Keywords

Public Health Ethics Issue

World-wide, obesity is a growing health problem (Fox et al. 2019, 1). The impact of this problem is clearly seen in Mexico. Over the past 20 years, obesity has increased steadily among Mexicans in conjunction with a transformation of the nutritional landscape. This transformation has involved increased availability of highly processed, inexpensive food; more advertising targeting fast food; and increased food consumption outside of the home. This has led to profound changes in the diet of a growing sector of Mexicans leading to increased consumption of food that contains high amounts of fat, sugar, and salt (Rivera et al. 2012, 119–151).

Nutrition and foodbehaviors are often approached as a matter of personal responsibility. This creates a challenge for health officials who need to ensure there is a comprehensive approach to obesity that focuses on creating public policy for reducing food insecurity and malnutrition (Loring and Robertson 2014), promoting public health interventions that foster better eatinghabits, and avoiding approaches that blame or stigmatize individuals (Puhl and Heuer 2009, 2010; Mexican Observatory of Non-communicable Diseases [OMENT] 2018).

Background Information

In Mexico, the Ministry of Health estimates that the total cost of obesity in 2017 was $12 billion and will continue to increase until reaching $13.6 billion by 2023, a projected increase of 13% over 6 years (Health Secretary of Mexico2013). A study by the Mexican Institute of Competitiveness (IMCO) estimated that the total annual cost of diabetes associated with obesity amounted to $42 billion in 2013, of which 73% represented medical expenses, 15% work-related losses due to absenteeism, and 12% income losses due to premature mortality (IMCO 2015).

To address the growing costs associated with obesity, the Health Secretary of Mexico launched the National Strategy for Prevention and Control of Overweight, Obesity and Diabetes (Health Secretary of Mexico2013). The government promoted this as an unprecedented effort to combat two of the main challenges to the health of Mexicans: overweight that affects seven out of 10 adults and three out of every 10 children, as well as diabetes that affects almost one in ten people. This strategy has three pillars: public health, medical care and health regulation/fiscal policy. For this strategy to be successful, it must consider that foodbehavior is not just a matter of individual willpower and personal responsibility determined by biological needs. Rather, food behavior is also impacted by social and cultural values, (Health Secretary of Mexico2013). Focusing solely on diet and exercise will not solve the obesity problem.

The scientific community, as well as various international organizations (i.e., the World Health Organization, the Food and Agriculture Organization of the United Nations (FAO), the World Obesity Federation (WOF) and the World Cancer Research Fund (WCRF) have concluded that the global epidemic of overweight and obesity arises primarily from an environment that promotes obesity. (WHO2018, 2020; World Health Assembly 2004). Such an “obesogenic environment” (Swinburn et al. 2001) results from multimillion-dollar advertising for ultra-processed foods high in sugars, fat, and sodium, and the omnipresence and affordability of these products (World Health Assembly 2004).

On international and national scales, Mexico is an obese nation. According to the Organization for Economic Co-operation and Development (OECD), which comprises 35 countries worldwide, representing each continent, Mexico ranks as one of the nations with the highest adult obesity rate (OECD2010). In schoolchildren without program food aid, the prevalence of obesity increased 97% between 2012 and 2018 (WHO2018). In adolescents without program food aid, the prevalence of obesity increased 60% between 2012 and 2018. In adults with moderate food insecurity, obesity increased 10% between 2012 and 2018 (Shama-Levy et al. 2019, 852).

In the face of such challenges, governments and society have not stood idly by. Massive campaigns that promote healthy eating habits, such as the consumption of fruits and vegetables, occur in almost all OECD countries. Mexico has the “5 fruits and vegetables a day” promotion, as well as regulations that seek to promote the consumption of fresh foods in season (5 x Día Verduras y Frutas, México 2006; Official Journal of the Federation [DOF] 2013). Likewise, social networks and mobile applications have encouraged users to reduce body weight and increase physical activity.

According to the National Institute of Public Health (INSP), Mexico is one of the countries with the highest incidence of obesity and diabetes (34% of the population in Mexico is obese and 9.2% have been diagnosed with diabetes) (INSP 2020). The health and economic implications are so large (Manzano 2017), that in 2016 the Health Ministry declared obesity and diabetes national public health emergencies (Rivera et al. 2018). Mexico is also a major consumer of sugary drinks, a known risk factor for obesity and diabetes. Up to 10% of all calories consumed by Mexican children and adults come from sugary drinks (National Health and Nutrition Survey [ENSANUT] 2018).

In January 2014, the Mexican government implemented a 10% tax to industrialized sugar sweetened beverages to curb the obesity and diabetes epidemic. Two years later, a first analysis by the National Institute of Public Health (NIPH) on the impact of this tax found that consumption of sugar sweetened beverages in the country had decreased by 6.1% (INSP 2020).

Obesity is not only a food problem; there are many factors that contribute to obesity, such as some genetic syndromes and endocrine disorders, (hypothyroidism, Cushing’s syndrome, tumors), medicines such as antipsychotics, antidepressants, antiepileptics, and antihyperglycemics, unhealthy lifestylehabits, age, unhealthy environments, family history and genetics, race or ethnicity and sex (Templeton 2014; Lee et al. 2019; Bolton and Gillett 2019). Educational and socioeconomic inequalities (Loring and Robertson 2014) also influence high rates of obesity. The obstacles and difficulties faced by many people in the labor market, such as lower recruitment, lower productivity and poor re-entry, reinforce these inequalities. In Mexico, as elsewhere, it is common to find that malnutrition and obesity coexist among the inhabitants of the same community and among the members of the same household (Pedraza 2009, 108). This is because among lower socioeconomic groups, prenatal and infant nutrition is often inadequate because they receive less expensive fast or processed foods that are high in calories, fat, sugar, and salt, but poor in micronutrients (Headey and Alderman 2019, 2020–2021).

Approach to the Narrative

In the following story, I share my personal story with obesity to illustrate the complex factors that impact weight and foodbehavior and how focusing on individual willpower and personal responsibility will not by itself solve the challenge of obesity.

Narrative

My mother and I struggled with weight issues all our lives.

Since 1997, I have been a Catholic priest, but my priestly formation began back in 1982 at the tender age of 12. The teachings and practices of Catholicism, which emphasize individual responsibility and forgiveness, shaped my personality and approach to my and my mother’s obesity.

As my story will show, my mother could not recover from obesity because the social factors that sustain it are powerful. My mother had to face obesity due to her circumstances. My father was a worker in the United States; he had to be out of the country for half a year and my mother had to take care of the family. My father did not allow my mother to work outside of the home. So, sometimes we did not have enough money to buy food. Sometimes we had to rely upon family and friends for our meals. My parents’ relationship gradually deteriorated. However, my mother never wanted to permanently separate from my father. These marital conflicts and my mother’s tendency to worry about her children had an impact on her physical and mental health and ultimately her obesity.

My mother and I were always very close. My father’s absence because of his work, as well as the fact that I am the eldest of five siblings, led me to behave not only as her son, but as her confidant and support in the care of my brothers.

Although she was a strong, determined, tenacious woman, she could not and did not want to face her obesity. Although she wanted to have adequate weight and a good quality of life, she did not decide to fully cope with her obesity. It wasn’t just about weight; it was about a different way of living. She died with obesity, although not only because of it. On one occasion she went to my room and, with tears in her eyes, she asked me: “Am I never going to be healthy?” At that time, I believed strength of will was enough to face any physical, moral, or spiritual problem. So, I answered to her: “It is enough that you decide to do it”. I was wrong. There is no universal recipe for recovering from obesity.

In 2011, I joined a support group to address my obesity. Thanks to the internal dynamics of this group I became aware of how my physical and emotional health impacted my weight. I lost 46 pounds in 1 year. I discovered that addressing my obesity was not a matter of willpower, but of goodwill, because it is not about following crash diets or extreme exercises, but about adopting a permanent healthy lifestyle.

My father, who is now 72 years old, has been an athlete and an amateur boxer all his life. To this day he is a strong and vigorous man who takes care of his physical health. He was always trying to get me to exercise, to train, to run, to jump rope. When the movie, Rocky, appeared in Mexico, 2 years after it appeared in the United States, my father took me to see it. As I watched the movie, I saw my father: an athletic, handsome sportsman who took care of his body and exhorted me to imitate him. My father wanted me to be like him or like my cousins, who possessed different physical skills than me. He told me that I had to be like them—that they ran, climbed trees and were not fat like me.

In 1982, when I was 12 years old, I participated in track and field at school. My team, the Blues, lacked competitors for a 2.5-mile race. I had never run that distance and, when the coach asked me to run this race, my first reaction was to refuse. Two and a half miles are 12 and a half laps around a soccer field. After 28 min and 30 s, I finished in last place, but I earned points for my team. This experience brought about a fundamental change in my life. I realized that I had many physical abilities that were not the same as my dad’s; they were also not the same abilities as other boys’ my age. My abilities were different, but real. When the time came for the awards, some of my classmates told me, “We didn’t know you were capable of this.” I had pain in my body, but joy in my heart. When I got home, I shared with my family what I had achieved. My brothers, sisters and my parents congratulated me, when I told them that this moment had been like an epiphany, a revelation. I started participating in other sports, because, unlike my father, I was not interested in in boxing. I discovered that I had ability for tennis, Tae Kwon Do, swimming, soccer, hiking, and jogging. At first, engaging in sports, caring for myself, my appearance and health, were influenced by family and social pressures. Afterwards, having a good quality of life was an issue I internalized and made mine. I learned to lead a new way of life.

I entered the Diocesan Seminary in 1985. An eleven-year stage for priestly ordination began. I was 15 years old, 5 feet, 7 inches tall, weighed 172 pounds, and my pants size was 32. My participation in sports and the intensity of my studies resulted in me losing weight and I dropped to size 28. In December 1985, when I went back home to see my father, whom I had not seen since June because of his work in United States, I thought he would be proud of my great achievement. I had lost weight, I was on the Tae Kwon Do team, I was part of the soccer team, and I was running or walking almost every day. When he saw me, my father said: “You are very skinny.” I wondered where the congratulations were, the recognition, the applause, the hug. I had thought that when my father saw that I had lost weight, he would be happy, he would feel proud of me and congratulate me. Within me, I experienced a kind of male rivalry between father and son because of my weight and physical appearance. When he said “you are very skinny” it broke my heart. Instead of a hug and a congratulation, I felt that he saw me as a rival and that his message was: “I am better than you.” I thought he should know that I was following his example and that he should feel happy.

In the Seminary I received many awards for my academic achievements. I obtained an average of A+ during the 11 years of priestly formation. As a prize for my intellectual capacity and my responsibility, I obtained the opportunity to study in Rome. While in Rome, I swam, ran, and went to the gym. I also was careful about my diet, so I returned from Rome weighing 165 pounds. However, I was not able to maintain this healthy lifestyle when I returned from Rome.

I came back to Mexico and the bishop appointed me director of a preparatory school. These were years of intense academic work, including contact with students, parents, staff, and administration. In addition, I provided marital counseling. I worked all day long and into the evening. The daily stresses contributed to my putting on weight. I became an obese person.

I tried to exercise. I played soccer and ran, but I could not manage a healthy lifestyle. When the evening meetings were prolonged, the dinners were plentiful, and since I skipped meals during the day, I overate at dinner. These attitudes created a vicious cycle. Not eating during the day led to overindulgence at night. To compensate, the next day I would forego breakfast or lunch and just drink coffee.

While I knew that many factors impacted my obesity, including my biology, and social and emotional factors, I was still focused on personal responsibility. I felt that I, like everyone else, had to take personal responsibility for starting a recovery process. I hit rock bottom when I realized that my obesity was preventing me from having a good quality of life.

At the time I went to Rome, my mother, weighed 221 pounds, but she was 5 feet, 3 inches tall. Although obesity is not just a matter of weight, she and I realized what was happening with us. Eating more food than we needed made us tired, and our growing immobility saddened us. Things did not get better and our health became precarious. In a span of just 2 years my weight ballooned from 165 pounds to 203 pounds. What was going on inside manifested itself on the outside. I once heard someone say that the body screams what silences the soul.

A friend of mine started losing weight and I asked him how he was doing it, to which he replied that he was receiving treatment from a nutritionist and that it really worked. Although it took me a few months; I finally went to see the nutritionist. The nutritionist told me that a healthy lifestyle includes regular exercise, a balanced relationship with food, enough sleep and rest time, and not forgetting good social relationships. If I had obesity problems it was because I had stopped having a healthy lifestyle (i.e., I was not taking care of my body, my mind or my relationships). The nutritionist became an important teacher for me, because he proposed a diet of specific foods, appropriate portions, fixed schedules for eating, exercise and establishing good social relationships. I knew that I needed a new way of life that included working to improve and maintain the health of my body; to respect, enjoy, and love my body as if it was a part of me and not my enemy.

What happened next was that I came home and talked to my mother and told her we should start together with this new lifestyle. I knew that I theory without practice is just information, because it was not just about improving our body image, but about improving our personal confidence, our psychological state and our functioning in the different areas of our lives. We had to assimilate that love for the body does not lead to creating a perfect body, but it is a condition of possibility to be happy in an imperfect, fragile body, full of challenges.

I started following the diet suggested by the nutritionist. I was walking an hour a day. In 3 weeks, I lost 13 pounds. I lost 46 pounds in a year. Deep down I was proud, because I had “willpower” and, under this premise, I asked my mother to do the same, to start this new lifestyle with me, that she should be strong, that she should eat only what was necessary and that she would soon reach good weight, but she did not, because even though she was a strong woman, determined and courageous, from my point of view, was weak in the face of obesity.

I confess I didn’t consider her genetic predisposition and environmental triggers conspired against her. I did not know that in the face of these conditions, little can be done by just focusing on individual factors. My mother suffered from hypothyroidism and was 23 years older than me. Although I took this into account, my focus still was on my mother’s willpower. My father, my brothers and I often blamed her for her excessive weight. We failed to understand all the pressures and circumstances that influenced her obesity. My mother had to choose the food, she had to adjust to a budget, she had to consider the different preferences of six different people and she had to cook something that everyone liked.

My main mistake was that I thought my mother should be like me, i.e., that it was enough for her to decide to change the way she ate, because I had done it that way. I wanted to lose weight because my motivation was health. I thought that everyone would react like me, that is, they would want to have a “normal” weight for health reasons. I didn’t consider that each person has different motivations not only to provide food to others, but also to eat.

What did my struggle with obesity teach me? It taught me that a complex of factors that range from the individual and physiological to the social contribute to the outcome of body weight. Obesity is about biopsychosocial and spiritual factors. That is why an integrated approach makes sense and is most effective. The whole community must get involved in a sustained way and engage on all levels from individual behavior, nutrition, and physical activity up to the individual’s environment, broadly conceived. The immediate social environment, the family, plays a key role in prevention by establishing healthy attitudes. Attitudes and good habits formed in the family in one generation pass on to children and can have a multigenerational effect on health. The family is a good place to start, but efforts cannot end there. Governments also play a role. Interventions that restructure the environment to make healthier choices easier and make healthy foods more available and cheaper play an important role in tackling obesity.

A holisticapproach will impact the entire population down to the level of individual behaviors. The focus should be on health as the motivator and the desired outcome rather than fixating on weight. This fixation goes hand in hand with stigmatizing the person, rather than focusing on the problem and the behaviors. I know. Fixating on some ideal body type and weight I was never destined to realize was my pathway to stigmatizing myself, one that thank God I eventually learned to avoid.

Questions for Discussion

  1. 1.

    Are stories of personal struggles with obesity useful? If so, what makes them useful; if not, why not?

  2. 2.

    Some people think stigmatizing obese individuals or making them feel guilty about their condition can help them. Do you agree with this idea? Why or why not?

  3. 3.

    Public health professionals emphasize that obesity is a disease. What do you see as the advantages and disadvantages of this view?

  4. 4.

    Obesogenic environments play a role in the obesity epidemic. How great a role do you think environments play, especially compared to individual behavior?

  5. 5.

    Do you think it possible to address the obesity epidemic without in some way limiting or restricting peoples’ lifestyle choices or access to obesogenic foods?

  6. 6.

    The narrative suggests that individual behavior, family life, and obesogenic environments all play a role in the obesity epidemic.

    1. (a)

      Do you agree that a holisticapproach is necessary or the best strategy to address the problem? Why or why not?

    2. (b)

      Do you think that focusing on the family, an obesogenic environment, and the idea of obesity as a disease run the risk of giving obese individuals an excuse not to take responsibility for their condition? If so, how would you address this concern?

    3. (c)

      What conditions do you think most influence the obesity epidemic and why?