Health comes from diet and exercise… But not only diet and exercise. Health comes from a secure job with benefits. Safe and affordable housing. A neighbourhood with easy walkability and recreational activities. Access and availability of nutritious foods. Opportunities to pursue education. And thus, our health is not solely determined by our behaviours and thus it is not our personal responsibility for it to be perfect. This also means that “people just need to eat less to lose weight and be healthy” is an inaccurate and unhelpful statement.
It is certainly true that eating well and engaging in physical activity improves well-being in the long term and on a day-to-day basis. Healthy eating behaviours and activity demonstrably boost energy levels throughout the day and offer a host of other immediate benefits (1). A dietitian, for example, can help you feel better on the day-to-day, improve your relationship with food, increase sport performance and avoid progression in chronic diseases. But I’ll get to that.
The choices that we make about what we eat and how active we are aren’t just about individual preferences, but are rooted in public policies that influence how affordable and accessible these lifestyle choices may be.
Up to 55% of the length and quality of our lives is determined by social determinants of health, which are the non-medical factors that influence health outcomes. The World Health Organization (WHO) defines them as conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life (2). Some examples include:
Income and social protection
Education
Unemployment and job insecurity
Working life conditions
Food insecurity
Housing, basic amenities and the environment
Early childhood development
Social inclusion and non-discrimination
Structural conflict
Access to affordable health services of decent quality
And these determinants are highly interconnected. For example, if you have access to good education, you likely have access to a job that pays well, which makes it easier to afford good housing, have access to healthcare and healthy food. Thus, you have a better chance at good health and a longer life expectancy.
Here are a few more specific examples of how these factors can determine health:
Environment and Food insecurity
Polluted air, contaminated water, and extreme heat are 3 environmental conditions that can negatively impact population health. The World Health Organization attributed 11% of U.S. mortality in 2012 (nearly 300,000 deaths) to environmental causes (3).
In addition to this, geographic location affects health. Access to neighbourhood walkability, outdoor recreation, public transport, grocery stores and restaurants that offer healthy and affordable foods, will all inevitably impact dietary choices and physical activity levels, which will ultimately impact our likelihood of developing chronic disease (4,5).
We may think the people we know are capable of spending their money on food, but just as an example, 40% of post-secondary students in Canada are food insecure. After tuition, rent and other expenses are settled, a student’s remaining budget for food may be very minimal (6).
Many people cannot afford to eat a nutritious diet, but we stigmatise by regarding it as a personal obligation.
Income
Nearly 5 million people in Canada – that’s 1 out of every 7 individuals – currently live in poverty. Poverty is a widespread issue across the country and the world, but vulnerable groups such as people living with disabilities, single parents, elderly individuals, youth, and racialized communities are more susceptible (7).
In developing countries, the link between low income and health is pretty clear. In developed countries like Canada, the link has more to do with stress than it has to do with lack of clean water and sanitary facilities or famine. The stress caused by low income leads to poorer health outcomes than those experienced by people with more privilege—differences in health that cannot be attributed to health behaviours (8). There's also the effect of food insecurity - and literally not having the budget for healthy food - of course.
Working life conditions
Being at the top or the bottom in an organization has a huge impact on health. The boss, let’s say, can expect to enjoy better health and live longer than someone in a lower-paid job, even if they share identical eating and exercise behaviours (9). In fact, people on the bottom usually have at least twice the risk of serious illness and pre-mature death as those near the top (10). The health disparity often seems to be due to low “decision latitude”—lacking a say in how you organize your work (11).
This concept has been known for a long time. Many years ago, the “Whitehall study” looked into mortality rates among male British Civil servants. These servants were grouped into 7 job categories, with those at the top having more job control and job support, and those at the bottom having less. What they found was that, even after controlling for risk factors like obesity, smoking, less leisure time physical activity, more baseline illness and higher blood pressure (that low status jobs were associated with), the lowest grade still had a mortality rate of 2.1 times higher than men in the highest grade. What may explain this is the differences in job control and job support, as well as job stress (lack of skill utilization, tension and lack of clarity in tasks) (12).
How stress affects health
Those who have been treated well by society, and who see themselves as valuable and worthy, benefit from a protective cushion that outweighs the stress response. On the other hand, lives under stress – due to noise pollution, damp houses, fear of crime, racism, or size discrimination, insecure or unsafe work, or a general lack of control over one’s circumstances - activate stress responses that work overtime and impair body resilience (1).
Long-term stress and reduced bodily resilience can be triggered by a variety of negative personal conditions, including chronic anxiety, insecurity, low self-esteem, social isolation, and a lack of control over work and home life. And, in developed countries, the lower one's socioeconomic status, the more common these issues are (1).
We all experience stress from time to time, but when it’s persistent, its effects are severe. With stress, our “fight or flight” response is activated (which releases hormones like adrenalin and cortisol, speeds the heart rate, slows digestion, diverts blood flow to major muscle groups, and gives the body a burst of energy and strength) so that we can run from or confront a perceived threat. Even though we’re not about to run from a bear, our bodies think we are. We haven’t evolved away from that yet! And if those tensions occur frequently or for an extended period of time, we become vulnerable to a wide range of poor health outcomes, including infections, diabetes, high blood pressure, heart attack, stroke, and depression (1).
If a good part of our health is pre-determined, what can we do?
There are still a multitude of behaviours we can change in order to improve our health. Social determinants do play a big part in health, but we play a part, too. For those of you reading this article, you have access to a computer or phone, which already puts you in a good position. I may be wrong in my assumptions (and if so, I’m sorry for that), but you likely have choices when it comes to diet and exercise.
If you have a chronic condition (like diabetes, for example), it may have a lot to do with social determinants. But, this doesn’t mean you can’t help it. You can re-organize your diet and find physical activity you like to help with day to day health and avoid the condition getting worse or having long-term effects.
If you have digestive problems, of course some modifications in your diet can help you.
If you play a sport, you can definitely benefit from learning more about nutrition. This can help you with your energy, your focus and thus your performance and help you reach your goals.
Conclusion
The main thing I want you to retain from this post is that health cannot be assumed, and neither can someone’s ability to change it. Some people do have the opportunity to change lifestyle habits to improve health, and some people don’t. And if you do, go for it! Personally, I feel extremely grateful to have some sense of control over my health, and I am passionate about giving people tools to make healthy changes as well.
Works cited
1. Bacon, L & Aphramor, L. Body Respect. BenBella Books, 2014.
2. “Social Determinants of Health.” World Health Organization, https://www.who.int/westernpacific/health-topics/social-determinants-of-health. Accessed 16 Jan. 2022.
3. “Social Determinants of Health.” Health.Gov, https://health.gov/healthypeople/objectives-and-data/social-determinants-health. Accessed 16 Jan. 2022.
4. Braveman, P. & Gottlieb, L. The social determinants of health: it’s time to consider the causes of the causes. Public Health Rep. 2014;129 (Suppl 2):19-31.
5. “‘Food Deserts’ Resources and Information from the Canadian Environmental Health Atlas.” Food Secure Canada, 14 Oct. 2013, https://foodsecurecanada.org/resources-news/resources-research/food-deserts-resources-and-information-canadian-environmental.
6 . Sing, N. “The Fight to End Hunger on Canadian University Campuses.” Macleans, 7 Oct. 2021, https://www.macleans.ca/education/the-fight-to-end-hunger-on-canadian-university-campuses/.
7. “Just the Facts - Poverty in Canada.” CWP, 16 Feb. 2017, https://cwp-csp.ca/poverty/just-the-facts/.
8. Marmot, MG. “Status syndrome: a challenge to medicine.” JAMA vol. 295,11 (2006): 1304-7. doi:10.1001/jama.295.11.1304
9. Wolrich, J. Food Isn’t Medicine. Vermillion London, 2021.
10. Marmot, MG. & Wilkinson, RG. Social Determinants of Health: The Solid Facts, 2nd ed. (Copenhagen, Denmark: World Health Organization, 2003).
11. Brunner, EG, Chandola, T. & Marmot, MG. “Prospective Effect of Job Strain on General and Central Obesity in the Whitehall II Study,” American Journal of Epidemiology 165, no. 7 (2007): 828–37.
12. “The Whitehall Study.” Unhealthy Work, 22 June 2011, https://unhealthywork.org/classic-studies/the-whitehall-study/.