Poor choice or no choice? ; Even more evidence links low income with
disease, so why keep blaming lifestyle choices like fries?;
Dennis Raphael. Toronto Star. Toronto, Ont.: Oct 11, 2002. pg. F.01

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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