The Fat Divide

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THE FATDIVIDE


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Theres an evident class divide in obesity, and for the first time in history,the poor are getting fatter and the rich thinner. Fran Molloy weighs in.


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And it seems that todays fat cats are taking

that philosophy to heart; the wealthier you

are, the more likely it is that you will have a

healthy body mass index (BMI).

Its a global phenomenon. According to

the WHO Global Strategy on Diet, Physical

Activity and Health, obesity is an epidemic

now recognised as critical, with more than

one billion people worldwide overweight and

around 300 million of those clinically obese,

including 22 million children.

What is behind this epidemic of fatties?

While theres a genetic component that

influences your susceptibility to gaining spare

tyres, humans generally become overweight

when the calories they eat are greater than

the calories they expend in physical activity.

Not that many centuries ago, most humans

were farmers or hunter-gatherers, working

hard to collect every calorie we ate. Storage

and transport of food was minimal and most

people existed on fairly stable diets of mostly

local foods. Sugar, for example, was only

discovered and mass-produced in Europe in

the middle-ages, and then only a few could

afford it.

But modern diets involve a far higher

proportion of fats and sugars and very little

raw food. At the same time, technological

advances have reduced the physical activ-

ity needed in our work, our transport, our

domestic lives and even our leisure pursuits.

THE SKINNY CLASSES

Australia is now one of the most overweight

developed nations, with more than 60 per

cent of our adults and one in four of our

children classified as either overweight or

obese and rates of Type 2 diabetes, a serious

related chronic condition, are skyrocketing.

The total direct health care costs (such as

hospitalisation, medical care and medica-

tions) directly attributed to overweight and

obesity in Australia is $21 billion a year.

And both obesity and Type 2 diabetes

are far more prevalent among disadvan-

taged socioeconomic groups, indigenous

Australians and those without post-school

qualifications.

Associate Professor Kylie Ball, a senior

research fellow in the School of Exercise and

Nutrition Sciences at Deakin University, has

published a number of papers on the link

between obesity and socioeconomic stand-

ing. She says theres definitely a link between

obesity and social standing, and that link

seems to be more consistent among women.

When you look at a persons level of

education, their occupation or perhaps a little

less consistently, their income, it seems to be

that the those who are the most disadvantaged

according to those type of measures are at

greater risk of obesity.

It is also the case that living in a neigh-

bourhood which is socioeconomically dis-

advantaged seems to confer an independent

risk, she adds.

Her current research involves pinpointing

the mechanisms by which socioeconomic

disadvantage leads to a risk of obesity.

Some of the more obvious ones are physical

activity behaviours, eating behaviours and

sedentary behaviours, that is, amount of time

that is spent sitting.

She says there is little good evidence on

why wealthy people dont get obese, but

plenty of theories.

Some of the things that we suspected

probably contribute are around social norms

and values and an idealised body image of

being slim for women in particular.

Ball says that women in more affluent

countries, or women at a certain socioeco-

nomic strata in both developing and wealthy

countries, tend to be more concerned about

gaining weight than do women in lower

socio-economic positions.

WWALLIS SIMPSON, THE AMERICAN SOCIALITE

behind the abdication of her third husband, formerBritish monarch King Edward VIII, famously said:

You can never be too rich or too thin.


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Obesity is a complex and multifaceted

thing and theres no one single cause, just

as there is not one single cause of the socio-

economic inequalities that we see, she says.

For people of low socioeconomic status,

theres a combination of factors, both as indi-

viduals and in the environmental context in

which they live, that makes it more difficult for

individuals to avoid unhealthy weight gain.

Professor Sir Michael Marmot, newly-

appointed president of the British Medical

Association, is a world-leading social epi-

demiologist who chaired the 2008 WHO

Commission into social determinants of health.

He says that the Commissions most striking

discovery was that non-communicable disease

dominated in almost every region of the world

except the very poorest.

Seventy per cent of women in Egypt are

overweight or obese, says Marmot, while in

Mexico, the problem of obesity far outweighs

problems of stunting and under-nutrition.

But while obesity is clearly part of a major

global health crisis, its the causes of obesity

that are the real issue and breaking these

down is complex.

It relates to the nature of our food supply, the

nature of opportunities for physical activity, the

changing nature of physical activity at work and

how people make food choices, says Marmot.

In the poorest countries, better educated

women are more likely to be obese because in

these countries, women with little education

are so poor they dont have enough calories

to eat. But in countries with an average

income per person higher than $2700, theres

an inverse association, where women with

more education are less likely to be obese.

We can speculate on why its the case

that more educated women in high income

countries are less likely to be obese, and

its presumably in part cognitive; its about

fashion and the ability to control your cir-

cumstances, what you eat, going to the gym

and so on, Marmot says.

Despite the rising incidence of bulging waist-

lines, starvation is not a thing of the past.

While millions of people are clogging up

their arteries and dying early from obesity-

related disease, the World Food Program

reported last year that another billion people

on the planet dont have enough to eat.

Societal change is driving a bizarre situa-

tion in which the overweight and the hungry

jostle for space on the healthcare agenda.

On the face of it, theres no reason for one-

sixth of the worlds people to go hungry; more

than enough food is produced to feed all of

humanitys rapidly growing population. Despite

world population increasing by 70 per cent over

the last 30 years, the worlds agricultural pro-

duction has increased even more substantially,

with nearly 20 percent more calories produced

per person today than was produced 30 years

ago, according to a UN Food and Agriculture

Organisation (FAO) paper released in 2002.

Enough food is produced to provide everyone

on the planet with about 2700 kilocalories a

day sufficient for a moderately active male

aged 19-30, according to the American Heart

Associations caloric tables, and more than most

other people really need.

But many people dont have the resources

to grow or buy sufficient food for themselves

and their dependants. It is this basic inequal-

ity of distribution that has been the source of

world hunger for centuries.

Most hunger and poverty is concentrated

in rural areas, among small farmers and

landless families in the developing world,

according to the FAO.


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Yet it is also in the developing world is

where much of the battle of the bulge is

taking place.

Overeating and its associated medical

costs are spreading rapidly beyond wealthy

countries to the developing world, wrote

the US-based Worldwatch Institutes Gary

Gardner and Brian Halwell in 2000.

The worldwide incidence of Type 2 diabe-

tes is projected to double between 1998 and2025, with more than three-quarters of this

growth occurring in the developing world.

FOOD GLORIOUS FOOD COMPANIES

Professor Bruce Neal is the Sydney-based

senior director of the George Institute for

Global Health and a professor at Sydney

Medical School. He also chairs the Australian

Division of World Action on Salt and Health.

It is widely accepted that the globalisa-

tion of the processed food industry is a key

factor behind diet-related ill health, he

says, adding that this is driving the growth

of chronic disease in both developing and

underdeveloping countries.

Neal says that the key problems are foods

with too much salt, too much fat (particu-

larly trans fats and saturated fats) and too

much energy (calories).

High consumption of processed food

is leading to conditions like high bloodpressure, abnormal lipid profiles, obesity,

diabetes and even some cancers, says Neal.

Gardner and Halwell also point to the

influence that the marketing practices of mul-

tinational food giants have on the purchasing

habits of millions of consumers.

This, together with a lack of nutrition

education, is driving consumption of high-

calorie, low-nutrient foods at the expense of

real food.

Food is the most heavily advertised com-

modity in Austria, France, Belgium and the

United States, and more than half of this

advertising is for candy, sweetened breakfast

cereals, fast food, and other items of dubious

nutritional value, wrote Gardner and Halwell.

With food companies largely unchal-

lenged in targeting our sweet tooth and

shaping our tastes, it is little surprise thatmore than half of American adults are

overweight and one in five are obese.

According to Professor Barry Popkin of the

Department of Nutrition at the University

of North Carolina, today, the burden of

sedentarianism, nutrient-dense poor diets

and obesity is shifting to the poor.

Popkins research into lower and middle-

income countries in Asia, Africa, the Middle

East and Latin America demonstrates that

diet, activity, and obesity are changing very

rapidly in the developing world.

Popkin says rapid globalisation is partly toblame for the fast adoption of a high-density

diet with reduced complex carbohydrates.

At the same time, the growing penetration

of modern mass media is promoting heav-

ily processed foods, and a substantial shift

in occupational structure is reducing the

typical daily physical activity of much of the

workforce.

Popkin says that his own (as yet unpub-

lished) research examining the structure of

rural and urban diets in China has shown

dramatic increases in energy density and

increased intake of edible oil and sugars,

rising by 10 per cent over the decade to 1997.

Popkin used data from the China Health

and Nutrition Survey (CHNS) results for

adult physical activity patterns over the same

198997 period and found a significant

downward shift in activity for adults aged

2045 categorised with moderate activity.

The main recommendations from the Final

Report of the WHO Commission on Social

Determinants of Health in 2008 included

improving daily living conditions and tack-

ling the inequitable distribution of power,

money, and resources.

Marmot says that one of the key areas for

action to resolve the social inequalities in

health is to start at the very beginning, with

early childhood health.

We emphasised a life course approach,

starting right at the beginning of life, he

says.

But just as the importance of preventing

obesity from early childhood is recognised,

researchers are identifying market forces

working in the opposite direction, with a

speed and effectiveness that has already

Dr Lauren Williams, an academic

dietician at the School of Health

Sciences at the University of

Newcastle, found a significant

link between social status and the

weight control practices of Australian

women aged 45 to 50 years.

Williams team analysed results

from around 8000 women aged

between 45 and 50 years who

completed a large national health

survey and found that on average,

the whole group gained weight over

two years.

However, the group of middle-class

and upper-class women gained around

one kilogram over the period, while the

working-class women gained 1.27 kg.

Its well reported in the literature

on this topic that people of lower

socioeconomic status tend to be

more overweight, Williams says.

However, we didnt know much

about what people were doing to

control their weight gain.

Williams found that women who

reported themselves of upper or

middle class status were more likely

to use a combination of exercise and

methods like reducing portion sizes

and between-meal snacks. These are

more effective long-term weight loss

methods, she adds.

However, she found it was more

common for women who self-

reported themselves as working

class to use methods shown to be

less effective in the long term, such

as dieting, weight loss powders, pills

and diuretics and this group was

less likely to exercise.

With sedentary occupations

now crossing all classes, and many

options for exercise (such as gym

membership) something of a luxury,

cost may be a factor.

But theres no data about

motivation and any conclusions are

speculative, Williams points out.

She theorises that what and how

people eat is a way for them to define

who they are and often reinforces

membership of a particular group.

Its possible that our weight

control practices are also a way of

defining who we are, in terms of

defining our social class, she adds.

Why weight?

The worldwide incidence of Type 2 diabetes is projected

to double between 1998 and 2025, with more than three-

quarters of this growth occurring in the developing world.


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outstripped the slow-moving pace of govern-

ments and NGOs.

A 2008 World Health Organisation

report completed by the Institute for Social

Marketing at the University of Stirling

showed that the food industry is systemati-cally targeting children in its marketing.

The report noted that children play an

important role in developing new market

opportunities for fast-food and quick service

restaurants in low and middle income coun-

tries. Children-friendly initiatives have been

effective entry strategies in fast growing mar-

kets in low and middle income countries,

the authors state.

The majority of foods and food products

promoted are energy dense, high fat, sugar and/

or high salt, and in sharp contrast to national

and international dietary guidelines.Strategies that have been tested and honed

on more media-savvy western markets are now

bombarding the children of developing nations.

Marketing strategies in lower income

countries follow very similar patterns to

more affluent markets, with the emphasis on

low nutritional quality foods, the dominance

of TV advertising but increasingly supple-

mented with other forms of promotion that

reinforce marketing objectives and build

brand awareness and allegiance.

Viral marketing, competitions, games, on-

pack promotions and store-based advertising

are all used to target children who increas-

ingly play a key role in family purchasing

decisions.

Sugar-sweetened breakfast cereals, soft

drinks, confectionary and savoury snacks

are the most frequently advertised categories,

with fast-food promotion continuing to gain

marketing share. Promotion of unprocessed

foods, such as fruit and vegetables, whole-

grain and milk is found to be almost zero.

REGULATION AND LEGISLATION

In the first episode of the 2007 Australian

political satire The Hollow Men, the Prime

Ministers proposed campaign against junk

food withers when food industry heavy-

weights pressure the government to instead

introduce a lame voluntary code.

The satirical storyline held no surprises

for Professor Neal. He made headlines

in September this year when he quit as

an independent arbiter of the Australian

Responsible Childrens Marketing Initiative

code, because the program was ineffective.

Can self-regulation of the food industry be

successful? Neal is unsure, but thinks we

have no choice but to try it. If governments

are prepared to legislate, a lot more could be

done, but it takes a long time and immedi-

ately puts everyone into a sparring position.

Industry will fight long and hard against

regulation, he points out, and global multi-

nationals have a lot of political clout.

Working with the food industry is the

key to getting action on nutrition content,

he says.

Neil believes that effective and fast food

reform can occur by pushing industry into

voluntary regulation, with clear voluntary

agreements, setting goals to be achieved in a

specific timeframe, with monitoring by a

credible independent third party.

When government regulation is a credible

fallback position if a voluntary code fails,

theres incentive to get it right, he says.

Neal cites the highly effective UK Food

Standards Agency salt reduction campaign

which began in 2003 with voluntary agree-

ments from food industry participants.

Britain now leads the world in salt reduction,

with average daily salt intake down from

9.5g in 2003 to its current 8g, and plans to

reduce it to 6g.

By changing even a small part of the food

supply, people cant help but make better

food choices, Neal says. Its much easier

to get a few hundred food manufacturers to

take ten per cent of salt out of everything

they make than it is to change the food habits

of six billion consumers.

In Shakespeares Comedy of Errors,

Dromio warns: Marry, he must have a long

spoon that must eat with the devil.

But as the global food industry wallows in

its profits from tubby junk-food consumers

the world over, it seems that sitting down

with the food-devils and developing co-

operative targets for nutrition content may

be our only chance to hold back the tide of

obesity.

Fat chance? Lets hope not.

LEFTBRUCE NEAL

RIGHTMICHAEL MARMOT, BMA

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The Fat Divide