INTRODUCTION

Obesity has long become a global concern, and its burden continues to grow. It is one of the most widespread civilization diseases, now affecting one in four people. Both adult and pediatric obesity rates are on the rise everywhere in the world. The World Health Organization (WHO) has recognized obesity as a 21th century epidemic [1]¹. According to expert estimates, 40% of men and 50% of women will be obese in 2025 [2]. 

In light of the woeful fact that obesity and its complications take 2.8 million lives every year, WHO has called for immediate action to end the epidemic and declared October 11 as the World Obesity Day [3]. Today, about half of the European population are struggling with excess weight.  The highest rates of obesity are observed in the Unites States [4], where this condition kills 300,000 people annually. In today’s Russia, obesity has too become an important social issue [5].

STIGMA: THE ETHICAL JUDGEMENT OF OBESITY

Obesity is being increasingly recognized not only as a health condition but also as a phenomenon with socio-ethical characteristics and consequences. The bioethics agenda outlined in the UNESCO’s program on bioethics, the ethics of science and artificial intelligence addresses obesity-related ethical issues, which, to a greater or lesser extent, affect millions of people worldwide.

Fat stigmatization is one of the most serious social and ethical challenges facing modern society. In Ancient Greece, a stigma was a brand that marked slaves or criminals. Later, this word developed the meaning of a socially shameful, indecent or detestable attribute. According to Erving Gofman, “today, the term… is applied more to the disgrace itself than to the bodily evidence of it” [6].

The stigma of obesity brands an overweight individual with a discrediting social identity and often turns him/her into an object of ridicule and bullying quite common among children and adolescents. Stigmatization is a process of negative stereotyping or marking an individual with a negatively connotated social label. As a socio-ethical phenomenon, stigmatization vilifies obesity as a socially shameful characteristic and shapes a debasing attitude toward overweight people. The latter often develop an inferiority complex, which has a dramatic impact on how they see society and their role in it. Stigmatization can result in derogatory or discriminatory policies toward obese people, foster alienation, frustration and resentfulness, and has social and ethical ramifications, including crime, immoral conduct, aggression, violent assaults, and self-harm.

Obesity stigma can manifest as negative stereotypes entrenched in the sociocultural environment, including claims that overweight people are inferior, inadequate or incapable of self-control. Thus, certain traits shared by some overweight individuals are assigned to all overweight people through unnuanced generalization.

Obesity stigma can be institutional if attempts are made to disenfranchise overweight people from some of their rights by passing discriminatory laws or introduce legal definitions related to obesity.  A number of transport service companies have been reported to impose restrictions on passenger weight or force an obese traveler to book 2 tickets instead of one; some of these discriminatory policies have been legalized.

Another type of fat stigmatization is self-stigmatization, i.e. adopting a negative attitude toward oneself and blaming oneself for the inability to control weight. This may have a devastating effect on the mental state of the self-stigmatizing individual and create problems for others. Positive stigmatization and self-excuse are often used as a compensation. This is reflected in sayings like “there is more of me to love”, plus-size comedy shows, contests for overweight people, etc.

Stigmatization as such is the manifestation of social and ethical undercurrents and realia.  Stigmatized people do not conform with socio-ethical views and expectations that form a virtual social identity perceived as a norm by society. If the actual social identity of a person significantly deviates from the norm in a society where such deviance is frowned upon or not tolerated, stigmatization may be the response. With obese people, the difference from the perceived norm is visible and can trigger stigmatization that will have a socially and ethically devastating effect, creating a divide between “normal” and stigmatized overweight people. This socially and ethically dangerous phenomenon is what Goffman called a spoiled identity [6].

Fat stigmatization may lead to psychological trauma or a disorder, which, in turn, may result in social alienation and discrimination.  Those who are prejudiced against obese or overweight members of society sometimes justify their discriminatory attitude by resorting to theories about hazards posed by overweight people to society or the ethical inadequacy of such people. Fat stigmatization can be propagated by accusing overweight people of faults they do not have, like intellectual incapacity, sexual inadequacy, etc.

In turn, people who live with obesity stigma are likely to sink into self-pity and use excess weight as an excuse for all the failures they have ever had in life. They become self-conscious about their own behavior and about how other people see them; they often develop a proclivity for self-stigmatizing, which makes their interaction with society inevitably flawed.

Fat stigmatization is a widespread phenomenon. According to different estimates, as many as half of overweight residents of Europe, which prides itself on tolerance, are stigmatized by their employers, colleagues, educators, healthcare providers, mass media, and even friends and family.

Fat stigmatization deeply affects children and has far-reaching social and ethical implications. Statistically, the chances of falling victim to bullying, abuse and denigration are by 63% higher for overweight children than for their peers with normal weight [3]. Bullying and victimization incite shame in an obese child. This fuels resentment, depression, low self-esteem and despair that often persist into adulthood and may push the person to commit suicide. Overweight children are especially vulnerable to stigmatization from teachers and parents, which may have a dramatic impact on their academic performance, reduce their chances in life, become a bitter disappointment, and promote social and ethical ineptness.

Parents of obese children should realize that they have a profound impact on their child’s mindset and are responsible for the psychological comfort of the child in no lesser degree than for the child’s health constituted, among other things, by a healthy diet. It is parental responsibility to protect the interests of the child, remember that bullying and victimization can have devastating effects on the child’s socio-ethical development and therefore do their best to prevent these malpractices by seeking help with state agencies and members of the community.

According to the Ethical Family Interventions for Childhood Obesity study conducted in 2001, no intervention can be successful if the family, especially parents or caregivers, are not involved [7].

Parents have the right to raise their children as they think fit as long as they abide by the law, but this does not exempt them from being responsible for their child’s safety and protection from harm. This gives rise to an ethical dilemma: there are people who believe that pediatric obesity is the result of parental neglect, inadequate parenting style, poor dietary choices and wrong attitude to physical exercise made and formed by the parents. However, experts think that pediatric obesity is a complex physiological phenomenon that cannot be explained by bad parenting alone even if parents make wrong choices or do not meet certain criteria. The socio-ethical controversy surrounding this problem is evident. Parents or caregivers may not always have the means to provide their child with a balanced nutritional diet and buy cheap, affordable foods, including those promoting obesity.

GLOBAL UN GOALS: END HUNGER, OBESITY AND SOCIAL INEQUALITY

There are still regions in the world where access to food and potable water remains a problem. Among the Sustainable Development Goals that were adopted by the United Nations in 2015 and are expected to be achieved by 2030, Goal 2 seeks to end hunger, achieve food security and promote sustainable agriculture. Today, 700 million people worldwide (9% of the planet’s population) are affected by hunger. The number of people who do not have sufficient access to food and drinkable water is growing and will have increased by 2 billion by 2050 if the trend continues [8].

Paradoxically as it may sound, there is a close link between hunger and obesity [12]. The primary goal in the battle against hunger is to provide the affected population with food and water for survival. The budget allocated for humanitarian food aid is tight, and the food should be distributed among as many people as possible. This means that the food delivered as humanitarian aid will be very cheap and rich in calories; it will help the person to survive but at the same may cause obesity.

The socio-ethical roots and causes of the global obesity phenomenon are worth a separate discussion. Social inequality, which is in and of itself a global challenge, is a great contributor to obesity. Goal 10 of the Sustainable Development Goals seeks to combat social inequality within and between countries. COVID-19 has aggravated social inequality, taking a terrible toll on the poorest and the most vulnerable populations [10]. The pandemic has substantially increased unemployment rates all over the world and resulted in income loss, widening the gap between the rich and the poor. Because of social inequality and low income, many people have no other choice but to consume cheap, high-calorie foods.  Inequality has a stronger impact on socially vulnerable groups. Migrants, refugees, the elderly and the disabled, children and obese people are at high risk. As a socially vulnerable group, overweight people fall the first victim to the consequences of social inequality and economic downturns: they lose their jobs, social status and the money to buy high-quality foods. Caught in this vicious circle, they have only slim hope to break out of it one day.

The socio-ethical aspect of the global obesity phenomenon is tightly linked to the so-called human factor, or, in other words, the social nature of man. Humans satisfy their vital need for nutrients by eating. The most natural eating behavior would be to adequately replenish the body with lost nutrients. However, there is a whole range of socially and ethically determined individual variations of eating behaviors and habits that fulfill a variety of other needs.  

Using food as a self-reward and food cravings are eating behaviors that are often adopted by overweight individuals as a means of relaxation or relief from stress, which in their case often has a socio-ethical nature. Paradoxically, an overweight person resorts to food to relieve stress caused by excess weight; this exacerbates the problem even further.

In times of social catastrophes like revolutions, wars or armed conflicts humans may find solace in food; in the absence of food, this function can be compensated by tea rituals or other attributes of eating behavior of peaceful times.

EATING BEHAVIOR AS A MANIFESTATION OF SOCIAL AND ETHICAL NEEDS

Eating behavior has an obvious socio-ethical function when used to demonstrate and maintain one’s social status through dining at expensive restaurants and ordering exquisite dishes in accordance with one’s ideas of prestigious foods. Sometimes exotic foods are bought and consumed to demonstrate expertise, unique eating habits and, ultimately, social or ethical superiority over other people.

Many see eating behavior as another opportunity to socialize; for some, it is a socially and ethically significant solution to the problem of loneliness. Overweight people are often very hospitable to the guests they invite to spend time together at the table so as not to feel socially and ethically rejected by society.

Hedonists make up another category of overweight people. They eat for delectation, i.e. the pleasure of senses, which is a goal in itself, both socially and ethically, and in some cases a denial of other pleasures and aspirations.

The process of food consumption and food itself can fulfill the socio-ethical function of maintaining and observing traditions or customs and preserving an ethnic identity, especially in ethnic communities. The UNESCO’s list of intangible cultural heritage contains approximately 480 foods and dishes, three national cuisines (Japanese, Mexican and French) and even a Mediterranean diet. On this list, the names of Italian dishes occur next to Armenian lavash and Uzbek pilaw known since the 10^th century [11]. This function of food is often used by overweight people as an excuse to justify their unhealthy or extravagant eating habits, which in some cases culminate in polyphagia².

The widespread habit of eating in front of TV or a computer only worsens the physical condition of obese individuals. Known as Fernsehkauen in Germany, this habit helps to cope with facts of life and “digest” social anxiety but also results in the continuous growth of obesity rates because, as a rule, the consumed food is rich in calories (nuts, chips, sandwiches, beer etc.).

Food is often used by overweight people to compensate for unsatisfied socio-ethical needs for communication, recognition, acknowledgement of their skills and abilities, including the ability to engage in a sexual relationship. Children with unhealthy eating behavior may be in acute need for the parental love they do not get. Sometimes, food is perceived as a reward or gratification, especially by food addicts³ in a socially or ethically dependent position. This phenomenon is observed among slaves, prisoners or people who have a strong code of taboos or are ethically controlled by others. Specifically, one of the popular punishments for children is depriving them of food or not allowing them to have sweet treats, ice-cream or delicacies; in the same way, food is often used as a reward. In orthodox Christianity, the end of fasting is celebrated with feasts as a reward for good faith and righteous behavior. There are certain dietary restrictions in other religions, too, including the prohibition of pork in Islam or beef in Hinduism, which morbidly obese people are sometimes exempt from because of their condition.

Among the diversity of socio-ethical manifestations of eating behavior demonstrated by obese individuals, another one is worth mentioning: meals as an aesthetic experience. This is achieved through rituals, beautiful food presentation, etc. It is reported that some people gain weight in order to protect themselves from unwanted socio-ethical changes imposed by the family, like marriage, partnership or employment, or to justify their own failures in life. Often an overweight individual seeks a mystical explanation for their condition, blaming it on supernatural powers, hidden and yet understudied properties of food, etc.

Research into the underlying causes of obesity has uncovered a few implicated social and ethical factors. One of them is psychological trauma caused by society or, more commonly, by family circumstances. Dissatisfaction with family life can result in escapism eating or overeating perceived as a rescue from the unfulfilling reality. Another contributing factor is adherence to social, ethical, ethnical and cultural eating stereotypes consisting in the consumption of profuse amounts of food and alcohol beverages.

The path to obesity can begin with the idea instilled in the child by their parents that chubbiness and good appetite are signs of good health. Another possible cause of obesity is one’s own perception of excess weight and overeating as evidence of social success, well-being and prestige. These ideas stem from parenting mistakes and too much parental care that takes the form of giving the child too much food. They are one of the primary social and ethical causes of pediatric obesity usually persisting into adulthood. Similar to excessive love, the total neglect of a child, who is unwanted, can promote obesity; usually such children are victims of the authoritarian parenting style, have frequent confrontations with their parents and develop the feeling of being unwanted in spite of exaggerated care of the child’s nutrition or clothing.

Other socio-ethical contributors to obesity include the impact of the social environment on eating habits, advertisement, dissemination of ideas that emphasize the attractiveness of feasts and inadequate consumption of food and beverages. The reality of today makes a person a hostage to food that contains taste enhancers and additives stimulating subconscious craving for such food. Some develop addiction to food and join the ranks of obese people, unable to resist the temptation and adopt a healthy lifestyle.

The ubiquitous feeling of insecurity in the face of multiple threats and challenges, powerlessness and the failure of the state to protect human rights, as was the case during the COVID-19 pandemic, spark an inner socio-ethical conflict. Many try to escape by taking to food and alcohol.

Some use food as a protection from troubles. This behavior was described in the book by the American author Louise Hay You can heal your life sold in 50 million copies [12].

Dissatisfied with their appearance or personal life, overweight people sink into depression, and start seeing food as their best friend and the way to cope with inner conflicts. In need of attention or facing a negative attitude from society, they consume more unhealthy foods, trying to satiate the void that stems from the lack of communication [13]. Inability to find a healthy strategy for coping with stress results in seeing a piece of cake or another delicacy as a compensation for negative impressions but at the same time aggravates the condition. Oftentimes, overweight people do not know how to control their emotions and seek comfort in food and alcohol. They struggle to prove their worthiness through the adopted eating behavior and recommend this strategy as effective. However, they forget about the consequences. Together or separately, all of these factors can exert their detrimental effect. In the presence of instability, increased stress and information overload, they can cause addiction just like alcohol or narcotic drugs.

CONCLUSION

Oversimplification of the obesity problem by reducing it down to physiological or medical factors and personal responsibility, and the lack of attention to its ethical and social aspects make the analysis of this global problem inaccurate and lead to wrong conclusions and solutions. If it were as easy as in the saying “eat less and move more”, obesity would have been eradicated long ago. When social and ethical aspects of the problem and its causes are ignored, most serious contributing factors are left out of the equation.

The socio-ethical duty of the state and society is to take effective measures aimed at reducing the prevalence and dangers of obesity and eliminating its causes. Such measures can considerably increase the well-being of the population. Inability to implement them will have a detrimental effect on the social capital and health of generations, promote inequality and multiply troubles.

Strategic mechanisms are needed to fight obesity at the national, regional and international levels and eliminate socio-ethical factors promoting the disease. It is important to bring up the subject of obesity in the context of bioethics discussed in the UNESCO’s program on bioethics, the ethics of science and artificial intelligence. International congresses, symposiums or round tables on different aspects of obesity, extensive research into this problem and practical work of bioethics committees of National Commissions for UNESCO would make a great contribution to elaborating strategies to fight obesity.

Obesity affects the lives of millions of people worldwide. Only a comprehensive approach to this social and ethical issue can help in finding the right solution.

¹ WHO measures obesity in kg/m². Normal weight: > 25; overweight:  25-29.9; obesity class I – 30-34.9; obesity class II: 35-39.9; obesity class III: 40-44.9; obesity class IV: >45

² Polyphagia: from Ancient Greek: πολύς (many, much) + φάγειν (eating) — an eating disorder manifested as increased appetite, excessive hunger and overeating.

³ Addict – a person who has substance or psychological addiction.