By Wayne Roberts
Food policy specialist Dr. Catherine Mah grew up in a food-centred household. Later, she would regularly invite people over for dinner to celebrate the social aspects of eating. Now Mah invites a wide range of experts, including people who work in mental health and addiction, around the same table to talk food, as head of the Food Policy Research Initiative at the Ontario Tobacco Research Unit (OTRU) at the Centre for Addiction and Mental Health in Toronto. She is also an assistant professor at the Dalla Lana School of Public Health at the University of Toronto. As a food system writer and public speaker, I was eager to sit down and share some food for thought with Mah.
Congratulations on your upcoming first anniversary as a researcher at OTRU. But I have to ask: What’s a nice young pediatrician and food policy specialist like you doing in the tobacco unit of a mental health and addiction hospital?
People ask me that all the time: What does smoking have to do with food? My answer: common risk factors. OTRU has built up a tremendous range of expertise in public health policy research and evaluation. People in the unit have been thinking for some time about linking what they know about making better tobacco control policies with what other researchers are discovering about risk factors behind various chronic diseases.
This is right at the front of the curve of big-picture global thinking about what we can do to reduce the global burden of chronic or noncommunicable diseases, which cause more deaths worldwide than all other causes combined. Changing just four common risk factors-tobacco, harmful use of alcohol, unhealthy food and lack of physical activity-could have huge benefits for our health and save lives. Last fall, the United Nations hosted a major meeting on this theme, the second such meeting on health ever called by the U.N. (the first meeting was about AIDS). Although mental health wasn’t formally included, the door was opened to discussion about risk factors across the board, and the link between food and mental health can help to open that door wider.
Tobacco and food have more links than meet the eye. We often forget that food, alcohol and tobacco are all agricultural products. As well, they exist in a social, cultural, economic and political context that can be part of the problem or part of the solution, depending on whether high-risk products are normalized and encouraged-or denormalized and discouraged.
Having said that, there are major differences. Most obviously, tobacco is a toxin with no safe levels. Food is essential to life and enjoyment of life, although certain food ingredients, such as salt, and production methods can have a clear negative effect on health.
Could you share some thoughts on parallels in the culture and social environment that influence both food and tobacco and that connect to overall mental health and well-being?
You could call me a framing scientist: I try to challenge the ways that health problems get talked about, understood and debated-what I call framed. Watching television or reading the newspaper, it is easy to think that health problems related to food are the result of an individual’s lack of self-control-their “lifestyle” choices, and the proposed solution is almost always to feature ways to improve individual awareness or will power. It’s as if individuals can just upload the right knowledge, attitudes and behaviors, and the problem will be solved.
Public policy and public health have always been about reframing that approach to personal diagnosis and treatment by putting a spotlight on what we call population health. That goes way back to the 1850s, when Dr. John Snow observed that most people with cholera in London, England, drank water from the same pump. When the pump’s handle was removed, the cholera outbreak ended. From there, health crusaders came up with ways to prevent other diseases that affect entire populations, such as immunization, generally seen as one of the major breakthroughs in the history of health.
Now with noncommunicable diseases, we’re talking about ways to prevent heart disease, cancer, diabetes and chronic lung diseases; to promote well-being by creating livable, healthy cities and environments. That’s population health. How do we prevent disease by closing the pump of social and economic risk factors? When people asked that for tobacco control, they saw the impact of advertising that made smoking seem cool and the political influence of tobacco industry executives. Instead of just asking individuals to quit smoking, we banned smoking in workplaces and public places, got rid of deceptive labeling, put taxes in place and limited the tobacco industry’s access to the political process.
So bring us back to how this influences food.
As with tobacco, often-invisible social and economic inequities and risk factors are at work with food. Someone with an empty stomach and empty wallet will notice that a calorie worth of fruits or vegetables costs a lot more than a calorie filled with fat or sugar. A planner with a trained eye will see that low-income neighbourhoods and areas near schools have fewer places selling healthy foods and more places selling fast food. I’m working with Toronto Public Health and others right now on some exciting research and pilot projects, showing that people make better food decisions when better food options are available to them. It’s the flip side of anti-smoking campaigns, which showed that fewer people started to smoke when fewer options to smoke were available.
But where is the mental health angle?
We’re partnering right now with University of Toronto researcher Valerie Tarasuk on that area. If I could start with the framing problem, too few people think in terms of all the emotional stresses and mental illnesses related to the stresses of getting enough decent food on a low income. The term that’s used to describe this-food insecurity-comes from right after World War II, when mass suffering from hunger had shaped the lives of millions of people over the previous two decades, people who had a deep understanding of this stressful population-wide problem. That’s what food insecurity means. It’s not just a problem of hunger pangs once a week when the food runs out. It’s the anxiety all week of knowing that the food will run out. The shame that parents feel about failing to provide for their children, even though mothers often go without so their kids can eat. The emotional pain and suffering is as harmful as the lack of nutrients. That’s why “household food insecurity” is such an accurate phrase, and not just a soft way of saying “hunger.”
Children feel as much shame, anxiety and depression as parents and suffer as much from feeling excluded and isolated in schools and communities. That’s the invisible cause of a lot of disease and a sheer waste of our human potential.
Why is it important for frontline mental health and addiction workers and policy makers to understand food insecurity?
When we learn how pervasive household food insecurity is-it’s a fact of daily life for nearly one in 10 people across Canada-teachers, doctors and other health providers need to make it a standard screening question. Just as we now automatically ask people seeking care if they are going through relationship difficulties, or if they have experienced family violence, we need to ask: Have you eaten today? Do you ever have a problem getting enough to eat? Was it ever a problem for you when you were growing up? One person in 10, and up to one person in three in some parts of Canada, such as the North, will say yes. Professionals will have some powerful new insights into what the person’s deep-down problems may be and what can be done.
It cannot be stated often enough that social isolation is one of the major risk factors for mental health problems. The three most significant determinants of mental health are social inclusion, freedom from discrimination and violence and access to economic resources. People experiencing food insecurity, almost by definition, don’t have any of these.
Anything else high on your to-do list?
We need to think about the work of Kevin Morgan at Cardiff University in Wales and his idea of “the convening power of food.” Hospitals-institutions dedicated to healing-need to think at a population level about the meaning of leaving people alone to eat from a tray. There’s also the practice of providing food to homeless people on styrofoam plates and cups, and dispensing plastic cutlery, as if it’s only the delivery of calories that matters, and not the feeling of isolation or exclusion or the sense of being totally disposable.
Is it just your professional training that brought you to this understanding or have you had personal experiences bringing you to this?
I grew up in Calgary without any personal experience of food insecurity. I grew up in a food-centered Chinese-Canadian culture. I became very familiar with the idea that mood, my health, my performance at school were always related to too much of this or too little of that. My mother would cook me a steak for breakfast on exam days, prepare special teas for colds and fevers and serve up soups and stews that were supposed to make my skin glow or improve my eyesight. I always cooked for friends, and the social side of food has always been part of me. As a researcher, I see myself as a convener around food, just as I am in my private life. My mother was very aware of the effect of food on well-being, which is the level of impact we need to be aiming for: not just reducing disease, but increasing well-being and, one of my new favourite words, flourishing.
Any final thoughts?
We started off talking about risk factors, and I’d like to conclude at the opposite end of the spectrum-protective factors and assets. When people-or local food systems-are resilient and have strong adaptive capacity, that means that they are able to withstand shocks and risks-they are able to bounce back and really thrive.
We need to frame our thinking beyond the safety net, beyond what was classified in the poor laws of old pre-industrial England and their notion of the “irreducible minimum” to keep the undeserving poor alive. We need to think beyond the individual and beyond the minimum. We’ve gone from there to health and well-being, and now we need to go to the next level, what American sociologist and psychologist Corey Keyes called flourishing, in mental health promotion.
Public health policy is about protecting people from risks to their health, but it is also about promoting the daily living conditions that cultivate well-being. We need to have more conversations about that and more action towards that end.
The chicken and the egg-or when you can’t afford either
When low-income mothers and children experience mental health problems, such as depression, their families are less likely to have consistent access to healthy food, according to a 2009 study in the Journal of Health Care for the Poor and Underserved.
Poor mental health contributes to household food insecurity by preventing the depressed household member from working, preventing other household members from working and limiting access to childcare for depressed children.
Researchers conducted annual in-depth interviews with 30 low-income mothers in two rural counties in New York over a period of three years. They found that having a high score on measures of depressive symptoms was related to the persistence of food insecurity.
This finding suggests a causal relationship-that it is more likely that mental health problems lead to food insecurity than it is that food insecurity leads to mental health problems. This relationship makes sense because depression may hinder a person’s ability to work, which in turn keeps people in poverty.