This was published today in the Canadian Centre for Policy Alternatives Monitor
http://www. policyalternatives.ca.
It originally appeared in the Toronto Star, October 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

 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.

 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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