By Dr Angela Donkin, Deputy Director at the Institute of Health Equity
I am honoured to be able to kick off this series of nine blogs on low income, debt, health and hunger. However I’m writing this blog with a heavy heart too – I had hoped that after decades in social policy that I might now have more good news to share. Given the statistics I see each day I often struggle to understand why the country is not up in arms. It could be that, generally, people just don’t care enough about the issue, but I’m hoping there are other reasons. Is it just that the figures I see don’t make the headlines? are we all so busy and overloaded with information we haven’t got time to engage with the issue? Are the measures confusing us? There is definitely an element of smoke and mirrors when it comes to reporting of such matters.
So, I’d like to start off with some relatively simple facts that I hope will set out the nature of the issue clearly.
4 out of 10 households with children (40%) don’t have enough income to meet a minimum acceptable standard of living.
Even if both parents work full time over 1 in 10 households with children still don’t reach an acceptable standard of living.
Over a million emergency food parcels were given out by food banks to people who couldn’t afford to feed themselves or their children in 2015/16, current figures for this year suggest it is worse.
The Government has been given a jolt regarding the level of dissatisfaction with the way things are with the Brexit vote. They are promising action, let’s hope that this isn’t just more smoke and mirrors. This is potentially a moment when voices can be heard, and change can happen.
Key to me, for action, is not that we focus on raising people above 60% of median income (the official poverty figure), it’s potentially meaningless to the public and depends on median incomes. Median income could be kept down with wage stagnation while prices rise, the official poverty figures (relative poverty) could come down while more people are struggling to make ends meet (absolute poverty). This is what has been happening until recently. We see through it! The key for people, for well-being, for health, is that the incomes are sufficient to live a healthy fulfilling life and that policy is set to improve income sufficiency and report on it. The Joseph Rowntree figures quoted above are one way of measuring adequacy.
The issue of low income, and dissatisfaction with the system is not just temporal and about what you can buy now, it is more than that now. Assets need to be considered alongside. Wealth inequalities have risen at a faster rate. My older neighbours include a plumber, a hospital porter and a hospital cleaner, a nurse and a gardener. My younger neighbours include a journalist, a GP, an architect and a leading scientist. 40 years ago, the plumber and the hospital workers could afford to buy a small terraced house, now they have no chance. If you haven’t already read it, then read ‘Capital’ by John Lancaster, it’s playing out on my street. Something similar could be happening near you. This doesn’t feel like social progress and we need to consider how, as a society, we have allowed this drift into a situation where key workers cannot afford accommodation and a million need to go to food banks. More importantly we need to work our way out of it.
There have already been a series of blogs regarding housing, and in this series we want to talk about the impacts that low incomes can have on health and wellbeing.
Income and health
Income can impact on health in different ways. Income impacts on health directly, for instance, because of insufficient money to heat your home or buy a healthy balanced diet. Cold homes increase rates of respiratory disease, cardiovascular disease, excess winter deaths and mental illness. Inadequate diets increase the risk of malnutrition, obesity, diabetes and cardiovascular disease.
Low income, and particularly debt or insufficient income also impact on health indirectly through increased stress, depression and anxiety, and sub optimal coping behaviours – such as increased rates of smoking and drinking.
The following examples illustrate these two ‘pathways’ from low income to ill health. The ‘direct’ impact and the ‘stress’ impact.
Living in a low income household can affect your health even before you are born. Women from low-income households are more likely than richer women to have low birthweight babies. Low birthweight babies have an increased risk of mortality, as well as neurodevelopmental problems, sub-optimal growth and long-term negative physical and cognitive outcomes in later life.[ii]
Poverty in early childhood then can limit parents’ ability to provide stimulating activities. Lower income and deprivation in childhood is therefore, unsurprisingly, associated with poorer abilities when entering school (lower levels of ‘school readiness’).[iii]
In addition, mental illness, increases with greater socio-economic deprivation.[iv] When a mother has mental ill health, her children face an increased risk of experiencing behavioural, social or learning difficulties.[v]
The negative consequences continue into childhood. In Britain, children and young people in the poorest households are up to three times more likely to develop mental health problems than their more advantaged peers.[vi] Higher rates of behavioural problems have also been identified among adolescents living in poverty,[vii]
Overcrowding is known to have a negative effect on mental and emotional wellbeing,[viii] and more than one in four adolescents living in cold housing are at risk of multiple mental health problems, compared with one in 20 adolescents who have always lived in warm housing.[ix]
Having sufficient income to buy a healthy diet is necessary to prevent malnutrition (which is relatively rare) and obesity. Money is by no means the only driver of obesity, but it could go some way to explaining why those who are poorer are much more likely to be overweight or obese. Some people might think that people on low incomes are buying too much food which is rather counterintuitive if you consider they have less money. However increasingly we have begun to realise that the types of food you eat are important. Foods that are nutrient dense per calorie, have more health benefits, and are generally more expensive for any given level of energy intake[x], so for instance a higher consumption of fruit and vegetables is associated with higher diet cost.[xi] So, in short, high calorie diets with a relatively low nutrient content, are cheaper.[xii] If incomes are insufficient, it follows that families will be more likely to purchase higher energy density, cheaper foods as opposed to the lower energy density, more expensive foods, richer in nutrients.
Data from the National Diet and Nutrition Survey 2008/09 to 2011/12 on food consumption and nutrient intake illustrate the impact of having a low income on diet quality.[xiii] The data show that the lowest income group generally consumes less protein, less iron, fewer fruits and vegetables, less vitamin C, less calcium, less fish, less oily fish and less folate. Lean meat, fresh fruit and vegetables and fish are expensive forms of calories.
I have included some examples here to illustrate that a) too many people have inadequate incomes, and b) that this can impact negatively on their physical health and well-being. Highlighting this issue is the theme of a set of nine blogs. I hope you read the blogs, share them, raise the issue, and comment. The Marmot review raised the need for a minimum income for healthy living to reduce health inequalities and it was the only recommendation not taken forward. We need a health in all policies approach and we need it soon. There really is a window for change, how can we make the most of it?
 Households below a minimum Income Standard. To note these figures will be updated next week by the Joseph Rowntree Foundation.
 As aboveThe exact number is 1,109, 309. Trussel Trust. Latest stats. https://www.trusselltrust.org/news-and-blog/latest-stats/
[ii] A Wilcox and R Skjaerven, ‘Birth Weight and Perinatal Mortality: the effect of gestational age’, American Journal of Public Health, Vol. 82, No. 3, 1992, pp378-82; M Hack, N Klein and H Taylor, ‘Long-term Developmental Outcomes of Low Birth Weight Infants’, The Future of Children, Vol. 5, No. 1, 1995, pp176-96
[iii] Marmot indicators, available at http://www.instituteofhealthequity.org/projects/marmot-indicators-2015, accessed 31 May 2016
[iv] L Ban, J Gibson, J West, L Fiaschi, M Oates and L Tata, ‘Impact of Socioeconomic Deprivation on Maternal Perinatal Mental Illness Presenting to UK General Practice’, British Journal of General Practice, Vol. 62, No. 603, 2012, pp671-78
[v] A Underdown and J Barlow, Maternal Emotional Wellbeing and Infant Development: a good practice guide for midwives, Royal College of Midwives, 2012; N Talge, C Neal, V Glover and others, ‘Antenatal Maternal Stress and Long-term Effects on Child Neurodevelopment: how and why?’, Journal of Child Psychology and Psychiatry, Vol. 48, Nos. 3-4, 2007, pp245-61; G Dawson, S Ashman and L Carver, ‘The Role of Early Experience in Shaping Behavioural and Brain Development and its Implications for Social Policy’, Development and Psychopathology, Vol. 12, No. 4, 2000, pp695-712; J Langhoff-Roos, U Kesmodel, B Jacobsson, S Rasmussen and I Vogel, ‘Spontaneous Preterm Delivery in Primiparous Women at Low Risk in Denmark: population based study’, British Medical Journal, Vol. 332, No. 7547, 2006, pp937-39
[vi] H Green, A Mcginnity, H Meltzer, T Ford and R Goodman, Mental Health of Children and Young People in Great Britain, 2004, Palgrave Macmillan, 2005
[vii] C Dashiff, W Dimicco, B Myers and K Sheppard, ‘Poverty and Adolescent Mental Health’, Journal of Child and Adolescent Psychiatric Nursing, Vol. 22, No. 1, 2009, pp23-32
[viii] A Jones, Black and Minority Ethnic Communities’ Experience of Overcrowding, Report No.16, Race Equality Foundation, 2010
[ix] M Barnes, S Butt and W Tomaszawski, The Dynamics of Bad Housing: the impact of bad housing on the living standards of children, National Centre for Social Research, 2008
[x] M Maillot, EL Ferguson, A Drewnowski and N Darmon, ‘Nutrient Profiling Can Help Identify Foods of Good Nutritional Quality for their Price: a validation study with linear programming,’ Journal of Nutrition, 138(6), 2008, pp1107-13
[xi] A Drewnowski, P Monsivais, M Maillot and N Darmon, ‘Low-energy-density Diets are Associated with Higher Diet Quality and Higher Diet Costs in French Adults’, Journal of American Diet Association 107(6), 2007, pp1028-32
[xii] A Drewnowski, N Darmon and A Briend, ‘Replacing Fats and Sweets with Vegetables and Fruits: a question of cost’, American Journal of Public Health, 94(9), 2004, pp1555-59
[xiii] Public Health England, National Diet and Nutrition Survey. Results from Years 1 – 4 (combined) of the Rolling Programme (2008/2009 –2011/12), 2014, available at http://www.gov.uk/government/uploads/system/uploads/attachment_data/file/310995/NDNS_Y1_to_4_UK_report.pdf, accessed 6 June 2016