In the United States, nearly 41 percent of the population is obese. In 2023, the American Academy of Pediatrics approved bariatric surgery and pharmaceuticals as an approach to pediatric obesity and revised recommendations, encouraging pediatricians to refer patients for obesity interventions including drugs and surgery sooner. The recommendations were part of a comprehensive plan that includes “intensive health behavior and lifestyle treatment,” yet the same document declares that aspect nearly impossible to deliver compared to the scope of the problem. The recommendation of bariatric surgery and drugs is a harm reduction strategy. Harm reduction policies target the negative consequences of actions, behaviors, or other phenomena without aiming to resolve the overall problem causing the harm. They avoid the root cause and focus on containing the damage.
Obesity is distributed unevenly in the US population, disproportionately impacting people by socioeconomic status. Non-Hispanic Black women have especially high rates of both overweight and obesity; Black children have almost double the obesity rate of White children. The effect of using drugs and bariatric surgery as earlier interventions based on harm reduction rather than as last resorts will result in experimentation on a disproportionate number of young people of color.
Needle exchanges are the best-known application of harm reduction. The conditions for applying harm reduction are not explicitly elucidated – philosophers continue to finetune parameters for its use. I have a concern about its overuse and hope to contribute to the dialogue, helping discern when it is ethically appropriate. Shannon Dea suggests harm reduction is appropriate in cases where the behavior is ubiquitous and intractable, harms are easily reduced, and abolition (forced abstinence or prohibition) would exacerbate the harm, despite being the ideal. Those favoring harm reduction point to its grassroots nature. It is seen as bottom up, a way for communities to reduce harm by providing easy access to a proven intervention. Some describe it as participatory. For a while, it had the reputation of supporting communities at their own level and meeting “people where they are,” avoiding the preachy feel of public health mandates. It has however become much more prevalent as a primary approach. Public health has suggested principles of harm reduction that recognize the importance of pragmatism. Obesity is like other subjects of harm reduction in that engaging in certain eating patterns fits the vice narrative and many conclude that mandating abstinence would likely not work. That backdrop suggests that obesity is ripe for harm reduction. However, using bariatric surgery and drugs for obesity is not a participatory, grassroots approach and is ethically problematic.
Criteria For The Ethical Application of Harm Reduction
I recommend additional criteria for applying certain harm reduction tactics: First, the absence of morally or legally culpable entities contributing to cause and not engaging in the harmful behavior (or the complete inability to hold them accountable); second, the inability to pinpoint the cause (an unmanageable complexity); third, the permissible harm reduction strategy must be risk-free or very low risk, not merely marginally less risky than continuing along the harmful path; and, fourth, there should be no financial conflicts of interest permitted in the harm reduction policy. These criteria would perhaps alter the application of harm reduction to obesity:
- 1. The food industry and government are culpable. Tobacco companies manufacture and market some of the most highly processed hyper-palatable junk foods; the meat, dairy, and grocery manufacturing industries lobby the USDA and interfere with nutrition guidelines; and pricing is skewed by policies subsidizing the least healthy foods.
- 2. We know the cause of obesity. It is clear – poor diet and sedentariness. There is no mystery at all. There are many social determinants of obesity as well. Education levels, wages, and social groups impact both food choices and options, access to fresh foods, and lifestyle. There is a social and public policy problem concerning access to food, with food deserts posing especially serious problems. However, many programs do focus on access to fresh foods. Obesity is nuanced. Studies demonstrate the social problem: “Cumulative social disadvantage, denoted by higher SDOH burden, was associated with increased odds of obesity, independent of clinical and demographic factors.” And other studies demonstrate genetic, epigenetic, and environmental factors are associated with obesity as well. However, obesity is primarily a social problem, not a genetic one, despite the genes associated with it. Migration studies further demonstrate that genes alone are unlikely to cause the widespread obesity the US has. And rarely do societies where people maintain healthy diets and lifestyles, like Blue Zones, develop high obesity rates, and there is ample proof healthy diets offer a powerful solution.
- 3. The widespread policies to increase the use of weight loss drugs (some off-label use of diabetes drugs) and to recommend bariatric surgery earlier carry health risks. The side effect profile is dismissed too easily. Drugs and surgery are misrepresented and not a universal remedy (although that may be why they fall under harm reduction). Bariatric surgeries, or gastric sleeve, etc. are not risk-free or very low risk. The patients are often high-risk. Some people travel to countries where the risks are even higher. Beyond the risks, there so far is a lack of evidence that people with obesity are improving their diets while on the drugs. I am sure some are, but many are not. Improving diet is crucial – needle exchanges are proven not to incentivize drug use. So far, there is not conclusive evidence that bariatric surgery and weight loss drugs do not incentivize poor eating. And a whole food, plant-based diet and exercise are as effective as bariatric surgery and can reduce the need for medication.
- 4. The fourth criterion I suggest for harm reduction is a lack of financial conflicts of interest and a robust body of independent research. Generally, no one benefits much financially from needle exchanges. I suppose the manufacturers of the syringes might to some degree. Ozempic pulled in $3.3 billion in the second quarter of this year. The global bariatric surgery market is expected to reach $4.81 billion by 2028.
There are many ways to engage in harm reduction for obesity that would be ethical—even recommending moderate weight loss while educating patients has shown to reduce diabetes and other obesity-related diseases. Similarly, replacing just one meal a day with fresh foods would reduce harm. Moving more during the day even without meeting the recommended amounts of exercise is beneficial. As a philosophy, harm reduction may benefit from more criteria and context governing when its use is ethical. It is a successful strategy, and I would never dismiss it. However, misusing harm reduction for obesity risks expanding pharma’s influence on the public at the expense of attention to diet and exercise, which are proven solutions.
Anne Zimmerman, JD, MS is the Founder and President of Modern Bioethics, Chair of the New York City Bar Association Bioethical Issues Committee, and Editor-in-Chief of Voices in Bioethics.