http://www.thestar.com/NASApp/cs/ContentServer?pagename=thestar/Layout/Article_Type1&c=Article&cid=1026146293252&call_page=TS_Life&call_pageid=991479973472&call_pagepath=Life/News&col=991929131147
Oct. 11, 2002
Poor choice or no choice?
Even more evidence links low income with disease, so why keep blaming lifestyle
choices like fries?
Dennis Raphael
special to the star
Stop smoking. Get off the couch. Don't touch those fries.
Do this, we're told, and we can fight off obesity, heart disease and diabetes.
But a new study published today in the British Medical Journal provides further
evidence that adverse life conditions - not lifestyle choices - are the main
contributors to obesity, heart disease and diabetes.
Even more significant, this study relates the risk factors for these diseases
in adults to the socioeconomic position they experienced as children.
Researchers at the University of Bristol assessed the degree of insulin
resistance, blood cholesterol levels, and obesity among 4,286 adult women.
Insulin resistance is the body's inability to utilize available insulin to
process blood sugars. It's a significant contributor to heart disease and to
Type II diabetes, the most common kind, which appears in adulthood.
Most disturbing is the news that childhood socioeconomic circumstances were
even better predictors of insulin resistance than adult situations.
Women from lower income conditions as children and as adults were 58 per cent
more likely to show high insulin resistance than those who lived under higher
income conditions as children and adults. But women living in better social and
economic circumstances as adults still had a 29 per cent greater chance of being
insulin resistant if they grew up in low-income families.
Women who grew up poor were more likely to show increased insulin resistance,
have higher levels of bad cholesterol and obesity than those who lived under
better socioeconomic circumstances as children. These relationships remained
after taking into account adult social and economic conditions.
This news comes one day after the release of the 2002 Report Card on Children
showing that childhood poverty is on the rise in Toronto. The number of children
in low-income families grew 9 per cent in the city from 1995 to 1999 and the
city's poorest neighbourhoods have experienced a 35 per cent increase in the
number of children since 1996.
Because they're growing up poor, these children are at greater risk for
obesity, heart disease and diabetes as adults.
Nevertheless, if disease awareness and prevention campaigns continue on their
current course, these kids may grow up to be adults who are blamed for putting
themselves at risk for these diseases by smoking, not exercising and indulging
in unhealthy food.
And yet, research since the mid-1970s has found lifestyle and biomedical
factors account for only a small proportion of whether someone develops heart
disease or diabetes.
In fact, Health Canada and Canadian Public Health Association policy statements
of the past 25 years outline what really matters for disease prevention:
adequate income, shelter, food, employment and working conditions, and a social
safety net.
The British Medical Journal study is consistent with the results of many
published studies indicating that socioeconomic circumstances are the best
predictors of both the risk conditions and actual incidence of heart disease and
diabetes.
Is it a lifestyle choice to have poor parents
or be homeless or hungry because of low
social assistance or minimum wage
levels?
Indeed, many researchers have noted that trying to prevent lifestyle illnesses
by changing adult lifestyle behaviours is unlikely to profoundly alter the
incidence of heart disease and diabetes if no change is made in the improvement
of people's economic conditions. Poverty influences health by determining the
level of material resources available such as income, shelter, food, etc.,
stress that threatens bodily functioning and the adoption of unhealthy coping
behaviours such as poor diet, smoking and alcohol use.
These factors - the social determinants of health - are clearly not under
individual personal control. They're not choices people make. Is it a lifestyle
choice to have poor parents or be homeless or hungry because of low social
assistance or minimum wage levels?
These social determinants of health are sensitive to social and economic
policies that result from government decisions.
Knowing all this, knowing that children living in poverty grow up at greater
risk of diabetes, heart disease and obesity - all of this costly to a government
health care system, by the way - would we not expect that governments at all
levels would promote the health of Canadians by assuring the quality of these
social determinants of health?
Wouldn't we also expect that public health, health care, and heart and diabetes
associations would consider how social and economic conditions affect health?
And yet, we hear little from these sources except to be preached to about the
importance of making "healthy lifestyle choices," even though these behaviours
are relatively unimportant to the health of Canadians.
Why is this the case?
One question to ask is: Who benefits from such neglect? Governments that weaken
the social safety net, transfer wealth from the poor to the wealthy through
income tax reduction and privatize public services create the risk conditions
that lead to heart disease and diabetes.
Yet these governments can point to their lifestyle-oriented heart, health and
diabetes programs as evidence of their commitment to health. Public health units
can appear to be working to improve health without raising sensitive economic
and social issues that will certainly draw the ire of their political
paymasters.
Better safe than sorry.
Why disease associations neglect the social determinants of health is less
clear. Perhaps research findings
? and especially today's report about the
impact of childhood poverty on adult risk of heart disease and diabetes ? will
guide the Heart and Stroke Foundation and the Canadian Diabetes Association to
communicate the following tips for better health in their pamphlets:
Reduce poverty.
Improve economic and social conditions to reduce stress and insecurity.
Restore the social safety net to assist Canadians in navigating their life
course.
Such tips - consistent with the latest research - would serve to focus public
attention on the real risk factors for heart disease and diabetes, and in the
process improve the health of all of us.
Dennis Raphael is an associate professor in the School of Health Policy and
Management at York University, and the author of Social Justice Is Good For Our
Hearts: Why Societal Factors - Not Lifestyles - are Major Causes
of Heart Disease in Canada and Elsewhere, published by the CSJ Foundation for
Research and Education.
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