This is an important week for food and health inequalities campaigners with the launch of two interconnected strategies related to the COVID-19 crisis. Welcomed are measures that tackle the power of food industry for example, to shape the eating habits of children, as are those to feed hungry children. Neither strategy tackles the underlying causes of our nutritional crises. Instead the exacerbation of ‘obesity’ and ‘hunger’ linked with the crisis are made the problems rather than tackling inequalities.
The Government describes its new obesity strategy as ‘comprehensive’. However, it fails to tackle health inequalities despite from the outset identifying disparities in obesity prevalence between least and most deprived social groups. Given how ethnicity intertwines with class and poverty it is also questionable how far this strategy can support ‘BAME’ communities who, as it points out, are at high risk of serious responses to COVID-19.
It situates the problem within childhood obesity. High prevalence among deprived communities is suggested to sow ‘the seeds of adult diseases and health inequalities’ (page 1). It does not suggest that social and economic inequalities are responsible – that ill health is an outcome of class inequality.
There is an appeal to the nation. We’re told ‘we owe it to the NHS to move toward a healthier weight’ (page 3). The ‘we’ being everyone who is classified as ‘excess weight’ that is BMI>25 (overweight + obesity). Responsibility is placed on those of excess weight to reduce the burden on the NHS. In reality the NHS crisis is due to privatisation, fragmentation and austerity. The press release is versed in the ‘Brexit’ messaging of ‘take control of our futures’, this time by ‘losing weight and getting active’ … ‘adopting healthier lifestyle’. That is populist, with little cost to the government.
The focus on individual responsibility, backed by government, remains a theme. Government will further restrict advertising of HFSS foods, ban ‘BOGOFs’, increase weight management services and technologies. The food industry is to enable choice by providing information. Calorie counts are to be placed on menus of larger hospitality companies. What about franchises – the fast food outlets – that densely populate deprived communities where ‘obesity’ rates are highest? Its not just consuming calories that is important. The nutritional value of those calories is determined by food access. BOGOFs might be banned, but remember the supersized bars? These have mostly been removed from our shops but industry seems to resize and repackage and so continues to sell the same product in deprived communities, as exampled in this photo of a local shop taken 5 days ago:
The energy cost is affordable compared to fresh fruits: £1 for 4 chocolate bars or £2.49 for 200g of strawberries.
Lack of public health nutrition and community resources
Health Secretary, Matt Hancock says ‘Everyone knows how hard losing weight can be so we are taking bold action to help everyone who needs it.’
The track record is not good. Long-term maintenance of lost weight is challenging. A minority of people maintain weight loss, and weight cycling (or yoyo-dieting) is a risk for all-cause mortality.
He continues ‘… supported by an inspiring campaign and new smart tools, will get the country eating healthily and losing the pounds’.
What support can we expect when austerity and tendering-out of nutrition services, including weight management, have reduced public health capacity? The emphasis on individual ‘effort’ – responsibility – is enabled by smart tools. Self-help, interactive computer programmes and Apps might not be so helpful for less advantaged.
Socially embedded stigma
The focus is on adults and children. Some media approached this in a stigmatising way – likely unintentionally but commonplace. For example, when talking about adult BMI the ‘Guardian’ used a manufactured, dehumanising photo of child (headless & dressed in clothes that do not fit – it was changed). This associates ‘child and adult’, assumes parent responsibility, assigns them as moral associates of child obesity, and promotes stigma and blame.
The press release uses worn out stigmatising language: ‘burden to the NHS’ , ‘time bomb’. This old metaphor also shows strategies and interventions over twenty years are failing. We need a new approach that is grounded in tackling inequalities, the right to food, good nutrition, and sustainable ‘healthy’ diets.
A healthier weight?
The PHE report adopts a ‘pragmatic’ approach to the research rather than systematic review because of the urgency in finding risk factors for COVID-19 hospitalisation and mortality. It points out limitations such as small sample sizes and some sources of BMI might not be accurate. Findings are tentative and further research is needed1. Plausibility for a link between obesity and COVID-19 severity has been provided. It is important that researchers look for risk factors and laudable that the report has been produced quickly. However, it provides a broad sweep of risk attached to carrying excess weight that starts from BMI > 25 to severe obesity BMI >40. It is not clear what ‘healthier weight’ means in the context of risk attached to ‘excess weight’. Does this mean a BMI 25 or less across whole population? How realistic is this and what does it mean in the context of food poverty, inequalities and health? And, for people in poverty, genetically susceptible to weight gain, and who have NO choice in their food consumption?
Fear and anxiety generated by ambiguity in the association between COVID-19 and BMI>40 is concerning. Similarly, fear and anxiety may increase for those with the ambiguity of risk with BMI>25. Stress and fear were caused by the lock-downs. Now millions of people are facing job losses, cuts to their living standards and intensification of work in an effort to hold onto their jobs. In this context, unclear health messages are unhelpful. If the purpose is using fear for behavioural change – we have to ask where is the ethic of ‘do no harm’?
Stress as a risk factor
The PHE report appears not to consider stress and the damaging effects of cortisol response. This is particularly important in the context of inequalities, poverty, racism and accompanying stigmatisation and discrimination that, internalised, create stress. Focus on individual responsibility and lifestyle changes assume choices are available. That is not the case in the context of inequalities. Going into the crisis, 14 million people, a fifth of the population, lived in poverty; seven in ten adults in poverty were working or living in poverty with someone in employment. Stress is a major workplace concern with 69% of trade union representatives reporting it as the most frequent problem. Everyday stress is caused by the physical food environments as these quotes from working class mothers of higher weight ‘obese’ children, living in a deprived area, illustrate2. The ‘nanny’ is a metaphor for resources – the time and money – that they do not have compared to affluent families, Leyla says:
They can afford to go out and buy these organics, healthy foods … have nannies that prepare the dinners before they get in … told the nanny ‘make sure you feed them healthily.’ But when you’re thinking every day, what am I going to cook them? Your money’s running low. You’ve got stresses about bills and everything else. The last thing on your mind is ‘what’s the healthy option? You can’t afford to buy the healthy stuff so you’re just going to go for the quick fix.
Samina, a mum aged 23 years with mixed weight children, one ‘healthy’ and one higher weight says:
When you’re from more lower … urban areas not so nice, there’s more crime, drugs and lot more things going on for people to have a clear mind and think ‘I want healthy food’ and to care about themselves. Whereas if everything looks nice like, you have a clearer mind … time to think and care for yourself. Whereas in the lower-class people they don’t … the way they dress … what they eat. They don’t have money to dress well and look after themselves. And where they live … kind of a cycle, it just goes on ….
National Food Strategy
‘Eating well in childhood is the very foundation stone of equality of opportunity. It is essential for both physical and mental growth’ (NFS, page 7)
The NFS has COVID-19, obesity and hunger at its core. It calls for government to tackle impending hunger, ensure good nourishment to support learning and tackle obesity through extending eligibility for free school meals to all children whose families are on universal credit, increasing value of Healthy Start Vouchers and tackling holiday hunger. In the light of COVID-19 it focuses on children’s diets, however, it does not advocate the right to food for all children and the responsibility of government to guarantee this.
It uses a category of ‘most disadvantaged children’ yet excludes the rights of the most disadvantaged to free school food – children in families with no recourse to public funds. We need universal free school meals for all infants and children.
It assumes good nourishment in childhood is foundational for ‘equality of opportunity’. However, much more is needed for all working class children to flourish. This cannot be enabled by meritocracy. Flourishment will be advanced through rights of parents/carers to universal living incomes and services, food for all, an end to racism and all forms of discrimination. The NFS does not advocate for legislation for right to food – maybe this will follow in parts 2 and 3?
There are wonderful opportunities that we should have in our communities. UFSM could be an anchor for developing the local food economy linking with local cooks, citizen shops, community food growers and caterers who are struggling due to COVID-19 and economic crisis. A food and health democracy should involve school students, parents and community in deciding the food culture of their school – menus, the length of meal times. A NFS should be grounded in our local visions and needs.
Sources
1 Additionally, BMI is a surrogate measure of body fat that is commonly used as being the best available, and is accepted as screening tool (although for children, it underestimates obesity in South Asian children and overestimates in Black children). It is not a reliable diagnostic tool. The risks attached to levels of obesity are questioned.
2Noonan-Gunning, S – in publication – please contact sharon.noonan-gunning.1@city.ac.uk