Obesity, equity and choice

By T.M. Wilkinson

An awful lot of people are getting fatter than is good for their health. Many jurisdictions, under pressure from public health advocates, are trying to steer choices away from the obesogenic by taxing and regulating sugary and fatty food and drink. No one I know of thinks these methods will solve the obesity problem alone, but that’s not an objection to them. A policy doesn’t have to solve a problem completely to be worthwhile. Still, taxes and regulations by and large don’t make healthy choices easier; they just make unhealthy choices harder. Why reduce people’s choice?

One key part of the case for reducing choice is that it would make people healthier. Would policies such as sugar taxes, banning or limiting fast food outlets, or mandating reformulation actually make people thinner to a large enough extent to make any important difference to their health? There’s a feast of evidence-based argument answering this question. Assuming the policies would make people healthier, it is often claimed that in rich countries the obese tend to be have less money and it is the badly off who would gain the most. So making unhealthy food and drink harder for everyone to get would be particularly beneficial for the health of the badly off, and that would be a gain in equity.

Not so fast. Jackie Mason once said of sushi: ‘here’s a piece of fish, I forgot to cook it’. His joke springs to mind when hearing advocates of the public health equity argument. They forgot to show that reducing choices would make poorer people better off.

Unhealthy food and drink can be cheap, quick, a pleasure, or all three. It doesn’t have to be a mistake to choose the unhealthy options. No readers of this blog will have to be told that health isn’t everything. If you are a single parent without much money trying to hold down two jobs, a takeaway might let you spend more time with your children than preparing a meal from scratch and it might well be cheaper too; and such an unhealthy option might be an entirely reasonable choice. If it is, bumping up the price or making it harder to get, while leaving the healthy options no easier or cheaper, is going to make the worst off worse off. On any sensible view of health equity, that’s more inequitable not less.

The more sophisticated advocates of reducing choice do go beyond saying `these policies would make people healthier so they are good’. Without usually putting it quite this baldly, they imply that badly off people largely make unreasonable decisions that are against their interests. If so, then reducing their choice could make them better off.

Now one can understand how people could choose against their interests. Maybe they are irrational and don’t pick what they themselves think is best for them. Who hasn’t been tempted sometimes to take the quick, easy, immediately rewarding options against one’s own better judgement? Who hasn’t sometimes hoped for, even aimed at, having less choice to prevent oneself from taking the worse options? But seeing that it’s possible is not the same as showing it’s actual. This bit got forgotten. Where is the evidence that on the whole badly off people choose against what they themselves think are their more important interests? Where, indeed, is the evidence that the question has been asked?

One final thought. A lot of people are on diets, and one can often think of diets as repudiating one’s prior consumption decisions. But the limited evidence there is suggests that most people are not on diets, the badly off least of all. Judged by their non-dieting behaviour, many of them are not displaying the ambivalence and conflict needed to show they would benefit from less choice.

I am not denying that reducing choice could be a net benefit to the badly off. My point is this: it has been tacitly assumed by many in public health that reducing choice would be a benefit, but we need a lot more evidence than has been given to believe what is assumed. Policy makers should to try to reduce obesity and maybe even reducing choice has good reasons in its favour. But for all we know so far, health equity is not one of them.

Paper: Obesity, equity and choice

Author: T.M. Wilkinson

Affiliation: Department of Politics and International Relations, University of Auckland, New Zealand

Competing Interests: None declared

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