Reducing inequalities in Reducing inequalities in Reducing inequalities in Reducing inequalities in obesity: obesity: obesity: obesity: insights insights insights insights from theory and practicefrom theory and practicefrom theory and practicefrom theory and practice
Professor Clare Bambra
Newcastle University & Fuse
1: Health Inequalities
2: Insights from Theory
3: Evidence from Practice4: Future Prospects
OverviewOverviewOverviewOverview
Part 1: Health InequalitiesPart 1: Health InequalitiesPart 1: Health InequalitiesPart 1: Health Inequalities
“systematic differences in health
between different socio-economic
groups within a society … Because
they are socially produced they are
potentially avoidable and widely
considered unacceptable in a
civilised society”
Prof Dame Margaret Whitehead
Bambra, C. (2016) Health Divides: where you live can kill you, Bristol: Policy Press
Bambra, C. (2016) Health Divides: where you live can kill you, Bristol: Policy Press
Then and Now
National Survey for Wales 2016-17:Percentage of adults who were overweight or obese, by area deprivation
0
10
20
30
40
50
60
70
Quintile 1 - Most
deprived
Quintile 2 Quintile 3 Quintile 4 Quintile 5 - Least
deprived
Pe
rce
nt
Overweight or obese Obese
13.6 13.5 13.2 13.5
7.89.4
8.6 8.8
2012/13 2013/14 2014/15 2015/16
Most deprived Least deprivedDifference between
most and least deprived
Percentage of children aged 4 to 5 years who are obese, most and
least deprived fifth in Wales, Child Measurement Programme for
Wales, 2012/13-2015/16
Produced by Public Health Wales Observatory, using CMP data (NWIS) and WIMD 2014 (WG)
5.74.1 4.6
4.7
Loring & Robertson (2014) Obesity and inequities - Guidance for addressing inequities in overweight and obesity.
WHO Regional Office for Europe
Country Total Prevalence Highest Lowest Absolute RII 95% CI
Italy 5.0 1.5 9.7 8.2 6.03 4.71–7.71
Norway 6.8 5.9 6.4 0.5 1.75 0.76–4.01
Spain 7.0 3.0 12.3 9.3 5.09 3.08–8.44
France 11.1 5.0 19.9 14.9 4.21 2.46–7.21
Netherlands 11.4 6.4 17.0 10.6 2.87 1.89–4.34
Sweden 13.5 4.7 28.2 23.5 3.87 2.12–7.04
Germany 15.2 4.9 24.6 19.7 5.07 2.95–8.71
England 23.3 15.6 29.4 13.8 2.19 1.66–2.87
Thomson et al. (2017) Regional inequalities in self-reported conditions and non-communicable diseases in European countries: Findings
from the European Social Survey (2014) special module on the social determinants of health European Journal of Public Health 27 (S1)
14-21
Part 2: Insights from Theory Part 2: Insights from Theory Part 2: Insights from Theory Part 2: Insights from Theory
A. Causes of health inequalities
B. Levels of intervention
C. Approaches to reduction
Socially Produced?
A: Causes of Health Inequalities
• Behavioural/Cultural model
• Materialist
• Psychosocial
• Life course
• Political Economy
Behavioural/Cultural model
Lakshman, R., et al., Association between area-level socioeconomic deprivation and a cluster of
behavioural risk factors: cross-sectional, population-based study. Journal of Public Health, 2011.
33(2): p. 234-245.
Materialist
• Study of Leeds, Yorkshire found that for every additional fast food outlet, child obesity increased by 1%
• Every 1 point Increase in neighbourhood deprivation led to 0.3% increased risk of obesity
Psychosocial• Whitehall 2 study found a dose-
response relationship between work stress and risk of obesity.
• Odds ratio of obesity for one, two, and three or more periods of work stress were 1.17, 1.24, and 1.73 (trend p < 0.01)
• Work stress higher amongst lower SES
Life course
• Intergenerational transmission -HSE study
• Two overweight parents associated with an increased risk of child obesity OR = 2.2
• Having two obese parents = even higher risk of child obesity OR = 12.0;
• Two severely obese parents OR = 22.3
Political Economy
Rise of neoliberalism by welfare regime
Women Overweight and/or Obese by welfare state regime
A neoliberal epidemic?
B: Levels of Intervention
• Strengthening individuals
• Strengthening communities
• Improving living and working conditions
• Promoting healthy macro policy
C: Policy Approaches
1. Improving the position of the most disadvantaged groups
2. Reducing the gap between the best and worst off
3. Shifting the entire social gradient in health
4. Proportionate universalism
Framework for Reducing Inequalities in Obesity
APPROACH
LEVEL
Individual Community Societal
Strengthening Individuals Strengthening Communities Improving Living and
Working Conditions
Promoting Healthy
Macro Policies
Disadvantage Targeted
Individual health
promotion and lifestyle programmes
Community based health
promotion and lifestyle programmes
Gap
Gradient
Proportionate
Universal Tackling obesogenic environment
Restrictions,regulations and
fiscal measures
Behavioural
Psychosocial
Material
Political EconomyLife course
Part 3: Evidence from PracticePart 3: Evidence from PracticePart 3: Evidence from PracticePart 3: Evidence from Practice
Child Review: Individual
• Screen time reduction can have beneficial effects in low SES but not high SES children (short & long term)
• Mentor-based health promotion can have beneficial long-term effects among low SES who are most at risk (overweight and obese)
Hillier-Brown FC, et al. A systematic review of the effectiveness of individual, community and
societal level interventions at reducing socioeconomic inequalities in obesity amongst children.
BMC Public Health 2014;14:834
Community
• School-based nutrition and physical activity education combined (not education only) with exercise sessions can be effective in low SES school-aged children
• Family-based education can be beneficial for weight loss and weight maintenance for whole social gradient
• Group-based exercise only (but not education only) may result in short-term weight loss among low SES school-aged children
Hillier-Brown FC, et al. A systematic review of the effectiveness of individual, community and
societal level interventions at reducing socioeconomic inequalities in obesity amongst children.
BMC Public Health 2014;14:834
Societal
• No societal level studies found –evidence gap
Hillier-Brown FC, et al. A systematic review of the effectiveness of individual, community and
societal level interventions at reducing socioeconomic inequalities in obesity amongst children.
BMC Public Health 2014;14:834
Example Interventions
Example 1:
• A two-year School Nutrition Policy Initiative based on multifaceted education and environment interventions in some low-income schools in the USA increased nutritional knowledge, the availability of healthy food, and reduced the amount of overweight children by 35%.
Example 2:
• An Australian ‘Be Active Eat Well’ intervention designed to build a community’s capacity to create its own solutions to promoting healthy eating, physical activity and healthy weight found that after three years children in the intervention schools had significantly lower increases in waist circumference and BMI.
Child Review Summary
• Evidence suggests that individual, community and societal interventions do not increase inequalities in obesity
• School-based educational and environmental interventions were found to be the most effective in reducing inequalities
• Community empowerment may also play an important role in effective public health obesity interventions.
• No evidence of societal interventions – evidence gap
• Evidence of effectiveness limited to primary school children
• Evidence is largely based on international studies
• High quality studies need to be undertaken in the UK and among adolescents.
Hillier-Brown FC, et al. A systematic review of the effectiveness of individual, community and
societal level interventions at reducing socioeconomic inequalities in obesity amongst children.
BMC Public Health 2014;14:834
For more …
• Dr Frances Hillier-Brown
• 3pm Friday
• ASO Symposium 4 "Public health & workplace interventions to tackle social inequalities and obesity"
• Main Auditorium
Part 4: Future ProspectsPart 4: Future ProspectsPart 4: Future ProspectsPart 4: Future Prospects
Women
Men
Trend in adult obesity prevalence by social classHealth Survey for England 1994 to 2013 (five year moving average*)
Adult (aged 16+) obesity: BMI ≥ 30kg/m2
I - Professional II - Managerial technical IIIM - Skilled manual
IIIN - Skilled non-manual IV - Semi-skilled manual V - Unskilled manual
I - Professional II - Managerial technical IIIM - Skilled manual
IIIN - Skilled non-manual IV - Semi-skilled manual V - Unskilled manual
Men Women
Acknowledgements