If everyone around you is

eating crisps, why would

you whip out a banana?

Katie Cunningham

 

Whilst out for lunch with a friend recently I was delighted to hear she'd read the article I'd written in SR about the pernicious effects of social deprivation on Scotland's poor. In it I had highlighted the need for urgent government action to address the social issues which leave men in eastern Glasgow with a lower life expectancy than men in Albania. I was less delighted, however, by her reaction to the piece.
     'I understand what you're saying Katie,' she began sheepishly,'it does seem terrible that some people won't see their retirement. But surely a lot of it is their own fault'.
     'Why do you say that?' I probed, trying to disguise my distain with an inviting tone.
     'Well, it's about choices. A huge proportion of societal ills are caused by the decisions people make. And when it comes to health matters, poor people make poor choices– smoking, drinking, using drugs and eating badly. A reduced life expectancy is perhaps just the price you pay.' Ouch.
     Of course, at face value, she's right. The World Health Organisation confirms lifestyle choices to be the main factor limiting lifespans in the developed nations, with behaviour-related conditions accounting for 70-80% of all deaths. Furthermore, a flick through Scotland's health statistics does little to support my argument that this particular social injustice is indeed so unjust. Almost half of adults in the most deprived tenth of the population are smokers compared to just 11% in the least deprived tenth.
     Deprived groups are also six times more likely to abuse alcohol and over 19 times more likely to be hospitalised for illicit drug use. Diets are lower in nutrients and higher in sugar, salt, fat and calories, and physical inactivity rates are almost eight times higher. Worse still is that, unlike 20 years ago, personal responsibility for these decisions is not mitigated by a lack of knowledge. National research finds that awareness of the healthy living messages no longer accounts for lifestyle disparities between classes. Poor people know what they should be doing – they're just not doing it.
     So how can I continue to defend the deprived? And if they can't help themselves, what hope does the government have of helping them? I believe the answer to both these questions lies with an increased appreciation of a single factor: the influence of context.
     Behaviour choices are not made in a vacuum. They are shaped by a multitude of influences including personal beliefs, priorities and perceived social norms. Whilst the deprived may understand the implications of their unhealthy lifestyles, the environments in which they conduct their lives are simply not conducive to change.
     Take the example of diet (I am a nutritionist after all). The easiest way to eat healthily is to shop at a supermarket, offering you the widest variety of fresh produce at the lowest price. However, the structure of many Scottish communities mean supermarkets tend to be located in suburban areas, suitable only for car owners and comparatively wealthy local residents. Even if public transport is available, the thought of lugging heaving bagfuls of buy-one-get-one-free apples and three-for-two baked beans to and from the bus stop is not exactly an appealing one.
     Instead, low-income neighbourhoods tend to rely on local convenience stores which offer a limited variety of items at a greater cost. Processed foods rich in fat, salt and sugar generally account for the majority of stock as these items have a long shelf life and can therefore be purchased in larger quantities by the retailer without fear of expiration and profit loss. Even if fresh foods are available, provisions are often inconsistent, overpriced and of reduced quality.

 

     In 2008, the Food Standards Agency conducted a study to investigate the extent of the issue and its impact on health in Scotland, visiting over 460 stores in nine regions of varying affluence. A 'healthy eating indicator list' of 35 healthy items from five food groups was established and over 460 shops visited. The results were unsurprising. While large shops generally sold a full range of all 35 items, smaller urban stores only sold around half at an average cost of 28% more per item. On a tight budget, it seems only logical to choose calorie-laden stodge over lighter options, which simply become a less cost-effective source of sustenance. Worryingly, at a time when UK food inflation rates are almost four times higher than the European average, the relationship between poverty and inadequate nutrition looks set to deepen.
     There are also psychological and cultural influences to contend with. Children raised in households where processed foods are the norm are much less likely to become healthy eaters as adults. With limited exposure to wholesome foods, they remain unfamiliar and therefore less desirable. These children are also less likely to develop proficient cooking skills. Processed foods are favourable not only because they are cheap but because they are convenient, requiring minimal preparation. This is also of particular importance for those experiencing fuel poverty or without adequate cooking facilities.
     It's also interesting to observe the relationship between social class and brand affiliation. Low income groups are more likely to purchase brand-named products in an effort to avoid the perceived social stigma attached to buying cheaper, unbranded alternatives. The desire to fit in is a powerful one, particularly for a group who already feel ostracised by society. The inclusion of pre-packaged, refined products in lunchboxes and other meals consumed in company is seen as a way of masking economic status, offering a culinary route to keeping up with the Joneses. Again, this becomes self-propagating; in an environment where everyone around you is proudly tucking into their Nestle KitKat and Walkers crisps, you're even less likely to want to whip out a banana.
     Let's face it – why would you? The main reason people engage in unhealthy behaviours is because they provide an instant hit of pleasure or relaxation. For those living in bleak environments, engulfed by the chronic stresses of poverty and isolation, the 'quick fix' offered by a cigarette or bar of chocolate becomes a particularly appealing source of comfort. Conversely, healthy choices are about sacrificing immediate gratification for a long-term benefit, namely a reduced risk of disease. However, if no one in your family has ever lived past 65, you're much less likely to see any point in changing your behaviour. Asides, who wants to prolong a bleak and stressful existence? Without hope of an improved future, it's difficult to feel motivated to invest in it.
     Instead of victim blaming, we must take action. The financial climate may remain challenging, but government decisions should not punish those who are already suffering. Social welfare budgets must be protected, prioritising such activities as neighbourhood regeneration projects and providing safe, affordable housing to improve physical environments. Business policies should be emcouraged which increase employment, giving individuals a sense of purpose, self-sufficiency and self-esteem. And there should be in-work tax credits and travel and childcare subsidies, as well as targeted skills development programmes to make work accessible for the most deprived.
     With the appropriate support, people can change their behaviour and prolong their lives. They just need to be worth prolonging.

Katie Cunningham is a registered nutritionist working as a health improvement advisor for NHS Grampian