By Dr Caitlin Randles
The link between diet and the impact on our health is undeniable. Cardiovascular disease, cancer, respiratory disease and diabetes are collectively termed ‘non-communicable diseases’ (NCD) and, according to the WHO, are responsible for 71% of global deaths, 80% of which are premature or avoidable.
These diseases are closely correlated with obesity, making diet a major modifiable risk factor. Aotearoa New Zealand has the third highest rate of obesity in the OECD, affecting 1 in 3 adults.
There is compelling data that unhealthy diets contribute to more death and disability than tobacco, alcohol and drug abuse combined with one comprehensive study attributing 1 in 5 deaths to an unhealthy diet.
These diseases, first noted in western countries have now spread globally, largely influenced by the spread of the ‘western diet’ via powerful food corporations. When talking about the population’s diet and individual food choices, it is important to apply some context. What actually dictates what we eat? Is it simply down to personal responsibility or education?
Unfortunately, the bigger picture in nutrition is often overshadowed by tedious debates about the exact optimal macronutrient content of our food. The current reality is that the majority of the population has a fairly homogeneous diet pattern and incidence of chronic lifestyle diseases continues to escalate. NCD disproportionately affects people in areas of social deprivation. Astonishingly, our public health challenge in these areas has completely flipped in the last century, from undernutrition to overnutrition.
Ultra-processed, energy dense foods more commonly known as ‘junk food’ are high in calories in the form of salt, sugar and fat but are nutrient poor. Unsurprisingly, there is a direct linear relationship between the consumption of these foods and the prevalence of diet-related non-communicable diseases. People who consume these products on a daily basis consume an extra 500 calories per day than those who do not.
There is undoubtedly a consensus amongst nutrition experts that diets that incorporate more whole plant foods and eliminating or minimising processed foods and animal products are the basic principles of what constitutes a healthy diet. So if we know what a healthy diet looks like, why is it so difficult for us to shift towards it?
Factors influencing personal food choices
and the obesogenic environment.
Personal choice to a large extent is an illusion. Mainstream understanding perpetuated by the powerful food industry is that individuals make a choice with what they want to eat. If people are overweight, then they should just eat less or exercise more.
But actually, there are some systematic relationships between larger socio-economic factors like inequality that constrains the choice of people to eat healthy nutritious food. This creates what is known as the ‘Obesogenic environment’ which is a tightly interconnected web of complex factors.
Physical availability of fresh produce
Studies show, in areas of social deprivation, access to fresh produce is more challenging. Geographical areas where access to fresh produce is limited or non-existent are known as ‘food deserts’. Furthermore, the composition of food available in a supermarket is tailored to the level of social deprivation in an area.
For example, there is less shelf space devoted to healthy food in more deprived areas compared to less deprived areas. Conversely, the proportion of processed and non-perishable foods such as tinned goods is higher.
Fresh produce is perishable
A factor limiting access to fresh produce if you live in a ‘food desert’ is that these goods are perishable. If you are on a lower income and perhaps only shop every fortnight due to financial and logistical constraints, you will be more likely to purchase foods that have a longer shelf life and these tend to be more processed.
Powerful transnational food companies
care about profits not people
There is a linear association between the density of fast food outlets relative to areas of social deprivation. In New Zealand, 13.7 fast food and takeaway outlets per 10,000 people in the most deprived areas and 3.7 in the least deprived areas. These areas with high relative density of unhealthy food outlets are known as ‘food swamps’.
Fast food outlets are a symptom of our current food system where the ‘free market’ decides what we eat. Transnational food and beverage corporations penetrate a market by drastically reducing the price and increasing the availability of ultra processed, energy dense foods.
These foods are engineered to be optimally palatable with the intention of overconsumption. This results in an increase in energy availability at a low cost. The outlets are strategically placed in areas of lower income where people have limited available resources such as time or money.
Food marketing shamelessly targeting
children and deceiving adults
The lack of regulation on marketing junk food to children is an obvious failure of the current system. In New Zealand, children watching TV at peak time (9am – 6pm) are exposed to 8 unhealthy food adverts per hour. Likewise, a median of 9 adverts for unhealthy food are found around schools.
Sadly, the number of adverts is higher around lower decile schools. Children are unashamedly targeted through all media channels resulting in a failure of the self-regulatory system to protect our children and young adults. One study found exposure to unhealthy adverts, especially during school years, may have long-term effects on eating choices and contribute to poor eating habits in young adulthood.
In addition, food companies have the freedom to use cunning and divisive marketing that is designed to deceive adults and parents.
For example, in New Zealand, 26% of unhealthy food products have a nutrition claim on the front of the packet. This is designed to entice the consumer and persuade them they are making a healthy choice which is frankly unethical.
The proportion of household income spent on food needs to be acknowledged. For families in New Zealand on income support or minimum wage, food is around half and a third respectively, of household budget. When costing a ‘healthy diet’ as set out by current national dietary guidelines, it is unaffordable for these families.
How can we expect these families to change what they eat when they simply do not have the disposable income to make the changes we recommend? Taking it further, if the income support and minimum wage does not provide people access to a healthy diet, we cannot be surprised when health inequalities continue to perpetuate.
Lack of time
A barrier to good nutrition that is commonly cited in the literature is lack of time. Research shows that individuals and families that spend the least amount of time on food preparation tend to be working long hours or multiple jobs. Furthermore, these individuals are more likely to prioritise convenience foods such as takeaways or ready meals that are heavily processed.
By contrast, greater amount of time spent on food preparation within the home was associated with a higher diet quality consisting of fresh fruits and vegetables and whole grains.
This is by no means an exhaustive list of barriers. What it shows is that the more deprived communities have far greater exposure to energy dense foods that are directly correlated with obesity and diet-related disease. The food environment is substantially more obesogenic.
What needs to be done?
It is essential that our food supply and the obesogenic environment is made into a political issue. Otherwise, the health disparity between rich and poor will continue to widen.
A report in the Lancet identified three barriers to policy change:
1. Food industry opposition.
2. Weak government.
3. Weak civil society.
The rhetoric that obesity results from unhealthy food choices or a lack of will power remains a concerning source of stigma. It also continues to perpetuate the inequalities we see in our health statistics because people feel personal shame or blame if they are affected by a diet-related chronic illness.
We need to put corporate interests and consumerist values aside and stop allowing powerful food corporations to decide what we consume.
That said, improving health advice for individuals by educating and empowering people to make healthy food choices is also essential and will certainly contribute to positive change.
However, unless we address these wider issues, health advice in our clinic rooms will be largely redundant. Upstream interventions through policy change needs to be a large part of the conversation.
The default environment needs to favour healthy lifestyle choices rather than a postcode lottery. The individual food choice approach is failing us.
Footnote: The article above was first published in the Autumn issue of Whole Food Living magazine. It is republished today in light of the current New Zealand election debate and in an effort to draw attention to the fact that obesity is a critical health issue that our elected representatives must face up to. – Peter Barclay, Editor
Dr Randles is an Accident & Emergency specialist based in Auckland. She takes a strong personal interest in lifestyle health care and is one of the founding members of Evidence Based Eating New Zealand.
Check out Isoa’s story in this New Zealand Herald article.
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