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Category Archives: Literature reviews

For a while now there have been worrying signs that food poverty is becoming an increasing problem in the UK.  This Guardian article reporting on some recent research carried out using a panel of 30 000 UK households highlights one finding as being that the consumption of filling, high-fat, processed foods has grown among households with an annual income below £25 000, which the article uses to raise concerns over nutrition. This took me back to a short literature review on the subject of obesity which I had written for my course last year and which touched on many of the issues which have recently been raised.

Literature review:  Income inequality, social relationships and well-being

 In their book the spirit level Wilkinson and Pickett link income inequality to a range of health and social problems their work forming a response to the puzzle presented by the persistence of social-class gradients in a range of health related measures (Macintyre1997p.735).  The emergence of concerns with these gradients can be seen to coincide with a developing awareness of relative poverty towards the end of the 20th century (see Townsend 1979) whilst similar concerns over health inequalities led in 1977 to the commissioning of the Black Report which despite its marginalisation by an incoming administration is credited as acting as a stimulus and guide for further research into the relationship between social status and health (Smith 1990p.373:Macintyre 1997p.726-730:Marmot 2001 p.1165). One strand of research which took root in the wake of Black was the Psychosocial approach which sought to explain class gradients through an analysis of the relationship between health, social position and stress with particular regard to factors such as self-esteem, social networks and autonomy at work (Macintyre 1997p.736 Brunner 1997 p.1473 Wilkinson 1997 p.593). The work of Wilkinson and Pickett’s seeks to build on the Psychosocial approach by using income inequality to explain differences in these factors between states resulting to observable differences in indicators of health and well-being (Wilkinson & Pickett 2010). Obesity is among the conditions they argue has a correlation with income inequality (Wilkinson & Pickett 2010p.92).

Wilkinson and Pickett discuss several pathways which link a state’s level of income inequality to obesity. These include calorie intake, diet, and the effect of stress in determining food selections and patterns of weight gain (Wilkinson & Pickett 2010p.95-96). They also suggest that considerations of status play a role in determining food selection and implicate the availability of particular types of foods. To illustrate this point they draw on a single source, a series from the Wall Street Journal, providing several examples centring round the consumption of fast-food as a method of demonstrating status, be this financial status or even status as a citizen (p.97-98).  The point underlined by Wilkinson and Pickett is remarkably similar to the suggestion of ethnologist Igor de Garine who in 1987 asserted that

Eating is a form of expression whereby a person in a sense acts out his or her position in a particular society. For this reason, the quest for prestige and distinction is a constant feature of the dynamic of food selection (p.5-6)

It would appear however, that beyond the boundaries of anthropology and ethnology such insights have failed to make an impact on academic work on diet and obesity. A large amount of the current research instead coming in the form of studies which have sought to establish correlations between measures of socio-economic status and various forms of dietary behaviour often putting forward the higher costs of nutrient rich foods as an explanation for observed social-class based differences (see Darmon & Drewnoski 2008: Giskes et al 2009). There has tended to be less emphasis on the meanings people attach to the food they choose to consume and how this relates to conceptions of social status. The role which status considerations plays in food choices have however, received more attention in the mass-media, in a piece cited by Wilkinson and Pickett (p.91), Polly Toynbee suggests that high inequality results in unmet aspirations leading to the poor giving up upon the high-class ideal of thinness in favour of seeking pleasure from eating whilst In a Newsweek article in which Pickett makes a cameo appearance Lisa Miller contrasts the ‘foodie’ culture of wealthier Americans  with what has become termed as the ‘food insecurity’ endured by the poorest who “often eat what they can: highly calorific, mass produced foods like pizza and packaged cakes that fill them up quickly”.

The mass-production of foods is central to numerous structural accounts of obesity such as the impact on, in particular Western diets, of the globalised, subsidised, industrialised food industry which ensures high profits for production of comparatively cheap, energy dense foodstuffs (Lawrence 2008:Delpeuch 2009) Such accounts often locate the fast-food industry within this wider agri-industrial-complex linking its expansion and global spread from an epicentre located in the USA with increased obesity rates in both the developed and developing world (Schlosser 2002: Delpeuch 2009). Interestingly Delpeuch (p.47) also points to the initial take-up of fast food by high-status groups in the developing world, whilst Schlosser presents an alternative explanation for the rise in obesity levels in post-reunification East Germany to that of increased inequality posited by Wilkinson & Pickett (p.101); the construction of East Germany’s first McDonalds branch in 1990 (p.229)

One focus of research which has emerged from the structural accounts is a number of studies seeking to analyse what have been called ‘community nutrition environments’ (Thornton et al p.1423). Some research has suggested there is a link between the concentration of fast-food outlets and neighbourhood-level characteristics such as measures of neighbourhood socioeconomic status (Reidpath et al 2002) or ethnicity (Molaodi et al 2010). There is however much debate as whilst some work supports a link between proximity to fast food outlets and increased odds of obesity (Currie et al 2010p.35) other work disputes the relationship between distribution of fast-food outlets and obesity (Pearce et al 2009 p.196:Thornton et al 2010p.1423) however, intriguingly  Pearce et al suggest their New Zealand based study may have drawn different conclusions to research situated in the U.S  was because of  “lower levels of urban residential segregation” in New Zealand (p.196)

Whilst acknowledging some of the factors put forward by the structural accounts; chiefly availability of “cheap, energy dense foods” (2004p.673 2010 p.96) Wilkinson and Pickett are generally dismissive of their explanatory potential (2004p.673) One work however, seeks to build a bridge between the two positions. Using welfare state regime types in their multiple-regression analysis Offer et al (2010) find that liberal regimes experience the highest levels of obesity. They suggest that this is due to high levels of insecurity, but they also find that low prices of fast-food are lowest within the liberal regimes compared to other regime types (p.301). They suggest that overall any explanations for differences between regime types may lie in the shared “historical and cultural roots” linking states within a regime cluster (p.306). The outright dismissal of such historical and cultural factors is indeed one aspect of Wilkinson & Pickett’s work which has attracted critique (Saunders 2010 p.117) Other research however, stresses the importance of both historical and cultural factors in shaping food preferences; Historian Steve Penfold charting the interplay between economics and cultural meanings which saw the donut becoming entrenched as a symbol of Canadian national identity (Penfold 2008). Perhaps this points to what may be a fertile area for future research on obesity.


Brunner, E. (1997) Socioeconomic determinants of health: Stress and the biology of inequality British Medical Journal 314: 1468-1472

Currie, J, Della Vigna, S, Moretti, E & Pathania, V (2010) The Effect of Fast Food Restaurants on Obesity and Weight Gain American Economic Journal: Economic Policy 2: 32-63

Darmon, N. & Drewnowski, A (2008) Does social class predict diet quality? American Journal of Clinical Nutrition 87: 1107-1117

Delpeuch, F. Maire, B. Monnier, E, Holdsworth, M (2009) Globesity: A Planet Out of Control? Earthscan: London

Garine, I. de. (1987) Food Culture and Society The Courier 1987 40: 4-7

Giskes, K. Avendano, M. Brug, J. & Kunst, A. E (2009) A systematic review of studies on socioeconomic inequalities in dietary intakes associated with weight gain and overweight/obesity conducted among European adults Obesity Reviews 11: 413-429

Lawrence, F (2008) Eat Your Heart Out: Why the food business is bad for your health London: Penguin

Macintyre, S. (1997)The Black Report And Beyond What Are The Issues? Social Science and Medicine 44 (6) 723-745

Malaodi, O. R., Harding, S, Leyland, A.H, Kearns, A (2010) Area deprivation, ethnic density and fast food outlets, supermarkets and physical activity structures in England Journal of Epidemiology and Community Health Vol. 64

Miller, Lisa (2010) Divided We Eat: As more of us indulge our passion for local, organic delicacies, a growing number of Americans don’t have enough nutritious food to eat. How we can bridge the gap Newsweek 29th November 2010

Offer, A. Pechey, R. & Ulijaszek, S.  (2010) Obesity under affluence varies by welfare regimes: The effect of fast food insecurity, and inequality Economics and Human Biology (8) 297-308

Pearce, J. Hiscock, R. Blakely, T. & Witten, K. (2009) A national study of the association between neighbourhood access to fast-food outlets and the diet and weight of local residents Health & Place 15: 193-197

Penfold, S (2008) The Donut a Canadian history  Toronto: University of Toronto Press

Pickett, K. Kelly, S., Brunner, E. Lobstein, T. Wilkinson, R. G (2005) Wider income gaps, wider waistbands? An ecological study of obesity and income inequality Journal of epidemiology and Community Health 59: 670-674

Reidpath, D. D. Burns, C. Garrard, J. Mahoney, M. & Townsend, M. (2002) An ecological study of the relationship between social and environmental determinants of obesity Health & Place 8: 141-145

Saunders, P. (2010) Beware False Prophets: Equality, the good society and the spirit level. Policy exchange: London

Schlosser, E.(2002) Fast Food Nation: What the all-american meal is doing to the world London: Penguin

Thornton, L, E. Crawford, D. A, Ball, K.(2010) Neighbourhood-socioeconomic variation in women’s diet: the role of nutrition environments European Journal of Clinical Nutrition 64: 1423-1432

Townsend, P. (1979) Poverty in the United Kingdom : a survey of household resources and standards of living Harmondsworth: Penguin

Toynbee, Polly (2004) Inequality is fattening: People will get thinner only when they have things that are worth staying thin for – self-esteem, social status and jobs The Guardian 28th May 2004

Wilkinson, R. & Pickett, K (2010) The Spirit Level: Why equality is better for everyone London: Penguin

Wilkinson, R. (1997) Socioeconomic determinants of health: Health inequalities: relative or absolute material standards? British Medical Journal 314: 591-595