Unequal weight: equity oriented policy responses to the global obesity epidemic

Food systems and behaviour

The increased availability of dietary energy, globally, is due to many factors. Liberalised trade opened many more countries to the international market.7 Food subsidies have arguably distorted the food supply in favour of less healthy foodstuffs such as those high in saturated fat,8 and transnational food companies have flooded the global market with cheap to produce, energy dense, nutrient empty foods.7 Supermarkets and food service chains have displaced small, family run stores or stalls, encouraging bulk purchases, convenience foods, and supersized portions.9 Energy density and fat intake have increased in both high income and “transitioning” countries.10 Although global food prices have dropped, on average,8 in rich countries the foods recommended in healthy eating guidelines are often more expensive than the less healthy options.11 Targeting community and personal norms and preferences, food advertising through television, which is omnipresent in rich countries and ever increasing in developing economies, aims to persuade individuals—particularly children—that they desire foods high in saturated fats, sugars, and salt.3

Built environment and behaviour

Research, mainly in high income countries, indicates that local urban planning and design can influence weight in several ways. The density of residences and the mix of land uses, together with connected streets and the ability to walk from place to place, are directly related to increased physical activity.12 Provision of and access to local public facilities and spaces for recreation and play are directly correlated with individuals’ levels of physical activity.13 The increasing reliance on cars is an important influence on shifts towards physical inactivity in both developed and developing countries.14 Low income groups are thought to be affected more by their built environments because their activity spaces are smaller, they are more constrained by lack of transportation, and opportunities to buy healthy food are lacking in lower income neighbourhoods.15

Social conditions and behaviour

Working and living conditions, such as having enough money for a healthy standard of living, underpin compliance with national health guidelines.16 Employment conditions can affect weight, although the evidence remains sparse. Current precarious employment conditions are related to sedentary work, disinclination to use active transport, and ready access to energy dense foods.17 18 More fundamentally, these labour market conditions mean increasingly less job control, security, flexibility of working hours, and access to paid family leave19—thereby undermining the material and psychosocial resources necessary for empowering individuals and communities to make healthy living choices.

Unequal society, unhealthy weight

A person or group’s place in the social hierarchy influences behavioural choices, which are governed by the material and psychosocial resources provided by the complex system consisting of the food, built, and social environments.20 Unequal exposure to health protecting or health damaging aspects of these environments adds health disadvantage to disadvantages of wealth, power, and prestige. These underlying structural inequities are likely to be responsible for the unequal distribution of obesity.

Global response

At the global level, international trade agreements offer opportunity for many people to benefit. However the nature of these agreements and the effect on health inequities between and within countries provoke concern. The experience of the Codex Alimentarius Commission (www.codexalimentarius.net) highlights the challenges. Codex is designed to help governments protect the health of consumers and ensure fair trade practices in the food trade. However, currently industry representatives hugely outnumber representatives from public interest groups, resulting in an imbalance between the goals of trade and consumer protection. This imbalance must be redressed.

Another concern is that international agreements restrict the policy space of national governments. This can be good for health, as in the case of the Framework Convention for Tobacco Control, where the global treaty is designed to narrow the policy space of governments, guiding them in a direction that is positive for health. However, WHO and other international agencies need to ensure that they have sufficient capacity and expertise, including legal expertise, to ensure that countries can implement international policy prescriptions, as well as provide technical guidance and support with respect to ensuring health concerns are represented at the international level. Building on the WHO global strategy of diet, physical activity and health, further collaboration with other UN agencies is needed to create a more extensive evidence base for understanding issues related to governance and healthy behaviours.

Ensuring that global food marketing does not target vulnerable societies requires binding international codes of practice related to production and marketing of healthy food, supported at the national level by policy and regulation. Regulating television advertising of foods high in fat or sugar to children is a highly cost effective upstream intervention.27 However, reliance on voluntary guidelines may result in differential uptake by better-off individuals or institutions and provides little opportunity for public and private sector accountability. Such global or national regulations must be developed by a consortium of public-private institutions and adhere to criteria for good governance.28

National responses

It is possible to intervene at the national level in the structural determinants of healthy food, including matters such as domestic subsidies for healthy food production. For example, Norway successfully reversed the population shift towards high fat, energy dense diets by using a combination of food subsidies, price manipulation, retail regulations, clear nutrition labelling, and public education focused on individuals.29 Few developing countries have interventions that have been evaluated, but Mauritius provides an example of a relatively successful programme that includes price policy, agricultural policy, and widespread educational activity in various settings.30 Both the Norwegian and Mauritian programmes produced positive dietary changes in the population at large, but relatively little is documented about the effect on health equity.

Much can be achieved through good governance at the national level, particularly when basic public goods such as transport infrastructure, clean water, and electricity remain elusive.31 At the heart of good governance lies the challenge of ensuring coherence between different ministries and levels within governments and between different agencies to enable the necessary intersectoral action. One of the few evaluated examples of such an approach is Healthy Food for All (www.healthyfoodforall.com), an all Ireland multi-agency, equity oriented initiative seeking to promote access, availability, and affordability of healthy food for low income groups.

Local responses

National and regional action is needed immediately to increase the opportunity for exercise within the environment and reduce the time spend in cars. The Brazilian population-wide Agita Sao Paulo physical activity programme successfully reduced the level of physical inactivity in the general population by using a multi-strategy approach of building pathways; widening paths and removing obstacles; building walking or running tracks with shadow and hydration points; maintaining green areas and leisure spaces; having bicycle storage close to public transport stations and at entrances of schools and workplaces; and implementing private and public incentive policies for mass active transport.32

Local, community based initiatives can promote equitable access to healthy food. The city of Sam Chuk in Thailand restored its major food and small goods market with the help of local intersectoral action including architects. The London Development Agency plans to establish a sustainable food distribution hub to supply independent food retailers and restaurants.9 The lack of systematic evaluation of initiatives, particularly with an equity focus, makes it difficult to generalise policy solutions in this field. In general, urban design and planning would be greatly aided by routine assessment of the impact on health equity of where food retail outlets are placed and how easy it is to get to them. Schools are another setting where inequities are reinforced. Schools can make money through placing soft drink vending machines on school property and by subcontracting lunch programmes, which encourage the sale of high profit, low quality foods, including fast food. If schools offer physical education, large class size and lack of equipment present barriers to participation.33 Effective interventions in schools are those that make healthy options available while also restricting the availability of competitive foods and options for inactivity.34