No-one chooses to be fat - obesity is an issue of fairness

Inequity is the invisible partner undermining the quest for the perfect body, or even a healthy population. As individuals are made to feel responsible and guilty for being overweight or obese, the new lifestyle script from the general practitioner’s consultation room – written advice that exhorts patients to eat less and exercise more – may be counterproductive. This seems a somewhat naïve approach that fails to tackle the underlying sources of the problem. The number of overweight and obese Australians has increased rapidly in the past two decades. It has been estimated that at the beginning of the decade 67 per cent of adult men and 52 per cent of adult women were overweight or obese; about 8 million Australians. The number of Australian children and adolescents who are obese or overweight has doubled in the past 15 years.

Are all Australians gaining weight? Are all socioeconomic groups affected equally? Are some groups more affected than others? Have any groups escaped the epidemic? These questions were addressed in a report, Are all Australians gaining weight? released late last year by the Australian Institute of Health and Welfare (AIHW). The report is based on self-reported height and weight data, so it is likely to underestimate the problem. Plus, the method of measuring obesity, the body mass index (BMI), is not ideal as it does not distinguish between weight due to muscle and weight due to fat.

The epidemic touched virtually all socio-demographic groups examined by the AIHW, but while the problem is widespread it is not randomly distributed. Those most likely to be obese are poor, Indigenous and living outside metropolitan areas. Queensland has the highest rate of obesity (18.5 per cent) and the ACT the lowest (13.5 per cent); the poorest women (22.6 per cent) are twice as likely to be obese as the richest (12.1 per cent). Men are more likely to be overweight but men and women report equal rates of obesity. The most vulnerable groups are aged between 45 and 64 in the most disadvantaged socio-economic group: men and women without post-school qualifications, the lowest incomes and Indigenous people.

The AIHW concludes that these groups should be the focus of prevention and intervention strategies. Socioeconomic status, education, employment status and income are strongly related to female obesity in industrialised countries. The lower a woman’s socioeconomic status, the more likely she is to be obese. The results hold for men, too.

International evidence reveals consistently that rates of obesity are greatest in those with the least education. Overweight and obesity are more common among people with a lower family income. Those at the bottom of the social gradient are most likely to become obese.

Risk-factor surveys can reinforce negative perceptions about individuals who adopt unsafe behaviours such as overeating and sedentary lifestyles. Is the main implication to be gleaned from all this research that we should exhort individuals at the bottom of the social gradient to eat less and exercise more? Why are these differentials occurring? Why do disadvantaged people appear to behave so badly?

At the conservative or neoliberal end of the ideological spectrum, there is an assumption that behaviours are chosen, which lends itself to “victim-blaming”. At the other end of the spectrum there is greater recognition of the extent to which socio-economic circumstances shape and constrain available options. This focuses attention on social disadvantage and unhealthy living and working conditions, beyond the health-care system.

As a result the public health community is keen for the National Obesity Taskforce to recognise the importance of “toxic environments” and social solutions – to counter the emphasis on individual behaviour change implicit in the lifestyle prescription.

Urban-planning solutions include rethinking the size and use of recreational space, making the suburbs safe for children to walk and play in and increasing the number of bike paths. This sounds a bit like Canberra – the city with the lowest level of obesity in Australia.

As with many guidelines and strategies, the temptation in developing guidelines for obesity and physical activity will be to focus on ideal weights, or body mass index ranges, or ideal amounts of different types of exercise: the lifestyle script. This may be counterproductive. It can lead to higher levels of fear, guilt and anxiety associated with food, exercise and the body. Rather than making perfect bodies, we should be making healthy people, individually and collectively.