Social Determinants of Health

Health falls along a social gradient. What we mean by this is that there’s an intricate relationship between “health” and socioeconomic factors. Higher socio-economic positions are associated with better health outcomes and lower socio-economic positions, poorer health outcomes and shorted life expectancies.

The social determinants of health are the conditions in the environments in which people are born, grow, age, work and live. They encompass many different factors including (but not limited to) income, level of education, transportation options, culture and housing. Each factor plays an important role and it is estimated that around 50% of health outcomes are determined by socioeconomic factors (1) In comparison, 25% are determined to health care, 15% to biology/ genetic and 10% to the physical environment (1).

Before studying nutrition, I competed a Geography degree and I was first introduced to the social determinants of health in my “Geographies of health” module, one of the most interesting and formative I undertook. Your health is influenced by your postcode we were taught. Indeed, in 2008-2010 life expectancy was 13.5 and 11.8 years lower in Glasgow city compared to South Kensington and Chelsea for males and females respectively.

The social determinants of health however, are rarely the focus of public health campaigns, particularly for those aimed as addressing the “ob*sity epidemic” which seemingly ignore them whilst placing all the onus on individual behaviour. Health behaviours are closely related to the conditions in which people are living. It is difficult for individuals to change lifestyle behaviours such as smoking cessation whilst under immense stress caused by debt or poor housing conditions. Additionally, poverty limits and restricts options available to individuals. The social determinants of health challenge the notion that we are all free to choose a “healthy” diet, so often assumed by public health campaigns (2). By placing the burden on the individual for health outcomes, we vastly oversimplify the complex determinants that contribute to overall health and wellbeing.

Too often individuals are unnecessarily blamed for their health status or “poor diet” when very little regard is shown for their lived environment or lived experience.

The Impact of Poverty on Health Status

The notion that people are poor because they make poor choices, and due to their poor choices they have poor health, is rejected by the evidence demonstrating that poverty leads to unhealthy choices due to the restricted range of options available to those on low-comes, as well as the direct health impacts associated with the stresses and poor conditions which result from poverty (3).

Family poverty during childhood affects all aspects of development and health, both long and short term. Parenting is influenced (although not determined) by parents’ childhoods and current lives (including mental wellbeing, support networks, and social and material circumstances) (4, 5). In the UK, the number of children in poverty exceeds 4 million, with some minority ethnic groups experiencing particularly high rates of child poverty (6). In 2017/2018, 45% of minority ethnic children lived in families in poverty, compared with 20% of children in white British families (7). These children are vulnerable to the impacts of poverty, exclusion and discrimination, which harms health even from the earliest age.

Food Insecurity

Food Insecurity, one of the most immediate impacts of being in poverty, is the inability to access adequate food, due to economic limitations or lack of resources (8). Between 8-10% of households in the UK were food-insecure between 2016 and 2018, and as a result, experienced poor physical and mental health (9). It is thought that stress, depression and anxiety associated with food insecurity affect more than 50% of households who are referred to food banks (9). Furthermore, children who grow up in food-insecure homes are more likely to have poor health and educational outcomes compared with children growing up in food-secure homes (10).

The exhortations and endeavours from public health campaigns to get people to eat “healthily” must be seen as rather ineffective given the fact that for the majority of the British households their requirements are financially unachievable. The poorest 10% of UK households would need to spend 74% of their disposable income on food to meet the NHS’s Eatwell Guide costs (2). In comparison, the richest 10% would only need to spend 6% of their disposable income (2).

Food Deserts

Food insecurity is often associated with ‘food deserts’, which are areas where poverty, poor public transport and lack of big supermarkets limit access to affordable and healthful food options (9). Over 1/2 a million people in the UK are thought to be living in ‘food deserts’ and are especially problematic for those on low incomes, limited mobility or with a disability that limits the ability to travel. An online survey carried out on 2,005 adults in 2018, found that 12% thought that “not being near a supermarket offering “healthy” food at low prices” was a barrier to being able to have a balanced diet (3). Those living in ‘food deserts’ often have to rely on small convenience shops for their food, which often don’t offer a wide variety and are more expensive than supermarkets. Research carried out by Which? in 2017, found that smaller convenience stores were more expensive than supermarkets, for example, Tesco Metro was 7% more expensive than Tesco (11).

Furthermore, those that suggest everyone cook their meals from scratch and turn their nose at convenience foods are very privileged as ~1 million people in the UK are living without a fridge, ~2 million without a cooker and ~3 million without a freezer (2). Some people only have access to prepared foods i.e those living in food deserts, some people can’t cook, some people can’t get to supermarkets and some struggle to afford or access fresh ingredients. If you are one of those individuals (or not) you have permission to have convenience foods to help nourish yourself!

Far too often we see the blame put on individuals for their health behaviours and completely disregard the fact that social determinants impact 50% of overall health status.

References

What are the Social Determinants of Health?

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What are the Social Determinants of Health?

Intuitive Movement - PART 1

Should we be saying bye to BMI?

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