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Obesity: stop accusing the poor of making bad choices

Last month, the UK health secretary, Jeremy Hunt, called childhood obesity “a national emergency”, but the government has once again delayed publishing its strategy aimed at combating it.

Obesity is much more common in people with less money and education and this socioeconomic gap is getting larger. An unhealthy diet is a leading risk factor for weight gain and chronic disease and there are marked socioeconomic differences in the types of food consumed.

Dietary inequalities of a different sort were also a concern 80 years ago. In 1936, John Boyd Orr, a Scottish doctor, published Food, Health and Income, which systematically described British eating habits in a way that was unprecedented and critically important both for nutrition science and public health.

Britain in the 1930s was rife with diseases related to malnutrition, particularly among the poor. Studies conducted in impoverished areas of Durham and London found rickets in as many as 80% of children, and inequalities in nutrition manifested themselves in height differences of up to five inches (about 13cm) between the lower and higher socioeconomic classes of school-age children.

New appreciation for food and health

This was also the dawn of modern nutrition science. Although the health benefit of specific foods had been known for centuries, the chemical constituents in food that supported growth and health – what we now call vitamins – were only being discovered in the 1910s and 20s. These discoveries spurred a new wave of science and medicine aimed at understanding the potential for better nutrition to alleviate disease.

John Boyd Orr. Wikimedia Commons

Boyd Orr’s analysis used this latest understanding of “nutritional adequacy” to assess whether people were consuming enough of the nutrients needed for good health. He also surveyed diets among people according to their income. This revealed striking differences in diet, notably in the foods and nutrients important for growth and health – what Boyd Orr called “protective foods”, such as fresh milk, vegetables, fruit, fresh fish and meat.

These foods were consumed much more by middle- and higher-income households – enough to support good health. But lower-income families (about one third of the population) consumed less-healthy diets, consisting principally of potatoes, bread, sugar, margarine and condensed milk. Even with enough of these foods, people were malnourished and vulnerable to disease.

Poor diet, not poor choices

Unlike much of the discussion of the topic today, Food, Health and Income did not talk about “unhealthy habits” or “poor choices”. On the contrary, Boyd Orr recognised that protective foods were more costly and in many cases out-of-reach of low-income families. He argued for improved policies to better enable healthier diets, especially among the poor. He also realised that progress on food and health could only come from a reappraisal of policies across all of government.

But what does any of this have to do with present day efforts to improve diets and combat obesity? At first glance, the public health problem with food has inverted. While in the past, socioeconomic disadvantage was associated with malnutrition and stunting, today disadvantage is linked to obesity. The modern problem appears to be overconsumption. But this superficial analysis misses the bigger point that healthier, protective foods are still less accessible for many.

While the poorest in society today typically receive sufficient calories, they frequently don’t eat enough healthy foods. This isn’t because they lack the knowledge, skills or willingness to make healthy decisions, but because of the influence of our social and economic circumstances in shaping food choices.

Real choice for people on low incomes and living in deprived areas may be limited. For instance, poor neighbourhoods tend to be saturated with takeaways and other shops selling unhealthy foods. While supermarkets provide healthier options, the importance of price may limit poorer people to make healthier choices. Calorie for calorie, healthier foods are three times more costly than less-healthy foods.

These environments are of our own making, through agriculture policy, product formulation, portion sizes, advertising, pricing strategies, taxation, and how our neighbourhoods, workplaces and schools are designed.

Now, as in Boyd Orr’s time, the policies and practices that determine the price, quality and availability of food are often at cross-purposes with health. Yet the arguments and government policies on diet and obesity are largely based on the notion of individual “choices”. These are exemplified in public health campaigns designed to encourage and educate us to choose healthier options. This approach has largely failed, because we have yet to address the unhealthy context in which choices are made.

Getting the bigger picture

There are promising signs of more constructive polices. Last autumn, Public Health England’s sugar reduction strategy provided evidence and recommendations for action to improve food environments. The test will be whether the government is prepared to take bold action in the much-delayed obesity strategy. Boyd Orr’s report was also delayed by the government in 1936, but his vision for coordinated food and agriculture policy aligned for the public’s health is as relevant today as it was then.

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