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From the Editor
March/April 2004: Obesity and Poverty
Posted 03/04/2004

Ursula Snyder, PhD

Although the problem of unhealthy overweight has much to do with how we
live as individuals, it seems profoundly determined by how we live as a
society. The fact that nearly two thirds of adults in the United States are
overweight and nearly one third are obese is pretty much common knowledge
in the general medical community. It's a crisis situation, one could argue,
and particularly for women. According to a recent study by the US Centers
for Disease Control and Prevention, women in the United States increased
their caloric intake by 22% (and men by 7 %) in the 30 years between 1971
and 2000.[1] The incidence of obese women in the United States stands now
at about 33% of the population; it has practically doubled within a single
decade.[2] At the end of 2003, the American College of Obstetricians and
Gynecologists issued a press release stating that female
obstetrician/gynecologists cite obesity as the leading health problem
confronting women today. What can the Ob/Gyn and primary care physician do
about thi
s? One can certainly bone up on the latest evidence-based analyses of diets
or studies of the effects of nutrition and physical activity on health and
disease. Medscape is offering more and more in the way of news, articles,
and CME in this area. Just type in "diet" into our much improved search
engine, for example, or "exercise." One would then be in a good position to
counsel patients to "eat well and exercise," and with some sophistication
suggest what kind of foods they ought to be eating and why and what forms
of exercise might be particularly appropriate. Well, fine -- especially if
your patient is relatively high up on the socioeconomic scale; but these
recommendations might cause utter frustration in a woman who is on the
lower end. And chances are you may have more obese women who are poorer,
given data from Health and Human Services that indicate women of lower
socioeconomic status are approximately 50% more likely to be obese than
those with higher socioeconomic status. (As an aside, men are about
equally likely to be obese whether they are in a low or high socioeconomic
group).[3]

A review published in the January 2004 issue of the American Journal of
Clinical Nutrition provides an important analysis of poverty and obesity
and supports the notion that addressing obesity more effectively requires
confronting it as a societal and public health problem.[4] Dr. Adam
Drewnowski, Director of the Center for Public Health Nutrition in the
University of Washington School of Public Health and Community Medicine,
and Dr. SE Specter, United States Department of Agriculture Human Nutrition
Research Center, Davis, California, analyze the rising trend of obesity in
the United States in terms of dietary energy density and energy costs. They
review a substantial body of literature showing that low income and low
education levels are associated with obesity in the United States; this is
especially the case for women. Food insecurity (limited or uncertain
availability of nutritionally acceptable or safe foods) has also been
associated with obesity. In particular, the authors point out that food
insecurit
y without hunger seems to be associated with overweight in women. But the
main thesis of the article by Drewnowski and Specter is that the
association between obesity and poverty may be linked to the low cost of
energy-dense foods (ie, foods high in added sugars and fat) and their
overconsumption. In their words, "the selection of energy-dense foods by
food-insecure or low-income consumers may represent a deliberate strategy
to save money...persons attempting to limit food costs will first select
less expensive but more energy-dense foods to maintain dietary energy." In
addition, "energy-dense foods tend to be well-liked, even perceived as a
reward -- a factor that would reinforce their initial selection and
repeated consumption."

In an illuminating section of the article, the authors compare the energy
density (MJ/kg) of some foods in relation to their energy cost (cents/10
MJ). For example, the energy cost of potato chips is about 20 cents/MJ
(1200 kcal/$) as compared with about 95 cents/MJ (250 kcal/$) for carrots.
As the authors write:

The inverse relation between energy density and energy cost suggests that
"obesity-promoting" foods are simply those that offer the most dietary
energy at the lowest cost. Given the differential in energy costs between
energy-dense and energy-dilute foods, the advice to replace fats and sweets
with fresh vegetables and fruits may have unintended economic consequences
for the consumer.
Or, as Drewnowksi was reported as saying in a press release:

It's a question of money...On a per calorie basis, diets composed of whole
grains, fish, and fresh vegetables and fruits are far more expensive than
refined grains, added sugars and added fats. It's not a question of being
sensible or silly when it comes to food choices, it's about being limited
to those foods that you can afford...People are not poor by choice and they
become obese primarily because they are poor.
So one has to think about what it means to recommend a healthy diet to a
patient. As Drewnowski and Specter point out, "any discussion of dietary
energy density in relation to diet costs has been missing from the
mainstream literature on the determinants of obesity in the United States."

Medical expenditures in 2003 attributed to obesity reached $75 billion.[5]
The official poverty rate increased in 2002 to 12.1%; at least 34.6 million
people live below the poverty threshold. The number of families with a
female head of the household (with no husband present) in poverty increased
to at least 3.6 million in 2002.[6] No doubt higher-wage earners are also
drawn to foods with high palatability and low-energy cost so that they can
spend a lower percentage of their income on food. The escalating rate of
obesity has been traditionally discussed in terms of biology, physiology,
and behavior (eg, see recent comments by Dr. J. Willis Hurst) the
discussion needs to include the role of economics and social policy.
Solutions to the obesity epidemic will in part require that healthy food be
accessible and affordable, and this will require our engagement not only as
health professionals but citizens.


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Ursula Snyder, PhD, Site Editor/Program Director, Medscape Ob/Gyn & Women's
Health


Disclosure: Ursula K. Snyder has no significant financial interests or
relationships to disclose.

Medscape Ob/Gyn & Women's Health 9(1), 2004. © 2004 Medscape

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