THE UNEQUAL BURDEN OF OBESITY?

By Lorraine Tulloch and Jennifer Forsyth of Obesity Action Scotland

Health Inequalities has been in the headlines frequently over recent months in Scotland. We have had an Inquiry at Scottish Parliament, an ongoing Independent Review led by Health Foundation due to publish in January, a report from CRUK indicating that cancer incidence rate and cancer outcomes are much worse for those living in deprivation in Scotland. Each report identifies obesity as a major contributing factor in the worsening picture.

This is a seemingly intractable problem we face in Scotland; the challenge of inequalities perpetuates the cycle of poverty, poor diet, overweight and obesity. Data released in the last month shows that rates of overweight and obesity in adults in Scotland are at their highest rates since records began.1 This is not entirely unexpected given that so many people reported gaining weight during the pandemic response measures. However, it should be a concern for us all; these trends pre-date the pandemic, having a higher weight impacts on our health, our quality of life and our length of life. We cannot afford to be numbed or overwhelmed by the statistics. We must see them as the driver for change.

HOW DOES THE BURDEN FALL IN SCOTLAND?

Overall life expectancy in Scotland is lower than in any other part of the UK, and what progress we had made has now been eroded, with life expectancy not just stagnating but actually reducing. Data included in a recently published report from the University of Glasgow2 shows there is a significant inequalities gap, with life expectancy for both men and women in the most deprived tenth of areas being markedly lower than those in the least deprived – a difference of 10.2 years for females, and 13.5 years for men.

When we look at healthy life expectancy, the inequality is even more stark. Babies born in the least deprived areas of Scotland can expect to live a staggering quarter of a century longer in good health than their most deprived counterparts. This pattern is replicated for both men and women. For males, those in the least deprived areas will have an average of 70 years healthy life expectancy compared to just 45 years for those in the most deprived areas. For females, the difference is 73 years and 49 years respectively. That means many people and families struggling in Scotland with their health, their ability to work, provide for themselves and their families before they enter their 50s.

These patterns of inequality are also emerging and changing when we consider weight. Prior to 2018, the risk of childhood obesity had fallen slightly in the least deprived areas, and increased in the most deprived areas. However, in recent years, there has been increase in rates of childhood obesity across all five deprivation quintiles. Significant inequalities still remain; children in the most deprived quintile were twice as likely to be at risk of obesity than their peers in the least deprived quintile, with an actual gap of 7.2%. These statistics show harm to children now, and store up problems for the future.

Deprivation is also linked to differences in adult BMI across Scotland, with those in the most deprived areas consistently showing a higher BMI than those in the least deprived areas.

This is evident across all age groups and for both males and females3, ultimately translating into consistently higher obesity rates in the most compared to the least deprived. For women in particular, the gap has been particularly pronounced. In 2019, 40% of women in the most deprived areas had obesity, compared to 18% in the least deprived.4

Proportion of children in Primary 1 at risk of obesity (%) according to fifths of area-level deprication: 2001/2 to 2019/20

Taken from Miall, N; Fergie, G; Pearce, A. Health Inequalities in Scotland: trends in deaths, health and wellbeing, health behaviours, and health services since 2000. University of Glasgow. November 2022. doi: 10.36399/gla.pubs.282637, page 61

WHAT ABOUT IMPACT ON DIET?

Diet has a profound impact on weight and there are clear influences of deprivation on dietary outcomes. The University of Glasgow report5 highlights that across the board there are low levels of fruit and vegetable consumption but, again, there are profound differences between the most and least deprived – just under a quarter (24%) of those in the most deprived areas had not eaten a whole portion of fruit or vegetables on the previous day, compared to only one-tenth (9.6%) for the least deprived. Inequalities in diet highlight the importance of both availability and affordability of healthy food, with those in more deprived areas facing real barriers to achieving a healthy diet. Data from the 2019 Scottish Health Survey confirms that there are also large inequalities in food insecurity according to arealevel deprivation, with adults living in the most disadvantaged fifth of areas five times as likely to experience food insecurity as those in the least.

The current cost-of-living crisis is presenting even more challenging circumstances. Not only is food getting more expensive but also with rising costs across energy and other outgoings there is much less money available in household budgets for food. We quote extensively the experience of people in Scotland at the highest and lowest percentages of deprivation, but inequality increasingly affects everyone except the most fortunate in society.

Food inflation continues to rise at a worrying rate, skyrocketing to 16.4% in October 2022 from 14.6% the previous month according to data from the Office for National Statistics. This remains markedly higher than overall inflation which is sitting at 11.1%.6

The rise in price is not equal across all food categories. An analysis of ONS (Office for National Statistics) data by Food Active has demonstrated that low fat milk has risen in price by 42% and frozen vegetables by 20%. By comparison confectionery has only risen by 6% and soft drinks by 9%.7 The consequences on our diets remain to be seen but Which? have called on supermarkets to take action to ensure the right type of products are affordable and accessible.8 It is too easy to tip the balance of the shopping basket towards harming health.

WHAT ARE THE SOLUTIONS TO HEALTH INEQUALITIES?

There are important income related solutions that have to be found, but there are also structural changes that can be made – changing our relationship with food production, retailing, buying and consuming. This includes changing the marketing and promotional landscape of the food system in Scotland. At a time when trends are heading in the wrong direction, these measures are urgent.

Such interventions are low cost to government, but extremely effective. They influence the causes of inequalities, they are preventative, they are population-wide, they impact on the structures of our society and are examples of ideal public health interventions. Evidence is accumulating of increasing public support to take such measures. They would ensure when we go shopping or eat out the healthiest option is the easiest and cheapest option for everyone. They require bold legislation and brave politicians. The bravery is needed to ensure action is not diluted in the face of a food and drink industry competing to sell at all costs, intent on putting profit before our health and contesting the need for legislation and interventions.

Obesity Action Scotland is working hard to ensure changes to promotions, marketing and advertising of food alongside improving the offer when eating out, to benefit everyone and those who face the greatest challenges most of all. The medical profession can take a strong stance on these issues and be a voice in the call for greater focus and action on prevention.

(1) Scottish Government (2022) The Scottish Health Survey 2021 https://www.gov.scot/publications/scottish-health-survey-2021-volume-1-main-report/

(2) Miall, N; Fergie, G; Pearce, A. Health Inequalities in Scotland: trends in deaths, health and wellbeing, health behaviours, and health services since 2000. University of Glasgow. November 2022. doi: 10.36399/gla.pubs.282637 https://www.gla.ac.uk/media/Media_892338_smxx.pdf

(3) Obesity Action Scotland (2022) The Weight of the Nation https://www.obesityactionscotland.org/media/1841/weight_of_the_nation_report-final.pdf

(4) Scottish Government (2020) Diet and Healthy Weight Monitoring Report https://www.gov.scot/binaries/content/documents/govscot/publications/statistics/2020/10/diet-healthy-weightmonitoring-report-2020/documents/diet-healthy-weight-monitoring-report/diet-healthy-weight-monitoring-report/govscot%3Adocument/diet-healthy-weight-monitoring-report.pdf

(5) Miall, N; Fergie, G; Pearce, A. Health Inequalities in Scotland: trends in deaths, health and wellbeing, health behaviours, and health services since 2000. University of Glasgow. November 2022. doi: 10.36399/gla.pubs.282637 https://www.gla.ac.uk/media/Media_892338_smxx.pdf

(6) Food Foundation, (2022) Food Prices Nov 22 Update https://foodfoundation.org.uk/news/food-prices-nov-22-update-what-are-retailers-doing-help

(7) Food Active (2022) Briefing Paper Cost of Living Crisis and Healthy Weight https://foodactive.org.uk/wp-content/uploads/2022/11/HealthyWeight_CostOfLiving_BriefingPaper_Nov2022-1.pdf

(8) Which? (2022) 10 point action plan for supermarkets https://www.which.co.uk/news/article/the-most-at-risk-areas-for-access-to-affordable-food-revealed-a9JFe8I1qmyx

(9) Food Active (2022) Briefing Paper Cost of Living Crisis and Healthy Weight https://foodactive.org.uk/wp-content/uploads/2022/11/HealthyWeight_CostOfLiving_BriefingPaper_Nov2022-1.pdf