Obesity, deprivation, women, and the cost of 'being too fat'

Speaking about the film - which is due for its UK cinema release on Friday - the actor said he hoped the portrayal would help to "end the bias against those who live with obesity".

READ MORE: Can calorie counts on menus really reverse the obesity crisis?

Separately, controversy engulfed recent comments by Susan Jebb, a professor of diet and population health and chair of the Food Standards Agency, comparing workers bringing cakes into the office to passive smoking.

Critics argued that it is a personal choice whether anyone eats the cakes, which of course it is.

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In some ways though, that response underlines why efforts at tackling obesity as a public health issue tend to crash and burn - and why those who are obese encounter prejudice: because it is perceived to be an individual problem and one that is simply down to a lack of self-control.

If that were really the case, however, we could reasonably expect obesity to be evenly distributed throughout the population.

Instead, it occurs on a sliding scale by deprivation from around 26 per cent among Scots adults in the most affluent areas to 36% in the poorest neighbourhoods.

Obesity becomes steadily more prevalent in line with deprivation (Image: PHS)

By Primary One, five-year-olds in Scotland are more than twice as likely to be at risk of obesity if they are from the most deprived catchments compared to the least.

Shockingly, that gap has exploded over the past 20 years: in 2001/02, the obesity rate among the poorest children versus the wealthiest was just 0.2% higher; now it is 8.2% higher.

The gulf in obesity rates in P1 children has steadily widened over the past 20 years (Image: PHS)

There are multiple reasons for this, but the food environment is undoubtedly one of them.

A Glasgow University study in 2018 found that clusters of alcohol, fast food, tobacco and gambling outlets were disproportionately concentrated in the most income deprived neighbourhoods in Glasgow.

In terms of fast food premises in particular - from Chinese takeaways to fish and chip shops - they were roughly six times more prevalent in the poorest areas.

These scenarios have been described as "passive obesity", whereby human biology - evolved to conserve calories - is exposed to an obesogenic environment containing an "abundance of energy dense food".

READ MORE: Surgeon warns patients have 'died waiting' or gone abroad for weight-loss surgery during pandemic 

Similarly, supermarket special offers such as multibuy deals or price reductions skew towards calorie-dense items.

Food Standards Scotland research in 2018 found that 46% of crisps and savoury snacks and more than 40% of confectionary and full-sugar soft drinks were sold on promotion compared to less than 30% for healthier products such as fruit and vegetables, fish, and bread.

Fast food outlets are more densely packed in poorer areas (Image: Getty)

To date, nothing has actually been done to address this.

There are no planning laws to limit the density of fast food outlets, and plans to restrict price promotions on junk food have been repeatedly delayed in both Scotland and England.

Opponents argue that it would "hit the poorest hardest" amid a cost of living crisis. Yet none of these foods (cans of Coke, crisps, chocolate bars) are a necessary part of anyone's diet - and such criticism surely misses the point that obesity itself is hitting the poorest hardest?

That might not be so bad if obesity existed in isolation; the problem is that it carries serious health consequences.

According to the Office for National Statistics, even after adjusting for all variables - age, ethnicity, deprivation, geography, smoking status, vaccination status, and co-morbidities including asthma and diabetes - obese adults aged 30 to 64 were 1.6 times more likely to have died as a result of  Covid by August 2022 than the non-obese. 

Type 2 diabetes is hugely more common among these obese compared to the non-obese (Image: ONS)

Rates of type 2 diabetes were also more than five-fold higher among the obese than the non-obese, which itself carries serious implications for their cancer risk.

UK research, published on Wednesday in the journal Diabetologia, found that overall cancer mortality was 18% higher in people with Type 2 diabetes and 1.5-fold higher for colorectal, pancreatic, liver and endometrial cancers combined.

It is thought that "prolonged exposure to the effects of increased blood sugar and insulin levels, insulin resistance and chronic inflammation" drives disease onset.

For bowel cancer specifically, mortality was 2.4 times higher in Type 2 diabetics during the study period, from 1998 to 2018.

READ MORE: Why are cancer rates lower in 2022 than before Covid? 

There is another curious discrepancy that tends to go unnoticed, however.

While obesity correlates closely with deprivation, that effect is much more pronounced for women.

As of 2019 - the most recent year for which a breakdown is available - 40% of women living in the most deprived parts of Scotland were obese compared to just 18% of women in the most affluent neighbourhoods.

In contrast, the obesity gap between men is just 6%: one in three (32%) men in the most deprived areas were obese compared to around a quarter (26%) of men from the wealthiest postcodes.

From the 'Diet and Healthy Weight' monitoring report 2020 (Image: Scottish Government)

The same pattern occurs in most Western societies (it inverts in poorer nations, where wealthier people - including women - tend to be heavier).

One theory is that there is an inherent economic benefit to women of "being thin" that does not exist for men.

Research in the US, Britain, Canada, and Denmark all finds that overweight and obese women earn less than their thinner peers, while there is little difference for men.

Economist David Lempert found that the "penalty" for women of being overweight actually appears to have increased as obesity has become more prevalent.

He told the Economist magazine that this may be because "the increasing rarity of thinness has led to its rising premium".

Likewise, a Harvard University study into implicit bias found that while negative attitudes on the basis of sex, race or sexuality have diminished among test takers over time, the exception is weight where attitudes have become "substantially more negative" towards heavier individuals.

All of which suggests that obesity is generally viewed as someone’s own fault and someone else’s problem: namely, poor people - and women.