university of copenhagen Backward- and forward-looking responsibility for obesity: policies from WHO, the EU and England Vallgårda, Signild; Nielsen, Morten Ebbe Juul; Hartlev, Mette; Sandøe, Peter Published in: European Journal of Public Health Publication date: 2015 Document Version Preprint (usually an early version) Citation for published version (APA): Vallgårda, S., Nielsen, M. E. J., Hartlev, M., & Sandøe, P. (2015). Backward- and forward-looking responsibility for obesity: policies from WHO, the EU and England. European Journal of Public Health. Download date: 06. jul.. 2015 The European Journal of Public Health Advance Access published April 29, 2015 European Journal of Public Health, 1–4 ! The Author 2015. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. doi:10.1093/eurpub/ckv076 ......................................................................................................... Backward- and forward-looking responsibility for obesity: policies from WHO, the EU and England Signild Vallga˚rda 1, Morten Ebbe Juul Nielsen 1 2 3 4 2,3 , Mette Hartlev 4, Peter Sandøe 3 Section for Health Services Research, Department of Public Health, University of Copenhagen, Copenhagen, Denmark Department of Media, Cognition and Communication, University of Copenhagen, Copenhagen, Denmark Department of Food and Resource Economics, University of Copenhagen, Copenhagen, Denmark Faculty of Law, University of Copenhagen, Copenhagen, Denmark Correspondence: Signild Vallga˚rda, Section for Health Services Research, Department of Public Health, University of Copenhagen, Farimagsgade 5, 1014 Copenhagen, Denmark, Tel: +4535327968, Fax: +4535327629, e-mail: [email protected] Background: In assigning responsibility for obesity prevention a distinction may be drawn between who is responsible for the rise in obesity prevalence (‘backward-looking responsibility’), and who is responsible for reducing it (‘forward-looking responsibility’). Methods: We study how the two aspects of responsibility figure in the obesity policies of WHO (European Region), the EU and the Department of Health (England). Results: Responsibility for the emergence and reduction of obesity is assigned to both individuals and other actors to different degrees in the policies, combining an individual and a systemic view. The policies assign backwardlooking responsibility to individuals, the social environment, the authorities and businesses. When it comes to forward-looking responsibility, individuals are expected to play a central role in reducing and preventing obesity, but other actors are also urged to act. WHO assigns to individuals the lowest degree of backward- and forwardlooking responsibility, and the Department of Health (England) assigns them the highest degree of responsibility. Discussion: Differences in the assignment of backward- and above all forward-looking responsibility could be explained to some extent by the different roles of the three authorities making the plans. WHO is a UN agency with health as its goal, the EU is a liberal economic union with optimization of the internal European market as an important task, and England, as an independent sovereign country, has its own economic responsibilities. ......................................................................................................... Introduction besity has become a part of the political agenda in several O countries and various interstate organizations, not least as a consequence of the growing prevalence of overweight over recent decades. Perhaps the two main questions in the framing of obesity as a political problem are about who bears responsibility for the rise in obesity and, more importantly, who is responsible for tackling the problem? As we shall argue below, it is necessary to distinguish these two senses of responsibility: the question of responsibility is distorted if we simply equate it either with causal, backwardlooking responsibility, or with its counterpart, forward-looking responsibility Obesity policies have been published by a number of countries and organizations. In this paper we analyze policies from one country, England (Note that, as a result of the devolution health policy in the UK to regional assemblies in Scotland, Wales and Northern Ireland, the British policy document we draw upon confines itself to obesity in England only. In view of this, we are obliged to use the term ‘Department of Health (England)’.), an economic-political supranational organization, the EU and an international organization which has health as its raison d’eˆtre, WHO (European region). We analyze the way in which they deal, in their obesity policies, with the questions of backward- and forwardlooking responsibility. Methods We study an obesity policy,1 a food and nutrition plan2 and a declaration from ministers, the Vienna Declaration,3,4 from WHO Europe, one general5 and one childhood obesity plan6 and a EU council conclusion7 from the EU and the latest obesity plan from the Department of Health (England).8 In our analysis, we have chosen to concentrate on the policy papers which have the most formal and legal status and which address the issue of responsibility most explicitly. Each plan has a distinctive scope. Thus the plans of the Department of Health (England) involves a series of commitments made by a sovereign government, the EU policies consist of a combination of commitments and recommendations to the member states made by the Commission, and the WHO charter, declaration and plan merely make recommendations to member states. The EU and WHO policies are results of negotiations and compromises between member states. The policy of the Department of Health (England) was developed against the background of a policy process which included the preparation of a foresight report,9 a policy published by the previous Labour government.10 Most likely The Nuffield Council of Bioethics’ report on public health ethics, with its liberal approach, including the intervention ladder, also informed the English policy.11 The EU’s general strategy was preceded by a green paper on healthy diets and physical activity.12 In the EU the strategy is followed up by ‘The EU platform for action on diet, physical activity and health’. WHO has also published policies on diet and physical activity on a global level13 and an action plan for the prevention and control of non-communicable diseases.14 WHO is monitoring the results of the policy through its ‘Division of Noncommunicable Diseases and Life-course at WHO/Europe’. WHO has a special focus on childhood obesity.15 The EU and WHO policies were chosen because they are directed upon many, or all, European countries, and because the two organizations have different roles and status. The policy of the Department of Health (England) was chosen to see how a national plan of action is framed. England is of interest because the country has a well-developed obesity policy, and because it has one of Europe’s highest levels of obesity. The purpose of the comparison is to consider whether and, if so, how the issue of responsibility is viewed differently depending on the perspective of the organization issuing the policy. 2 of 4 European Journal of Public Health Who is responsible? Two types of responsibility are relevant in the analysis of policies designed to prevent obesity. The first revolves around the question of who is responsible for the rise in obesity witnessed over recent years—what we here call backward-looking responsibility. The second concerns who is responsible for preventing or reducing obesity, i.e. what we here label forward-looking responsibility. The two types of responsibility are related in the sense that backwardlooking responsibility may point at possible areas in which to intervene in order to prevent obesity. Some may also say that backward-looking responsibility generates, and helps to identify those who have a responsibility or duty to do something about a problem, i.e. forward-looking responsibility.16 The answer to the question about who is causally responsible for the emergence of an unwanted phenomenon does not, however, necessarily lead to an answer to the question of who is responsible for amending it. Even if we take the view that obese individuals are ‘not’ responsible, in a backward-looking perspective, for being overweight, they may have to take some degree of forward-looking responsibility for not becoming heavier, or even for reducing their weight, if any real change is to occur. Conversely, even if we take the view that obese people have themselves chosen to act in ways which cause overweight, we may need to concede that, because of the social and biological mechanisms counteracting weight loss, others will have to take part of forward-looking responsibility for dealing with the ensuing problems—e.g. by making weightenhancing choices less available—if the growing problem of obesity is to be contained or reversed. This view will lead to the assignment of more forward-looking responsibility to authorities and private business. Politicians and researchers, epidemiologist and public health ethicists, when assigning responsibility, both backward- and forward-looking, often take one of two positions, either that individuals or that politicians and industry are responsible. The latter could be characterized as a systemic view.17 Sometimes they try to reconcile them.18–21 Results Backward-looking responsibility Why is obesity becoming more prevalent, and who, or what, is responsible for this development? All policies analyzed here identify energy imbalance—too many calories, too little physical activity—as the reason why obesity levels have gone up. The policy discussions then depict a number of causes of this imbalance. WHO writes in its obesity plan that: ‘The root of the problem lies in the rapidly changing social economic and environmental determinants of people’s lifestyles’.1 It adds: ‘Holding individuals alone accountable for their obesity should not be acceptable’.1 Individuals are thus seen as, at least to some extent, shaped by their environment, as victims, not as fully responsible actors. The EU frames the issue differently. In its general plan it starts by saying that ‘the individual is ultimately responsible for his lifestyle’, but then it modifies that statement: ‘while recognizing the importance and the influence of the environment on his behaviour’.5 Lack of information is seen as an important explanation for the rise in obesity: ‘a well-informed consumer is able to make rational decisions’.5 This accords with a view of individuals as free agents who are capable of choosing, and who are therefore responsible for their own lives, including their health-related conduct— provided, at least, that they are well-informed. The childhood obesity plan adds the physical environment to the explanations, and thereby also places backward-looking responsibility on politicians. Lifestyle changes, which mainly seem to be results of individuals’ (parents’ and children’s) choices, are, however, the most frequently mentioned cause of childhood obesity.6 The Department of Health (England) policy document portrays responsibility in a similar vein: ‘Each of us is ultimately responsible for our own health’, but ‘busy lifestyles and the twenty-first-century environment often make it hard to make the healthy choice’.8 It adds other explanations including biology and the effects of people’s close environment: ‘The choices we make are influenced—perhaps more than we realize—by the day-to-day pressures we face, the behaviour of those around us, the sort of neighbourhood we live in and the prevailing culture relating to food and physical activity which favours overconsumption and inactivity’.8 Thus, backward-looking responsibility is placed both on individuals and on collective factors concerning culture and lifestyle. To some extent, then, the issue of backward-looking responsibility is conceptualized in contradictory terms in the three plans: while individual responsibility is emphasized, that claim is immediately moderated—and to some extent withdrawn, especially in the WHO obesity document. Individuals are responsible for their weight; but their choices do seem to be, not free, but influenced— and perhaps determined—by a number of factors, some of which are within the control of politicians and private business, and others of which are of a anonymous ‘cultural’ nature, and more difficult to connect with any causally responsible individual or organization. External influences tend to be emphasized more when obesity among the socially disadvantaged, including people from lower socio-economic groups, is at issue: WHO wishes ‘to support lower socio-economic groups, who face more constraints and limitations making healthy choices’,1 focus on the most vulnerable and create healthy environments3 and the EU states that ‘higher prevalence among people in lower socio-economic groups (is) indicating the need to pay particular attention to the social dimension of the issue’.5,3 People from lower socio-economic groups seem to be considered to be less able to choose freely. The English plan states ‘that the whole system at a local level must be engaged to facilitate change’ for people in deprived areas,8 thus, an extra effort from other actors is required. All plans present composite explanations and attribute backwardlooking responsibility to several actors. The EU general obesity policy stresses individual responsibility most explicitly, whereas WHO obesity policies are the most eager to downplay it. Responsibility for preventive measures: forwardlooking responsibility Who is responsible for reducing obesity? The plans all state that people themselves ultimately decide what to eat and whether to be physically active or not, and that therefore their behaviour has to change if the public health goal of reducing the prevalence of obesity should be reached. Responsibility for achieving these behavioural changes is addressed in the policies. WHO states, in common with the policy documents from EU and England, that: ‘A balance must be struck between the responsibility of individuals and that of government and society’.1 Here forward-looking responsibility is assigned to multiple actors; the question becomes one about a suitable division of responsibility which is yet to be identified. The WHO charter lists a number of goals and stakeholders: ‘The private sector should play an important role and have responsibility in building a healthier environment, as well as for promoting healthy choices in their own workplace.’1 And later: ‘The media have an important responsibility’.1 The WHO charter also presents a long list of initiatives in which, it says, governments should play a leading role. Likewise, in the food and nutrition plan many actors but notably the governments are seen as responsible for providing healthy food environments and are encouraged to restrict marketing of unhealthy foods and use economic incentives such as subsidies and taxes to influence people’s food related behaviour.2 The EU points to initiatives that could be taken, at EU level, by the Commission, including ‘labelling requirements, health claims authorizations and food controls procedures’.5 It mentions initiatives Backward- and forward-looking responsibility for obesity within the Common Agricultural Policy and in ‘education, regional policy (. . .) and last but not least audiovisual and media policy.’5 The idea, advanced in the passage quoted above, that wellinformed citizens make healthy choices, leads naturally to an emphasis on the need to ensure higher levels of information. When addressing the environment, the EU’s focus is on what it calls the ‘information environment’—an environment that should provide ‘access to clear, consistent and evidence-based information’.5 Providing this information is the responsibility of EU, its member states, the private sector and civil society. The EU council conclusion from 2014 likewise emphasizes the importance of information, and states that is the responsibility of many stakeholders. The EU should ‘involve all policy sectors and stakeholders to raise awareness of the importance of healthy diet and physical activity’.7 In the childhood obesity plan civil society, defined as NGOs, industry and research institutes, is given a major role both in shaping the environment and providing information.6 Using the information to make healthy choices on the other hand is the responsibility of individual parents. However, the EU also mentions the availability and affordability of healthy foods as an important factor, and here the same actors are again mentioned as responsible actors. ‘Private actors have a major role to play in developing the healthy choice for consumers, and in empowering them to make healthy lifestyle decisions.’5 Employers are also said to be responsible for healthy workplaces. EU encourages member states to restrict marketing directed to children, but does not, as the WHO does, mention economic incentives. Private business should be encouraged to act not compelled to do so. Urban planning, which is a member state responsibility, is also suggested as a means to increase physical activity.6 The Department of Health (England) document speaks more directly to citizens, and stresses the individuals’ forward-looking responsibility more vigorously: ‘The solution lies in each of us taking responsibility for our health and taking appropriate action to manage our weight.’8 It recognizes, however, that other actors will have to support citizens: ‘it is for Government, local government and key partners to act to change the environment to support individuals in changing their behaviour’. Two central means reflect this dual assignment of responsibility: ‘Empowering individuals—through provision of guidance, information, encouragement and tailored support on weight management’ and ‘Giving partners the opportunity to play their full part’8 (emphasizes original). The partners here include the food industry, employers, service providers and the voluntary sector. The government and its partners are ‘to transform the environment so that it is less inhibiting to healthy lifestyles, to provide the information and practical support we need to make healthier choices to prevent weight gain’.8 The food and drink industry is urged, but no suggestion is made to compel them, both to inform consumers through calorie labelling, food promotion, improving at-a-glance information for consumers, and to provide healthier options through reformulation, portion control and the support of healthier food provision in the educational system. In spite of the emphasis on individual responsibility for reducing obesity, each of the policies presents a number of measures to be taken also by other actors, such as politicians, local authorities, civil society and business. Some of the interventions are intended to encourage consumers to choose differently; others will make some choices less available and others more available. All suggested initiatives are presented as voluntary, and there is little discussion of mandatory options. However, WHO gives politicians a more central role, than the other two do, and suggest more statutory means. Discussion In this paper, we have analyzed how two aspects of responsibility for obesity, backward- and forward-looking, are considered in several 3 of 4 policy documents. All documents assign responsibility both for causing and controlling obesity to individuals, public authorities, businesses and civil society organizations. When it comes to individuals, all plans claim that individual consumers have both backward- and forward-looking responsibility, but the Department of Health (England) plan of action seems to rely more heavily on individual initiative as the driver than the policies from the WHO. The latter clearly states that individuals alone should neither be held responsible in a forward- nor in a backward-looking sense. WHO also favours more regulation than the EU and the Department of Health (England), and focuses more steadily on structural factors. The plans from EU and England are more in line with liberal ideas of public health ethicists such as Knowles,14,18 Bayer and Fairchild19 and the Nuffield Council of Bioethics, while WHO seem to favour more socialist or communitarian ideas22 with a focus on collective responsibility and with allowance for paternalism.23 Whether or not the combination of the two ideas about responsibility, individual and systemic, could be seen as different positions on a ‘continuum of discourse’13 or whether it rather is a mixture of two separate positions, which need not be connected logically, but obviously are pragmatically, is contested. However, politics will often be a combination of means derived from different ideologies. What reasons can be given for the similarities and differences between the policies? One important factor behind the differences is probably that the three authorities have different roles. The British government, like the EU, has responsibility not only for the promotion of public health, but also for ensuring the smooth running of the nation’s or region’s economy. For the EU, economic growth and the effective functioning of the internal market are central tasks. The EU has limited direct influence on health care, but issues such as labelling and product information, together with agricultural policies, fall within its purview. Its strong focus on the information environment could be connected with this. WHO has a strong public health focus, which, however, also takes ‘socio-economic preconditions and a State’s available resources’24 into account. It also strives to work within a rights-based approach to health. The differences could also reflect differences in ideology. In England and the EU, a liberal ideology seems to have a stronger influence than in the WHO. The less liberal position of WHO could be a result both of its public health approach and the fact that member states are not formally obliged to comply with WHO policy, if they disagree, and therefore the states might not care as much about the content of the policy. The similarities between the ideas in the English and the EU paper could be a result of similarities in ideological commitments as well as of an actual influence from EU on English politics or vice versa. One limitation of the study is that we have only looked at stated policies, not the implementation of them. Differences and similarities may change if and when the policies are put into practice. This could be a relevant topic for future research. Acknowledgements The work was carried out as a part of the research programme ‘Governing Obesity’, funded by the University of Copenhagen Excellence Programme for Interdisciplinary Research (www.go.ku. dk). Conflicts of interest: None declared. Key points ! Obesity policies from WHO, the EU and England all assign responsibility for the increasing prevalence of obesity, backward-looking responsibility, both to individuals an politicians and industry, a mixture of positions. WHO stresses the importance of not only blaming obese people. 4 of 4 European Journal of Public Health ! When it comes to responsibility for reducing obesity prevalence, forward-looking responsibility, a similar pattern is seen. Individuals must change behaviours. The EU stresses the importance of information, while especially the WHO mentions a number of other initiatives resting with the governments. ! Interestingly there are few suggestions about regulation of either individuals or industry in spite of the meagre results of previous attempts at obesity prevention. References 11 Nuffield Council of Bioethics. Public Health: Ethical Issues. London: Nuffield Council, 2007. 12 Commission of the European Communities. Green Paper. Promoting Healthy Diets an Physical Activity: A European Dimension for the Prevention of Overweight, Obesity and Chronic Diseases. Brussels: Commission for the European Communities, 2005. 13 WHO. Global Strategy on Diet, Physical Activity and Health. Geneva: WHO, 2002. 14 WHO. Global Action Plan for the Prevention and Control of Non-communicable Diseases 2013–2020. Geneva: WHO, 2013. 15 Wijnhoven TMA, van Raaij JNA, Sjo¨berg A, et al. WHO European Childhood Obesity Surveillance Initiative: School Nutrition Environment and Body Mass Index in Primary Schools. Int J Environ Res Public Health 2014;11:11261–85. 16 Nielsen MEJ, Andersen MM. Should we hold the obese responsible? – some key issues. Camb Q Healthc Ethics 2014;23:443–51. 1 WHO. European Ministerial Conference on Counteracting Obesity. Istanbul: WHO; 2006. 2 WHO Regional Office for Europe. European Food and Nutrition Action Plan 2015– 2020. Copenhagen: WHO, 2014. 3 Vienna Declaration on Nutrition and Noncommunicable Diseases in the Context of Health 2020. WHO Europe. Vienna 4–5 July 2013. 4 Gulland A. Europe’s health ministers vow to tackle obesity. BMJ 2013;347:f4491. 20 Wikler DI. Coercive measures in health promotion. Can they be justified? Health Educ Monogr 1978;6:223–41. 5 Commission of the European Communities. White Paper on a Strategy for Europe on Nutrition, Overweight and Obesity Related Health Issues. Brussels: Commission of the European Communities, 2007. 21 Verweij M, Dawson A.The meaning of ‘public’ in ‘public health’. In: Dawson A, Verweij M, editors. Ethics, Prevention, and Public Health. Issues in Biomedical Ethics. Oxford: Clarendon Press, 2007: 13–29. 6 EU Action Plan on Childhood Obesity 2014–2020. Athens, 2014. 7 Council conclusions on nutrition and physical activity (2014/C 213/01). Off J Eur Union 2014; C 213: 1–6. 22 Jennings B. Public health and civic republicanism: Toward an alternative framework for public health ethics. In: Dawson A, Verweij M, editors. Ethics, Prevention, and Public Health. Issues in Biomedical Ethics. Oxford: Clarendon Press, 2007: 30–58. 8 The Department of Health. Healthy lives, healthy people: a call to action on obesity in England. London: HM Government, 2011. 23 Dawson A. Information, choice and the ends of health promotion. Monash Bioethics Rev 2014;32:106–20. 9 Foresight. Tackling Obesities: Future Choices – Project Report, 2nd edn. London: Government Office for Science, 2007. 24 UN Committee on Economic, Social and Cultural Rights. General Comment 14, The right to the highest attainable standard of health (Twenty-second session, 2000), U.N. Doc. E/C.12/2000/4 (2000), reprinted in Compilation of General Comments and General Recommendations Adopted by Human Rights Treaty Bodies, U.N. Doc. HRI/GEN/1/Rev.6 at 85.2003. 10 Department of Health and the Department for Children Schools and Families. Healthy Weight, Healthy Lives: A Cross-Government Strategy for England. London, 2008. 17 Lawrence RD. Framing obesity. the evolution of news discourse on a public health issue. Harvard Int J Press/Politics 2004;9:56–75. 18 Knowles JH. The responsibility of the individual. Daedalus 1977;106:57–80. 19 Bayer R, Fairchild A. The genesis of public health ethics. Bioethics 2004;18:473–92.
© Copyright 2020