The obesity and poverty paradox


The recent TOS obesity congress in Boston was an excellent opportunity to catch up with the latest research. While it is interesting to hear about what other people are working on, it is also interesting to note what isn’t trending so much.

Many areas of research have obviously come and gone from the limelight as we naturally go through cycles and phases in research, with some topics having considerably more longevity than others.

Short-lived topics with rapid cycles of boom and bust include things like new diets or exercise fads, something many (if not most) obesity experts got fed up with a long time ago. The basic rule here is that the more extreme the new diets are, the more volatile the cycle. Such strategies rarely make sense if you are genuinely concerned about obesity, even though they can stir remarkable amounts of curiosity in the short term. The science eventually catches up.


Obesity research is inevitably a mix of trending topics with shorter cycles, and less trendy but enduring topics that have withstood considerable scientific scrutiny over decades. While these long-lasting areas of research might not always be the most exciting for lay people, they arguably have a more robust potential for providing effective solutions.

For me, there was one such long-lasting topic I had hoped to hear much more about in Boston, namely the negative influence of low socioeconomic status. Obesity and poverty may appear to be a paradox but it was a long time ago, at least in developed nations, that obesity was a condition among the wealthy.


It is now well established that obesity is much more common in individuals at the bottom of the socioeconomic pyramid, and rare towards the top. This particular association is also noted for its strength and consistency across populations in developed nations. Since such associations are rare in obesity research, socioeconomic adversity could well be the strongest risk factor we have for obesity development, hence its long-lasting appeal to researchers.

When we investigate causes behind the obesity epidemic we can obviously point to the junk food invasion and increasingly sedentary lifestyles, for example, but we also need to be aware of the quite dramatic changes in wealth distribution, with financial inequality now at its highest level in seven decades.


So, since socioeconomic adversity is so well established as an obesity risk factor, the topic I wanted to hear much more about in Boston was why this association is so strong. In other words, what is it about being at the bottom of the socioeconomic pyramid that increases the risk of obesity so drastically?

While there were very interesting studies in Boston that touched upon the potential mechanisms, such as food insecurity, stress, junk food, mental health issues, addiction, lack of sleep, and malnutrition, I would have liked to have seen much more.

This is clearly an area where we can find many interesting pieces of the obesity puzzle and really develop our understanding of weight gain and body weight regulation. This work clearly needs to be multifactorial in nature and not just include experts on socioeconomics, but also experts on social interaction/family dynamics, psychology, emotion regulation, behaviour and lifestyle, diet and nutrition, sleep, fitness, metabolism, endocrinology, immunology, inflammation, genetics, epigenetics, and so on.

Once we start to identify the drivers of weight gain among the socioeconomically disadvantaged, the road to some much needed progress in terms of both treatment and prevention of obesity should be considerably wider.

Erik Hemmingsson

Why are we not doing more to prevent obesity?


In many ways, obesity is a very complex disease, and it’s likely to remain so for many years. You can always go deeper down the rabbit hole, regardless of whether you are researching fat cells, metabolism, eating psychology or socioeconomics. Researchers are usually very happy to do this, it’s what we trained for.

There comes a point, however, when new studies do not add very much to what is needed in order to bring about a certain outcome, such as prevention of obesity. It’s true that we need much more research, for example on obesity etiology, but do we really need more evidence to tell us that junk food and inequality/poverty (this latter risk factor only applies to countries that have already made the nutrition transition from natural food to junk food, such as Europe and North America) are major causal factors? I think not.

Indeed, we can and should act now to reduce both, and in so doing, we would very likely help to prevent new cases of obesity and probably many other diseases that are also linked to both risk factors, such as depression, arthritis, diabetes and heart disease.

Apart from getting rid of junk food and lowering rates of poverty, we should also be promoting healthy nutrition across the lifespan, where the food contains minimal quantities of pesticides, preservatives, sugar, salt, unhealthy fats, steroids, and antibiotics – just plain natural food, it’s simple. We should also be doing things like promoting physically active transport, and reducing sitting time at work and at home. Healthy eating and regular physical activity will not get rid of obesity, but they can probably go some way in lowering the obesity incidence rates at the very least.

And while messages to promote healthy eating and physical activity can be helpful, we have to be much more comprehensive in how we change the environment. Indeed, the food environment has become so toxic that it feels like we almost have to completely rethink how we produce food. Junk food simply has no place in a society where we value and place emphasis on prevention on chronic disease. Reducing poverty will also require much more than pretty messages, it requires major political decisions and pressure from voters. Bear in mind that the difference between the rich and the poor is at its widest in over 7 decades.

There will always be times when we have to do more research in order to understand more about a particular disease or problem, but if we are talking about obesity prevention, this is probably not that time. This is the time for action, like what is happening in Mexico (see my previous post), where they are successfully working to reduce their more or less catastrophic childhood obesity rates, for example by taxing soda, during very challenging conditions.

Actually, if there is one thing that we should do more research on, it would be to find out why we are not implementing much more serious obesity prevention programs and why we have let mega food corporations take over close to our entire food supply. And while we try to find answers to those two question, there is nothing stopping us from implementing healthy nutrition and physical activity habits for everyone, especially for children in socioeconomically challenged areas.

If you have an answer as to why we are not doing more to prevent obesity, I would love to hear from you. Please share.

Erik Hemmingsson

Food insecurity and eating disorders in obese children


Today Dr June Tester presented the first qualitative study I have seen at Obesity Week ever, on the very interesting topic of disordered eating in children growing up with food insecurity. There is quite a marked association between food insecurity and obesity, which may seem paradoxical, but makes perfect sense to me. Subjects were 47 focus groups from a paediatric weight management clinic. Grounded theory was used to describe themes surrounding food insecurity and eating problems in the children.

There was a lot of secretive eating practices and food hiding, as one would expect. There was also a high frequency of hidden candy wrappers in the children’s rooms. Likewise, food insecure parents also hid food, i.e. fending for themselves: “Otherwise I don’t get any”. It was striking to me the low quality of food that these very poor families can afford to buy. All members of the family tend to binge eat food when there is food insecurity. Parents describe how they want to put locks on their fridges or anywhere there is food. These behaviors certainly complicate treatment of obesity.

Given the marked association between socioeconomics and obesity, we could certainly do with more of this type of studies.

How can we possibly prevent obesity when there is so much inequality?

Make no mistake about it: wealth inequality is one of the main drivers of health and disease generally. Inequality is strongly associated with outcomes such as obesity, depression, diabetes, cancer, heart disease, arthritis, etc. The list is very long.

Given that inequality is reaching new heights every day it seems, we have to ask ourselves how we can possibly hope to prevent obesity, and other major diseases, in the face of this massive inequality? Please watch this short and very informative video of how skew the distribution of wealth really is.

If you have the time, you can also listen to self-confessed plutocrat Nick Hanauer talk about how the pitchforks will come out soon if this situation is not remedied.

Indeed, the situation in the US, the UK and elsewhere is not unlike the pre-revolution situation in France some 225-230 years ago. The good thing is that a financial crisis like we have today can act as a very powerful catalyst for replacing the current dysfunctional economy, that only works for the wealthy few, with something that allows everyone to thrive.

Because obesity mostly affects the poor, it is not surprising that the epidemic is doing so well, since more and more people are crossing the poverty line and the middle class is being squeezed. How would you react if you were below that poverty line, and you were being told to buy more vegetables and exercise more, when you are working 2-3 jobs just to stay alive and put food on the table, and not knowing if you are going to have any job next month or even next week?

If governments were really serious about preventing disease, they should first do their utmost to reduce wealth inequality. Only then will it be realistic to expect our prevention programs to have any kind of positive effect on the obesity epidemic.

Erik Hemmingsson