Fat Chance - the hidden inequalities in public health

An edited version of this post is cross-posted at The Vibe Online, an excellent political internet magazine. I also have a letter published in The Guardian along the same lines.

The Health Secretary Andrew Lansley MP has been a busy man since taking office. Not content with driving through radical reforms to the NHS – including controversial plans for healthcare budgets to be handed over to consortia of GPS – he recently unveiled the Department of Health’s White Paper on Public Health – Healthy lives, healthy people. Whilst this White paper sets out a compelling case for the need to improve public health outcomes, I want to highlight one policy measure in particular which may well worsen the picture considerably – that of putting major food corporations in charge of setting policy, which the blogger Dr. Aust says is akin to putting the fox in charge of the chicken coop.

The case for improving public health revolves around the recognition of the intolerably large inequalities in mortality and morbidity that exist within the country. By now the statistics are probably familiar to the reader; studies lead by UCL’s Prof. Sir Michael Marmot shows that there are ‘gaps of up to 7 years in life expectancy between the richest and poorest neighbourhoods, and up to 17 years in disability-free life expectancy.’

The previous government did of course have policies in place to tackle poor public health, defended with great vigour by Prof. Joe Millward in The Guardian last week. Of particular concern for Prof Millward is the government’s intention to place major fast-food and beverage corporations at the heart of setting public health policy; he argues that

the increase in childhood obesity has now stopped

and that

[t]his is almost certainly because of a coherent, effective policy on diet, implemented by the Labour government following decades of opposition from the food industry.

As evidence for his former claim (which he repeats later in his article, suggesting that the “prevalence of obesity is falling in girls and no longer increasing in boys”), Prof. Millward cites a study published in the International Journal of Obesity. This study does indeed show that the proportion of children who are overweight and/or obese didn’t increase between 1997 and 2007 and so appears to support Labour’s record on public health – until we look a little closer at the data.

The authors of that study describe a disturbing underlying trend – in scientific terms it’s more than a trend, it’s a significant finding – that seriously undermines Prof. Millward’s championing of the previous government’s success in curbing obesity; moreover it poses serious questions about the current government’s approach as well.

Stamatakis et al. show that the odds ratio (a measure of how likely an outcome is) for children being overweight and/or obese was no greater in 2007 than in 1997 – an apparent vindication of public health policy at the time. But when they separated the subjects they studied not by gender but by socio-economic position – in other words, by income and class – those in the lowest bracket were nearly twice as likely to be overweight and/or obese in 2007 than they were ten years previously, whereas there was no significant difference for children in the highest bracket.

The finding is worth re-stating and emphasising. More deprived children were overweight in 2007 than was the case 10 years before then, whereas children from better off families were no more likely to be of overweight – put bluntly, under the last government poor kids got fatter and rich kids didn’t. Any overall trend towards better weight control in the population at large – which Prof. Millward claims is a result of Labour’s health policy – appears to mask a significant worsening amongst the poorest in society. The deterioration of this marker of public health may well be hidden as widening of inequalities rather than worsening overall trends, but it’s there nonetheless – and it’s vital we don’t miss this point as Prof. Millward seems to have done.

So here’s the crunch. With the poorest already suffering from lack of affordable means for exercise and poorer diets, the authors devastate Labour’s approach to improving public health:

As lower socioeconomic groups tend to be wary of measures and messages aimed at changing their lifestyle because they see them as ‘nanny-statism’ that erodes their autonomy it is possible that policies targeting children's eating and physical activity habits have been perceived less favourably by lower-income and social-class groups.

This is where Mr. Lansley’s White Paper gets things both nearly right – by devolving funding and responsibility for improving public health away from the central State to local authorities and focusing on results not fancy campaigns – and so very wrong – by drafting in the very vested interests that fuel the obesity epidemic to dictate health policy. Because if a policy that purports to tackle inequalities in health recruits as its executive arm the corporate entities responsible for widening the gap between the rich and poor, whose aim is to maximise their profits by selling to people whose health they are now charged with improving, who’s to say that in another 10 years time we won’t be looking back at the co-opting of the junk food industry as the point at which the poor, already getting fatter than the rich, finally saw the government make their health subject to the vagaries of market forces.