Obesity in lower-socioeconomic areas

Independent Research Task

Ainsley Meale | 2018 | Global Studies

Table of Contents

Introduction

Background

Literature Review

Methodology

Results of Primary Research

Solutions

Recommendations

Reference List

Appendix Interview TranscriptsProgress Log

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IntroductionThe focus question of this investigative report is How can we lower the rate of obesity in lower-socioeconomic areas? The goal is to establish why and how socioeconomic factors, especially income, employment and education, influence the rate of obesity and thus, why lower-socioeconomic areas have comparatively higher rates of obesity. Additionally, this report aims to explore the current methods in place to reduce the issue (such as the ‘flattening’ of the social gradient), particularly looking at the European Union (EU) and Australia.

Obesity is a significant and detrimental issue around the world, made more significant, and growing every day, due to the inequitable environments and the consequent social exclusion that creates socioeconomic differences. This is partly due to the social gradient most attempted solutions contain, in that they end up benefiting the most advantaged and worsening the less advantaged, and thus worsening the problem. This results in the problem to become worsened as society progress.

To examine the solutions put forward in this report a Utilitarian paradigm will be used, in aid with personal judgement influenced by external research. A Utilitarian paradigm centres around the doctrine that the only test of the goodness of moral precepts or legislative enactments, is their tendency to promote the greatest possible happiness of the greatest possible number [Bentham 1843]. Therefore, the best action is the one that maximizes utility, termed with the highest wellbeing of the greatest number of individuals. In this case, solutions should better the greatest number of individuals.

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Background  Obesity Obesity is defined as an individual with a Body Mass Index (weight in kilograms divided by height in metres) of 30 or more [Australian Government Department of Health n.d.].

The increasing gap between lower and higher-socioeconomic groups in society, the changes in food environments and the new age of ‘consumption’ has allowed obesity to become one of the biggest problems throughout every country in the world, regardless of how affluent or necessitous they and their citizens are. According to a report published by the World  Health Organization [Loring & Robertson n.d.] 16-20% of deaths in the older EU Member States. Similarly, in western and central European countries, the total disease burden has 10% located to obesity. In parallel, more than 5% of the total disease and injury burden is attributable to overweight and obesity (defined by high BMI) [Australian Government Department of Health n.d.] in Australia.

Socioeconomic Factors Socioeconomic factors are the social and economic experiences and realities that help mold one's personality, attitudes and lifestyle [Chase 2018]. It mostly refers to the social and economic position of a given individual, or group of individuals, within the larger society. Socioeconomic status is usually, but not always, conceived of as a relative concept and can be measured for the individual, family, household or community/area. The Australian Bureau of Statistics defines relative socioeconomic advantage and disadvantage in terms of people’s access to material and social resources, and their ability to participate in society [Australian Bureau of Statistics 2011]. It consequently shapes an individuals’ lifestyle and therefore their local economy and community.

There are many different types of socioeconomic factors that can influence an individual and their way of life. These are termed the social determinants of health, and include the following:

 

Despite the number of factors placed in the social determinants of health, the proxy measures that the ones that most affect risks of obesity are; income, employment, and education. The physical areas in which these factors are challenged, where the access to material and social resources, and where an individual’s ability to participate in society is limited, is what will be centred on, along with obesity rates within these areas, within this investigative report.

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Fig. 1 Australia’s Health 2016

The Correlation The assertion that socioeconomic factors directly influence the rate of obesity is directly supported by Houle [2013] where he states that studies show that factors that increase the risk of being obese affect socioeconomic status groups, and may cause disparities in obesity between socioeconomic groups that worsen health and shorten longevity for those who are most disadvantaged. This is further explored by Loring & Robertson [n.d.] under the World Health Organisation when they state that the prevalence of obesity in Europe is rising in many countries, and rising fastest in low socioeconomic population groups. European countries with higher income inequality have higher levels of obesity. They summarise by affirming that there is a strong relationship between obesity and low socioeconomic status [Loring & Robertson n.d.]. This is because of how strongly this status influences one's health.

Causes

Despite the multifaceted influences and causes of obesity, income, education and occupational status are arguably the most responsible for the high rates of obesity in lower-socioeconomic areas. This is because of the intimate influence between the three factors - your employment will dictate your income. Your income level often correlates to your level of education and your level of education helps to dictate your employment [pdhpe.net n.d.] because of the educational requirements employers look for [Doyle 2018]. Therefore, financial insecurity or little income as a result from income inequality is the primary by-product and ironically, the beginning of an individual's employment and education. Money gives an individual freedom and choices, and access to resources and facilities. Therefore, when an individual experiences economic instability or receives low income due to their socioeconomic situation, access to these aspects such as nutritious food can be severely sacrificed. These areas have a critical role in keeping someone out of the 30 BMI range of obesity and out of poor health in general. Therefore, someone with lower-socioeconomic status and with financial insecurity or low income from a ‘low-brow’ occupational status (usually the result of a poor education), will have a higher risk of developing obesity.

This is demonstrated in Figure 1 on the right, completed by the World Health Organization, and shows how obesity is prevalent in women of all levels of education throughout countries of the EU. Additionally, it intimately depicts the correlation between low-level education and high rates of obesity, showcasing how socioeconomic status heavily influences the rate of obesity. The transformation of society, particularly social gradients steepening, is a causation of socioeconomic factors playing such a crucial role in obesity rates. Steepened social gradients also allow, in many areas, between the poor and affluent, to become more substantial. Our society allows this steepened social gradient to become the determinants of the level of health of an individual. They therefore determine how big a risk an individual poses to incurring obesity. It also increases the difficulty of reducing the rates and ultimately solving the issue of obesity because it is so complex - due to the inequity that you first must address and then reduce [B Duckworth 2018, personal communication, 29 July].

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Fig. 2 Obesity and inequities n.d.

Consequences Life threatening health problems are associated with an unhealthy BMI and its consequent obesity. It may increase the risk for many health problems, including; type 2 diabetes; high blood pressure; heart disease and strokes; certain types of cancer; sleep apnoea; osteoarthritis; fatty liver disease; kidney disease; pregnancy problems, such as high blood sugar during pregnancy, high blood pressure, and increased risk for caesarean delivery [National Institute of Diabetes and Digestive and Kidney Disease 2015]; and a range of other health problems.

These put a large strain on a country’s resources, economy and community. The cost of obesity to the Australian economy was 8.6 billion dollars from 2011-12 [Australian Institute of Health and Welfare 2017]. Direct medical spending on diagnosis and treatment of these conditions, therefore, is likely to increase with rising obesity levels [Hammond & Levine 2010] and also put a substantial strain on an individual's financial means. This strain can impact many other areas of an individual's life because of the money sacrificed for treating these health problems. Furthermore, this treatment seeked can put a considerable strain on a country’s healthcare system, ultimately taking money out of taxpayers’ pockets. In the UK it is estimated to be around twenty billion pounds per year, taking lost productivity and sick days into account [Loring & Robertson n.d.]. It also causes a range of indirect consequences, such as loss of productivity. The productivity costs of obesity have been well-documented in a variety of studies, with widespread consensus that such costs are substantial, but with important differences in magnitude between the individual estimates [Hammond & Levine 2010] which is seen primarily in the labour market, including first-order productivity costs and decreased productivity of employees.  Thus, said economy would be significantly affected because of decreased motivation, achievement and work status amongst employees.

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Literature ReviewA range of literature, including recent articles, books, websites and interviews were gathered and conducted to create a broader understanding of the topic. Literature was chosen because of the accurate, reliable and relevant information it provided. It also spoke to the scope of the report.

It was agreed that obesity is a genuine epidemic worldwide [CIBER 2018] despite knowledge of it being one of the largest out of all health problems. It is now at its largest extent due to the economic growth, industrialization, mechanized transport, urbanization, an increasingly sedentary lifestyle [Hruby & Hu 2015], and the changing food environments we are so heavily influenced by [Duckworth 2018].

Additionally, a socioeconomic gradient in obesity is extremely prevalent [Devaux & Sassi 2011] in society and obesity, resulting each socioeconomic group being relatively more obese than the next group above them in the social spectrum [Loring & Robertson n.d.]. This means obesity and socioeconomic status are interrelated and equate to worse outcomes in each other when one fails to be solved.

Current research available on obesity is highly accessible, unbiased and reliable due to the prolific nature of it being studied across the world, particularly from individuals or groups belonging to developed nations. However, when combined with socioeconomic influence (as socioeconomic related obesity rates) information tended to be less accessible and reliable, and there are less perspectives presented.

Certain socioeconomic factors had more information on their influence on obesity than others; education and income tended to be the most approved - income and education are inversely associated with obesity [Pavela, Lewis, Locher 2016] – while quality of neighbourhoods was under-approved and under-researched. Despite this, a majority of sources agreed that socioeconomic factors influence on obesity was extremely substantial. A majority of the information regarding this perspective was thorough, accurate and reliable.

A couple of reports announced the opposite - socioeconomic status might not be an important risk factor for obesity [Lee, Kim, Choi 2017], because the associations are different across countries due to different environments resulting in different socioeconomic factors. However, it was concluded that this report was significantly influenced by the author’s personal bias. An article by Peeters & Blackholer supported this statement, suggesting that evidence shows that these socioeconomic factors might not be experienced similarly across the socioeconomic gradient [2015] and therefore can’t be associated with rates of health problems. Other information regarding this perspective was scarce and usually unreliable.

Many sources agreed that improvements should be made to ensure that solutions, particularly strategies and practices, do not make inequities worse given that rates are highest in lower-socioeconomic areas. The World Health Organisation support this statement where it said that unless equity is explicitly taken into consideration, policies, programmes and services are created that have a social gradient in their effect. This allows the gap between the poor and affluent to grow and obesity rates to heighten.

How this can be avoided was discussed by a report by the New Zealand Ministry of Health, where the setting out of a framework that can be used at national, regional and local levels by policy-makers, funders, service providers and community groups to take action to reduce inequalities [2002] was suggested. This was highly reliable information due to the reputation of the source.

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How this can be done the quickest and to the best extent to create equity throughout the general population is one common question currently being asked by professionals of the field.

The championing of healthy eating was another common solutions found. A Harvard report announced that hospitals, clinics, educational institutions, and similar facilities can support healthy changes by making sure they promote healthy environments [Harvard n.d.] while another stated that a successful ‘whole-of-system’ approach to increasing healthy eating and physical activity requites action from all levels of government, industry, non-government organisations, individuals and communities and a range of strategies [NSW Health 2013]. This solution was the one most emphasized by the most reliable sources, however proved ineffective when applied to lower-socioeconomic areas because of the costly expense of buying healthy foods.

Other solutions put forward were; promoting breastfeeding; subsidizing healthy foods [A Cottam 2018, personal communication, 19 October] and desensitizing unhealthy foods; restricting marketing of unhealthy foods; and offering counselling and support to the disadvantaged.

To conclude, the literature on the influence of socioeconomic factors on obesity and how it can be reduced is useful in gaining an understanding of contemporary data, repeated themes, conclusions, and solutions formed by varying parties. Generally, most sources agreed that obesity was an increasingly relevant and growing issue, and the information and knowledge on it extremely large. It was also concluded that socioeconomic related obesity was arguably, understudied. An expanse of literature also highlighted healthy eating as a strategy and agreed policies and strategies aimed at solving obesity should be ensured to not worsen inequities effecting obesity so prevalently.

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MethodologyTo gain a further understanding of the topic, two interviews were conducted with professionals. I chose to conduct interviews not surveys because; of the difficultly in shaping questions that could be used in a survey that provided information that I could effectively use; the quantitative information it would provide; and the opinions of respected professionals it would relieve rather than the beliefs of my peers and other acquaintances that have little knowledge of the topic.

Seventeen emails were sent out to a range of parties requesting an interview. These groups and people were contacted due to the extensive knowledge and strong opinion on the issue that they held. Two interviews were conducted off the back of these emails, with Ms Belinda Duckworth from NSW Department of Health and Ms Angela Cottam, a nurse at Barker College.

The interviews were both conducted face to face, recorded with permission, and transcribed. These interviews provided a range of valued opinions on the topic and extensive information that was effective. The two interviews were 30 minutes and 15 minutes.

With Ms Belinda Duckworth, the questions that provided the highest value to the report were questions 3, 6, and 7 because they spoke to the scope and couldn’t be attained through secondary research.

While the second interview with Ms Angela Cottam was where the same seven questions were asked, only five were answered because of the experience she thought she lacked to fully answer the questions. This slightly disadvantaged my process of primary research because of the unreliability of the methods being used, however the questions that were answered provided useful and accurate information.

The first interview was conducted with Ms Belinda Duckworth, chosen because of her reputable stance. The responses she gave were more opinion based. The second interviewee was Ms Angela Cottam. She was chosen, partly because of the time constraints of the collection of primary research, and because of her unique position in providing information on a health related topic. This meant she knew more on obesity as a whole. The responses she gave, particularly in question 4, were highly reliable and relevant. She had considerable bias to including education in solving the issue, due to her background.

A limitation to the process was that I did not interview a professional previously or currently working in an occupation related to socioeconomic factors. Interviews also could’ve been conducted with professionals from countries other than Australia. This would have allowed the information being gathered to be more accurate and reliable, and present a wider range of perspectives. However, I was able to attain this through secondary research. Obviously, a greater number of interviews would have provided a broader perspective on the topic. However, due to time constraints, two interviews had to be called sufficient.

Overall, the interviews conducted in the attainment of primary research were thorough and provided an insight into the topic that could be used to create a more accurate report.

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Results of Primary Research

Two interviews were conducted in the collection of primary research. Both interviews, Ms Belinda Duckworth and Ms Angela Cottam, provided a resourceful insight into the topic at hand. The information that provided this is seen below:

Both interviewees emphasised that obesity was a significant and detrimental problem to society in itself and to the individuals coexisting in it. They also stressed that obesity is a particularly a relevant and large problem in lower-socioeconomic areas due to the social determinants of health [Duckworth 2018].

In her interview, Ms Belinda Duckworth first talked about the strong correlation between the environment and the incidents of obesity, by using examples of Indigenous communities and lower-socioeconomic areas in Western Sydney, such as Blacktown. Using these areas as examples, she stressed that obesity was because of the social, physical, and cultural environments in which the individuals lived in. Because of this fact, she then insisted that physical environments and social environments must be improved, with the work of all levels of government, councils, individuals and businesses, such as with Coles. This effectively promotes healthy eating in lower-socioeconomic areas.

Ms Duckworth also mentioned the key role of education and the importance of working with new parents and their general practitioners in intervening early in a child’s life, in order to reduce the risk of said child incurring obesity in later life. These statements were the short and long term solutions Ms Duckworth believed to be the most effective in reducing obesity in lower-socioeconomic areas. Overall, in her interview, Ms Belinda Duckworth presented a wide perspective on the issue.

Many of the themes, solutions and findings spoken by Ms Belinda Duckworth were later reiterated by the second interviewee, Ms Angela Cottam. Because of her involvement in the educational system as a school nurse, she particularly emphasized the importance of early intervention in order to form healthy habits early, in children and adolescents. She also stressed that education is a key solution. This involves placing nurses in all schools, not just at Barker, because they are in a position where they have the access and resources to teach and educate children about health. The subsidizing of healthy foods was also briefly mentioned in the interview.

The interviews conducted in the collection of primary research created a broader understanding of the influence of socioeconomic factors on obesity and how it can be solved as an issue.

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SolutionsMany solutions were identified in the collection of secondary research literature and primary research on solving socioeconomic related obesity. However, after collecting and analysing a number of solutions, three were identified as the strongest and most effective in reducing socioeconomic related obesity.

Solving inequalities and ‘flattening’ the social gradient

Strategies combining universal and targeted measures that offer support to lower-socioeconomic individuals was a recurring theme within research. This is because it allows the social gradient to be ultimately ‘flattened’, ridding the causes of socioeconomic related obesity. If we were to reduce this gradient, by intervening via strategies that incorporate workplaces, government, schools and other key organisations, we would see these rates of obesity, especially in lower-socioeconomic areas, largely diminish [Duckworth 2018].

Given that the social spectrum fosters the development of obesity greatly it is exceedingly important that policy and strategy choices do not make this social spectrum steeper. If obesity is most prevalent in socially disadvantaged groups, yet interventions are most effective in advantaged groups, there will be less chance of reducing overall prevalence and as a result, obesity inequities are likely to widen [Loring & Robertson n.d.]. Therefore, these practices would involve a combination of policies that address inequities.

This involves a range of involvement that contains short-term actions but a long-term focus, as well as both simple and complex interventions. Developers of these strategies would also not have a business-as-usual approach – this results in the strategies having a social gradient in their effect, without the consideration of equity, and therefore have a negative effect on the rates of socioeconomic related obesity.

Strategies that attend to those significantly affected by obesity that live in lower-socioeconomic circumstances allows both issues of inequity and socioeconomic related obesity to be solved rather than singly achieving a flattened social gradient. This strategy will also be significantly more effective than to rely solely on individual-level interventions [Hawkes, Ahern, Jebb 2014] that are unlikely to be impractical or cost effective.

Reducing the gap between the affluent and poor is the key course of action in resolving the issue of obesity within lower-socioeconomic areas, and is easiest to do after the above steps. By completing them we can successfully achieve lower rates of socioeconomic related obesity - because it eliminates all factors that have placed them in this lower area, while simultaneously creating equity for the general population. This satisfies the needs of a Utilitarian paradigm because of the large amount of people satisfied - better levels of equity will generate benefits for the entire population, such as economic improvement, because they are likely to reduce a range of issues related to social in-cohesion. However, properly addressing these inequities throughout the general population is unrealistic because of the magnitude of it today, with Oxfam affirming that the world’s eight richest people own as much as wealth as the poorest 3.6 billion [Basu 2017]. Therefore, the chance of the success of this solution actively reducing obesity rates in lower-socioeconomic areas is low.

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Advocating for the importance of healthy eating in lower-socioeconomic areas

Healthy eating is a critical behavioural risk factor that can have a significant impact on health at all ages. Healthy eating contributes to achieving and maintaining a healthy weight [NSW Health 2013]. It also significantly minimizes the risk of onset of a complete range of noncommunicable diseases [R. Shrivastava, S. Shrivastava, Ramasamy 2016], including obesity, thus showing the importance of this solution.

Using subsidies to incentivize healthy food, as emphasized by Ms Angela Cottam, and taxes to disincentive less-healthy purchases is one of the most effective ways to achieve this advocation. This is because it addresses the social determinants of health and therefore can coexist with lower-socioeconomic individuals. A successful strategy similar to this was seen in 2013, in Mexico, when then President Enrique Pena Nieto proposed a soda tax [Rosenberg 2015] to a country with the highest death rate from chronic diseases caused by consumption of sugary drinks. This law saw a successful impact in the consumption of sugar drinks with a 5.5% drop in its first year, while health problems such as diabetes and obesity significantly reduced.

Therefore, these subsidies and taxes would involve working with levels of government, individuals and private organisations such as Coles in order to integrate the solution effectively to ensure that these subsidies give aid to lower-socioeconomic individuals, resulting in the solution being effective. It also means working with effective partnership with organisations to understand that not everyone is blessed to live in an environment where there is access to fresh fruit and vegetables [Duckworth 2018]. An example of this is the UK’s School Food plan, a result of Jamie Oliver’s Food Revolution, that saw food education returned to the school curriculum throughout England, and practical cooking lessons compulsory up the age of 14. This demonstrates the cooperation between individuals and government to advocate for healthy eating [Jamie Oliver Food Foundation 2014].

This is more effective in lowering socioeconomic related obesity once the social gradient has been ‘flattened’. This is because an individual’s eating choices and access to healthy foods are heavily influenced by their socioeconomic position. Therefore, the advocation of healthy eating is probable to be ineffective with individuals who have adapted to a food environment in which they consume unhealthy foods because of its affordability. Thus, it proves to be unsuccessful once implemented via a Utilitarian paradigm, due its probability of solving obesity in lower-socioeconomic areas and benefiting a large number of individuals.

Working with General Practitioners and new parents

22% of children in NSW, by the age of four are already above a healthy weight, highlighting the importance of early intervention with parents and their children. Targeting this group of new parents of young children is easiest and most effective because they are motivated and only want the best for their child [Duckworth 2018].

This can be achieved by getting new parents to work alongside their general practitioners (GP). This then allows them to monitor and be aware of their child’s weight by having a clinical measurement. Awareness of their child’s weight status is an important first step in parents taking action [Davidson & Vidgen 2017] of reducing obesity incurrence.

Because of their involvement, GP’s also need to have the skills to talk about weight, monitoring health, and promoting early habits [Duckworth 2018], amongst new parents. They also tools to talk about weight of young children to parents so that it is similar to a normal conversation, given that discussions are currently challenging and interactionally delicate.

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Highlighting the clinical relevance of weight appears to be effective [CSIRO 2018] and displays the successful nature of the solution. Due to research conducted that shows eating behaviours and meal habits in early childhood have an impact on children’s food preferences and eating patterns in adulthood [Steinhoff 2016], early intervention is vital in significantly effecting weight gain in early childhood and therefore reducing the chances of incurring obesity in later life, no matter the individuals socioeconomic circumstances. It also, if successful, would be more clinically effective and cost-effective [Pediatr 2015] than other strategies and would not take long to implement, thus results appearing fastest. This solution is currently being pushed to be implemented further in Australia by the Australian Medical Association so that mothers.

Analysed under the lens of a Utilitarian paradigm, the involvement between GP’s and new parents proves effective but does not successfully benefit the largest number of people affected by obesity, especially in lower-socioeconomic areas.

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RecommendationsA report conducted by the US National Library of Medicine stated that their conclusive results added to the growing body of evidence that demonstrates an inverse relationship between socioeconomic status and obesity [Ghosh, Charlton 2016]. Another report by the Australian Institute of Health and Welfare stated that in 2016, adults living in the lowest socioeconomic areas were more likely to be overweight or obese than those in the highest socioeconomic areas (66% compared with 58%) [2016]. Furthermore, a report published under the Boden Institute emphasized that people who live outside major cities are more likely to be above a healthy weight, shown in the graph below. This difference is due to the higher concentration of people of a lower-socioeconomic status [Australian National Preventative Health Agency 2014].

This shows that rates of obesity are significantly higher in lower-socioeconomic areas, and the correlation between socioeconomic factors and the risk of incurring obesity extremely strong.

The ‘flattening’ of the social gradient, although proven hard to achieve, can remarkably reduce rates of obesity across the general population, thus helping the greatest number of people. To do this, policies and strategies developed at multinational, national, state and local levels should be altered [Loring & Robertson n.d.] to a format that ensures that they don’t benefit the advantaged and disservice the disadvantaged, and therefore worsen inequities and steepen the social gradient. A ‘flattened’ social gradient can also rid society of inequities that cause gaps between minorities and higher parties, ultimately reducing societal problems that result in bigger and more consequential problems. Currently, the reverse goal is being achieved within countries aiming to place strategies and policies to reduce obesity in lower-socioeconomic areas. Thus, there aren’t many examples of whole equity amongst the general population, that reduce obesity rates, in the modern world.

Utilitarian analysis also shows that this, the ‘flattening’ of the social gradient, is the most effective solution. This is because it results in the biggest number of people being benefited. ‘Flattening’ the social gradient would benefit all members of society, including the most advantaged and disadvantaged by reducing obesity based on socioeconomic status. Creating policies and strategies that incorporate many parties, that cohere to each other, is vital and crucial – policies and strategies must complement rather than contradict each other in relation to health equity [World Health Organization n.d.].

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Fig. 3: OBESITY: PREVALENCE TRENDS IN AUSTRALIA

In conclusion, after analysing multiple solutions and recommendations of individuals, groups and organisations, solutions of improving practices aimed at reducing rates of obesity should be improved so that they do not worsen inequities present within society, that create gaps between lower and higher-socioeconomic individuals, and heighten obesity, especially in lower-socioeconomic areas.

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Pavela, G, Lewis, D & Locher, J 2016, Socioeconomic Status, Risk of Obesity, and the Importance of Albert J. Stunkard, US National Library of Medicine National Institute of Health, NCBI, accessed 16 October 2018, <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4798886/>.

Peeters, A & Blackholer, K 2015, Reducing socioeconomic inequalities in obesity: the role of population prevention, The Lancet, website, accessed 16 October 2018, <https://www.thelancet.com/journals/landia/article/PIIS2213-8587(15)00373-3/fulltext>.

Pediatr, A 2015, Treatment interventions for early childhood obesity: a systematic review, US National Library of Medicine National Institute of Health, NCBI, accessed 15 October 2018, <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4491410/>.

Rosenberg, T 2015, How one of the most obese countries on earth took on the soda giants, The Guardian, accessed 20 October 2018, https://www.theguardian.com/news/2015/nov/03/obese-soda-sugar-tax-mexico.

Shrivastava, SR, Shrivastava, PS & Ramasamy, J 2016, World Health Organization advocates for a healthy diet for all: Global perspective, Journal of Research in Medical Sciences, US National Library of Medicine National Institutes of Health, accessed 15 October 2018, <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5122184/>.

Socioeconomic factors n.d., Pdhpe.net, accessed 22 September 2018, <https://www.pdhpe.net/better-health-for-individuals/what-influences-the-health-of-individuals/the-determinants-of-health/socioeconomic-factors/>.

Steinhoff, A 2016, The Importance of Healthy Early Eating Habits, Novak Djokovic Foundation, accessed 15 October 2018, <https://novakdjokovicfoundation.org/the-importance-of-healthy-early-eating-habits/>.

The problem of Obesity 2018, CIBER, accessed 25 September 2018, <https://www.ciberobn.es/en/about-us/the-problem-of-obesity>.

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AppendixInterview Transcripts

Global Studies IRP Interview #1 Transcript

Name of Interviewee: Belinda Duckworth

Date of Interview: 29/07/18

What is your name and occupation?

Belinda Duckworth and I am a senior policy officer at the NSW Ministry of Health.

What is your experience with discussing/researching this relationship between socioeconomic factors and the rate of obesity.

I’ve worked in health for 20 years as a clinician and looking at health behaviours not necessarily related to obesity, so I worked at the National Breast Cancer Foundation, and spent 5 years working for Diabetes Australia – so that’s a charity (or company) that aims to raise awareness and raise money for people with diabetes. Um, but specifically in terms of overweight and obesity for the past four and a half years I’ve worked at Western Sydney in the health promotion team looking at this very issue, and now, more recently, working at the Ministry of Health – looking at health strategies for obesity.

Can you please explain how socioeconomic factors influence obesity rates?

I think what’s probably good to refer to is, and you might want to Google this, called the Foresight model. It’s an obesity systems map and what you need to do is to Google it and to then highlight it, but really there are so many factors that influence obesity. We know that there is a correlation between the environment – the social environment – and the incidents of obesity, and health outcomes in general. So, for example, if you look at the Aboriginal population, their life expectancy is lower, the incidents of diabetes are higher and obesity, and if you map hotspots of obesity and diseases such as type two diabetes, Western Sydney is the hotspot in Sydney. The incident rate is much greater than say North Sydney.

So, education plays a key part, which is why health works very closely with education to integrate messages early so early habits are formed, so that healthy habits are formed at a young age. This is why you use specific programs with new mums, so they know that breast is best. So, the link between people’s knowledge and education around health issues is critical.

When I was working in Western Sydney, the rates of physical activity were lower in a project that we were doing at Blacktown than say, in another part of Sydney. They weren’t walking because they didn’t think it was important, they weren’t walking through certain areas because they didn’t feel safe – so that actual physical environment. Also think about access to healthy food – fruit and vegetables – if you look at some of the inner-city suburbs where they’ve got markets and they have access to fruit and vegetables, it is easy as compared to some parts of Sydney, whether there’s a fast food outlet on every corner and there is a debate around healthy food is too expensive. So, I was speaking to a health worker in Campsie, who was working with Aboriginal people. She said what the key issue there is that the grandparents are often looking after the children because the parents are in jail, or are gone or whatever, and they’ve got a certain amount of money. Now how do they make that one-hundred dollars spread for the week and you can get a bucket of chips for two dollars whereas compared to a

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big salad. So, there are those types of issues around the actual physical environment. Therefore, if you look at the healthiest areas in New South Wales – Northern Sydney has the lowest rates of obesity as compared to areas out in Western Sydney – so there is a direct correlation between those key issues such as income and education, and that’s not to say that all overweight people are uneducated but to deal with obesity is such a complex issue. Often, as a society of how we viewed what is the normal amount, serving size – if you look at the size of a muffin from thirty years ago to now were expecting bigger servings. It’s normal to upsize things. The food environments have changed as well. When I went to school we used to walk to school but now parents are concerned of the safety of their children. So even looking at the way we live, like the environments in terms of density of housing there is a lot more people living in high density houses so access to greenspace and parks and looking at that relationship as well. Part of the strategies we look at is working with councils and infrastructure to make it easier for people to ride their bikes to work or that you can ride to Artarmon station, you know, all those types – there are so many different issues that are impacting. It is really, really complex.

In your opinion, do you currently think that enough is being done here in Australia to lower obesity rates that are influenced by socioeconomic factors?

No, I don’t. I think we all have a role to play in making healthy choices easier, creating healthier environments providing better education around the importance of healthy behaviours and good role modelling and advertising around foods to young children. So, I think that multiple levels can be improved. I think that corporations have a role to play in, and a responsibility, to reduce the amount of stuff like sugar content. There is better access to identifying that there are some groups that are of greater risk, such as Aboriginal communities where we know that they have a higher rate of illness, particularly smoking rates and tobacco usage. So, I think that ensuring that there are enough resources that are targeting groups at a high risk. I feel as though we really need to target areas, and we are doing this in areas such as South-west areas where we are integrating levels of departments to try and reduce obesity rates, so there is a greater appreciation that obesity is not just because someone is eating too much. There is lots of issues around the physical environment that we can help influence so that is where there’s policy around including physical activity in primary school programs, the Live Life Well program for example, so that there are investments in targeting mothers of new parents so that they are given the education and particularly looking at areas of high risk and greatest need and having a real collaborative approach and realising obesity has many different levers that can shift change.

Furthermore, which institutions do you think need to be involved in lowering obesity rates in Australia? Why?

I think we need a better partnership with private organisations so I think that Coles and Woollies and they’re at point of purchase that they have a role to play. So, an example of a project that was done, that I read about recently in the U.K. was they looked at poorer areas and for new mothers in those areas they were given an amount of money to buy fresh fruit and vegetables and they could redeem that at the local outlets. So that’s an example of working more effectively with private organisations. So, yes, the government has a role to play in terms of education and through established systems such as working with councils to build healthier environments to make sure that there’s stuff like water available – water stations at the local park – or those healthy built environments are available. So that whether you’re at Liverpool or Lindfield that you have opportunities to have access to affordable fresh fruit and vegetables and that there’s sporting facilities available.

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It’s so complicated. There is so many things. Individuals obviously have responsibilities with what they put into their mouths but we also need to ensure that workplaces and the government and schools and key organisations have a role to provide healthier environments.

If together, environments, organisations, can help create healthier environments and help shift those norms, it can directly influence and reduce obesity rate. I feel as though it must be a big shake-up because, even though the child obesity rates are starting to plateau, it’s not getting better – it’s not decreasing. People talk about it, they know it’s an issue, but they don’t do anything. They say, ‘it’s their fault, they should just stop eating it’ but it’s like well hang on, and I remember we did a project with St Vincent De Paul in Western Sydney and we were encouraging their staff and volunteers to, many of whom were on the ‘doll’, sign up to a health programs, because, we found in a case study, their dealing with complex issues, they don’t have time to make their cow smoothie. They’ve got different priorities so it’s really understanding the complex environment that families are working in and that, they might have to travel a couple of hours to get to work, and that because they can’t afford to live in Potts Point, so they’re travelling out from Liverpool and by the time they get home they’re like I don’t have time to cook but I can go get Maccas. So, there’s so many different factors that are influencing the choices they make. They might know that it’s not the healthiest thing, but they’re tired, they’ve got mouths to feed and don’t have much money. So how do you create or influence that social environment to allow that mother to help make healthier choices easy. It’s so complicated.

The issue is that there are many factors that contribute to obesity and we are now in an environment where it is normal, and we’ve run focus groups with parents recently where people have been overweight but they think they’re fine! And they think that their kids that are overweight are fine! This is because of what our perception of what is a normal, healthy weight has changed. The cycle of disadvantage can be directly correlated with obesity – low income, poor education etc. It gets worse every generation. We run programs

What are the most effective short-term solutions Australia could put in place to not only lower obesity rates but reduce the inequities that are causing these obesity rates?

I think that targeting new parents of young children and helping them work with their GP’s, clinicians and early childhood providers to monitor their child’s weight, so having a clinical measurement. I think GP’s need the skills to talk about it and to say that. So, helping new parents that are motivated, they just want the best for their child – so you’re more likely to get healthy behaviours with new parents that are ready to achieve good outcomes for their child. So, working with GP’s, local doctors and nurses by doing a routine measurement of weight and having those conversations and giving new solutions. Helping new parents know what is and what isn’t a healthy weight. We are finding that 22% of children in NSW, by the age of 4 are already above a healthy weight. We’ve got an opportunity to better establish healthy habits early. To me that would be a short-term strategy. It is what we are doing currently – working with doctors and giving them the skills to talk about weight so that it’s a normal conversation and then providing them the tools. Also, talking in languages that are relatable. This is shown in the health star rating and working with canteens, and so the kids at school have healthier options. In canteens, I’d love to see schools having better choices for kids and getting them involved.

I think we should be getting children better involved in problem solving and in what we call co-design, in getting them involved in the solutions so whether they come up with ideas for campaigns or the school menus so that they are wanting to act on their own decisions rather than someone forcing them to do something. This means it’s a movement from the grass roots not from top down. I think that short term solutions – yes, the government should be working with companies such as food and beverage council to look at key ingredients and how do you remove some of the bad stuff out of the offering that we are giving.

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I would be interested in to see the program in the UK – giving them greater financial incentive directed into healthy behaviours so that there’s a new way to do things. The Active Kids sports vouchers in NSW – it gives a financial incentive and encourages people to be active which I think is a good thing to lower the inequities that are causing high obesity rates. If there’s only a certain amount of money, directing money to services in areas of need. So, we did a project in Western Sydney with a school and we did a “Crunch and Sip’ project. But a lot of the kids couldn’t afford to bring in fruit so we partnered with an organisation who would donate the fruit from fruit markets. So, working with better effect, effective partnership with organisations to understand that not everyone is blessed to live in an environment where there is access to fresh fruit and vegetables – so how can we create support those environments.

What are the most effective long-term solutions?

The policies around working with the food and beverage councils, and ensuring that poorer areas where there is stuff like new housing developments – ensuring that the built environment considers the lifestyles of those people – there are bike paths, there is water stations – that they are creating greenspace and access to places they can exercise – the environment they are in encourages those behaviours. That’s quite long term.

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Global Studies IRP Interview #2 Transcript

Name of Interviewee: Angela Cottam

Date of Interview: 19/10/18

What is your name and occupation?

I’m Angela Cottam and I am a nurse at Barker College.

What is your experience with discussing/researching this relationship between socioeconomic factors and the rate of obesity.

I would say that obesity is prevalent in all socioeconomic groups but with my experience, I think in the lower socioeconomic groups there is more – I think education plays a key role there, it really does come down to education.

They say to you, look I can’t afford to cook fresh food like vegetables and put that on the table, but actually when you analyse it, as you probably know, it’s actually cheaper to do that than buying fast food. You know, going to MacDonald’s in the old days used to be very expensive but now it’s cheap.

Yeah, so I think education’s got a lot to do with it. It’s across all areas but I would say more significant and prevalent in lower socioeconomic areas.

Can you please explain how socioeconomic factors influence obesity rates?

I think it rattles back to the below question, about what is currently being done here in Australia to lower obesity rates that are influenced by socioeconomic factors.

In your opinion, do you currently think that enough is being done here in Australia to lower obesity rates that are influenced by socioeconomic factors?

No. I think education and I think nurses are great at that. I think that we are given a big bubble here on the North Shore – we are well educated compared to the whole of Australia and one of my things is getting nurses into schools in deprived areas because kids have to go school and usually want to. If you educate kids – young kids – and build routines and good habits like a healthy lifestyle. So putting health educators into schools and putting into the curriculum and that sort of thing – to start young.

Also subsidizes on fruits and vegetables, or healthy food, to encourage healthy food to be eaten. This is because it is very expensive to eat healthy but also to eat badly. You can buy a five dollar domino’s pizza. If you’re fifteen and you have ten dollars to spend on lunch you could buy a can of coke and a pizza at domino’s or something healthy for much more.

So that is the answer, getting educators into schools, I think would be really helpful. Obviously education, like big media campaigns and that sort of thing, also for everybody, is really important in lowering obesity rates, and it can work in lower socioeconomic areas. Putting nurses in all schools, not just Barker, is really important.

Furthermore, which institutions do you think need to be involved in lowering obesity rates in Australia? Why?

n/a

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What are the most effective short-term solutions Australia could put in place to not only lower obesity rates but reduce the inequities that are causing these obesity rates?

n/a

What are the most effective long-term solutions?

n/a

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Progress Log Date: 27th of March 2018:

Today in Global Studies we received our IRP. We spent most of the lesson going through the assessment task booklet and clarifying any queries we had for the teacher. I used the rest of the lesson to complete the first Progress Report (Project Overview and Proposed Area of Research which I did in class and at home) which included marking two past Global Studies’ students IRP’s and analysing their ability to meet the criteria. This was a good exercise as I could get a good look at what I am aiming for throughout the entirety of this task. I examined Eve Timm’s and Bailey White’s. Following this, I read through the details of the assessment task again just to make sure I understood everything.

  Date: 29th of March 2018:Today in my Global Studies lesson we were given time to complete the first Progress Report for the second time in a lesson. As I have already done this I spent the lesson time brainstorming ideas for my possible topic and thus, my focus question. This proved some difficulty as I didn’t come into this task with any clear idea of what direction (topic wise) I would take. I also spent the lesson time making a timetable for the course of the project – when I would have areas of the IRP completed so I could stay on track and not be stressed right before it was due. I feel this structured timetable will be of great use to me – as I can do the massive task in little chunks so I; don’t get stressed, enjoy the task more and can improve my time management skills.

 Date: 31st of March 2018:Today I stuck to my timetable that I had established in my previous Global Studies lesson. This meant I had to use my brainstorm to knuckle down on a topic so I could get started. Within my brainstorm, I had five big bubbles; technology, environmental, political, justice + human rights and health related issues with several points under these concepts. After close analysis of the pros and cons of studying these issues I concluded that it would be easier and more interesting to gather information and study health related issues with the issue of obesity being the one I was most accessible to (for information). After deciding this I continued to brainstorm this topic and came up with four sub-topics under this issue; socio-economic, education, the rise of fast food chains (the accessibility, fast and cheap) and political contributors. I felt that the socio-economic area would benefit my research largely and it would be extremely interesting. I also found that I had naturally good accessibility for people to interview, research and survey to this topic. Under this bracket of socio-economic I had four points; rural/urban/remote factors, the rate of obesity in areas of Sydney and Australia and the comparison of these areas and lastly, the correlation between poverty and obesity. I am still yet to decide which bracket I will research under obesity (socio-economic reasoning). I think I will weigh up the pros and cons so I can pick the best one for my report. The things I am yet to do is to choose my paradigm and pick my focus question.

 Date: 3rd of May 2018:This Thursday, I decided to brainstorm possible focus questions, that relate to my current chosen topic, how socioeconomic factors influence the rate of obesity. I found this quite difficult, as even though I had got the relative gist of my topic, I couldn’t find the right words to word it properly into an actual problem, contained in a question. But, after speaking with Ms Hildreth, I held a lot more clarity when it came to my focus question and the shape of my future and completed IRP.  It was important to narrow down my focus on socioeconomic influencers, so I chose social standing and income. This is because I feel that there is a lot of information and opinions regarding these two influences on the rate of obesity. It also interests me.

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In the end, I narrowed down my chosen topic to a focus question; ‘How can we improve the rate of obesity in low socioeconomic areas? Currently, I am happy with this focus question, particularly with the wording of it – because it covers what I’m interested in, within the topic, and further captures what I want to further understand about the issue. Even though it is not a current priority of mine, I am focusing on Utilitarianism as my chosen paradigm, although I am yet to consider other paradigms off the IRP booklet. After I had found my focus question and looked at a possible paradigm, I decided to spend the rest of the lesson setting up my bibliography. This is important because I need to keep track of and keep the good secondary sources I find along the course of studying this issue for my IRP. I also concluded that I should set up my bibliography with the ‘Harvard Reference’ format. This is because it is used here at Barker and I think it would be easier to start putting it into this format early so I don’t have to spend extra time later putting it into this format. I filled out the second progress report too.

 Date: 01/06/18Today I filled out my Progress Report 3. Even though there is a large gap between my last progress log entry, I have been collecting secondary information throughout this time. Since this has been rather tedious I haven’t wrote up a progress log.I have been thinking about who I would like to interview, as per Progress Report 3 and its outcomes. I think a good person to interview for my IRP would be Bernard Salt who first developed the ‘Red Rooster Line’. As I am using this idea in my IRP I thought his opinion and knowledge would be very valuable to my research. Plus, my parents have connections that can possibly get an interview with him, meaning it might be slightly easier to set up the interview. Progress Report 3 also detailed some possible questions to ask in my interviews. I am still working on this as it is a bit challenging to get down questions that are clear and precise but still allow room for the person to elaborate and answer the question to a degree that holds information that I can then use effectively in my IRP. Apart from filling out this progress report, I have also started to brainstorm ideas on which format I will present my gathered information in. Currently, I am drawn to the idea of a report but something else a little more creative would allow me to present my information in a more entertaining and engaging way for the reader/viewer. I have also decided that I will use Utilitarianism as my paradigm for my focus question (it is still the same). This is because the idea that we need to benefit/help the biggest amount of people on relation to a health issue such as obesity makes sense.

 Date 28/07/18Over the past month I have been collecting secondary research for my IRP. This has allowed me to gain a better insight into the issue I am researching in my project. This secondary research has been through the internet so far, though I plan to go to a local library soon and see if I can find any works on my issue. I feel collecting my information from different medias allows me to get a broader scope of information. In the secondary research, I am collecting opinions on how my issue should be solved and what needs to be done in order to make this happen. I have also collected lots of statistics and facts that can be used in my background and can help me gain a better understanding of my topic.

30/07/19I have realised that my IRP question is a little confusing. This came after much thought over the last couple of days where I got to thinking if I was really doing this IRP on how we can improve obesity rates in lower socioeconomic areas in Australia or Sydney or in general, as an international issue (in lower socioeconomic areas around the world).

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Because of Progress Report 3, I have had a chance to form some draft questions for my interviews and my emails that I will send to my future interviewees to ask if they can be interviewed for this assignment. At the moment I am looking towards interviewing Bernard Salt, an author and columnist at The Australian and Herald Sun and head of Demographics at KPMG and friend of my mums who works as a public servant in health care. I feel that both perspectives these two interviewees could bring are while completely different, could bring a lot to my IRP as it is not secondary research.

06/08/18Today I discussed with Ms Hildreth about the information and to what scale I will be talking about with ‘lower socioeconomic areas’. We came to the conclusion that because it is an IRP concentrating on a global issue then I should incorporate a sense of global obesity into my project, especially because it is such a big issue today. Therefore I have decided for my background I can present facts and statistics on obesity in Australia and compare it to areas around the world, especially in developed nations such as the United States and Britain because they also share the issue of obesity as greatly as Australians do. However I am still going to primarily focus on Australia’s problem of obesity.

In my background I plan to really knuckle down on Sydney’s issue of obesity in lower socioeconomic areas while still referencing and relating it back to an issue as a national sense.

In my solutions I plan to compare different countries views on how they would solve obesity due to inequities (low socioeconomic standards) and draw this back to how it is currently being dealt with in Australia and referencing any other countries ideas if they can confidently be applied here, not just in Sydney but as Australia. In this solution section i also plan to incorporate utilitarianism as a way, in conjunction with my proposed solutions, can improve the rates of obesity in lower socioeconomic areas.

In my recommendation I plan to choose the most likely to be successful in fixing the problem and discussing it in this area of my IRP.

I feel that knuckling down this plan has been an important and good step made in the process of my IRP because now I know what exactly I am looking for when conducting secondary and primary research.

08/08/18Today I have uploaded everything to Google Drive so it is more accessible to myself and teachers. I have also updated my bibliography and eliminated any secondary research that I have collected, but now know I won’t need because of the plan I finished two days ago (see above progress log entry).

10/08/18Today I made adjustments to my progress report 3 as per Ms Hildreth's editing. This included narrowing my focusing question, making my initial email to my interviewees less-revealing in what I needed to ask and why I was interviewing people, and narrowing down my interview questions.

16/08/18In the global studies lesson today I worked on narrowing down and getting rid of unnecessary secondary information that I had collected when my question was not finalised. This means I can now fully concentrate on collecting my primary research. To do this I need to conduct interviews. Therefore, I am currently looking for people in the field of my topic question to provide information that I can use in my primary research. My mum has several connections in the NSW Health Department that I plan to use to get in touch with people who can provide opinions and information on my chosen topic.

19/08/18

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Today I called to see if she was available for an interview in regards to my project. Her name is Belinda Duckworth and she works in North Sydney at NSW Health. I reached out to her because her job allows her to work on health projects all around Sydney, in a variety of areas that have different socioeconomic factors influencing the rates of obesity. She also has access to new information recorded and collected by the Government that can be highly useful for my report. After leaving her a message, she called me back later in the day.

After first mentioning what I am researching for my report, she then asked me what type of questions I would be asking - to make sure she could properly answer the questions or if she needed to get someone else from her work to be interviewed by me. As it turns out, after mentioning some of the work she is doing currently, we both came to the conclusion that she would be perfect to be interviewed.

One thing that Ms Duckworth mentioned several times is  the social determinants of obesity and that unlike many other health problems, obesity is a combination of factors that are mostly environmental. This could be an individual’s social, physical or mental environment etc. She said that I should briefly research this before we meet for an interview.

We also discussed meeting on either the 25th or the 26th of August for the interview. I said that I would email her with an outline of the types of questions I would be asking, if I could record it and which date would suit after she checks her calendar.

20/08/18Today I received an email from Ms Duckworth with an attachment to some documents from the Government that have not been released yet to the public. They concern how social determinants affect obesity in the state of NSW. Even though the information only concentrates on this state, not internationally or even nationally, I can still use it when I knuckle down later in my report on Sydney itself - after looking at obesity rates and socioeconomic factors internationally and nationally. I also emailed Ms Duckworth the heads-up on confirming either the 25th or 26th of August for an interview and giving her a rough idea of the type of questions I would be asking in the interview. I also asked if it was possible that I could record the interview on the day, for transcript purposes.

21/08/18In class today I discussed with Ms Hildreth my progress currently with the IRP. This meant updating her on how my interviews were coming along (I have one planned this weekend with Ms Duckworth). I also talked to her about what I would be talking about in each of my sections of my IRP (my introduction, background etc.). She suggested that I work backwards because I feel so swamped with the amount of information I am collecting (secondary research). Because of this, I am now finding three solutions to discuss in my solutions that the stuff before will be based on. So far I have two of these three solutions; fixing society’s inequities and government intervention, campaigns, and working with communities and institutions. By doing this I can get rid of a lot of unnecessary secondary research and knuckle down on finding information that I can properly apply to my background, literature review etc. that can be then to form my three solutions and then come to the conclusion of one.

29/08/18Today I interviewed Belinda Duckworth who works at the NSW Department for Health in health advocacy. The interview went for approximately half an hour and took place at my house because of her close relation to my mother. I found the interview went well - I got through all my questions and she answered them with good information. I had a slight issue with her going off on a tangent but I found this was often good information too. Tonight I did some transcribing of the interview which I have put as a Google Doc.

30/09/18Today I transcribed the interview. This took place in my Global Studies lesson. It is slow progress :((

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1/10/18Today I finally finished transcribing my interview - this makes me very happy ahhhh as I hate transcribing!!! After doing this I added some more information into the document that she had later sent in an email. Ms Duckworth has also forwarded me several reports releases by the government that i have found very helpful with my secondary research and that I am very grateful for!! I spent the rest of my time reading through this information and writing down any important details for when I write my background and literature review.

10/10/18Today I finally started my background. This started out with me looking at some examples on the Global Wiki (e.g. Eve Timms). This meant I could record some outcomes that I have to reach within my background (e.g. what is the issue, what will be investigated in the report etc.). This allows me to not overwrite or repeat information when I am writing my first draft. I also did this for my literature review even though I have not started that yet.

After gathering all the secondary information I have collected over the past couple of weeks I started writing out the outcomes I mentioned earlier. This process works for me as it makes sure I am not blabbing, storytelling or writing information that is not useful or does not meet the marking criteria for the IRP.

15/10/18

Today I have finished my background and introduction and have started the literature review, solutions and methodology. These areas was what I submitted as my Progress Report 5.

19/10/18

Today I submitted my draft IRP to Ms Hildreth and completed an interview with a Barker school nurse, Ms Angela Cottam. Now all I have to do is transcribe the interview and edit down my IRP.

20/10/18

Today I edited my IRP according to the suggestions sent to me by Ms Hildreth from my submission the day before.

21/10/18

Today I edited my IRP down and transcribed my interview with Ms Angela Cottam.

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