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
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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.
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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
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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.
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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.