“It’s so cold outside now. I think about vegetables when I shop, but for the same price I can buy one piece of broccoli or a huge bag of frozen fries. The fries keep me feeling fuller and warm for longer.”
We were discussing Tom’s* weight and how it might be affecting his health and lower back pain. Tom was a man in his 20s living with obesity. He was surviving on government benefits and living in public housing. There were many obstacles for him living the full and healthy life he had once imagined.
Obesity is a condition progressively affecting more people across the globe. In Australia, approximately 30% of the population have obesity, ranking in the highest three countries of the OECD. Obesity disproportionately affects poor people, indigenous people and those living in rural areas.
Dr Sandro Demaio (World Health Organisation), is working to end non-communicable diseases by focusing on the food environment. He has pointed out that if we had a class of 30 children and one was having trouble with their work, we would focus our energy on the child. But if 20 were having trouble, we would look at the teaching and school environment. With 60% of the population either overweight or living with obesity, why aren’t we looking at possible public health solutions?
Every time I talk to a patient about their nutrition, whether that be to improve their mood, weight or pain, I feel like I am asking them to push an overloaded wheelbarrow up a very steep hill, all by themselves. There is little in our community environment that supports healthy nutrition, especially for those living in poverty.
Dr Sean Lucan has studied the food environment in American cities and found an oversupply of unhealthy food choices in lower socioeconomic areas. Finding healthy food in these environments is difficult.
Family doctors can move beyond the “education” of individuals to improve nutrition choices. Education by itself will only work for the motivated patient, who has the personal ability and resources for change, who also lives in an environment that supports this change.
There is a great social movement for improved nutrition with various labels and evidence base. However most of these movements are aimed at the middle classes and wealthy, those with personal resource for change. As family doctors we are in a powerful position to advocate for our patients who do not live in environments that support healthy nutrition.
The starkest Australian example would be the food access for Indigenous people living in rural and remote areas. Indigenous people have the worst outcomes for health in my country affected by years of colonization and mistreatment. Rural stores generally have very high prices fresh food, processed foods that have a longer shelf life and ease of transport are the most available and affordable. Projects now exist to improve the access to healthy foods. Solely educating people about healthy nutrition is useless if there is none available.
Family doctors know their patients and their communities. We see the most marginalized and can advocate for changes that will assist them. We also witness any unintended impacts of public health policies on the health of individuals. It would be a travesty if improvements in the food environment only benefited the affluent, and this expanded the health disparities in our communities. We mustn’t lose sight of the those living with the worst health outcomes.
I could not argue with my patient Tom’s logic. Hot fries are more satisfying on a cold winter night than a steamed piece of broccoli. We now work together on the “hole” that the fries are filling in Tom’s life during his consultation. In my community I will advocate for food environment changes that will support healthy food choices when Tom is ready to move in that direction.
Written for North American Primary Care Research Group (NAPCRG) Blog Competition; first prize winner in 2017.
*patient name and details changed for anonymity