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THE FAT DIVIDE

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

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W
WALLIS SIMPSON, THE AMERICAN SOCIALITE

behind the abdication of her third husband, former British monarch King Edward VIII, famously said: You can never be too rich or too thin.
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 activity 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 medications) 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 disadvantaged 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 standing. 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 neighbourhood which is socioeconomically disadvantaged 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 socioeconomic strata in both developing and wealthy countries, tend to be more concerned about gaining weight than do women in lower socio-economic positions.

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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 socioeconomic inequalities that we see, she says. For people of low socioeconomic status, theres a combination of factors, both as individuals 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, newlyappointed president of the British Medical Association, is a world-leading social epidemiologist 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 circumstances, what you eat, going to the gym and so on, Marmot says. Despite the rising incidence of bulging waistlines, starvation is not a thing of the past. While millions of people are clogging up their arteries and dying early from obesityrelated 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 situation in which the overweight and the hungry

jostle for space on the healthcare agenda. On the face of it, theres no reason for onesixth 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 production 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 inequality 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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The worldwide incidence of Type 2 diabetes is projected to double between 1998 and 2025, with more than threequarters of this growth occurring in the developing world.

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 diabetes is projected to double between 1998 and 2025, 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 globalisation 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 (particularly trans fats and saturated fats) and too much energy (calories). High consumption of processed food is leading to conditions like high blood pressure, abnormal lipid profiles, obesity, diabetes and even some cancers, says Neal. Gardner and Halwell also point to the influence that the marketing practices of multinational food giants have on the purchasing habits of millions of consumers. This, together with a lack of nutrition education, is driving consumption of highcalorie, low-nutrient foods at the expense of real food. Food is the most heavily advertised commodity in Austria, France, Belgium and the United States, and more than half of this

Why weight?
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 selfreported 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.

advertising is for candy, sweetened breakfast cereals, fast food, and other items of dubious nutritional value, wrote Gardner and Halwell. With food companies largely unchallenged in targeting our sweet tooth and shaping our tastes, it is little surprise that more 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 middleincome 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 to blame 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 heavily 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 unpublished) 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 tackling 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

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outstripped the slow-moving pace of governments 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 systematically 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 countries. Children-friendly initiatives have been effective entry strategies in fast growing markets 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 supplemented with other forms of promotion that reinforce marketing objectives and build brand awareness and allegiance. Viral marketing, competitions, games, onpack promotions and store-based advertising are all used to target children who increasingly 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, wholegrain and milk is found to be almost zero.

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BRUCE NEAL MICHAEL MARMOT, BMA

RIGHT

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 heavyweights 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 immediately puts everyone into a sparring position. Industry will fight long and hard against regulation, he points out, and global multinationals 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 agreements 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 cooperative targets for nutrition content may be our only chance to hold back the tide of obesity. Fat chance? Lets hope not.

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