Preventing Childhood Obesity - Evidence Policy and Practice.pdf

No country for fat children? Ethical questions concerning community-based programs to prevent obesity
the direct prevention of harm is at stake. But many
parents find it more difficult when it comes to restricting
or denying pleasures. However, this is something
the child will have to accept in his or her life. If it is
not “ no ” to the sweets, it will be “ no ” to something
else. One will have to live with requests being refused
from time to time.
This means that one has to illustrate the advantages
of self - control: the enjoyment of tasting instead of the
“ mindless stuffing ” , the idea that you are not the
victim of habit, feeling or an urge stronger than you,
but that you are the master of yourself. That is a
reward in itself. Also, control is more effective if
embraced rather than imposed. Self - control actually
increases freedom. And it also has to be compared to
the alternatives: bariatric surgery at the age of 14 is not
an attractive proposition.
This does not mean that one can rely on self - control
and that it is, therefore, not necessary, for example, to
remove soft drinks vending machines in schools. But
removing the vending machines without changing the
idea that one needs gallons of soft drinks every day is
not helpful either.
However, we also want to stress that the importance
of engendering self - control and carefulness in relation
to eating should not be conceived in an overly moralistic
frame. Many obese adults and children do exhibit
self - control and carefulness even in their eating.
Although they eat too much for their caloric needs
they do so in a controlled way. They do not stuff
themselves but have become habituated to eating large
portions. So what is needed in many cases is to re - set
the perception of what is a normal meal.
Proportionality
The fifth question concerns proportionality:
Is there a balance between the goals, the chosen
methods and the possible ethical impact?
Can a certain goal be reached with less intrusive
measures? For example, to take all children with a
BMI above 28 out of parental care and raise them in
foster families or clinics is clearly disproportional
(apart from being quite unrealistic).
How can one evaluate proportionality? The Nuffield
Council has designed a framework to evaluate public
health measures that can be used in the debate. It is a
ladder that indicates different levels of intrusiveness,
from “do nothing ” up to “eliminate choice ” . The
higher up the ladder, the more intrusive a program is
and the stronger its justification needs to be. 24
We want to emphasize the distinction of enabling
versus enforcing.
Enabling v ersus e nforcing
Enabling means that the opportunities are provided
for children and parents to choose the healthy habit
or lifestyle, whereas enforcing means they have no
choice. There are important arguments to prefer enabling
to enforcing. The chances that a certain healthy
lifestyle or certain eating habits will be integrated,
incorporated or embraced is greater if people themselves
learn to appreciate them and feel better, enjoy
the advantages, rather than when they feel they are
submitting to dictates put upon them by others as the
internal motivation may then be lacking.
Slippery s lope
The sixth question regards the slippery slope:
Are the measures sensitive to the argument of the slippery
slope?
The slippery slope concept is that if one measure or
intervention is permitted then this will result in
further, more intrusive measures being taken in the
future which would then significantly infringe upon
an important right or ethical principle, such as adults
choosing whether to exercise or not. Fears of “ 1984 ” ,
total health control, or moral imperialism are enlisted
in this argument along with the notion that we will all
die sooner or later and that there is no point in living
a frugal life with no pleasures. These slippery slope
fears are often accentuated when proposed interventions
are either novel or vague in their definitions and
boundaries.
In many areas of public health, especially for injury
prevention, tobacco control, and to some extent
infectious disease control, regulations are enacted
which place restrictions on individual behaviours in
addition to changing the environment. Influencing
personal choices regarding behaviour is also used in
the prevention of overweight. This varies from the
subtle pushing message “ Please take the stairs ” that
one may encounter as health promotion notices at the
base of the stairs 25 , to employers forcing their employees
to walk by locating the cafeteria far away from the
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