Diseases, Disorders, and Impact
Non-Communicable Diseases are not a question of happenstance, “bad luck”, or due to a group's genetic make-up. They are highly linked to exposure to pollution, contaminants, and marginalisation.
“Trauma stemming from exposure to contaminants like air pollution, inadequate housing and psychosocial stressors also creates systemic biological and cellular changes. For example, it can change our gut bacteria environment, which has implications for obesity (source). In cases of acute trauma, some can experience PTSD, which creates neurobiological abnormalities which alters the function of various biological systems, this too has implications for obesity (source). The link between obesity and trauma also provides a wide ecological scope to understand the different determinants of a disease that is complex and not just a lifestyle choice.”
This is a quote from Centric Lab’s report ‘Obesity & Trauma’. The purpose of this quote is to bring forward the understanding that disease and disorder outcomes can have multiple pathways.
Non-Communicable Diseases are not a question of happenstance, “bad luck”, or due to a group's genetic make-up. They are highly linked to exposure to pollution, contaminants, and marginalisation.
Our engagement with health and local governing systems often frames them as individual issues. Despite non-communicable diseases having multiple, structural, top-down pathways our public conversation and narrative is shaped by our need to change our lifestyles in order to adapt to living with them.
For people living with obesity, the experience is toxic and the behaviour and attitudes of systems is endemic. This stigmatisation starts in the science journals and moves to the doctors office and spills out to socio-cultural psyche. In a letter to the editor for the Journal of Primary Care and Community Health, the authors point to a recent paper titled Childhood Obesity: An Evidence-Based Approach to Family Centred Advice and Support - which in their words the paper “highlighted how biases amongst physicians can lead to stigmatising beliefs, which blame individuals for exercising insufficiently and eating excessively” (source). They go on to state how this thinking is unhelpful as the shame can lead to obese patients not seeing medical help and it ignores the upstream determinants (source).
When it comes to the socio-cultural psyche, the stigmatisation also manifests in reducing obesity as a weight problem that is solved by dietary changes. In a recent campaign by Cancer UK, obesity was metaphorised into cigarette packets full of fries (chips). This creates a socio-cultural framing of obesity that blames a person not only for having obesity, but also for subsequently putting themselves at risk for cancer. This is not only psychologically harmful to those experiencing cancer and obesity, it is also scientifically inaccurate.
Another example of the problematic depiction of obesity can be seen in how it is explained by the National Health Service in the United Kingdom. For example, the health A-Z about the causes of obesity (source) focus on individual behaviours and choices by saying that obesity is generally caused by “eating too much and moving too little” and is “ a result of poor diet and lifestyle choice”. In a further section, it says “some people claim there's no point trying to lose weight because it runs in my family or it's in my genes. While there are some rare genetic conditions that can cause obesity, such as Prader-Willi syndrome, there's no reason why most people cannot lose weight.” There are two problems with this statement, the first is that it fails to give a clear explanation about the complex interplay between genes and environmental factors. Secondly, it firmly puts the blame on the individual. A national health service cannot use inaccurate messaging or narrative as it contributes to health injustice and further marginalisation.
This stigmatisation also compounds racial marginalisations. A recent series of health campaign adverts from the NHS look perfectly helpful at first glance. They depict an overweight Black woman eating a salad to promote healthier eating habits, especially in the wake of COVID. It is now well known that comorbidities such as obesity and diabetes played a key role in Covid susceptibility. Additionally, these comorbidities were identified as being prevalent amongst Black communities and offered an explanation to the high prevalence of Covid within the community. However, when we look deeper there are three things wrong with this and more insidiously these three factors point to the prevalence of structural racism within the health system.
There are various problems with targeting a community based on their race, specifically in the context of health. To say “Black community”, “Asian community” or “Indigenous community” is a misnomer as it doesn’t see the person-to-place relationship, which is essential to understanding health. Health is a process that requires a multi-systemic engagement between our bodies and external environment, this engagement happens throughout a person’s entire lifetime. Engagement means the interactions, relationships, experiences and encounters between all our biological systems and our external environment. Secondly, the engagement is either supportive or non supportive. For example, if we live close to nature, breathing clean and nourishing air, then this interaction is supportive of our health, as oxygen provides all of our biological systems with sustenance. However, if we live close to a high traffic road, where we breathe air pollution, causing damage to all of our biological systems, then this is an interaction that is not supportive to our health.
When our bodies are forced to engage with environments that have high environmental pollutants, extreme climatic events, contaminated food sources, non nourishing food, and violence our health suffers. We have published several papers on the phenomena of biological inequity, which identifies that poverty exposes people to disproportionate levels of biological stress through the aforementioned factors. In these environments our bodies “wear and tear” through a process called allostatic load, which is one the pathways to disease, including obesity.
Given how much habitat plays a role in a person’s health, it is inaccurate to simply correlate poor health outcomes with a phenotype or “race”, additionally, it is more important to look at the interaction between a person in a specific place than just their “race”. Finally, it is a person who experiences the environment not their phenotype, race, or ethnicity. In other words if a Black person is living in a neighbourhood with clean air, water, access to healthcare, access to safety, access to nourishing food they will have very different health outcomes than a Black person living in an environment with high air pollution, no running water, no feelings of safety, etc.
Therefore putting out the narrative that the Black women should be eating salads, simply because being Black is a health risk rather than structural racism that forces Black people to disproportionately live in biological inequity is incorrect. It also leans into eugenics.
Habitat, Not Individual Choice
Obesity is a very complex disease, it is a dysregulation of the endocrine, immune, digestive, and metabolic systems. Its disease pathology is complex. For example, people that experience childhood trauma are more at risk of obesity due to allostatic load. There are also various studies linking obesity to both air and light pollution as well as with food insecurity. Most people think children are obese because of too much food, however, once the body’s metabolic system is dysregulated its interaction with food, nutrients, fat storage, and insulin change, meaning that quantity of food only plays a small factor.
Therefore, to simplify a complex disease to the food choices a person is making is damaging. Firstly, it gaslights people into thinking they are personally to blame for a complex disease. Secondly, it is not an honest depiction of the disease pathology, which means we don’t solve the problem. Thirdly, if we want to get serious about solving obesity, then we have to look at the places people live, which means that public health also extends to those that build cities.
Lived Experience and Habitat
A crucial element of a habitat are our experiences within it. It is important to take into consideration where people work, the type of work, the length of communities, their urban footprint, their economic standing, their social network, their age, physical mobility etc. For example, a person that lives in an area of biological inequity, who is neurodivergent and has not been able to build economic or social infrastructure might be more at risk for social isolation and loneliness than a person in the same area but with stronger economic and social infrastructure. Loneliness is a risk factor for obesity and cardiovascular disease.
Another person in the same community, could be a bus driver, which exposes them to over eight hours of air, noise, and light pollution due to being a driver, they also may not have the time to eat proper meals or eat them at regular schedule. All of these factors play a key role in whether or not their metabolic system will dysregulate due to their stressors and whether or not they are more at risk for obesity.
Conversely, take a person in the same exact neighbourhood as the bus driver, but they work as a security guard in a leafy area, close to their home. The job may afford them outdoor breaks away from traffic, more physical mobility, and a shorter commute, which can contribute to longer sleep cycles, more time to pack a nourishing meal, more downtime, more exercise. All of these different factors can change the level of risk for obesity for the security guard despite living in the same community as the bus driver. Furthermore, both could have the same exact diet, but when these extra factors are added in, the way their body metabolises the food will be different.
Again this illustrates that it is not about race or ethnicity nor is it not as simple as eating a salad. Therefore, if health campaigns are to be anti-racist and anti-classist they have to be honest about the contributing factors to complex diseases such as obesity. Whilst healthy eating habits are important, the outcomes will not be as effective if a person is living in biological inequity.
Looking at this ad from the NHS and given what we know about the complexities in the disease pathology of obesity, it is very difficult to deny its racist and classist approach. To succeed in our effort against obesity, we need to identify all the factors that contribute to its disease pathology, which includes creating healthier neighbourhoods, eradicating poverty, eradicating inequity, eradicating racism, and eradicating classism. It is time that we look at obesity in a more accurate light.
DIABETES
This narrative and evidence point is not exclusive to obesity, it also applied to the development of type 2 diabetes, which by 2030, 552 million people will be diagnosed with diabetes with 95% being cases of Type 2 diabetes. Type 2 diabetes (T2D) is a metabolic disorder, which prevents the body’s ability to regulate glucose,.
GENETICS IS ONLY ONE DIMENSION OF TYPE 2 DIABETES
Genes are a unit of heredity, meaning they store biological information that is passed down from one generation to another, including the susceptibility of a disease (source).
This has led disease like Type 2 Diabetes (T2D) to be studied from the perspective of genes (source). In more recent years the western diet has also been highlighted as a factor in the aetiology of T2D.
However, we must also look at another crucial dimension, geography. Research indicates how geographical location also plays a role in the development of T2D (source). A recent study highlighted how the significant geographical variation in global distribution of T2D is linked to air pollution (source).
Given that distribution of air pollution is driven by systemic racial strategies, it is very important that we take geospatial factors into consideration when studying the aetiology of T2D (source).
THE MICROBIOME, AIR POLLUTION, AND TYPE 2 DIABETES
Our gut environment is made up of microbes that mitigate all biological processes, from digestion, immune response, metabolic and even brain function (source).
The microbiome is now being considered the study of disease (source). The interplay between the microbiome and air pollution in disease pathology are increasing, this work is highlighting that air pollutants, such as nitrogen oxides and ozone have the potential to alter the microbes in the gut environment, which in turn increases the risk for T2D through inflammatory pathways (source).
This presents yet another consideration for an ecological framing of T2D.
HEALTH JUSTICE CONSIDERATIONS
To focus the development and experience of living with non-communicable diseases as a person-to-doctor dynamic is it hugely unpleasant, the stigmatising narrative as outlined above serves as a barrier to public health and health justice in a number of ways.
It is simply inaccurate
It is becoming clear that complex interactions of environment, neurohormonal systems, and trans-generational effects directly contribute to development of NCDs (source). It is simply inaccurate to depict obesity as a problem of “the individual” and, in doing so, the real contributing factors (and thereby solutions) are not explored. Consequently, the problem persists.
It exacerbates the problem
People feel fearful, ashamed and blame themselves - can lead to low self-esteem, stress and mental health problems that feeds into feedback loop
People don't seek healthcare, and the healthcare they receive can be poor as a result of bias
It sustains inequality
The obesity and individual blaming narrative helps to deflect from, and sustain, oppression, health inequities and structural violence.
Blaming the individual means that the systems which actually cause the problems (e.g. capitalism, supremacy) can persist without challenge
A key takeaway from this lesson is:
We hope to walk towards the following:
Research from neuroscience provides a cognitive infrastructure that helps physiologically link health to place.
Use neuroscience to add another layer to social justice work, particularly providing communities with a further lexicon to express the phenomena of injustice. In order to be able to advocate for their health in the face of injustices.
A change towards a more accurate narrative of health. One that acknowledges the physiological link between health and place.