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Our big fat complicated population health problem, Part 2: It may be worse than we thought

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Monday, 25 March 2013
in CHNET-Works!

Big fatFew now dispute the importance for population health of the rapidly rising prevalence of overweight and obesity, in countries rich and poor alike.  What to do about it is a matter of greater dispute.  An accumulating body of evidence suggests, as Rob Moodie and colleagues argued earlier this year in The Lancet, that overweight and obesity should be regarded at least in part as an “industrial epidemic” in which “the vectors of spread are not biological agents, but transnational corporations” like those that dominate the food and drink industries. 


In this vein, an important  exposé in the November-December 2012 issue of Mother Jones tried to answer the question of how the sugar industry “kept scientists from asking: Does sugar kill?”  The authors obtained documents dating back to 1942 describing the industry’s use of a strategy that David Michaels, a former senior official of the US government, has called “manufacturing uncertainty”.  The strategy was perfected by the tobacco and asbestos industries, but has been applied far more widely to resist regulation and other policy interventions aimed at protecting public health.  On March 20, The Guardian  reported on a series of talks given in Britain by Robert Lustig, an endocrinologist who argues that: “The food industry has made [sugar] into a diet staple because they know when they do, you buy more.”   This point is of special importance because of the continuing insistence, notably in the documents supporting and emanating from the UN High-level Meeting on Non-communicable Diseases, that public-private collaborations can contribute meaningfully to prevention of such conditions as cardiovascular disease and diabetes.  And evidence is accumulating that fructose, in particular, has destructive effects that go beyond its direct contribution to excessive caloric intake – a point that was emphasized during a panel on sugary drinks I recently attended at the 15th Public Health Research Conference at Mexico’s impressive National Institute of Public Health.

As noted in an earlier posting, rising overweight and obesity represent a complex problématique that cannot be isolated from issues of political economy, health equity and social justice.  On the political economy front, a fascinating recent open-access article on “exporting obesity” argues that the combination of farm subsidies in the United States and the removal of trade and investment barriers between the US and Mexico under the North American Free Trade Agreement  led to rapid transformation of the Mexican “consumer food environment” in several unhealthy ways.  One of these involved a dramatic increase in US exports of (subsidized) corn to Mexico, partly in the form of high-fructose corn syrup (HFCS) following a 2006 World Trade Organization ruling against a Mexican tax on soft drinks sweetened with anything other than cane sugar.  Pediatric obesity researcher Michael Goran, one of the panelists at the Mexican meeting, has made a similar point.  These exports have, in turn, no doubt contributed to a prevalence of obesity in Mexico that is actually higher among adults than in Canada.  So, too, has the rapid transformation of the Mexican food system through foreign direct investment.


On the social justice front, an article written by Goran and colleagues, including the Director of Health Assessment and Epidemiology for Los Angeles County’s Department of Public Health, demonstrates a pronounced socioeconomic gradient in the prevalence of childhood and adolescent obesity in the sprawling county, “with a striking fourfold difference in childhood obesity prevalence between the communities with the highest and lowest levels of EH [economic hardship].”  Equity concerns have often been left aside in discussions of how best to deal with overweight, obesity, and their health consequences.  This finding underscores the urgency of addressing not only the challenges presented by corporate interests in the food industry but also such issues as economic deprivation, access to and affordability of healthy diets, and disparities in access to safe options for physical activity as part of any comprehensive approach to the problem.

LA

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More on diet and population health

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Tuesday, 08 January 2013
in CHNET-Works!

A recent posting featured two important research syntheses on overweight and obesity. Another, especially useful for non-specialist audiences, appeared as a special report on “The big picture” in the December 15 issue of The Economist.

Commendably, the report does not sugar-coat the difficult politics of reducing overweight and obesity. It notes, for example, that “while lots of people remain fat, the associated ailments represent big business for the drug companies.”  It is candid about the role of companies like soft-drink manufacturers and fast-food chains in contributing to the epidemic of overweight, and the conflicts of interest that can arise in partnerships like one between Nestlé and the International Diabetes Federation, or the “Responsibility Deal” between food and alcohol companies and Britain’s Department of Health. (In negotiations about the action plan that emerged from the UN Summit on non-communicable diseases in September 2011, Canada was among the countries pressing for removal of text that mentioned such conflicts.) And it presents a succinct overview of efforts to deal with overweight and obesity through taxation and regulation. So far, those efforts have met with modest success, although that may be a consequence of modest ambition rather than of limitations intrinsic to the available policy instruments.

Unfortunately, the report is not open-access, although non-subscribers will be able to read part of it online. Unfortunately as well, the report pays insufficient attention to connections between the built environment and overweight, or to the cost of a healthy diet. Nevertheless, it is a refreshing signal that approaches going beyond the usual health promotion nostrums are moving into the policy mainstream.

Shortly before the Economist report appeared, Britain’s Department of Environment, Food and Rural Affairs released its annual Family Food Survey for the year 2011. Among the survey’s disturbing findings: fruit and vegetable purchases were 10 percent lower in 2011 than in 2007, with an even larger decline among the bottom fifth of Britain’s income distribution. Households in the lowest tenth of the income distribution were spending 17 percent more on food in 2011 than in 2007. A report in The Guardian quoted the director of the consumer protection organization Which? as saying: “One in six people say rising food prices are making it difficult to eat healthily,” and the preceding month a report in the same newspaper warned of a “nutrition recession” - this in a country where benefit caps planned for 2013 will cut the incomes of many people in full-time jobs as well as those who cannot find work. 

Closer to home, Ottawa's deparment of public health released the lastest issue of an annual calculation showing that if you are living on social assistance and paying market rents in the city, it is arithmetically impossible - as it is much of the rest of the province- to pay for the diet recommended by Ontario's Public Health Standards. In the capital of a weathly G7 country, 48,000 people a month turn to food banks. Against the background of ongoing concern about health care spending and areport recommending an immediate increase in Ontario social assistance rates to " the lower rate category, single adults receiving Ontario Works, as a down payment on adequacy while the system undergoes transformation," it may be worth asking`just how does making healthiy diets unaffordable contribute to a healthier population and lower health system costs down the road?

Our big fat complicated population health problem: Perspectives from both sides of the Atlantic

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Friday, 30 November 2012
in CHNET-Works!

 Overweight and obesity contribute directly to a variety of adverse health outcomes, as pointed out in a recent Lancet series.  At least in high-income countries, these conditions exhibit a pronounced socioeconomic gradient, and therefore present both a challenge and an opportunity.  A challenge, because of the complex etiology of overweight and obesity; an opportunity, because of the tremendous improvements in health that can be anticipated from any population-wide shift toward healthy weights.

Two recent syntheses of research findings offer useful insights, and also a few (intentional and unintentional) warnings, about how best to address overweight and obesity. A report by a committee of the US Institute of Medicine got the diagnosis absolutely right, from a health equity perspective: “If a community has no safe places to walk or play, lacks food outlets offering affordable healthy foods, and is bombarded by advertisements for unhealthy foods and beverages, its residents will have less opportunity to engage in physical activity and eating behaviors that that allow them to achieve and maintain a healthy weight.” Unfortunately this valuable analysis was not, in the end, used to arrive at system-level recommendations appropriate to the scale of the problem. The committee described its approach in terms of “large-scale transformative approaches,” but in its proposed responses it drifted back into behavioural nostrums like “mak[ing] physical activity and integral and routine part of life” and “mak[ing] schools a national focal point for obesity prevention” – an example of the phenomenon Jennie Popay and colleagues have described as “lifestyle drift.” 

Blog-Overweight

Some environments are far more supportive of maintaining healthy weights than others.

 

A recent literature review on policy interventions to tackle the obesogenic environment produced by the Scottish Collaboration for Public Health Research and Policy, a research unit headed by expat Canadian John Frank, is more effective at avoiding what I have come to think of as the lifestyle trap. Focused on the situation of working-age adults, the review is organized using a framework called ANGELO (Analysis Grid for Environments Linked to Obesity): a simple four-by-two matrix in which four aspects of the environment – physical, economic, political or legislative, and sociocultural – are each analyzed at two levels, micro (the household or community) and macro (the region, province or nation). The authors make a point that has broad applicability in other population health contexts: “[M]any strategies aimed at obesity prevention may not be expected to have a direct impact on BMI, but rather on pathways that will alter the context in which eating, physical activity and weight control occur. Any restriction on the concept of a successful outcome … is therefore likely to overlook many possible intervention measures that could contribute to obesity prevention.”

 

 The authors of the review are candid about the difficulties facing large-scale interventions that are expensive or challenge vested interests, yet do not shrink from asking tough questions about the need for these, noting (for example) that the transport mode split in urban areas is 84% by car versus 9 percent walking in the United States, while it’s 36% by car versus 39% walking in Sweden. “Suffice it to say, it has been a concerted combination of infrastructure provision, integrated transport planning and disincentives for private cars which has helped to bring about the higher active travel rates,” which include a much larger role for cycling as well. And they argue that because of the relatively high price elasticity of soft drink taxation, it should be considered as a promising intervention along with price reductions of healthy foods like fruit and vegetables. (As an aside on a related point, I once heard a leading aboriginal health researcher wonder why Ontario can ensure that a bottle of whisky costs the same in the province’s far north as in downtown Toronto, but can’t or won’t do this for a carton of milk or a bag of apples.)

 

A further step in the Scottish review was to create another matrix classifying potential interventions on two criteria: certainty of effectiveness and potential population impact. Here a sugared beverage tax scored high on both criteria, as did healthy eating advocacy campaigns backed with supportive regulation, although curiously none of the policies that have been adopted to increase the costs of car travel scored similarly high, despite the authors’ extensive documentation of the role of public policy and their warning about defining successful outcomes too narrowly. But this is a minor disagreement with an important research synthesis on a complex problem that also provides a methodological template for reviews in other areas. It should be read by everyone concerned with social determinants of health, even if not specifically with overweight. Health policy analysis has joined other, more familiar high quality products for which Scotland is justifiably known far beyond its borders.  

 Blog-overweight 2

 Not the only quality product of Scotland.

 

 

 

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Suitable for framing

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Monday, 18 June 2012
in CHNET-Works!
Herewith a selection of quotations and images charting the path of social determinants of health in policy analysis. We start with a trip in the wayback machine, to 1983 and a review article(1)on hypertension in Canada by Helen Johansen, then with the Health Protection Branch of Health and Welfare Canada.

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Closer to the here-and-now, a team of researchers with Toronto’s Institute for Clinical Evaluative Sciences wrote in a 2009 report comparing public health policies across Canada’s provinces that:

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A similar point comes from an important new report on overweight and obesity from the Institute of Medicine south of the border (the quotation is from the web summary):

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More about this report, and about recent studies that have been quoted as casting doubt on the importance of “food deserts,” in a subsequent posting. I invite comments from readers on the latter point, in particular; meanwhile, some of the comments posted on the New York Times article that describes the studies  offer valuable insights into the real world of life on a limited income, where both money and hours in the day are in short supply.

Most recently, the authors of a May, 2012 report on income differences among patients using hospitals in Toronto began the study with a brief discussion of health equity in which they noted:

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The phrase currently used to describe the policies needed to address those core social determinants of health is “intersectoral action,” which was the topic of an earlier posting. The unequal distribution of opportunities to be healthy was central to the work of the WHO Commission on Social Determinants of Health. It was also central to the public health strategy proposed in a 2007 report to Norway’s Storting  (the national legislative body) by the country’s Ministry of Health and Care Services, and was communicated in an image that remains remarkably powerful.

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What we should learn from this brief journey was captured in a 2011 Toronto conference presentation by Nancy Edwards, director of CIHR’s Institute of Population and Public Health.

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Against the background of this accumulated wisdom, why is so much activity still focused on individual-level behaviour change and lifestyle modification, and so little on structural disadvantage? The question is, of course, too ingenuous by half. In a commentary written shortly after the World Conference on Social Determinants of Health in October, 2011, Sir Michael Marmot captured the underlying realpolitikof resistance as it played out at the conference:

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It should now be clear that “less safe” policy directions are the only ones that will generate meaningful progress toward reducing health inequities. How willing are those of us who profess a commitment to that objective, perhaps especially those with academic tenure or collective agreement protection (I have never had the former, and have not had the latter for two decades) to insist on those directions? Can viable coalitions for change be built outside the universe of health researchers and front-line workers, for example by making long-overdue common cause with the trade union movement? Such questions may decide the future of health equity in a Canadian political context that, at least over the short term, looks distinctly hostile.

(1)  Johansen H.  Hypertension in Canada: Risk factor review and recommendations for further work. Canadian Journal of Public Health, 1983;74:123-128.

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