Of course the reality of good medicine, and good healthcare practice, is based on mutual
trust. Whereas doctors must have the capacity to listen to patients, they must also
demonstrate humility in implementing their expertise and skill. There must be a bond on
confidence between doctor and patient, with a mutual understanding that the best way a
doctor can treat a patient is with their consent. To understand this mutual
interdependence is the most secure basis for achieving the best results when tackling
jointly their common enemy, namely disease.vii.
The extremes of patient autonomy and paternalism have no place in practical clinical
practice, and patients will vary in how much expert advice they will take, and act on. The
trust that is created between doctor and patient will determine the value of the treatment,
and how successfully doctor and patient can tackle and deal with the disease, in this case,
obesity. Pressures health care providers are themselves put under may hinder the
doctor/patient relationship, and a balance must be created.
Where paternalism is practiced by the government or society on individuals or the
population as a whole, this will also only be successful if it is understood that government
is acting wholly in the best interests of society which is at risk. The individual
relationship between patient and doctor is easier to define and analyse. The relationship
between government and the judiciary and the population as a whole is open to more
debate, as the range of opinions of those included will be greater and more diverse.
Governments must, by necessity, act on the basis of mutual trust, as in a democratic
society they may otherwise be removed from power. Nevertheless, recent years have
seen progressive governments worldwide adopting a tougher paternalistic position in
order to safeguard the interests of society as a whole.
23

24. i.
Beauchamp T L, Childress J F: Principles of Biomedical Ethics, 6th ed pg. 111, Oxford University
Press: Oxford, 2009
ii
Downie RS, Tannahill C, Tannahill A: Health Promotion: Model and Values, 2nd ed. Oxford
University Press: Oxford, 2006
iii.
Hayry H. The Limits of Medical Paternalism. Routledge: London 1991.
iv.
Beauchamp T L, Childress J F: Principles of Biomedical Ethics, 6th ed, pg. 213, Oxford University
Press: Oxford, 2009
v
Louis Rogers ‘Junk food as Addictive as Cocaine’ (5 September 2010) The Sunday Times London, and
Steve Connor ‘Junk Food could be addictive ‘like heroin’; Rats become ‘hooked’ on Sausage and
Cheesecake in the same way as drug abusers’ (29 March 2010) The Independent London
vi
Abend, Lisa ‘Beating Butter: Denmark Imposes the World’s First Tax’ Time World Thursday 6th
October 2011
vii
Turner-Warwick, Dame Margaret ‘Paternalism versus patient autonomy’ Journal of the Royal Society of
Medicine Supplement No 22 Volume 87 1994
Chapter 2
Obesity - The Size of the Problem
24

25. In the year 2000, the number of people in the world classified as obese became greater
than the number of people suffering from malnutrition. Obesity is replacing infectious
diseases and under-nutrition as the single most significant contributor to ill health within
populations worldwide. This extraordinary fact illustrates the extent of the problem, and
the reason governments around the world accept that obesity presents complex areas for
concern that need to be addressed as a component of public health care. Obesity is no
longer regarded as simply being a cosmetic problem affecting certain individuals, but an
epidemic threatening global well-being.
What is obesity?
Obesity can be defined as the accumulation of excess fat in the body that arises as the
result of an imbalance between energy intake and energy expenditure, over a prolonged
period of time.
Obesity is not a disorder with a single root cause. Body weight itself is determined by an
interaction between genetic, environmental and psychosocial factors that all impact on
energy intake and expenditure. Although genetic differences are undoubtedly important,
the vast rise in the level of obesity is best explained by the behavioural and
environmental changes that have resulted from technological advances.
How is obesity measured?
Worldwide health care providers agree that men with more than 25 percent body fat, and
women with more than 30 percent body fat are obese.
Measuring the exact amount of a person's body fat is not easy. The most accurate
measures are to weigh a person underwater, or to use an X-ray test known as Dual
Energy X-ray Absorptiometry (DEXA). These methods are not practical in most
situations, as specialist equipment is required, and this is normally available only in
certain research centres.i.
25

26. Figure 1: source Google images
The measurement of supplemental fat using a pair of calipers
Simpler methods exist to estimate a person’s body fat. One is to measure the thickness of
the layer of fat just under the skin at several places around the body. Another involves
sending a harmless amount of electricity through a person's body. Both methods are used
at health clubs and with commercial weight loss programmes. Results from these
methods, however, can be inaccurate if conducted by an inexperienced person, or if
conducted on someone who is severely obese.ii.
Because measuring a person's body fat is difficult, health care providers often rely on
other means to diagnose obesity. Weight-for-height tables, which have been used for
decades, usually have a range of acceptable weights for a person of a given height. One
problem with these tables is that there are many versions, all with different weight ranges.
Another problem is that they do not distinguish between excess fat and muscle. A
particularly muscular person may appear obese, according to the tables, when he or she is
not.
In recent years, the body mass index (BMI) has become the medical standard used to
measure overweight and obesity.
Body Mass Index
The Body Mass Index (BMI) is one of the most commonly used ways of estimating
whether a person is overweight and hence more likely to experience health problems than
someone with a healthy weight. It is also used to measure population prevalence of
overweight and obesity. It is used because, for most people, it correlates reasonably well
with their level of body fat. It is also a relatively easy, cheap and non-invasive method for
establishing weight status. However, BMI is only a proxy for body fatness. Other factors
26

27. such as fitness, ethnic origin and puberty can alter the relation between BMI and body
fatness and must be taken into consideration. Other measurements such as waist
circumference and skin thickness can be collected to indicate a person’s weight status or
body fatness. None of these is as widely used as BMI.iii.
What is BMI?
BMI is a summary measure of an individual’s height and weight, calculated by dividing a
person’s weight in kilograms by the square of their height in metres. Using a measure
such as BMI allows for a person’s weight to be standardised for their height, thus
enabling individuals of different heights to be compared.
Although BMI is used to classify individuals as obese or overweight, it is only a measure,
but does not explain the reasons for, the underlying problem of excess body fat. As a
person’s body fat increases, both their BMI and their future risk of obesity-related illness
also rise. There is, however, still some uncertainty about the exact nature of the
relationship between obesity and ill health, especially in case of children.
Why use BMI?
Excess body fat is known to be linked to both current and future morbidity. BMI is an
attractive measure because it is an easy, cheap and non-invasive means of assessing
excess body fat. True measures of body fat are impractical or expensive to use at
population level (e.g. bioelectrical impedance analysis or hydro densitometry), and
alternative measures for the amount of body fat are difficult to measure accurately and
consistently across large populations (e.g. skin fold thickness or waist circumference)
because they are open to errors of either implementation or interpretation.
BMI is widely used around the world and has been measured for some time, enabling
comparisons between areas, across population sub-groups and over time. Another
advantage of BMI as a practical measure of obesity is the availability of published
thresholds, and even to growth references to which children’s BMI can be compared.
BMI scales for children vary with age and sex, and this prevents the use of fixed
27

28. thresholds, as can be used with adults. Equivalent growth references do not exist for other
measures such as waist circumference.
What are the problems with its use?
BMI does, however, have some drawbacks. It is only a proxy indicator of body fatness;
factors such as fitness (muscle mass), ethnic origin and puberty can alter the relationship
between BMI and body fatness. Therefore, BMI may not be an accurate tool for assessing
weight status at an individual level, and other ways of measuring body composition may
be more useful and accurate.
BMI does not provide any indication of the distribution of body fat and does not fully
adjust for the effects of height or body shape, which may be particularly important when
comparing figures across ethnic groups.
These drawbacks are not necessarily very important at population level as these problems
even out when used across large numbers of people; in any case, many of these issues
also apply to the other anthropometric measures that might be used in place of BMI.
The widespread use of BMI and the resulting supporting literature mean that very
convincing arguments would be needed to move to routine use of any other index of
fatness.
How should we interpret different BMI levels?
BMI provides an indication of health status: a number of research studies have
demonstrated a relationship between raised BMI and increased risk of illness or death.
For Caucasian adults, aged 18 years and over, a person’s weight status is categorised
according to the level of their BMI as shown in the table below. The thresholds do not
change with age, and are the same for both men and women.
BMI (kg/m2) Weight Status
28

29. Below 18.5 Underweight
18.5 to 24.9 Healthy weight
25.0 and above Overweight
30.0 and above Obese
Research has shown that individuals whose BMI falls into the overweight or obese
categories are more likely to experience health problems associated with excess weight.
Although there is still some debate as to whether the same thresholds should be employed
for all individuals or whether, for example, different thresholds should be used with some
ethnic groups, these BMI thresholds are used worldwide.iv.
Is BMI interpreted the same way for children as it is for adults?
For children the picture is more complicated than it is for adults. The relationship
between fatness and BMI varies with age and sex, so definitions of obesity and
overweight need to take these two variables into account. Children’s BMI measures are
therefore usually compared to a growth reference in order to determine a child’s weight
status. Factors such as timing of puberty or ethnicity can cause additional difficulty when
classifying children’s BMI.
Internationally, a number of different child growth references and associated thresholds
are currently in use. In the UK, the UK90 Growth Reference is the most commonly used
adjustment tool; new UK growth charts using the WHO standard have recently been
introduced for children from birth to four years.v.
The evidence linking specific BMI thresholds to future morbidity and mortality is weaker
for children than for adults. There is however a body of evidence showing that those
children with a high BMI are also more likely to have a high BMI when they become
adults, and thus a raised risk of future health problems.
What other measures of fatness are available?
29

30. Some research suggests that other measures may provide a better indication of ‘fatness’
than BMI. Among these alternative measures are waist or hip circumference, body fat
ratio and skin fold thickness.
Although these measures may provide a better indication of an individual’s propensity to
future ill health, they are more difficult or expensive to collect in large numbers. To
measure body fat, body density or skin fold thickness requires special equipment and
measures such as hip or waist circumference are harder to record accurately and
consistently, especially when conducted on a large scale.
By contrast, as BMI relies solely on height and weight, most individuals will either know
or have access to the equipment to take these measurements. BMI can therefore be
measured and calculated with reasonable accuracy by members of the public in their own
home.
Furthermore, the precise thresholds used to classify individuals as obese, overweight or
underweight using other measures are not as well established as those for BMI, although
standard thresholds for waist circumference do exist. This means that, even if these
measures were routinely collected, it would not be easy to produce population prevalence
figures. There would also be a lack of published data with which to compare the resulting
statistics.
Increased BMI is correlated with increased values of other measures such as waist
circumference, body fat ratio and skin fold thickness. BMI provides a reasonable measure
of ‘fatness’, although other measures might provide a more accurate indication of any
individual’s weight status.
So what should we conclude?
BMI is an adequate measure for monitoring the underlying increase in health risk due to
excess weight at a population level. Although BMI is not a ‘gold standard’ measure of
overweight or obesity, its advantages in terms of ease of measurement, established cut
30

31. offs, and existing published statistics make it the only currently viable option for
producing high level summary figures at population level.
BMI uses a mathematical formula based on a person's height and weight. BMI equals
weight in kilograms divided by height in meters squared (BMI = kg/m2). A BMI of 25 to
29.9 indicates a person is overweight. A person with a BMI of 30 or higher is considered
obese.
Like the weight-to-height table, BMI does not show the difference between excess fat and
muscle. BMI, however, is closely associated with measures of body fat. It also predicts
the development of health problems related to excess weight. For these reasons, BMI is
widely used by health care providers.
Figure 2: Graph to show the calculation of BMI (height versus weight)
Source: National Institutes of Health
Identify the person’s weight from the horizontal axis, and read off against the person’s height on
the vertical axis. This reading will give an idea of the zone in which a person with these
measurements best fits.
31

32. Figure 3: Table to calculate BMI plotting height against weight
BMI is determined by reading a person’s height (along the vertical axis) against their weight in
pounds on the horizontal axis). At the point of intercept, read up for the BMI scale.
In what sense is obesity a problem?
Epidemiological research provides evidence to show that obesity is a key factor for a
wide range of chronic and potentially disabling diseases, including type 2 diabetes,
hypertension, coronary heart disease, stroke, osteoarthritis, some cancers, respiratory
dysfunction, gall bladder disease and metabolic syndrome. In addition, morbid obesity
may have serious implications for day-to-day functioning.
In recognizing the rapid expansion of the problem of obesity worldwide, the World
Health Organization is prioritizing studies to fully identify the risks, and also the likely
32

33. causes of obesity, in order to issue informed advice to governments and health
institutions throughout the world as to how best to tackle the problem at a national level.
Key Facts
• The problem of obesity, worldwide, has more than doubled since 1980.
• In 2008, 1.5 billion adults, 20 and older, were overweight. Of these over 200
million men and nearly 300 million women were obese.
• 65% of the world's population lives in countries where overweight and obesity
kills more people than underweight.
• Overall, more than one in ten of the world’s adult population is obese.
• Nearly 43 million children under the age of five were overweight in 2010.
• Obesity is preventable.
Facts about overweight and obesity
Overweight and obesity rank fifth in terms of responsibility for global deaths. At least 2.8
million adults die each year as a result of being overweight or obese. In addition, 44% of
the diabetes burden, 23% of the ischemic heart disease burden and between 7% and 41%
of certain cancer burdens are attributable to overweight and obesity.
Raised BMI is a major risk factor for non-communicable diseases such as cardiovascular
diseases (mainly heart disease and stroke), which were the leading cause of death in
2008, diabetes, musculoskeletal disorders (especially osteoarthritis - a highly disabling
degenerative disease of the joints), and some cancers (endometrial, breast, and colon).
The risk for these non-communicable diseases increases as a person’s BMI increases.
In 2010, around 43 million children under five were overweight. Once considered a high-
income country problem, overweight and obesity are now on the rise in low- and middle-
33

34. income countries, particularly in urban settings. Close to 35 million overweight children
are living in developing countries and 8 million in developed countries.
Childhood obesity is associated with a higher chance of obesity, premature death and
disability in adulthood. In addition to increased future risks, obese children experience
breathing difficulties, an increased risk of fractures, hypertension, and early markers of
cardiovascular disease, insulin resistance and psychological damage.
Overweight and obesity are linked to more deaths worldwide than underweight. For
example, 65% of the world's population live in countries where overweight and obesity
kill more people than underweight (this includes all high-income and most middle-
income countries).
What causes obesity and overweight?
The fundamental cause of obesity and overweight is an energy imbalance between
calories consumed and calories expended. Globally there has been an increased intake of
energy-dense foods that are high in fat, salt and sugars but low in vitamins, minerals and
other micronutrients; and a decrease in physical activity due to the increasingly sedentary
nature of many forms of work, changing modes of transportation, and increasing
urbanization.
Changes in dietary and physical activity patterns are often the result of environmental and
societal changes associated with development and a lack of supportive policies in sectors
such as health, transport, urban planning, environment, food processing, and education.
Facing a double burden of disease
Many low- and middle-income countries are now facing a "double burden" of disease.
While they continue to deal with the problems of infectious disease and under-nutrition,
they are experiencing a rapid upsurge in non-communicable disease risk factors such as
34

35. obesity and overweight, particularly in urban settings. It is not uncommon to find under-
nutrition and obesity existing side-by-side within the same country, the same community
and the same household.
Children in low- and middle-income countries are more vulnerable to inadequate pre-
natal, infant and young child nutrition. At the same time, they are exposed to high-fat,
high-sugar, high-salt, energy-dense, micronutrient-poor foods, which tend to be lower in
cost. These dietary patterns, in conjunction with low levels of physical activity, result in
sharp increases in childhood obesity while under nutrition issues remain unsolved.
How can overweight and obesity be reduced?
Overweight and obesity, as well as their related non-communicable diseases, are largely
preventable. Supportive environments and communities are fundamental in shaping
people’s choices, making choice of healthier foods and regular physical activity the
easiest choice, thus diminishing the likelihood of obesity.
At the individual level, people can limit energy intake from total fats, increase
consumption of fruit and vegetables, as well as legumes, whole grains and nuts, limit the
intake of sugars, engage in regular physical activity, and achieve energy balance and a
healthy weight.
Individual responsibility can only have its full effect where people have access to a
healthy lifestyle. Therefore, at the societal level it is important to support individuals in
following the recommendations outlined above, through sustained political commitment
and the collaboration of both public and private stakeholders. It is also important to take
regular physical activity and healthier dietary patterns affordable and easily accessible to
all, especially the poorest individuals.
The food industry can play a significant role in promoting healthy diets by reducing the
fat, sugar and salt content of processed foods, ensuring that healthy and nutritious choices
35

36. are available and affordable to all consumers, practicing responsible marketing, and
ensuring the availability of healthy food choices, and supporting regular physical activity
practice in the workplace.
The World Health Organization 2008-2013 Action Plan
The World Health Organization has developed their ‘2008-2013 Action Plan for the
Global Strategy for the Prevention and Control of Noncommunicable Diseases’ to help
the millions who are already affected cope with these lifelong illnesses, and prevent
secondary complications.
The six objectives of the 2008-2013 Action Plan are:
• To raise the priority accorded to noncommunicable disease in development work at
global and national levels, and to integrate prevention and control of such diseases into
policies across all government departments
• To establish and strengthen national policies and plans for the prevention and control of
noncommunicable diseases
• To promote interventions to reduce the main shared modifiable risk factors for
noncommunicable diseases: tobacco use, unhealthy diets, physical inactivity and harmful
use of alcohol
• To promote research for the prevention and control of noncommunicable diseases
• To promote partnerships for the prevention and control of noncommunicable diseases
• To monitor noncommunicable diseases and their determinants and evaluate progress at
the national, regional and global levels.
WHO recognizes the unique position it is in compared to other organizations, and
actively seeks to play a leadership role in promoting global action against
noncommunicable diseases, including obesity.
36

37. Can intervention be justified in the case of obesity?
There is little argument that affording the population a greater measure of health and well
being has enormous consequences, not just for the individual, but for the whole of
society. Health is fundamentally important because of its inherent value and its
contribution to human functioning. Each individual understands, at least intuitively, why
health is vital to well being. Those with physical and mental good health socialize, work
and engage in family and social activities in a way that can bring creativity and
happiness. Where a population has good health it is more likely that social organization
and economic structures have strong roots, and in this sense good health is critical to
public welfare. The autonomous right of individuals to make their own decisions, and
thereafter to accept the consequences of their actions and activities is central to the
concepts of liberty and freedom, but it could also be argued that, in exchange for an
element of personal freedom, well directed paternalism may promote a greater freedom
for many.
i.
WHO World Health Organization
ii.
National Institutes of Health, Understanding Adult Obesity
iii.
Swanson, Dr K and Frost, M: ‘Lightening the load: tackling overweight and obesity: a toolkit for
developing local strategies to tackle overweight and obesity in children and adults.’ National Heart
Foundation in association with the Faculty of Public Health and the Department of Health,[Online]
London (2007) Department of Health publications www.dh.gov.uk/publications
iv.
Royal College of Paediatrics and Child Health, World Health Organisation, Department of
Health, 2009. ‘UK-WHO Growth Charts: Early Years’. [Online] London: Department of Health.
Available at: http://www.rcpch.ac.uk/Research/UK-WHO-Growth-Charts
37

38. v.
Cross Government Obesity Unit ‘The National Child Measurement Programme Guidance for
PCTs: 2008/09 school year.’ Department of Health 4th
Available at:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/DH_086724
Chapter 3
Obesity – A Global Health Problem for Children and Adults
Despite incredible improvements in health since 1950, there are still a number of
challenges which should have been easy to solve.
• One billion people worldwide lack health care systems.
• 36 million deaths per annum are caused by noncommunicable diseases such as
cardiovascular disease, cancer, diabetes and chronic lung disease. This is almost two-
thirds of the estimated 56 million deaths each year worldwide.
• Cardiovascular diseases are the number one group of conditions causing death annually.
• Over 7.5 million children under the age of 5 die from malnutrition and mostly
preventable diseases each year.
• In 2008, some 6.7 million people died of infectious diseases alone.
• AIDS/HIV has spread rapidly. UNAIDS estimates for 2008 that there are roughly 33.4
million living with HIV, 2.7 million new infections of HIV and 2 million deaths from
AIDS.
• Tuberculosis kills 1.7 million people each year with 9.4 million new cases a year.
• 1.6 million people still die from pneumococcal diseases every year, making it the number
one vaccine preventable cause of death worldwide.
• Malaria causes some 225 million acute illnesses and over 780,000 deaths annually.
• 164,000 people, mostly children under 5, died from measles in 2008 even though
effective immunization costs less than I US Dollar and has been available for more than
40 years.
Though there may be many reasons why an individual should become obese, it is also
true to say that obesity is a preventable condition, and the fact that the level of obesity has
reached epidemic levels worldwide is shocking.
38

39. Obesity typically results from overeating (especially an unhealthy diet) and lack of
enough exercise. In the modern world with increasingly cheap, high calorie, prepared
foods that are high in salt, sugars or fat, combined with an increasingly sedentary
lifestyle, increasing urbanization and changing modes of transportation, it is no wonder
that obesity has increased so rapidly. The number of people overweight or obese is now
greater than the number of people suffering from hunger around the world. Obese people
were thought to be mainly from richer countries or wealthier segments of society, but
poor people can also suffer as the food industry supplies cheaper food of poorer quality.
Environmental, societal and life style factors all have an impact on obesity and health,
and while individuals are responsible for their choices, others such as the food industry
and government, are part of the problem, and the solution.
Obesity and health
Being obese or overweight as an adult can lead to an increase in the risk of developing a
range of serious diseases. In 2008 the Department of Health updated the Wanless report,
‘Securing good health for the whole population’ and linked obesity to smoking in terms
of associated burden as a determinant of future health. A recent comprehensive review
report by the National Health Foundation found that body mass index was a strong
predictor of mortality among adults. A general moderate level of obesity of BMI 30-
35kg/m² was found to reduce life expectancy by an average of three years, whereas
morbid obesity of BMI 40-50 kg/m2
was found to reduce life expectancy by 8 till 10
years. This timeframe of 8 to 10 year’s loss of life is equivalent to the effects of being a
lifelong smoker.i.
The fact is that adult obesity is reducing life expectancy by an average of three years, or
eight to ten years in the case of severe obesity (BMI over 40). Though it seems to be that
around 8% of annual death in Europe at least one in13 have been attributed to overweight
and obesity. The costs to the taxpayer are significant. Obesity and overweight patients
39

40. are forecast to cost the nation £50 billion - half the entire NHS budget for a year - by
2050 if the trend continues unchecked.ii.
What does obesity do to your health?
Obesity has a significant effect on an individual’s health. The visible effects of obesity on
the body are clear; his is because of the increased mass of fatty tissue and changes at
cellular and metabolic level due to increased production of various productions by
enlarged fat cells. Due to the physical change of the body, tremendous pressure is put on
the musculoskeletal, which increases the pressure on the joints. Due to a build up of fatty
tissue around the airways, sleep apnoea can develop, which has a direct influence on the
metabolic system of the body and cardiovascular system. In addition, the psychological
and social stigmas associated with obesity are tremendous.
The greatest danger associated with obesity is not actually visible. The invisible changes,
such as an increase of fat in the blood, and a change of response of insulin comprise the
greatest jeopardy.iv.
The circulatory system is very vulnerable when adults are obese. Because with and
increased BMI the risk of hypertension is there. This means that the risk of coronary heart
disease and stroke are substantially increasing. The prevalence of thrombosis and
pulmonary embolism is increasing also.
The metabolic and endocrine systems are under risk when adults are obese, because the
risk of type 2 diabetes is substantially raised. Studies have suggested that excess body fat
underlies almost two third of cases of diabetes in men and three quarters of cases in
woman. At this moment in time an estimated 285 million people, corresponding to 6.4%
of the world's adult population, will suffer from diabetes in 2012. The number is expected
to grow to 438 million by 2030, corresponding to 7.8% of the adult population. The
burden in developing countries, with limited funding in the health care system, is due to
40

41. be extremely high. With obesity also causing hypertension, there is a significant risk of
dyslipidemia because of the high total cholesterol or high levels of triglycerides.v.
This
contributes to the risk of circulatory disease that may in turn lead to the development of
atherosclerosis, because atherosclerosis will change the linings of the arteries. Metabolic
syndrome is a combination of disorders including high blood glucose, high blood
pressure and high cholesterol and triglyceride levels. This is very common in obese
individuals and is associated with significant risk of coronary heart disease and Type 2
diabetes.vi.
Obesity, cancer and other illnesses
Being obese increases the risk of certain cancers. The World Health Organization states
‘Overweight and obesity are the most important known avoidable causes of cancer after
tobacco’. Current levels of obesity could lead to approximately 19,000 cases of cancer
each year, and because the number of people defined as obese is rising, so the number of
people suffering from cancer will also rise.vii.
Obesity increases the risk of breast cancer in women after menopause. Scientists have
estimated that anywhere between 7% and 15% of breast cancer cases in developed
countries are caused by cancer. Cancer Research UK funded two large studies, a study
on postmenopausal breast cancer, the EPIC study, and the Million Woman Study. The
studies found that obese women have a 30% higher risk of postmenopausal breast cancer
than women with a healthy weight. Although obesity does not increase the risk of breast
cancer in women before their menopause,viii.
putting on weight over time could increase
the risk of breast cancer.
Obesity appears to increase the risk of bowl cancer. When BMI is used to measure body
fat, studies tend to find that only obese men have a higher risk of bowel cancer. However
when researchers use waist circumferences or waist-to-hip ratios, both obese men and
woman have higher risk of bowel cancer.ix.
This suggests that for woman at least, fat
around the stomach is more of a problem than fat elsewhere on the bodyx.
.
41

42. There appears a strong correlation between obesity and cancer of the womb. A study of
one million woman estimated that up to half of all cases of womb cancer in the UK are
caused by being overweight.xi.
Obesity can even increase the risk of oesophageal cancer.
It seems to be that the rate of oesophageal adenocarcinoma in white UK men is among
the highest in the world and rising. Studies suggested that this type of cancer may be
becoming more common because of rising levels of obesity.xii.
Obesity is linked to increases in many other types of cancer. Obesity can change hormone
levels, which can increase the risk of cancer, with a greater likelihood of risk when the
levels of oestrogen and insulin are changing. Keeping a healthy weight reduces the risk of
cancer and losing weight may further reduce these risks.
Obesity has an influence on reproductive and urological problems. Women who are
obese can have a greater risk of menstrual abnormalities, polycystic ovarian syndrome
and infertility.xiii.
For men with obesity there is a higher risk of erectile dysfunction. Even
maternal obesity creates an increased risk for both the mother and the child, during and
after pregnancy. Adult obesity can cause gastrointestinal and liver disease, non-alcohol
fatty liver disease, an increased risk of gastro-oesophageal reflux, and can increase the
likelihood of gallstones developing.xiv.
Obesity in adults can cause psychological and
social problems; overweight and obese people may suffer from stress, and low self-
esteem which can cause depression and a reduced libido.
Childhood Obesity
Childhood obesity is a universal public health problem, and one of the most serious
public health challenges of the 21st
century. The level of childhood obesity is increasing
at an alarming ratexv.
; this problem is global, progressively affecting many low and
middle income countries, particularly those living in urban settings. In worldwide terms,
the number of overweight children under the age of five was estimated to be over 42
42

43. million, with close to 35 million of these living in developing countries. It is extremely
likely that overweight and obese children will maintain the condition of obesity into
adulthood, so the ethical issue is raised as to who is responsible. Children are not legally
responsible for their own condition; it is the role of parents and guardians to protect the
child and to take responsibility for their physical well being. Children cannot be held
responsible for the adversity and deprivation that may harm them, as they are incapable
of changing their circumstances. Children are therefore dependent on their
environmental structures and on the social habits within the family.
Obese children are more likely to develop non-communicable diseases such as diabetes
and cardiovascular disease at a young age. Nevertheless, the condition of overweight or
obesity is largely preventable, so, therefore, must be the preventable diseases. The
prevention of childhood obesity, therefore, requires to be rated with the highest priority,
according to the World Health Organization.
Why the focus should be on children
To tackle the obesity epidemic the focus must be on children. Some would consider this
as social justice, as children are vulnerable and society has the obligation to protect them
in the sense that children depend on others for their health and safety. Others would
argue that the focus should be on children because they are the future citizens, and will be
need to productive citizens supporting society. If children become the creative and
constructive citizens of the future, the entire community must take a share in the
responsibility for their health care. Prevention of obesity through social and behavioural
intervention would seem a logical process for tackling this epidemic, for by taking action
in infancy and childhood, it may be possible to cut down on obesity levels in adulthood.
The medical condition of childhood obesity
Obese children are more likely to experience a wide range of psychological and physical
ailments, including low self esteem, depression, anxiety problems with high risk
43

44. behaviour, type 1 and 2 diabetes, cardiovascular conditions, asthma and sleep disordered
breathing. Research shows that between 40% to 77% of obese children stay obese as an
adult, which in turn can lead to further health risks such as heart disease, stroke,
osteoporosis, lower body disability, some types of cancer and premature mortality in
general.xvi.
Early life obesity can produce permanent changes in biological process from the body,
such as energy metabolism and neuroendocrine functioning. Diet habits and activity
patterns learned during adolescence often persists into adulthood. Losing weight can be
very difficult for the obese person, yet the loss of weight does not completely eliminate
the health problems that might have already been established.
Tackling the issue
Pediatricians have long been concerned about the way food producers have used media
campaigns to induce children to desire high calorie, low nutrition ‘junk food’. Campaigns
full of colour, familiar characters and catchy jingles have been effectively designed by
marketing companies to catch the imagination of young children, and making them
extremely successful methods of promotion. In the UK, advertising foods and drinks that
are high in salt, sugar and fat has been banned before the 9 o’clock watershed. In turn,
schools are promoting healthy living in a thorough way, with knowledge of food and
nutrition recognized as a high priority within the National Curriculum (of England and
Wales) and with the education authorities in Scotland taking a particularly rigorous route.
Local education authorities across the UK have set rules governing the snacks which can
be sold within schools, and guidelines on healthy lunches available to pupils and staff
alike. Fresh fruit is given free to school children in Scotland in Years 1, 2 and 3
(corresponding to Key Stage 1, or infant classes in England).
The London Borough of Waltham Forest council worked closely with Professor Jack
Winkler, Director of the Nutrition Policy Unit at the London Metropolitan University,
particularly with reference to his research on what he refers to as the ‘school fringe’. His
44

45. studies concentrated on the food shops that were located close to secondary schools.xvii.
He found that the nutritional quality of food available was generally poor, that a
significant proportion of the students’ fat, salt and sugar came from these outlets, and that
some shops were using student offers to enhance the volume of custom. Waltham Forest
council used the research of Professor Winkler, as well as existing policy guidance, to
include a ‘proximity to schools, youth facilities and parks’ as a test in dealing with
planning and licensing applications. The council use the ruling that planning and
licensing applications will be resisted if the proposal falls within 400 metres of any of
these facilities. The policy aims to limit the opportunities that young people have to eat
‘fast food’, thus reducing obesity. Waltham Forest council was the first council to turn
down applications from businesses wanted to establish hot take away food shops near
schools, or facilities for young people. Following this, 15 other local authorities have
implemented the plan to ban the opening of new business near to schools.
The question that everyone wants the answer to is, of course, will this planning policy
reduce levels of unhealthy eating in the borough? Although the borough has recorded a
very small fall in levels of childhood obesity, the causal link is very hard to make. Ian
Butcher, Local Development Framework Project Manager at Waltham Forest is cautious
in stating: ‘It’s early days – we can’t prove or disprove any link between reduction in
obesity levels and planning policy. However, the publicity this issue generated locally
has maybe made people think more about what they eat. The council is keen to combat
health inequalities and there are a number of initiatives and proposals coming forward.’
Paternalistic measures to combat childhood obesity
If the collective benefits are high, and the individual burdens are low, the political
community should be open to the idea of paternalism to prevent or improve on harms in
the population. Where the harm can be identified in relation to children, pro-autonomy
arguments that the individual knows best about their interests and preferences are easier
to challenge. As personal behaviour is heavily influenced and not simply a matter of free
will, it can be argued that government regulation is sometimes necessary to protect the
45

46. individual’s health or safety. Regulation to protect people against their own temptations
is clearly paternalistic, but in the field of health care, paternalism is best viewed in terms
of protecting whole groups, such as the young, or indeed, the whole of society.
i.
Zimmermann E, Holst C, Sorensen TI Morbidity, including fatal morbidity, throughout life in men
entering adult life as obese. Institute of Preventive Medicine, Copenhagen University Hospital,
Copenhagen, Denmark. ez@ipm.regionh.dk
ii.
ten Have M, de Beaufort ID, Teixeira PJ, Mackenbach JP, van der Heide A. Ethics and prevention of
overweight and obesity: an inventory. 2011 Sep;12(9):669-79. doi: 10.1111/j.1467-789X.2011.00880.x.
Epub 2011 May 4. Department of Medical Ethics, Erasmus Medical Centre, Rotterdam, the Netherlands.
m.tenhave@erasmusmc.nl
iv.
Al Lawati NM; Patel SR and Ayas NT; ‘Epidemiology, risk factore and consequences of obstructive
sleep apnea and short sleep duration’. Progress in Cardiovascular Diseases. 2009 51 (4):285-293
v.
The European Atherosclerosis Society http://www.eas-society.org/recipe-study.aspx
vi.
The Metabolic syndrome, http://www.weightlossresources.co.uk/body_weight/metabolic_syndrome.htm
vii.
Bianchini, F, Kaaks H, and H. Vainio, ‘Overweight, obesity and cancer risk’, Lancet Oncol, 2002.3
(9):P.565-74. PubMed
viii.
Macinnis, R, et al, ‘Body European size and breast cancer risk: findings from the European Prospective
investigation into Cancer and Nutrition’ (epic): Int J Cancer, 2004. 111: p. 762-71 PubMed
ix.
Pischon, T, et al, ‘Body mass and Colorectal Cancer Risk in the NIH’-AARP Cohort. Am J Epidemiol,
2007. PubMed
x.
Dai, Z, Y.C.Xu, and L. Niu, ‘Obesity and colorectal cancer risk: A meta-analysis of cohort studies’ World
J. Gastroenterol, 2007. 13(31):p.4199-206. PubMed
xi.
Reeves, G.K. et al, ‘Body-mass index and incidence of cancer: a systematic review and meta-analysis of
prospective observation studies’. Lancet 2008.371(569-578) Pub-Med
xii.
Kubo,A. and Corley, D A: ‘Body Mass index, height and risk of adenocarcinoma of the oesophagus and
gastric cardia: a prospective cohort study’. Gut, 2007. PubMed
xiii
Pasquali R. Pelusi C. Genghini S, Carcciari M, Gambineri A. ‘Obesity and reproductive disorders in
woman.’ Hum reprod update. 2003:
xiv.
Prospective studies collaboration. ‘Body mass index and cause-specific mortality in 900 000 adults:
collaborative analyses of 57 prospective studies’. Lancet 2009; 373:1083-96
xv.
‘Preventing Childhood Obesity: Health In Balance’ Institute of Medicine Washington DC National
Academic Press 2005 at22
xvi.
Freedman, D S et al ‘Relationship of Childhood Obesity to Coronary Heart Disease Risk Factors in
Adulthood: The Bolagusa Heart Study’ Pediatrics 2001L712-18
xvii.
Sinclair, S and Winker J ‘The School Fringe: What pupils buy and eat from shops surrounding
secondary schools’ London Metropolitan University 7 July 2008
46

47. Chapter Four
Why Are People Obese?
Obesity and diet in history
The demographics of obesity have changed over the last two centuries. The origins of
obesity can be traced back 30,000 years ago to our prehistoric ancestors. At that time the
rule was ‘survival of the fittest’. Humans who stored energy in the most efficient way
would survive the hard life. In fighting obesity, in some senses we are flying back in
time, creating conflict between evolution and instinct, consciously countermanding the
urge to eat for survival, and to be as inactive as possible in order to conserve energy.
Prehistoric statuettes from 30,000 years ago show obese woman, such as the famous
Venus of Willendorf, portraying abdominally obese woman. The function of these
statuettes of obese woman is not known. They may be fertility symbols, though,
ironically, the medical world now acknowledges that obesity can cause infertility, not
improve it!
Moses was one of the first people in history to set out a diet, His recommendation were
Jewish bread, wine, milk and honey, meat from the flesh of quadrupeds that divide the
hoof and chew the cud, meat from the flesh of feathered birds, with only a few
exceptions, and fish that have fins and scale; a balanced diet with purpose and variety.
Recognizing obesity as a medical phenomenon has been slow, because the overweight
condition has been exceptional and has therefore not been studied in any great detail. It is
important to consider that in some cultures obesity has been prized as an indication of
status and wealth, as only the richest could afford to put on weight. Nevertheless, the
Ancient Greeks were the first to realize the danger associated with this disease.
Hippocrates understood that obesity led to infertility and early death. He wrote that ‘in
the beginning man made us eat the same food as the beast, and it was the many
distempers brought upon him by such indigestible aliment, which taught him, in length of
47

48. time, to find a different diet, better adapted to his constitution, teaching that the
spontaneous and crude productions of earth must have shortened rather than lengthened
their live’.
Changes in the modern world and contemporary society
People are obese when they have a fundamental energy imbalance; obesity will occur
where energy intake is not matched with physical activity. In general terms, people are
eating much more than they used to do. During the last century a proportion of people in
the developed countries could have been identified as being obese, but in the space of a
very short time period obesity has become a pandemic problem, i.e. the trend has spread
worldwide. Even in countries with a high level of poverty, a proportion of the population
is becoming obese.
Lifestyles have radically changed over time, and it is true to say that for most people in
the developed world, life is more sedentary than was the case fifty or more years ago.
Today’s world is full of electronic gadgetry that makes life easier, simpler, and more
pleasurable, from televisions with remote controls, computers, washing machines,
vacuum cleaners, and dishwashers. People were more physically active, walking to work,
school, the shops, and walking to bus stops and train stations where public transport was
used.
Social life was embedded outside the home, with people more connected to the
community and therefore for more enhanced to social events. Children would play on the
street, and this was their social bonding opportunity of the day, rather than sitting chatting
on Facebook as a way of communicating with their friends.
Life has drastically changed over the past fifty years, with some children being driven to
school, shopping done in often large out of town shopping facilities that has to be done
by care, and walking less in their day to day activities. More people are working full
time, including women in particular, meaning that for many there is less time to spend on
planning family menus, or preparing meals. Families increasingly do not eat together, so
48

49. eating habits concerning the way food is consumed, the amount of food consumed, and
the balance of food, is less closely monitored than it can be when a family sits together as
a social unit. Rather than eating at defined mealtimes, people are eating at irregular
intervals. It may be said that children are taking an increasing role in choosing the food
they consume, rather than a parent or responsible adult making such decisions. Adults are
working longer hours, and spending less time both cooking, and exercising. Globally,
there is a significant difference in the way people are spending their free time. Education
can help to make people aware of the problems that arise when there is an imbalance
between energy consumption and energy outlay, and low levels of physical exercise.
What are the factors that cause obesity?
Obesity will occur when a person consumes more calories from food than they are
burning through movement. Humans need calories to sustain life and be physically
active. However to maintain weight there needs to be a balance between energy
consumed and energy used. When a person consumes more calories than they burn, the
energy balance may lead to weight gain and obesity. The imbalance between calories in
and calories out may differ from one person to another. Genetics, the environmental, and
other factors may play a part. Even hormones can have an effect on a person’s body
weight, because physical activity has an effect on hormones, and hormones have an effect
how the body deals with food. This is exemplified by the relationship between insulin
and exercise, i.e. physical activity has a beneficial effect on insulin levels by keeping
insulin levels stable and preventing quick weight gain.
Genetic Factors
Some people think that obesity ‘runs in the family’; they are suggesting that there is a
genetic component. It is of course true that families who share a diet and lifestyle habits
that contribute to obesity will be susceptible as a whole. To realistically and, for the sake
of studies, academically, separate lifestyle influences and genetics, is particularly
difficult. Obesity can be linked to heredity; science shows us that. However, the way
49

50. people live in a group and the way they have maintained their food habits for generations
is not inherited.
Environmental and Social Factors
Environments certainly influence levels of obesity. In the United States of America, and
in some countries in Europe, notably the United Kingdom, levels of obesity have
escalated exponentially, though of course the genetic make up of the population has not.
What has changed is the environment. Lifestyle behaviours include what a person eats,
and their level of physical activity. The habit of eating large cheap meals that have a high
fat calorific value, especially those from outlets such as Macdonalds and KFC, puts
convenience ahead of nutrition, and encourages the consumption of large portions.
Where these types of outlets are commonplace they are often extremely popular due to
effective advertising, their cheap prices, and because of the establishment of new eating
habits. The consumption of such foods can be problematical when levels of physical
activity decline.
The modern world sees people travelling much further distances to work, making it less
likely that individuals may take the option of walking or cycling. The use of public
transport means that some level of physical activity normally takes place, if only to walk
to bus stops or train stations, though people will continue to drive their cars where the use
of public transport is not a viable option.
Environment also includes the world around us—our access to places to walk and the
option of purchasing healthy food, for example. Today, more people drive instead of
walking, live in neighborhoods without pavements, tend to eat out or order a ‘take away’
meal instead of cooking, or use vending machines with high-calorie, high-fat snacks at
their workplace. Our environment often does not support healthy habits.
In addition, social factors including poverty and a lower level of education have been
linked to obesity. One reason for this may be that high-calorie processed foods cost less
50

51. and are easier to find and prepare than healthier foods, such as fresh vegetables and fruits.
Other reasons may include inadequate access to safe recreation places or the cost of gym
membership, limiting opportunities for physical activity. Although it is true that the link
between low socioeconomic status and obesity has not been conclusively established,
studies have shown that lower levels of education, unemployment and poverty are
inextricably linked, though recent research has found that obesity is also increasing
among high-income groups.
Cultural Factors
An individual’s cultural background may also play a role in their weight. For instance,
foods specific to certain cultures that are prepared with a large amount of fat or salt may
hamper weight-loss efforts. Similarly, family gatherings offering large amounts of food
may make it difficult to pay attention to proper portion control and serving sizes. Lastly,
where an individual’s food intake changes significantly, such as may occur as the result
of an expansion of calorie rich fast food outlets worldwide, individuals may have
difficulty physiologically adjusting to ingredients that they may not be familiar with.
Whereas genetic make up cannot change, individuals, groups and indeed whole societies
can change eating habits, levels of physical activity, and can work towards changing
environmental factors. Suggestions that have been put forward and tested successfully as
methods of reducing weight gain, include:
 Learning to choose sensible portions of nutritious meals that are lower in fat.
 Learning healthier ways to make favourite foods.
 Learning to recognise and control environmental cues that may encourage a person to
eat even when they are not hungry.
 Having a healthy snack an hour or two before a social gathering to prevent
overeating. Mingle and talk between bites to prevent eating too much too quickly.
51

52.  Engaging in at least 30 minutes of moderate-intensity physical activity (like brisk
walking) on most, preferably all, days of the week.
 Taking a walk instead of watching television.
 Eating meals and snacks at a table, not in front of the television.
 Paying attention to what is being eaten, determine to eat at regular mealtimes, and
eating when actually hungry, rather than due to boredom, depression or loneliness.
 Keeping records of daily food intake and physical activity.
Other Causes of Obesity
People become obese for several reasons, and chief amongst these are consuming too
many calories and leading a sedentary lifestyle. These factors are common in society, and
determine the level of obesity among the vast majority. On an individual basis, other
factors which affect the prevalence of obesity are:
Illnesses
Some illnesses may lead to or are associated with weight gain or obesity. These include:
 Hypothyroidism: a condition in which the thyroid gland fails to produce enough
thyroid hormone. It often results in a lowered metabolic rate, and loss of vigour.
 Cushing’s syndrome: a hormonal disorder caused by prolonged exposure of the
body’s tissues to high levels of the hormone cortisol. Symptoms vary, but most
people have upper body obesity, rounded face, increased fat around the neck, and
thinning arms and legs.
 Polycystic ovary syndrome: a condition characterized by high levels of androgens
(male hormone), irregular or missed menstrual cycles, and in some cases, multiple
small cysts in the ovaries, with these cysts being fluid filled sacks.
52

53. A doctor can determine whether there are underlying medical conditions that are causing
weight gain or making weight loss difficult.
Drugs and medication
Certain drugs such as steroids, some antidepressants, and some medications for
psychiatric conditions or seizure disorders may cause weight gain. These drugs may slow
the rate at which the body burns calories, stimulate appetite, or cause the body to hold on
to extra water.i
Insufficient sleep
Not getting enough sleep doubles the risk of obesity, according to research carried out at
the Warwick Medical School.ii
This risk applies to both adults and children, according to
research led by Professor Cappuccio. His team found evidence that sleep deprivation
significantly increased the risk of obesity in both adults and children. Cappuccio stated,
‘The ‘epidemic’ of obesity is paralleled by a ‘silent epidemic’ of reduced sleep duration,
with short sleep duration linked to obesity both in adults and in children.’ He found
evidence of trends detectable in adults as well as with children as young as 5 years.
His explanation was that sleep deprivation might lead to obesity through increased
appetite as a result of hormonal changes. A lack of sleep triggers the production of
Ghrelin, a hormone that stimulates appetite. Lack of sleep also results in your body
producing less Leptin, a hormone that suppresses appetite.
Whereas a lack of sleep may contribute to obesity, recent studies suggest that people with
sleep problems may gain weight over time. On the other hand, obesity may contribute to
sleep problems due to medical conditions such as sleep apnea, where a person briefly
stops breathing at multiple times during the night.iii
Endocrine disruptors (foods that interfere with lipid metabolism)
53

54. The rise in America’s obesity rates parallel the rise in consumption of high-fructose corn
syrup, which occurred as manufacturers replaced costlier cane sugar (sucrose) in drinks
and snacks with high-fructose corn syrup. America’s consumption of HFCS increased by
more than 1000% between 1970 and 1990, far exceeding the changes in any other food or
food group. A team from the University of Barcelona published a study providing clues
to the molecular mechanism through which fructose may alter lipid energy metabolism,
and cause fatty liver and metabolic syndrome.iv
Fructose is mainly metabolized in the
liver, the target organ of the metabolic alterations caused by the consumption of this
sugar. In this study, rats receiving fructose containing beverages presented pathology
similar to metabolic syndrome, which in the short term causes lipid accumulation
(hypertriglyceridemia) and fatty liver, and eventually leading to hypertension, resistance
to insulin, diabetes and obesity.
Poorly balanced diets and the lack of physical exercise are key factors in the increase of
obesity, and other metabolic diseases in modern societies. In epidemiological studies on
humans, the effect of the intake of fructose seemed to be more intense for women.v
Although there appears to be a consensus on the negative effects of fructose-sweetened
beverages, there is still some debate over the effects of fructose versus high fructose corn
syrup.
Smoking
Smoking is known to suppress the appetite, and quitting smoking is often relates to
weight gain. According to the National Institutes of Health, USA, ‘Not everyone gain
weight when they stop smoking. Among people who do, the average weight gain is
between 6 to 8 pounds, with roughly 10% of those who stop smoking gaining a large
amount of weight (30 pounds or more)’
Medications that cause a patient to put on weight
54

55. According to research outlined in an article in the Annals of Pharmacotherapy,vi
some
medications cause weight gain. “Clinically significant weight gain is associated with
some commonly prescribed medicines. There is wide inter-individual variation in
response and variation of the degree of weight gain within drug classes. Where possible,
alternative therapy should be selected, especially for individuals predisposed to
overweight and obesity.”
Choice and responsibility
It is commonplace for people to be held as being responsible for the foreseeable
consequences of their choices and actions. This way of thinking would seem to indicate
that the obese are responsible for being obese, and for the health consequences of their
obesity. As has been outlined in this chapter, there are, however, a number of
complications in making a claim of personal responsibility.
It is not entirely clear that lifestyle is actually a matter of conscious choice, and there are
large elements of socialization that are involved in acquiring and maintaining a given
lifestyle. To break with one’s lifestyle may alter an entire range of socioeconomic
factors. In fact, the lifestyle in question may be viewed as being unhealthy, but may
contribute significantly to the person’s sense of well being. Individuals may simply like
to live the way they do, and may see possible dangers to their health in the future as being
a reasonable trade off for the current pleasure and well being. Even if it could be
established that the obese were obese because of conscious actions on their part, should
society treat them differently, or would this be seen as being unjust?
If society concentrates on the issue of choice and responsibility it will be extremely
difficult to tackle the problem of obesity, as it would be hard to argue that expensive
large scale interventions should be paid for by those who are not obese. In this sense it is
ethically problematical to pursue policies that emphasize choice and responsibility. All
interventions have costs, both ethical and economic, and it is only where evidence exists
55

56. outlining their effectiveness, and it would be possible to make a judgment on whether the
benefits outweigh the costs.
i
WIN Weight Control Information Network ’Do You Know the Heath Risks of Being Overweight?’
National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) US Department of Health and
Human Services, National Institutes of Health NIH Publication No 07-4098 November 2004 Updated
December 2007
ii
Cappuccio, Prof F ’Sleep deprivation doubles risks of obesity in both children and adults’ University of
Warwick Medical School Press Release PR53 PJD 12th July 2006
iii
WIN Weight Control Information Network ’Do You Know the Heath Risks of Being
Overweight?’ National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) US Department
of Health and Human Services, National Institutes of Health NIH Publication No 07-4098 November 2004
Updated December 2007
iv
Roglans N, Vila L, Farre M, Alegret M, Sanchez RM, Vazquez-Carrera M, Laguna JC ’Impairment of
hepatic Stat-3 activation and reduction of PPARalpha activity in fructose-fed rats’ Hepatology 2007 March;
435(3): 778-88
v ’New Data On Fructose-Sweetened Beverages and Hepatic Metabolism’ Universidad de Barcelona 18th
March 2007, http://www.ub.edu/
vi The Annals of Pharmacotherapy: Vol. 39, No. 12, pp. 2046-2054. DOI 10.1345/aph.1G33
56

57. Chapter 5
Socio Economic Issues and Obesity
What are socioeconomics?
The term socio-economic status is generally used to identify a person’s status social
status relative to others, based on characteristics such as income, qualification,
occupation, and where they live. As a result, a number of measures have been developed
to classify people into groups based on different characteristics. These measures are used
to assess inequalities between social groups.i.
Do social economic factors play a role in obesity?
Obesity has been shown to be associated with low socio-economic status (SES) in
industrialized, developed nations. Overwhelming evidence accumulated globally
demonstrates that social economic status does influence the tendency for obesity. In
researching social economic factors, researchers analyze different mechanisms such as
education level, income, and other markers of socio-economic status, all of which have
been shown to lower levels of physical activity, poor nutrition and certain psychosocial
factors.ii.
Evidence would also seem to show that a low socio-economic status has been
associated with a lower level of health consciousness, making changes more
problematical, and therefore leading to lower life expectancy.iii.
It might also be true to
say that behavioural choices that may be labelled as unhealthy are associated with
attitude factors.iv.
There is some research that queries a direct link between socio-
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58. economic status and obesity, but most studies worldwide has found evidence of a clear
and direct link between obesity prevalence and socio-economic status.v.
Although levels of obesity are growing, worldwide, at an alarming rate, it is still not
entirely clear why the poorer people are, the more likely it is that they will be obese. A
better understanding of the socio-economic factors which are linked to the problem of
obesity is vital if governments are to be expected to implement health and food policies
in an effort to control increases in the level of obesity, and reduce the effects on health
and well-being.
Adult obesity and socioeconomic status
Obesity prevalence in England is known to be associated with many of the indicators of
socioeconomic status, with higher levels of obesity found among more deprived groups.vi.
The association is stronger for woman than for men.vii.
However this is a pattern that has
been observed in many other developed countries.viii.
Household income is a good indicator of socio-economic status, however for woman,
occupation (and its indication of social class) gives a significant relationship with obesity
prevalence. The prevalence of obesity in unskilled occupation for woman is twice that of
those in professional occupations.ix.
A similar pattern can be found for men. Those in
professional occupations have lower obesity prevalence than any other professional
group.x.
For women, statistical evidence published by the National Obesity Observatory,
suggests that obesity levels are higher in unskilled professions (33% of the unskilled
female workforce), with woman working in skilled professions presenting obesity levels
of 14% of the skilled professional female workforce. For men, the level of obesity among
the unskilled workforce has been calculated at a level of 25%, which is 8% less than the
woman in unskilled professions. This data would indicate that women present higher
levels of obesity in the unskilled sector of the adult working population. The natural
conclusion would therefore be that a woman from a low socio-economic status stands a
58

59. greater risk of being obesexi.
, though for men, other factors would appear to have an
impact as the correlation is not as strong.
Child Obesity and socio-economic status
Socio-economic status has significant influence on childhood obesity, with the
prevalence of obesity rising as household income falls. Levels of obesity have proven to
be significantly higher in the lowest income groups, compared with the highest. In the
highest income group, an analysis of data shows that of children aged 2 to 15, 11 % of
boys have been found to be obese from the highest income groups, compared with 19.8%
of boys from the lowest income groups? The difference in levels of obesity found
between the highest and the lowest income groups therefore presents at 8.8%. Studies
also show that of girls in the higher income group, 14.5% have been found to be obese,
which compares to 19.4% in the lowest income groups. The difference in levels of
obesity found, in terms of the difference between the highest and the lowest income
bands, is 5%. Nevertheless, it would appear that boys in general are less likely to be
obese in comparison with girls, except for in the lowest income group, where boys are the
most obese.xii
The prevalence of childhood obesity varies according to occupation based
social class; where children are in a household where the main income earner works in a
manual occupation, they are more likely to be obese than the children from a household
where the main income works in a professional occupation. In a household where the
main income earner has professional status, data suggests that 10.8% of boys are likely to
be obese, compared with 12.3% of girls. In households where the main income works in
an unskilled manual profession, 20.5 % of boys are likely to be obese, compared with
19.7% of girls. Where social classes are combined and split between manual and non-
manual workforce groups, the prevalence of obesity is significantly higher in children
from the manual group.xiii.
Deprivation of income has been found to affect the children’s Index, with the Income
Deprivation Affecting Children Index showing a similar increase in child obesity as
income deprivation increases. Child obesity prevalence in areas with the highest level of
59