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Thursday, May 28, 2015

Obesity, poverty and convenient myths

Policy makers don’t read tabloid newspapers. They read more serious broadsheets from the London Times to Figaro to the Washington Post. And these broadsheets often perpetuate the beliefs that make the upper social echelons happy or indeed smug. And among these beliefs is that which argues that the present epidemic in obesity is primarily a problem of the lower socio-economic groups. One cannot argue against the line that obesity rates are higher among the socially disadvantaged. Neither can one argue against comparably higher rates of suicide, homicide, drug abuse, violent crimes, indebtedness, heart disease, cancer and anything you care to mention but which you’d rather do without, thank you very much.

The fact that obesity, like suicide and homicide, is higher in those who are socially disadvantaged doesn’t mean it is absent in the socially advantaged. The differences in obesity rates are in high fractions such as 0.8 or thereabouts such that for every 5 obese persons who are socially disadvantaged, there are 4 obese persons among the economic elite. Think of the Clintons, Hilary in recent times and Bill, a while back. However, as I’ve already said, obesity is higher among the socially deprived. The question is why so and what to do about it.

A recent paper in the American Journal of Public Health[1] looked at residence mobility in relation to social status and the economic deprivation of the areas of residency in the city of Dallas. The study was part of an on-going study on heart disease and followed subjects (about 1,800) over the period 2000 to 2009. Weight was monitored at baseline, at various intervals and at follow up. Half the subjects moved from one neighbourhood to another and of these, 600 subjects moved to a neighbourhood with a higher ‘Neighbourhood Disadvantage Index’ (NDI: ~ perceived neighbourhood violence, poor physical environment, and low social cohesion). Compared to those who moved to a neighbourhood with a lower NDI or who remained where they originally resided, those moving to a higher ranked NDI suburb gained significantly more weight and the longer the residence in the higher NDI suburb, the greater the weight gain.

Well of course, the answer is simple. These people moved to “food deserts”, the trendy middle class quasi left wing term to describe regions which are so poor, its not worth anyone’s time and money in building them a supermarket. Consequently, the creed goes, they cannot get access to affordable and varied food supplies but are forced to shop in local stores that don’t sell fruit and vegetables at a reasonable price and which prefer to stock their shelves with cheap and, of course, high fat, high sugar and high salt foods (Credo in unum dieta!). Enter a governmental initiative that subsidised the building of a brand new supermarket in the suburb of Morrisania in the New York borough of the Bronx with a ‘control’ suburb of Highbridge where no such investment was made. A research paper just published[2] examined food choice 5 weeks and 52 weeks after the supermarket was opened. The authors concluded as follows: “The introduction of a government-subsidized supermarket into an underserved neighbourhood in the Bronx did not result in significant changes in household food availability or childrens dietary intake. Given the lack of healthful food options in underserved neighbourhoods and need for programmes that promote access, further research is needed to determine whether healthy food retail expansion, alone or with other strategies, can improve food choices of children and their families”. So, access to healthy food options is not the issue. It is most likely lifestyle choice arising from a particular educational stance.

Now enter the ultimate holy grail of the urban middle class food priests, the Farmers Market. What can be more morally upright than buying wholesome food directly from the farmer who toiled the land to produce such heavenly fare? Well, a recent study[3], also in the Bronx, paints a different picture. Following a comprehensive study of farmers markets (FMs) in this region, they conclude as follows:  (1) FMs operate overwhelming fewer months, days, and hours than nearby stores, (2) FMs carry less-varied, less-common, more-expensive produce than nearby stores. (3) FMs offer many items not optimal for good health (e.g., jams, pies, juice drinks) and OMG, (4) FMs might provide little net benefit to food environments in urban communities.

Social inequality lies at the heart of many patterns of chronic disease. Tackling it is outside my expertise but I’ll vote for it

[1] Tiffany M. Powell-Wiley et al (2015) Am J Public Health, in press
[2] Ebel B et al (2015) Public Health Nutrition, Feb 26:1-10.

[3] Lucan SC et al (201)  Appetite 90, 1 July 2015, Pages 2330