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The Ethical and Public Health Importance of Unintended Consequences: the Case of Behavioral Weight Loss Interventions

The Ethical and Public Health Importance of Unintended Consequences: the Case of Behavioral... Abstract Behavioral weight loss interventions (BWLIs) that promote healthy eating as a way to achieve and maintain healthy weights do not work for most people. Most participants encounter significant challenges to behavior change and do not lose weight or maintain meaningful weight loss. For some, there may be negative consequences of participating in a BWLI, including social, psychological and economic costs. The literature is largely silent on these negative unintended consequences, but they are important for both practical and ethical reasons. If efforts to eat healthier have too many negative consequences for individuals and groups, then these efforts are unlikely to be effective, and promoting them may not always be ethical; this would boost the case for moving away from individual-focused efforts as part of healthy eating efforts. Alternatively, if we can make BWLI interventions more effective and more ethical by mitigating these unintended consequences, then it may be too soon to give up on individual-focused efforts. We make a case for systematic assessment and reporting of the unintended consequences of BWLI. This could contribute to more effective and ethical BWLI and inform obesity interventions and policies more broadly. Introduction Behavioral weight loss interventions (BWLIs), those research, clinical or public health efforts to promote individual healthy eating and physical activity behaviors as a way to achieve and maintain healthy weights, run up against practical and economic barriers and may exact social and personal costs. Most participants do not lose a meaningful amount of weight; fewer maintains the weight loss, and some gain weight (Ayyad and Andersen, 2000; Mann et al., 2007; Fildes et al., 2015). In addition, some individuals and groups may experience adverse consequences of BWLI that, although unintended, may have negative impacts on their social, psychological and economic well-being that could exacerbate continuing disparities in obesity, health and well-being. We propose measuring a broader range of the outcomes and consequences of BWLI research. While some BWLIs help participants anticipate barriers and strategies for dealing with them, these kinds of outcomes and unintended consequences and how they might be experienced differentially by individuals with different life circumstances are not systematically measured and reported (Waters et al., 2011). Notably, the silence in the scientific research literature on the costs of BWLIs exists alongside well-developed critiques in the philosophical and bioethics literature of dieting and weight loss efforts, and critiques of the public discourse surrounding obesity and obesity prevention (Orbach, 1980; Bartky, 1990; Bordo, 1993; Wilkerson, 2010; Womack, 2014, 2015). Important ethical critiques of dieting, weight loss efforts and obesity prevention are made in the literature. Yet current scientific research on weight loss interventions does not provide the granular understanding of weight loss efforts that is needed to assess and advance these ethical critiques. There is a missed opportunity here, both to improve weight loss interventions and to deepen our ethical understanding. We identify some potential unintended consequences of BWLI, and then highlight four reasons why these unintended consequences matter. First, unintended consequences may serve as barriers to effective behavior change; uncovering these barriers and re-characterizing them as unintended consequences may lead to more effective BWLI that are better adapted to individual characteristics and life circumstances. Second, some of the unintended consequences of BWLI, such as increased stress levels, are outcomes of interest which we have good reasons to promote or discourage, whether they influence eating behavior. These unintended consequences should be seen as costs of behavior change efforts, not just barriers to be overcome. Understanding them as costs opens up the possibility that an intervention is not worth its costs, or at least that these costs should be minimized. Thus a third way in which unintended consequences matter is that BWLI may not be ethical, if their potential costs are too high and anticipated benefits too low. Fourth, the unintended consequences of BWLI matter to the ethics of research on BWLI. A better grip on the consequences of BWLI will improve the consent process and may also improve retention in studies. Understanding the consequences of BWLI can help us improve the effectiveness and ethics of BWLI and can inform ethical and policy debate about healthy eating and obesity prevention efforts. Potential Social, Psychological and Economic Unintended Consequences of BWLI The unintended consequences of BWLI can carry both costs and benefits for participants. We describe three areas of potential unintended consequences: social, psychological and economic. Crucially, we are interested in the unintended consequences of trying and not succeeding in changing behavior or losing weight as well as the unintended consequences of engaging in healthier behavior and how those consequences may be experienced. The social costs of BWLI may include strain on family or other social relationships. People who are trying to adopt healthier food choices may feel that they can no longer eat with other household members, comfortably attend community events involving food such as church services, or participate in meals with family or coworkers because their food choices set them off as different (Falk et al., 2001). Dietary changes can lead to family conflict (Rosland et al., 2010) or objectionable changes in family meals or cultural practices that require a range of adaptations, navigations and negotiations (Eldridge et al., 2016). Social benefits of BWLI may include support from others who are also trying to adopt healthier behaviors (Allon, 1975; Hwang et al., 2010), positive contacts with intervention staff (Eng and Young, 1992), social recognition of healthier food choices (Germov and Williams, 1999) or positive spillover on the diets of other family members (Gorin et al., 2008). The psychological costs of BWLI may include loss of self-efficacy (Linde et al., 2006), self-esteem and the ability to cope with barriers to healthy eating (Venditti et al., 2014), as well as increases in body dissatisfaction and social stigma (Carter et al., 2011; Mensinger et al., 2016). Participants may express self-blame to explain their failure to lose weight (Jeffery et al., 1990; Thomas et al., 2008) or discouragement and feeling that the costs of BWLI may outweigh the benefits (Perri, 1998). Individuals who use food as a mood regulator may lose that strategy in a weight loss program (Byrne et al., 2003). These consequences vary by gender, race–ethnicity, age and other social characteristics. Interventions requiring a high level of individual agency are most challenging and least effective for members of lower socioeconomic groups. They may contribute to attendance, participation, retention and attrition rates in BWLI trials, to success or failure in these efforts, and increased social disparities (Backholer et al., 2014). There are potential economic costs of BWLI strategies. Healthy foods are often experienced as having higher costs (Carlson and Frazao, 2014). Low-income parents may hesitate to invest in foods that will not be eaten (Haynes-Maslow et al., 2013; Daniel, 2016) or to allocate too much money to food in a limited budget. There may be higher time (Jabs et al., 2007; Monsivais et al., 2014) and opportunity costs associated with healthy eating (Cawley and Liu, 2012). Parents may trade-off food preparation and meal time so that their children will have more time for homework or sleep (Devine et al., 2006). Unintended consequences may be disproportionately experienced by those whose social or physical environments are not conducive to healthy eating or who lack the capability to overcome barriers that make it difficult to access environmental resources (Ruger, 2010). Why do the Unintended Consequences of BWLI Matter? The unintended consequences of BWLI matter, practically and ethically, in at least four ways. First, negative consequences of BWLI matter as barriers to behavior change. When efforts to change eating behavior have negative consequences, this may be a barrier to sustained behavior change: if eating more healthfully turns out to be costly in various ways, people may be less likely to stick with it. But labeling negative consequences only as barriers to behavior change sells them short. They are also consequences that may be elicited or exacerbated by the kinds of dietary changes typically involved in BWLI. A second way in which unintended consequences matter is that some may be outcomes of interest to public health or policymakers. For example, minimizing stress, minimizing family or financial strain or increasing parental engagement with children may be important public health or public policy goals, independently of their connection to healthy eating and weight loss. Third, the unintended consequences of BWLI matter for the ethics of these interventions. Starkly put, we may question whether interventions that have negative outcomes for participants, and have little chance of providing benefit, are ethical. Fourth, the unintended consequences of BWLI bear on the ethics of research on BWLI. Information about the unintended consequences of BWLI could provide more realistic information to recruits about what to expect, improving the informed consent process and contributing to better retention (Goldberg and Kiernan, 2005). Understanding how BWLI might enhance or undermine an individual’s self-efficacy, social relationships and work and family roles, and understanding the economic decisions of BWLI participants, will shed light on participants’ capacity for choice and access to resources and the extent to which these are restricted by program expectations. This information could match participants with strategies that are most likely to provide benefits, minimize harms and help screen out those who would not benefit. While additional measurements may increase the research burden in the short run, matching may reduce this burden over time. The Value of Measuring Unintended Consequences We propose that research on BWLI should measure a broader range of social, economic and psychological consequences of efforts to change eating behavior. Systematically measuring these consequences could help make BWLI more effective and more ethical. It might also inform broader debates about obesity prevention policy. First, and most basically, systematic measurement of the unintended consequences of BWLI may reveal ways to make BWLI more effective and minimize their negative consequences. Ideally, interventions will be designed to help minimize negative trade-offs. For example, an intervention might encourage parents to develop strategies to minimize meal preparation time, allowing time for other valued family activities. Designing such interventions requires a good understanding of the range of unintended costs and consequences of BWLI. Minimizing the negative outcomes and promoting positive outcomes of BWLI are clearly ethically preferable (MacLean, et al., 2009; Barnhill et al., 2014). Second, understanding the negative consequences of BWLI could help illuminate the ways that eating practices are conditioned by broader social and economic forces. This research will show trade-offs between healthy eating and other positive outcomes, and could help show which trade-offs are a result of the structure of work and family life and social norms about eating. For example, a parent may feel that she must accept evening work hours and miss meals with her family because she needs the job or she is trying to save on child care costs (Devine et al., 2003). A better understanding of these trade-offs could shed light on the ways that social and economic forces make healthy eating more difficult. Third, systematic measurement of the unintended consequences of BWLI could inform ongoing debate about individual vs. environmental approaches. Some researchers have questioned whether individual-focused approaches to healthy eating and weight loss should be abandoned because they are ineffective (Jain, 2005; Brownell et al., 2010; Hunger and Tomiyama, 2015), in favor of environmental approaches—that is, policies and interventions that change the food and eating environment (e.g. school nutrition standards or financial incentives for healthy foods) to make healthy behaviors more likely or less costly (Alderman et al., 2007; Story et al., 2008). Measurement of the unintended consequences of BWLI may reveal that there are significant social, economic and psychological costs for participants, thus strengthening the case for deemphasizing individual-focused approaches. This research could also show, on the contrary, that BLWI have hitherto unrecognized benefits for individuals, which would strengthen the case for individual-focused approaches. Fourth, measurement of unintended consequences could elucidate the ways in which individuals connect to their physical, social, economic and policy environments for food and eating, thus strengthening understandings of the complementary interactions between individually based and environmentally based interventions, and helping policymakers to create conditions under which people are better able to pursue their individual goals (Glickman et al., 2012; Teixeira et al., 2012; Green et al., 2013). Recognizing the range of ways in which healthier behavior incurs costs or harms may help us to design more effective BWLI using innovative research approaches such as adaptive design (Collins et al., 2004; Brown et al., 2009) or using systems models (Hammond, 2009; Finegood, 2011). Developing effective strategies to achieve healthy eating behaviors and healthy weights is a practical and ethical challenge. We propose that assessment of the unintended consequences of BWLI can shed light on the experiences of people who change their behavior and people who do not, and people who lose weight, people who gain and people who experience no changes. In addition to helping make interventions more effective and ethical, routine measurement and reporting of a broader range of outcomes and consequences in BWLI research can contribute to improved research and health policies. The costs associated with measuring unintended consequences are countered by the costs of not measuring these consequences, as BWLIs provide lasting benefits for only a small proportion of participants, especially for those who do not benefit from current approaches. References Alderman J. , Smith J. A. , Fried E. J. , Daynard R. A. ( 2007 ). Application of Law to the Childhood Obesity Epidemic . Journal of Law, Medicine, and Ethics , 35 , 90 – 112 . Google Scholar Crossref Search ADS Allon N. ( 1975 ). 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Glickman D. , Parker L. , Sim L. J. , Valle D. , Cook H. , Miller E. A. (eds) ( 2012 ). Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation . Washington, DC : The National Academies Press . Goldberg J. H. , Kiernan M. ( 2005 ). Innovative Techniques to Address Retention in a Behavioral Weight-loss Trial . Health Education Research , 20 , 439 – 447 . Google Scholar Crossref Search ADS PubMed Gorin A. A. , Wing R. R. , Fava J. L. , Jakicic J. M. , Jeffery R. , West D. S. , Brelje K. , DiLillo V. G. ( 2008 ). Weight Loss Treatment Influences Untreated Spouses and the Home Environment: Evidence of a Ripple Effect . International Journal of Obesity , 32 , 1678 – 1684 . Google Scholar Crossref Search ADS PubMed Green L. W. , Sim L. , Breiner H. (eds) ( 2013 ). Evaluating Obesity Prevention Efforts: A Plan for Measuring Progress . Washington, DC : The National Academies Press . Hammond R. A. ( 2009 ). Complex Systems Modeling for Obesity Research . 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J. , Gao Y. , Armstrong R. , Prosser L. , Summerbell C. D. ( 2011 ). Interventions for Preventing Obesity in Children . Cochrane Database Systemativ Reviews , Art. No.: CD001871. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001871.pub3/epdf/standard. Wilkerson A. ( 2010 ). “Obesity,” the Transnational Plate, and the Thin Contract . Radical Philosophy Review , 13 , 43 – 67 . Google Scholar Crossref Search ADS Womack C. A. ( 2014 ). Gender, Obesity, and Stigmatization. In Thompson P. B. , Kaplan D. M. (eds), Encyclopedia of Food and Agricultural Ethics . New York, NY; Heidelberg : Springer , pp. 1100 – 1107 . Womack C. ( 2015 ). What We Talk About When We Talk About Obesity. Available from: http://theconversation.com/what-we-talk-about-when-we-talk-about-obesity-38512 [accessed 5 September 2016]. © The Author(s) 2017. Published by Oxford University Press. Available online at www.phe.oxfordjournals.org This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Public Health Ethics Oxford University Press

The Ethical and Public Health Importance of Unintended Consequences: the Case of Behavioral Weight Loss Interventions

M, Devine, Carol; Anne, Barnhill,
Public Health Ethics , Volume 11 (3) – Nov 1, 2018
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Oxford University Press
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© The Author(s) 2017. Published by Oxford University Press. Available online at www.phe.oxfordjournals.org
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1754-9973
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Abstract

Abstract Behavioral weight loss interventions (BWLIs) that promote healthy eating as a way to achieve and maintain healthy weights do not work for most people. Most participants encounter significant challenges to behavior change and do not lose weight or maintain meaningful weight loss. For some, there may be negative consequences of participating in a BWLI, including social, psychological and economic costs. The literature is largely silent on these negative unintended consequences, but they are important for both practical and ethical reasons. If efforts to eat healthier have too many negative consequences for individuals and groups, then these efforts are unlikely to be effective, and promoting them may not always be ethical; this would boost the case for moving away from individual-focused efforts as part of healthy eating efforts. Alternatively, if we can make BWLI interventions more effective and more ethical by mitigating these unintended consequences, then it may be too soon to give up on individual-focused efforts. We make a case for systematic assessment and reporting of the unintended consequences of BWLI. This could contribute to more effective and ethical BWLI and inform obesity interventions and policies more broadly. Introduction Behavioral weight loss interventions (BWLIs), those research, clinical or public health efforts to promote individual healthy eating and physical activity behaviors as a way to achieve and maintain healthy weights, run up against practical and economic barriers and may exact social and personal costs. Most participants do not lose a meaningful amount of weight; fewer maintains the weight loss, and some gain weight (Ayyad and Andersen, 2000; Mann et al., 2007; Fildes et al., 2015). In addition, some individuals and groups may experience adverse consequences of BWLI that, although unintended, may have negative impacts on their social, psychological and economic well-being that could exacerbate continuing disparities in obesity, health and well-being. We propose measuring a broader range of the outcomes and consequences of BWLI research. While some BWLIs help participants anticipate barriers and strategies for dealing with them, these kinds of outcomes and unintended consequences and how they might be experienced differentially by individuals with different life circumstances are not systematically measured and reported (Waters et al., 2011). Notably, the silence in the scientific research literature on the costs of BWLIs exists alongside well-developed critiques in the philosophical and bioethics literature of dieting and weight loss efforts, and critiques of the public discourse surrounding obesity and obesity prevention (Orbach, 1980; Bartky, 1990; Bordo, 1993; Wilkerson, 2010; Womack, 2014, 2015). Important ethical critiques of dieting, weight loss efforts and obesity prevention are made in the literature. Yet current scientific research on weight loss interventions does not provide the granular understanding of weight loss efforts that is needed to assess and advance these ethical critiques. There is a missed opportunity here, both to improve weight loss interventions and to deepen our ethical understanding. We identify some potential unintended consequences of BWLI, and then highlight four reasons why these unintended consequences matter. First, unintended consequences may serve as barriers to effective behavior change; uncovering these barriers and re-characterizing them as unintended consequences may lead to more effective BWLI that are better adapted to individual characteristics and life circumstances. Second, some of the unintended consequences of BWLI, such as increased stress levels, are outcomes of interest which we have good reasons to promote or discourage, whether they influence eating behavior. These unintended consequences should be seen as costs of behavior change efforts, not just barriers to be overcome. Understanding them as costs opens up the possibility that an intervention is not worth its costs, or at least that these costs should be minimized. Thus a third way in which unintended consequences matter is that BWLI may not be ethical, if their potential costs are too high and anticipated benefits too low. Fourth, the unintended consequences of BWLI matter to the ethics of research on BWLI. A better grip on the consequences of BWLI will improve the consent process and may also improve retention in studies. Understanding the consequences of BWLI can help us improve the effectiveness and ethics of BWLI and can inform ethical and policy debate about healthy eating and obesity prevention efforts. Potential Social, Psychological and Economic Unintended Consequences of BWLI The unintended consequences of BWLI can carry both costs and benefits for participants. We describe three areas of potential unintended consequences: social, psychological and economic. Crucially, we are interested in the unintended consequences of trying and not succeeding in changing behavior or losing weight as well as the unintended consequences of engaging in healthier behavior and how those consequences may be experienced. The social costs of BWLI may include strain on family or other social relationships. People who are trying to adopt healthier food choices may feel that they can no longer eat with other household members, comfortably attend community events involving food such as church services, or participate in meals with family or coworkers because their food choices set them off as different (Falk et al., 2001). Dietary changes can lead to family conflict (Rosland et al., 2010) or objectionable changes in family meals or cultural practices that require a range of adaptations, navigations and negotiations (Eldridge et al., 2016). Social benefits of BWLI may include support from others who are also trying to adopt healthier behaviors (Allon, 1975; Hwang et al., 2010), positive contacts with intervention staff (Eng and Young, 1992), social recognition of healthier food choices (Germov and Williams, 1999) or positive spillover on the diets of other family members (Gorin et al., 2008). The psychological costs of BWLI may include loss of self-efficacy (Linde et al., 2006), self-esteem and the ability to cope with barriers to healthy eating (Venditti et al., 2014), as well as increases in body dissatisfaction and social stigma (Carter et al., 2011; Mensinger et al., 2016). Participants may express self-blame to explain their failure to lose weight (Jeffery et al., 1990; Thomas et al., 2008) or discouragement and feeling that the costs of BWLI may outweigh the benefits (Perri, 1998). Individuals who use food as a mood regulator may lose that strategy in a weight loss program (Byrne et al., 2003). These consequences vary by gender, race–ethnicity, age and other social characteristics. Interventions requiring a high level of individual agency are most challenging and least effective for members of lower socioeconomic groups. They may contribute to attendance, participation, retention and attrition rates in BWLI trials, to success or failure in these efforts, and increased social disparities (Backholer et al., 2014). There are potential economic costs of BWLI strategies. Healthy foods are often experienced as having higher costs (Carlson and Frazao, 2014). Low-income parents may hesitate to invest in foods that will not be eaten (Haynes-Maslow et al., 2013; Daniel, 2016) or to allocate too much money to food in a limited budget. There may be higher time (Jabs et al., 2007; Monsivais et al., 2014) and opportunity costs associated with healthy eating (Cawley and Liu, 2012). Parents may trade-off food preparation and meal time so that their children will have more time for homework or sleep (Devine et al., 2006). Unintended consequences may be disproportionately experienced by those whose social or physical environments are not conducive to healthy eating or who lack the capability to overcome barriers that make it difficult to access environmental resources (Ruger, 2010). Why do the Unintended Consequences of BWLI Matter? The unintended consequences of BWLI matter, practically and ethically, in at least four ways. First, negative consequences of BWLI matter as barriers to behavior change. When efforts to change eating behavior have negative consequences, this may be a barrier to sustained behavior change: if eating more healthfully turns out to be costly in various ways, people may be less likely to stick with it. But labeling negative consequences only as barriers to behavior change sells them short. They are also consequences that may be elicited or exacerbated by the kinds of dietary changes typically involved in BWLI. A second way in which unintended consequences matter is that some may be outcomes of interest to public health or policymakers. For example, minimizing stress, minimizing family or financial strain or increasing parental engagement with children may be important public health or public policy goals, independently of their connection to healthy eating and weight loss. Third, the unintended consequences of BWLI matter for the ethics of these interventions. Starkly put, we may question whether interventions that have negative outcomes for participants, and have little chance of providing benefit, are ethical. Fourth, the unintended consequences of BWLI bear on the ethics of research on BWLI. Information about the unintended consequences of BWLI could provide more realistic information to recruits about what to expect, improving the informed consent process and contributing to better retention (Goldberg and Kiernan, 2005). Understanding how BWLI might enhance or undermine an individual’s self-efficacy, social relationships and work and family roles, and understanding the economic decisions of BWLI participants, will shed light on participants’ capacity for choice and access to resources and the extent to which these are restricted by program expectations. This information could match participants with strategies that are most likely to provide benefits, minimize harms and help screen out those who would not benefit. While additional measurements may increase the research burden in the short run, matching may reduce this burden over time. The Value of Measuring Unintended Consequences We propose that research on BWLI should measure a broader range of social, economic and psychological consequences of efforts to change eating behavior. Systematically measuring these consequences could help make BWLI more effective and more ethical. It might also inform broader debates about obesity prevention policy. First, and most basically, systematic measurement of the unintended consequences of BWLI may reveal ways to make BWLI more effective and minimize their negative consequences. Ideally, interventions will be designed to help minimize negative trade-offs. For example, an intervention might encourage parents to develop strategies to minimize meal preparation time, allowing time for other valued family activities. Designing such interventions requires a good understanding of the range of unintended costs and consequences of BWLI. Minimizing the negative outcomes and promoting positive outcomes of BWLI are clearly ethically preferable (MacLean, et al., 2009; Barnhill et al., 2014). Second, understanding the negative consequences of BWLI could help illuminate the ways that eating practices are conditioned by broader social and economic forces. This research will show trade-offs between healthy eating and other positive outcomes, and could help show which trade-offs are a result of the structure of work and family life and social norms about eating. For example, a parent may feel that she must accept evening work hours and miss meals with her family because she needs the job or she is trying to save on child care costs (Devine et al., 2003). A better understanding of these trade-offs could shed light on the ways that social and economic forces make healthy eating more difficult. Third, systematic measurement of the unintended consequences of BWLI could inform ongoing debate about individual vs. environmental approaches. Some researchers have questioned whether individual-focused approaches to healthy eating and weight loss should be abandoned because they are ineffective (Jain, 2005; Brownell et al., 2010; Hunger and Tomiyama, 2015), in favor of environmental approaches—that is, policies and interventions that change the food and eating environment (e.g. school nutrition standards or financial incentives for healthy foods) to make healthy behaviors more likely or less costly (Alderman et al., 2007; Story et al., 2008). Measurement of the unintended consequences of BWLI may reveal that there are significant social, economic and psychological costs for participants, thus strengthening the case for deemphasizing individual-focused approaches. This research could also show, on the contrary, that BLWI have hitherto unrecognized benefits for individuals, which would strengthen the case for individual-focused approaches. Fourth, measurement of unintended consequences could elucidate the ways in which individuals connect to their physical, social, economic and policy environments for food and eating, thus strengthening understandings of the complementary interactions between individually based and environmentally based interventions, and helping policymakers to create conditions under which people are better able to pursue their individual goals (Glickman et al., 2012; Teixeira et al., 2012; Green et al., 2013). Recognizing the range of ways in which healthier behavior incurs costs or harms may help us to design more effective BWLI using innovative research approaches such as adaptive design (Collins et al., 2004; Brown et al., 2009) or using systems models (Hammond, 2009; Finegood, 2011). Developing effective strategies to achieve healthy eating behaviors and healthy weights is a practical and ethical challenge. 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Available online at www.phe.oxfordjournals.org This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

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Public Health Ethics – Oxford University Press

Published: Nov 1, 2018

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