One hundred years ago in the United States, obesity was a sign of plenty and leisure: People who could afford to eat what they wanted and to pay others to work for them were the ones that put on the extra pounds.

The economics of obesity have changed dramatically since then, with the burden of overweight and obesity falling disproportionately on the poor.1

Beyond Behavior

Since poor eating habits and lack of exercise are the main causes of obesity, researchers and physicians have focused on ways to change these individual health behaviors in low-income communities.

Recent studies, however, suggest that these direct causes have their roots in systemic social and economic factors that are not easily overcome with messages of "eat less and move more." Unsafe neighborhoods, lack of convenient grocery stores, less leisure time and tight food budgets may all contribute to obesity and accompanying diseases such as diabetes among the poor.

Money and More

The link between obesity and poverty can be complicated by race, gender and education, researchers have found. For instance, a national survey of 9,621 people found that education, more than race or income, predicted whether people got most of their exercise from work or leisure-related activities.2

In another national study, researchers discovered that children from higher income families eat more at fast food restaurants than those from low-income families, possibly because they have more personal disposable income.3

The economics of poverty also seem to affect women more strongly than men, according to some researchers.4,5

The Facts:

Differences in the prevalence of obesity among low, middle and high socioeconomic groups in the United States have decreased since 1971, according to a recent review. 6

In a recent review of obesity in developed countries, researchers found that weight gain over time was associated with lower education levels and "blue-collar" occupations.7

A review of obesity in developing countries suggests that the prevalence of obesity tends to shift toward lower socioeconomic groups as the country's gross national product rises.8

Results from a 2003 study suggest there is a significant link between food-stamp program participation and the likelihood of obesity among low-income women. 9

A 34-year study found that weight gain among women in the study was associated with low overall socioeconomic status calculated over three decades.10

A survey of more than 2,000 black men and women found that those with higher incomes and higher education levels ate more fruit daily than those with lower incomes and education.11

A 2004 study of fast food restaurants around New Orleans found 2.4 such restaurants per square mile in mostly black and low-income neighborhoods, compared with 1.5 restaurants in predominantly white neighborhoods.12

Among white teen girls, the prevalence of overweight decreases with increasing socioeconomic status. Among black teen girls, the prevalence of overweight remains the same or increases with increasing socioeconomic status, according to national survey data.13

Low-and middle-income neighborhoods have significantly fewer resources for physical activity such as parks, fitness and community centers and walking trails than high-income areas, according to a 2003 survey.14

Children are less likely to be physically active in low-income neighborhoods deemed unsafe by their residents, according to several reports.15, 16, 17

National survey data analyzed in 2003 suggest that the more hours a mother works each week over a child's lifetime, the more likely that child is to be overweight. The effect is strongest among high socioeconomic-status mothers.18

Adolescents with no insurance or public insurance such as Medicaid are more likely than those covered by other insurance to be overweight, according to a 2003 study.19

The True Cost of a Calorie

Obesity is everywhere in the United States, but numerous studies suggest it is more prevalent and may lead to more serious health problems such as diabetes in low-income families. There are probably a variety of factors behind this connection, but researcher Adam Drewnowski says America's poor simply may be getting fat from the only kinds of foods they can afford.

"Obesity in America is, to a large extent, an economic issue," according to Drewnowski, a nutrition sciences professor at the University of Washington.

Drewnowski's studies20, 21, 22 center on the price difference between energy-dense and energy-poor foods. Energy-dense foods, usually those higher in refined grains, fats and added sugars, are those that pack a lot of calories into a small amount of food. Energy-poor foods contain fewer calories per unit of food, so a person would need to eat several bushels of energy-poor carrots to equal the calories contained in one energy-dense doughnut.

In the United States, energy-dense foods tend to taste good, are more convenient to buy, store and cook, and are much cheaper than energy-poor foods, Drewnowski says. "There are data from the USDA [U.S. Department of Agriculture] to the effect that prices for fruits and vegetables jumped by 130 percent or so in the past 20 years, whereas prices for sugar, fat and sweetened beverages increased by no more than 30 percent," he notes.

Agricultural subsidies to sugar and corn growers, among other factors, have played a role in keeping the price of energy-dense foods low. "Until recently, no one has seriously questioned wither a low-cost food supply brought anything but benefits to the United States," Drewnowski says.

People living on low incomes may have no choice but to choose energy-dense foods to satisfy their families' appetites while still remaining within a budget, Drewnowski says, acknowledging that his viewpoint has caused a stir among some researchers who have long believed that "eating healthy costs practically nothing."

When his first papers on topic drew intense criticism from those researchers, "I knew I had hit a nerve and was on to something," he says.

Drewnowski says economic changes might succeed in reducing obesity among the poor where other tactics such as "healthy eating" messages have not. For instance, a 2002 study23 by Katherine Horgen and Kelly Brownell of Yale University found that price decreases alone, rather than a combination of price decreases and health messages, helped boost restaurant sales of healthy food items.

"Health messages may have paradoxical effects if foods labeled as healthy are assumed to taste bad," Horgen and Brownell write.

Drewnowski agrees. "The so called 'social marketing' has not really worked since it appeals to a sense of duty rather than to pleasure or satisfaction. Marketers also tell us that labeling a product as 'healthy' is the kiss of death - nobody wants it."

Expert Sources:

Adam Drewnowski, Ph.D.
University of Washington
(206) 543-8016
adamdrew@u.washington.edu

Paul Estabrooks, Ph.D.
Kansas State University
(785) 532-3365
twist@ksu.edu

Kimberly Morland, Ph.D.
Mt. Sinai School of Medicine
(212) 241-7531
kimberly.morland@mssm.edu

Shanthy Bowman, Ph.D.
U.S. Department of Agriculture
(301) 504-0619
bowmans@ba.ars.usda.gov

References

1. U.S. Department of Health and Human Services. Healthy People 2010 Report. Last accessed 8-19-05 at http://www.healthypeople.gov/Document/tableofcontents.htm#volume1.

2. X.Z. He and D.W. Baker (2005) Differences in leisure-time, household, and work-related physical activity by race, ethnicity, and education. Journal of General Internal Medicine, 20, 259-266.

3. S.A. Bowman et al. (2004) Effects of fast-food consumption on energy intake and diet quality among children in a national household survey. Pediatrics, 113, 112-118.

4. S.A. Robert and E.N. Reither (2004) A multilevel analysis of race, community disadvantage and body mass index among adults in the U.S. Social Science and Medicine, 59, 2421-2434.

5. J. Wardle et al. (2002) Sex differences in the association of socioeconomic status with obesity. American Journal of Public Health, 92, 1299-1304.

6. Q. Zhang and Y. Wang (2004) Trends in the association between obesity and socioeconomic status in U.S. adults: 1971 to 2000. Obesity Research, 12, 1622-1632.

7. K. Ball and D. Crawford (2005) Socioeconomic status and weight change in adults: a review. Social Science and Medicine, 60, 1987-2010.

8. C.A. Monteiro et al. (2004) Socioeconomic status and obesity in adult populations of developing countries: a review. Bulletin of the World Health Organization, 82, 940-946.

9. D. Gibson (2003) Food stamp program participation is positively related to obesity in low income women. Journal of Nutrition, 133, 2225-2231.

10. P.T. Baltrus et al. (2005) Race/ethnicity, life-course socioeconomic position, and body weight trajectories over 34 years: The Alameda County Study. American Journal of Public Health, July 28 [E-publication ahead of print]

11. T.L. Gary et al. (2004) Fruit, vegetable and fat intake in a population-based sample of African Americans. Journal of the National Medical Association, 96, 1599-1605.

12. J.P. Block et al. (2004) Fast food, race/ethnicity, and income: a geographic analysis. American Journal of Preventive Medicine, 27, 211-217.

13. P. Gordon-Larsen et al. (2003) The relationship of ethnicity, socioeconomic factors, and overweight in U.S. adolescents. Obesity Research, 11, 121-129.

14. P.A. Estabrooks et al. (2003) Resources for physical activity participation: does availability and accessibility differ by neighborhood socioeconomic status? Annals of Behavioral Medicine, 25, 100-104.

15. B.E. Molnar et al. (2004) Unsafe to play? Neighborhood disorder and lack of safety predict reduced physical activity among urban children and adolescents. American Journal of Health Promotion, 18, 378-386.

16. A.L. Cradock et al. (2005) Playground safety and access in Boston neighborhoods. American Journal of Preventive Medicine, 28, 357-363.

17. A.J. Romero (2005) Low-income neighborhood barriers and resources for adolescents' physical activity. Journal of Adolescent Health, 36, 253-259.

18. P.M. Anderson et al. (2003) Maternal employment and overweight children. Journal of Health Economics, 22, 477-504.

19. J.S. Haas et al. (2003) The association of race, socioeconomic status, and health insurance status with the prevalence of overweight among children and adolescents. American Journal of Public Health, 93, 2105-2110.

20. A. Drewnowski and N. Darmon (2005) The economics of obesity: dietary energy density and energy cost. American Journal of Clinical Nutrition, 82, 265S-273S.

21. A. Drewnowski (2003) Fat and sugar: an economic analysis. Journal of Nutrition, 133, 838S-840S.

22. A. Drewnowski et al. (2004) Replacing fats and sweets with vegetables and fruit - a question of cost. American Journal of Public Health, 94, 1555-1559.

23. K.B. Horgen and K.D. Brownell (2002) Comparison of price change and health message interventions in promoting healthy food choices. Health Psychology, 21, 505-512.

The Center for the Advancement of Health is an independent nonprofit organization that promotes greater recognition of how psychological, social, behavioral, economic and environmental factors influence health and illness. The Center advocates the highest quality research and communicates it to the medical community and the public. The fundamental aim of the Center is to translate into policy and practice the growing body of evidence that can lead to the improvement and maintenance of the health of individuals and the public. The Center was founded by the John D. and Catherine T. MacArthur Foundation and the Nathan Cummings Foundation, which continue to provide core funding. Funding for this series was provided by the Robert Wood Johnson Foundation.

For Information Contact:
Lisa Esposito
Editor, Health Behavior News Service
Center for the Advancement of Health
2000 Florida Ave., NW, Suite 210
Washington, DC 20009
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http://www.cfah.org

? Copyright 2005, Center for the Advancement of Health
Source article : Facts of Life: Issue Briefings for Health Reporters
Vol. 10, No. 9 September 2005
http://www.cfah.org/factsoflife/vol10no9.cfm
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