Challenging Health Inequalities in European Families Lucia A. Reisch (Copenhagen Business School)

What might work? Testing policy tools targeting inequalities Overview Why focus on the disadvantaged? Health inequalities and vulnerable families What might work? Testing policy tools targeting inequalities What can be done? Implications for effective policies Why focus on the disadvantaged? Health inequalities and vulnerable families What works? Testing policy tools targeting inequalities within I.family research Pilot Intervention in Danish low SES households More results from SES research in I.Family What can be done? Implications for effective polices

1. Why focus on Disadvantaged Families?

Consumer research shows that... availability of essential resources (i.e., income, time, skills, knowledge) food preferences and purchases social norms ...are closely linked to socioeconomic status (SES) It is important to target the whole LIFSTYLE and not only FOOD CHOICE It is an ecological problem – the social and physical setting is key – NOT only a knowledge or price issue

Obesity research shows that... “Low income and low education are a prime risk factor for obesity” – in particular for woman and children UN Special Rapporteur on “Right to Food” (2016) Risk for being overweight for normal weight children tend to increase with lower SES Most influential risk factors: parental BMI, feeding and eating practices, physical activity, sedentary behaviours, media exposure Bammann et al. (2012; 2016) G20: Overall obesity prevalence does appear to be correlated with a country‘s wealth (G20 countries) (MGI 2014, p. 15) In developed economies, lower income-groups tend to have higher obesity prevalence Relativ index of inequality is higher for women than for men (for women: from 1.6 (US) to 18.4 (South Korea) times as high as the low end of the education spectrum as it is for those in the upper end. This inverse relationship holds for different measures of SES, including HH income, occupational status of perents, educational achievement, score of area deprivation US: almost no difference for men, but for women (Ogden et al. 2010) IDEFICS/ I-Family: Behaviours should be targeted Women should be targeted primarily most disadvantaged in the key position to change family meals part of their identy as mother

How inequities in obesity compound over the life course OWN RESEARCH - Fernandez (2014): lower SES associated with „processed“ food pattern as opposed to „healthy“ food pattern - Bammann et al (2012): In five of the eight investigated regions (in Belgium, Estonia, Germany, Spain and Sweden), the prevalence of childhood overweight followed an inverse SES gradient. In the other three regions (in Cyprus, Hungary and Italy), no association between SES and childhood overweight was found. „Vulnerable groups“ Young and unexperienced Pressured by time and resource scarcity („cognitive bandwidth“ Shafir/Mullainathan) Limited in their mobility (the elderly, disabled, socially isolated, those without a car) Less educated regarding healthy food choices Other issues (e.g., job, crime) and other expenses (e.g., rent, food) have higher priority Why is obesity a social class phenomenon? can be passed from generation to generation tied to parental BMI through both physiological (genetic) and behavioural mechanisms (eating habits, food preferences) Poor households have often limited „cognitive bandwidth “(Mullainathan & Shafir, 2013) due to scarce resources An obese mother is a significant predictor of obesity of her children because fetuses develop a compromised metabolism and a resistence to insulin Food desert = „an area with limited access to affordable and nutritious food, particularly such an area compoed of predominantly lower income neighbourhoods and communities“ (Food, Conservation, and Energy Act 2008) Source: WHO (2014), Obesity inequalities

Good reasons to target low SES families Societal level: Return on investment of interventions the largest Overall savings on costs (health, absenteeism) Increase equity and social justice, decrease inequality Individual level: Disrupt the vicious circle of poverty, ill-health, low paid jobs, time scarcity, and obesity End discrimination (psychological cost) and increase life chances (kids in particular) Obesity - has roughly the same economic impact as smoking or armed conflict (McKinsey Global Institute 2014) is one of the top 3 global burdens generated by human beings (p. 17) LANCET Studie 2017

2. What Might work? pilot studY with low SES Families Are notoriously difficult to reach for interventions

Pilot study with low income families 18 vulnerable families in Denmark Co-creation and testing of a “Guide to healthy eating” (families and field workers) Website and gamification (quizz, lottery) „vulnerable“ families (low eduction, low income, migrant, single parents) VERY difficult to recruit Results: Low knowledge about healthfulness of foods & food system, such as food labels Fresh produce perceived as expensive (price is an issue)

3. What can be done? Implications for policy

“Making the healthy choice the easy choice” Simplification Personalisation of dietary information Gamification Improve access, availability, affordability of healthy food Fruit and vegetable school programmes „Farm to school“ programmes Subsidies for healthy food or at least, end subsidies for unhealthy food Make healthy diets and physical activity part of urban planning „Farm to school“: Procurement (local foods) Education School gardens (hands-on) US: fewer supermarkets in African Amercian neighbourhoods (Powell et al. 2007; Berg & Murdoch 2008; Dutko et al. 2012); greater number of large supermarkets and grocery stores in white neighbourhoods (Raja et al. 2008) → Convenience stores and gasoline stations as main food sources („food deserts“) Lower income households spend more time traveling to grocery stores and shop less frequently (Hamrick & Hopkins 2012) Food desert areas are a significant driver of CO (Nayga 20??). EU: Some large retail chains adjust their prices and offered range of food according to store location (Robertson et al. 2004)

Questions and comments welcome lr.ikl@cbs.dk