Critically evaluate and demonstrate the link between rising obesity levels in women from low- income households in the UK with reference to the influence income has on food choice

Numerous studies and reports over the past 40 years (Marmot, 2010; Acheson, 1998; DEFRA) have identified social patterning in levels of obesity. Results in the UK have shown a growing trend amongst women from low-income households and obesity. Income along with other social factors influences food choice.

There is widespread public and government knowledge that low-income households are most likely to have an unbalanced diet which contributes to poor health outcomes (Marmot, 2010; LINDS, 2007; Acheson 1998). Low-income impacts on obesity by limiting access to resources, the more income a household has the more accessibility to food choices they will have (Sobal & Stunkard, 1989). Low-income can be defined as lower than half of the average income (Acheson; 1998). This essay will attempt to explore the causes and consequences of the prevalence of obesity for women from low-income backgrounds whilst taking into account environmental & social aspects. Research on dietary behaviours indicate that accessibility and knowledge of healthy practices are significant factors that must be also be considered (American Psychological Association, 2005).

In 1997, following the election of New Labour, the government commissioned an inquiry into health inequalities. The Acheson Report followed the inquiry making many recommendations to address health inequalities amongst women, families and children. The report advised the benefits of improving the diet of women and girls to make improvements not only to their own health, but also the health of their children and future families (Acheson, 1998). Likewise, the Health Survey for England (2003) found women from the lower social classes are more susceptible to obesity, no correlation was found for men (Sproston & Primatesta, 2004). Elsewhere the global pattern appears to be the same, the World Health Organization carried out a study across 26 countries and found the social gradient of obesity levels consistently higher amongst women than men (Wilkinson & Pickett, 2010 pg98). More recent studies such as the Marmot Review (2010) showed income along with other prevalent social factors; social deprivation and ethnicity increased the risk of obesity for women.

The UK has one of the fastest growing rates of obesity in the developed world. This steady increase has led to a society where overweight is the norm (Weight Management Centre, 2010). Despite the increase over the last 50 years there has been a shift in values in modern, developed societies towards slimness as a preferred body shape (Sobal & Stunkard, 1989). Conversely, it is interesting to note historical observations of female body weight, for example, in 19^th Century Britain, voluptuous women of the middles classes where regarded as objects of beauty, a large curvy figure was a symbol of wealth and high status (Williams & Germov, 2009). In developing societies plumpness is portrayed as positive, whereas in developed societies it is seen as negative. An extreme example of this can still be observed in some African cultures where they send young women to fattening huts to gain excessive weight to increase their beauty, status and marriage potential (Brink, 1989).

The way we choose and eat food can be deep rooted in complicated cultural reasons. We may choose foods based on what we had as a child, foods that mean something to us, provide feelings of comfort or to aspire to a lifestyle. Food has always been linked to social meanings but never before as it been so widely available and affordable to consume such cheap energy rich foods (Wilkinson & Pickett, 2010). In a similar way foods we eat can be habitual and mood enhancing, women more frequently report food cravings than men (Dye & Blundell, 1997). New research suggests some high fat high sugar diets can cause changes in the brain comparable to drug addiction, moreover the studies found these brain changes can be passed on to offspring (Society for Neuroscience, 2012) although this research is intriguing the evidence is very limited but future expansion into this area could prove very insightful.

Cultural habits and norms develop and change throughout the life course, past events and experiences shape food choice, equally future expectations and social determinants influence food selection. Early in life we develop food roots that in time lead to established diet patterns.

The social environment can play a role in food choices we make and may influence patterns of obesity in some groups. Of interest to note is a study that looked at the spread of obesity in a large social network over 32 years, finding a link suggesting siblings and friends of the same sex shared an obesity spreading pattern. The study found the link to be strongest with female siblings although it was also present in same sex friends and spouses. This implies obesity as infectious, showing that people are influenced by the appearance and behaviours of social contacts. That said, other imitation behaviours that may occur under the same influence such as exercise and smoking can also have an effect on obesity (Christakis & Fowler, 2007).

Studies reveal that women from ethnic minority groups living in the UK have a higher obesity rates than men from the same groups (Health Survey for England, 2004). The figures for obesity in women from these groups in particular, Black African and Bangladeshi females, is higher than the rest of the general population. However, the results may be limited due to the small numbers representing some of the ethnic minority groups. According to the Department of Health, Equality Analysis: A call to action on obesity in England (2011), there is not enough evidence available to attribute causative factors to ethnic obesity prevalence in the UK. The correlation between obesity and ethnicity is complex. Some evidence points at underlying genetic susceptibility to obesity related illness such as diabetes made worse by changes in dietary habits , lack of exercise and environmental circumstances (Holmboe-Ottesen & Wandel, 2012). The same study looked at the dietary changes of immigrants from low-income countries to Europe, revealing two factors which could alter lifestyle and health outcomes of immigrants. Firstly, acculturation a process whereby the immigrants are influenced by the food culture of the host country, secondly, nutrition transition which has a global trend, for instance, if processed foods are only available to the high income groups in the country of origin, then after migration these foods are more available and cheap, making them appear an ideal choice.

The pattern between income inequality and obesity appears to be stronger for women than men (National Obesity Observatory, 2011). In an attempt to understand this pattern it is important to consider many factors. There is a belief that obesity has a genetic predisposition ‘thrifty phenotype’ (Hales & Barker, 2001). Whilst genetics can have a role, Wilkinson and Pickett (2010) argue the correlation is not strong enough to explain rapidly increasing obesity over the last 30 years. They suggest the rise in obesity more likely related to changes in society in the way we live such as, increasing food prices, accessibility, the growth in fast food outlets, microwave cooking, poor culinary skills and changes in physical activity levels.

It is unclear as to why the obesity pattern for women from low-income groups is stronger than for men, research in this area is limited. What is of concern is the health implications that these women face, startling figures from Healthy Lives, Healthy People (2011) report obese woman are thirteen times more likely to develop type 2 diabetes, four times more likely to develop high blood pressure and three times more likely to have a heart attack than a woman of healthy weight. Similar results were reported from Health England (2009) stating women in overweight and obese BMI categories are more likely to be diagnosed with a long standing illness than men, a similar correlation is shown between depression and obesity from the same paper.

Pregnancy poses further problems, women from socioeconomic deprivation are more likely to retain weight gained during pregnancy and after birth, age and number of births were also found to be contributing factors (National Obesity Observatory, 2011).

The Low-Income Diet and Nutrition Survey (LIDNS) reported price, value, income for food expenditure and quality/freshness of the food as the main influences affecting food choice. With 44% of women surveyed indicating they would like to change their diets.

Several studies (DEFRA, LIDNS, Acheson), have shown low-income groups are more likely to consume unbalanced diets and have a lower fruit and vegetable intake, they also have reduced levels of vitamins, minerals and dietary fibre with higher intakes of white bread, processed meats and sugar (Dowler, 2007). It can be argued that the obesity pattern in women from low-income groups is a consequence of globalisation and the resulting problems it leads to with job security leading to pressure on low-income individuals and families which creates an environment that encourages over consumption of high energy foods, in an area where working hours are longer with less time to prepare food thereby opting for cheap, convenience fast-foods which inevitably have a higher fat content, this shift in working patterns means people are more likely to consume convenience foods but be less likely to burn off the extra calories (Qvortrup, 2003). Increased demand in convenience foods associated with changing lifestyles over the past 20 years, has given rise to a food evolution (Buckley, Cowan, & McCarthy, 2007).

For some accessibility to healthy food on a low-income is a problem (Dowler, 2008). Living in low-income urban areas often means limited opportunities for daily exercise and reduced access to stores that sell healthy foods (Black, 2008).

It could be said that income is the biggest indicator in food choice as it often determines the quality and accessibility of food, but income can also be a contributing factor in education, housing, safety and transport, for example income often determines where you can live. It can be argued, if lack of income was the main cause in rising obesity levels, the greatest increase would be seen in the highest-income groups since they would be able to afford to buy more food. This is not the case, obesity has a new social distribution. In the UK and other developed countries it is the lower income groups who have the highest growth in obesity rates, no longer is it the case where the rich are fat and the poor are thin (Wilkinson and Pickett 2010).

Quality of food eaten may be an important indicator for low-income women. The cost of food has risen dramatically, the Department for Environment, Food and Rural Affairs (DEFRA) (2011) reported food prices to have increased by 12% between 2007 and 2011. The report showed the poorest are most affected by price increases with £1 in every £6 being spent on food for the poorest 20%, compared with £1 in every £9 for all UK households. LIDNS (2007) reported 39% of low-income households sometimes worried about having no money to buy food, 36% said they could not afford balanced meals, with 22% reported skipping meals.

Education is a component of socio-economic status that may be associated with obesity. People with higher education levels are more likely to make healthier food choices A study using diet data from the UK Womens Cohort Study (Morris, Hulme, Clarke, Edwards, & Cade, 2014) used a food cost database to estimate cost of dietary patterns using diet records, the results they found show a significant association between diet and cost, with a healthy diet costing twice as much as an unhealthy one. The results also demonstrated those subjects who consumed the healthiest diet have a higher SES indicated by education and occupation. Allowances should be made for overestimations and bias to the results of this study which used a food frequency questionnaire, it should also be noted, the data collected was from the diet survey 1995-1998 therefore not allowing for the inflated prices of todays food which would also influence food choice.

The Acheson Report (1998) advised government to have a greater responsibility in reducing nutrition related inequalities. The report emphasised the need to address not only changes at individual and family behavioural levels but also multi-sectoral action at national and local levels. Criticisms of the report say the recommendations were too similar to the Black Report of 1980. The main difference, noted by Exworthy (2002), is that the Acheson report was well received by the government.

In conclusion, globalisation of the UK economy has led to a shift from a traditional industrial nation to a society with altered work and lifestyle patterns. This shift in patterns has led to changes in food consumption and opportunities for exercise. Those who are in low-income households are most affected. Low-income is a factor in particular for women, who may take several actions to ensure that their families are fed, including skipping meals and eating cheaper, less nutritious foods. Education and accessibility can play a key role in improvements. Many government interventions at national and local level have already been initiated, however, too many are individual focused and more needs to be done at a social level.

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