Later this month, nutritionists in Britain will have a new and controversial set of figures to play with: revised estimates of the amounts of nutrients needed for a balanced national diet. The figures come from what is probably the largest survey ever made of published studies on diet and will help nutritionists and government policy makers to set national dietary goals. The figures are also likely to cause a storm, for they imply that people in Britain must make drastic cuts in their consumption of fat and sugar. Although the report itself offers no recommendations about healthier eating, consumer groups are ready to seize on the findings to demand corresponding changes in dietary advice.
The report, a 400-page tome containing 50 tables, comes from a panel of the Department of Health’s own Committee on Medical Aspects of Food Policy (COMA) and so is likely to command wide respect. COMA has christened its figures on nutrients ‘dietary reference values’; in the past such figures have been known as ‘recommended daily allowances’ (RDAs). Nutritionists use RDAs not only to plan diets, but to design labels for foodstuffs and alssess whether we are eating a balanced diet. COMA’s new figures may eventually form the bench mark for harmonising the different RDAs used in food labelling throughout the European Community. Four observers from the European Commission’s Food Directorate sat in on the panel’s deliberations.
COMA’s report follows the launch last month of a comprehensive set of global dietary goals in a 200-page report from the World Health Organization (see Table). The WHO report gives general targets for nutrients which governments can convert into a set of guidelines for individuals. Unusually, the goals are expressed in terms of ranges rather than upper limits. For example, the report says that the percentage of our energy from fat should range between 15 and 30 per cent. The corresponding figure for sugar, 0 to 10 per cent, emphasises the need for populations to cut out sugar consumption altogether if possible.
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The WHO report, a recent healthy eating campaign spearheaded by the Consumers’ Association and the imminent COMA report all serve to focus public attention on the nature of dietary advice to consumers. This topic dominated a meeting in London during March entitled ‘The food network-achieving a healthy diet by the year 2000’. The impetus for the meeting, organised jointly by the Health Education Authority and the British Dietetic Association, was the lack of progress in changing the dietary habits of the British.
Despite indications in a recent national food survey that Britons are gradually switching to healthier diets, nutritionists still face an uphill struggle. Rates of coronary heart disease, for instance, are still higher in Scotland and Northern Ireland than anywhere else. Meanwhile, nations such as the US and Finland, which once headed the league table of premature deaths among the richest nations, have reported marked improvements in the health of their citizens through successful food education programmes.
There are many possible reasons why Britain still lags behind. The food industry’s vast advertising drives eclipse messages about healthy eating from nutritionists. Britons may receive what appear to be conflicting signals from nutritionists and close their ears to what little advice reaches them. Some consumer groups accuse retailers of pricing healthy products beyond the means of the poorest families-who often have the worst diets-using the wholesomeness of some foods as an excuse for charging more. Some say that food labelling in Britain is too confusing. A Common Agricultural Policy that provides farmers with financial incentives to overproduce some of the least healthy foods does little to help.
The most persistent plea at the recent conference was for the government to give a clearer lead, perhaps by forming its own policy on nutrition. Although the government issued a booklet earlier this year, entitled Eight guidelines for a healthy diet, consumer groups say it is too vague. David Maclean, the food minister, defended the government’s free-market principles at the conference, declaring that ‘we must not be dictatorial or prescriptive’. Nevertheless, he acknow-ledged that the government had a duty to target some groups, notably the young and the old. ‘We still eat too much fat and too few complex carbohydrates; therefore we must refine the messages and direct them where they are most needed,’ Maclean said.
The publication of Dietary Reference Values is likely to add to pressure on the government for a clearer lead, as will the WHO report. The previous British report, published in 1979, gave RDAs for just eight nutrients-calcium, iron, thiamine (vitamin B1), riboflavin (vitamin B2), nicotinic acid (niacin) and vitamins A, D and C-as well as for fat and protein. The revised version is vast by comparison, it stretches the list to around 30 nutrients and includes all the so-called ‘macronutrients’, the things we eat large amounts of-not just fat and protein. For the first time, the government will be issuing RDAs for refined and added sugars, the interpretation of which is likely to spark fierce debate between consumer groups and the sugar industry.
The new RDAs are being kept secret until publication. When they do appear, the figures will be compared not only with those of the 1979 report, but also with the findings of two later reports. In 1984 an influential COMA report on diet and cardiovascular disease recommended that, for the population as a whole, fat should not make up more than 35 per cent of the total energy intake, and saturated fats no more than 15 per cent. In 1989 a COMA report on sugar and health concluded that sugar contributes to obesity and that we should eat less of it. It also stated that sugar causes dental caries, a condition which costs Britain’s National Health Service more than £1 billion a year to treat, twice the amount it spends treating people with coronary heart disease.
A source familiar with the contents of Dietary Reference Values says: ‘It’s a very scientific report . . . it’s much more extensive than previous reports.’ The source points out that the panel has reviewed most of the new evidence that has emerged since the 1979 document, and has used more scientific evidence than ever before in reaching values for RDAs. The most significant figure in the new COMA document, says the source, is a downward revision in the RDA for fat. Though declining to give exact figures, the source says of the section on fat: ‘It’s a very important part of the report, and it’s very, very high profile.’
Unlike the 1984 COMA report on cardiovascular disease and the 1989 report on sugars, however, the new document makes no recommendations about healthier eating. According to the source: ‘The RDAs of nutrients are not dietary guidelines, and are not for use in looking at individual people . . . everyone’s requirements are different, and so you must issue dietary guidelines (for individuals to use).’ The main reason that the panel rechristened RDAs as ‘dietary reference values’ was to avoid the figures being misconstrued by politicians, consumers and food manufacturers as recommendations for individuals. Nonetheless, and as acknowledged by the source, the figures will force a re-evaluation of national nutritional goals.
Despite the exhortations not to apply the new figures to individuals, Jack Winkler of the pressure group Action and Information on Sugars sees the list as Britain’s first ‘comprehensive definition of a healthy diet, in numbers’. He says that the only document published in Britain carrying similar advice about the whole diet was compiled by the National Advisory Committee on Nutrition Education (NACNE) in 1983-and the government rejected its recommendations. The 1984 COMA report on diet and cardiovascular disease only set dietary targets for total fat and saturated fat, and COMA’s 1989 report on sugars simply advised Britons to ‘eat less’, without giving targets.
Dietary Reference Values is therefore the first comprehensive list of RDAs and, in Winkler’s opinion, could form the basis for Britain’s first officially endorsed nutrition objectives. He expects the report’s reference values for sugar intake to be controversial. He says that COMA has taken the unprecedented step of subdividing our carbohydrate intake into categories which clearly identify refined and added sugars as the only harmful ones.
According to Winkler, the COMA report recommends that refined sugars should not make up more than 10 per cent of national energy intake, a figure echoed in the WHO report. In Britain, says Winkler, if this was applied to individuals, average consumption would drop by about 50 per cent to the equivalent of about 12 teaspoonfuls a day. Winkler bases this calculation on COMA’s 1989 estimate that in Britain, between 15 and 20 per cent of energy intake comes from refined sugars.
However, the Sugar Bureau, which represents Britain’s sugar industry, questions the scientific basis of advice to reduce sugar consumption. ‘The scientific literature would not support a call for a reduction,’ says Janice Harland, the director of the bureau. Of the connection between sugar consumption and tooth decay, for example, she says that in Britain, ‘the nation’s teeth are improving at a time when sugar consumption has remained static’.
Of the possible link between sugar and obesity, she quotes work showing that obese people often eat less sugary food than people of average weight. If anything, she says, they overeat food mixtures that contain fat. Harland also points out that the new WHO report has not been endorsed at the highest levels of the organisation. ‘It’s not a report, it’s a technical bulletin (by a group of scientists) and it’s not representative of the views of the WHO,’ she says.
Today, in Britain, around 30 per cent of the refined sugar we eat comes from ‘visible’ sources, to sweeten beverages, breakfast cereals and fruit. The remainder, says Winkler, is ‘hidden’ in manufactured foods, particularly confectionery, soft drinks, biscuits, cakes, dairy goods, jams, canned fruit and vegetables. ‘Thus, the (10 per cent) target can be met by reducing sweet snacks which are not essential to a healthy diet,’ he says.
The forthcoming COMA report brackets all sugars under the general heading ‘carbohydrates’, and splits them off from subdivisions on starch and fibre, which are generally regarded as healthy and deserving of wider consumption. Sugars exist in three main categories. ‘Intrinsic’ sugars, which are naturally ‘internal’ to cells of fruit and vegetables, present no threat to health. Another category, milk sugars, also pose no danger to health. Winkler explains that lactose, the sugar in milk, is less harmful to teeth than other sugary substances. Not only is it inherently less harmful, its acidity is reduced by the alkaline components in milk. It is the final category-non-milk extrinsic sugars-which, according to the COMA report, should account for no more than 10 per cent of our energy intake. ‘These rot teeth and contribute to obesity by encouraging overeating,’ says Winkler. There are three major non-milk extrinsic sugars: sucrose (table sugar); glucose (corn syrup, usually extracted from maize); and fructose (concentrated sugars from fruit juice). ————————————————————- Table 1: Dietary recommendations and agreement between studies ————————————————————- Nutrient WHO Current Agreement between report UK studies*** (1990)* intake** ————————————————————- % Total calories Eat Yes No Total fat 15-30 38.4 Less 59 1 Saturated fat 0-10 16 Less 55 1 Polyunsaturated fat 3-7 5.8 More 38 3 Free/refined sugar 0-10 14 Less 50 0 Complex carbohydrate 50-70 27 More 39 0 Protein 10-15 14.7 —- — — Grams of nutrient Fibre 27-40 21 More 33 0 Salt 6 7.4 Less 36 2 Fruit and vegetables >400 290 More 43 0 Cholesterol 0-300mg 335mg Less 33 2 ————————————————————- *Figures taken from Diet, Nutrition and the Prevention of Chronic Diseases, WHO, 1990 **Figures taken from OPCS Dietary and Nutritional Survey, 1990 ***From a survey showing broad agreement between the recommendations of 64 different reports on diet published between 1965 and 1987. The survey was made by Geoffrey Cannon, a consultant on nutrition and diet ————————————————————-
Winkler believes that the reduction in average sugar intake required to achieve the 10 per cent goal, may be even greater than the previous and present COMA reports suggest. In a forthcoming book co-written with Maggie Sanderson, head of nutrition at the Polytechnic of North London, he analyses previous reports on sugar consumption and dietary sugars and concludes that people underestimate significantly the amount of sugar they consume.
Dietary delusions
Some of the key evidence supporting Winkler’s conclusion comes from William Rathje, an archaeologist at the University of Arizona, who in 1983 examined the household rubbish from people participating in a dietary survey. His striking findings were that people underreported consumption of colas (38 per cent); pastries and biscuits (40 per cent), ice cream (71 per cent), table sugar (80 per cent) and confectionary (86 per cent). The Food and Drug Administration, which commissioned the study, rejected Rathje’s findings, however, and did not incorporate them into its 1986 report on sugars and health.
Further evidence of underreporting comes from research by Alison Black of the Dunn Nutrition Unit in Cambridge working with investigators at the University of Ulster at Coleraine. Using isotopically labelled water, they showed that the energy intake of one group-as measured by what they discharged in their urine-was 25 per cent higher than the amount the participants said they consumed.
Winkler’s organisation, a voluntary network of health professionals concerned about aspects of sugar in the diet, plans to lobby for stricter codes of practice on advertising of food products, justifying its case with the new COMA figures. ‘If we are eating twice as much (sugar) as we should, part of the responsibility lies with the advertisers of foods,’ he says.
His organisation is to petition the Independent Television Commission, the government-appointed agency charged with upholding voluntary codes of practice on advertising standards. Its big weakness at present, says Winkler, is that it only responds to complaints from viewers-it does not vet advertisements prior to screening. The Independent Television Association, essentially a TV programme makers’ trade association, runs a copy-clearance secretariat which aims to prevent violations of the code before transmission. But even this will disappear in 1993 in accordance with the 1990 Broadcasting Act.
Sugar is not the only issue for consumer organisations. Seven years on from publication of the COMA report on diet and cardiovascular disease, fat still provides Britons, according to last year’s National Dietary Survey by the Office of Population Censuses and Surveys, with 42 per cent of their energy. The same survey showed that 45 per cent of men and 36 per cent of women are overweight. Overall, diet-related diseases kill more Britons each year than smoking, drugs, accidents and AIDS put together, so some kind of action is desperately required.
Imogen Sharp of the National Forum for Coronary Heart Disease Prevention warned the recent conference in London that the food industry currently spends £555.5 million on advertising, £605 million if soft drinks are included. Half the adverts are for sweetened foods. Compare this with expenditure by the Health Education Authority, which has been given less than £1 million to spend on its new nutrition and dental health programme.
The Ministry of Agriculture, Fisheries and Food spent less than £200,000 last year on nutrition surveillance and education, said Sharp. Maclean, the food minister, told the same conference that he was particularly concerned that young people should learn good eating habits. Yet Sharp, in her discussion document for the conference, pointed out that more than half of all advertisements on children’s television are for foods, four-fifths of them advertising high-fat or high-sugar products. But even if the message about healthy eating does get through to people, the food they require may be too expensive. Often, retailers and manufacturers demand a ‘health premium’ for healthier products. Winkler says: ‘The trend in food retailing has been toward increasingly inaccessible nutrition in the inner city and in the lower income brackets. This development exacerbates the already wide class differentials in diet-related problems.’
Research by Jo Malseed of the Department of Independent Studies at the University of Bradford supports these claims. In a 1989 critique of government food policy, Malseed conducted qualitative research into diet and poverty by interviewing several families on income support in northwest England. She found that they seldom have access to the stores that sell the healthiest food, perhaps because they have no transport, and even if they do they lose out financially because, unlike richer families, they cannot afford to buy in bulk.
Europe’s Common Agricultural Policy (CAP) is the other absurdity which may help to explain why Britons eat so much unhealthy food. ‘We subsidise the production of excessive amounts of fat and sugar,’ says Winkler, explaining that dairy farmers receive the highest subsidies for producing full-fat milk, cheese and butter-which are least healthy. In a discussion document for farmers at the recent London conference, David Ansell of the Department of Agricultural Economics at the University of Reading said that price incentives through the CAP are too weak to encourage livestock farmers to produce leaner carcasses, which would also be healthier.
Lord Carter, an opposition spokesman on agriculture, health, and social security in the House of Lords, and a farmer himself, put it more strongly when he told delegates to the conference that ‘the sooner the CAP is buried, the better’. But like almost all other parties in the food network, Carter’s strongest plea was for some kind of government lead. ‘It’s the only thing that can bring the countervailing power against the big interests. It should give the lead,’ he said. His sentiments were reflected by most other participants.
Closer to home, education should be stepped up, and attempts should be made to make healthier foods cheaper, not dearer. Imogen Sharp recommends a multitude of initiatives in her discussion document for the conference. ‘Producers of drama, especially soaps, should be encouraged to write issues of health and eating into their story lines,’ she declares. Like Winkler, she backs firmer rules on advertising.
Sharp also urges national health promotion agencies to issue model codes of practice to ensure that industry-sponsored dietary information is impartial, particularly when provided to schools. She quotes an investigation by the National Consumer Council: in a random survey of teaching materials, one-third was inaccurate and of this, half had a promotional bias. ‘There is growing concern about the way that the food industry can hijack educational ventures for purely promotional purposes . . . the British Heart Foundation, for example, has recently withdrawn from any collaboration with food companies,’ she says.
However, consumer groups do acknowledge that retailers have played an important part in disseminating independent advice to consumers. Winkler points out that since the mid-1980s, Tesco and Sainsbury alone have distributed 54 million nutrition leaflets, compared with the 100 000 issued by the government. ‘Whether we achieve a healthy diet by the year 2000 will depend in substantial measure on how responsibly they (the retailers) use their power,’ Winkler says.
But the predominant message is that government must accept its responsibility to take the lead. The forthcoming COMA report is one welcome development upon which government could base future action. But there are signs that it is wary of clashes between its ‘free-market’ policies and the ‘nannying’ tones of health education advice. As Maclean pointed out to the recent London conference: ‘We must not be dictatorial or prescriptive . . . we cannot force our views on others and must not make the easy assumption that ours is the only right view.’
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Why do consumers ignore dietary advice?
Over the next three years, researchers at the Institute of Food Research in Shinfield near Reading, Berkshire, hope to discover why Britons react so apathetically to dietary advice which is meant to prolong their lives. The programme of work, costing around £1 million and commissioned by the Ministry of Agriculture, Fisheries and Food, is divided into three projects.
The first, led by Richard Shepherd, is designed to evaluate whether consumers can make use of the information on food labels, particularly that featuring claims about nutrition and healthy benefits of the food. The second, also led by Shepherd, will examine the perceptions that consumers have of risks associated with biotechnology in food production. The third project, led by Dave Mela, will focus on barriers to the adoption of low-fat diets.
Both researchers stress the scientific consensus emerging over the past few years from nutritionists all over the world, and hope to understand the disproportionably fickle response to the advice by consumers. ‘When you talk to people, they are aware of what the recommendations are. The problem is that they don’t seem to act on them,’ says Shepherd. ‘We want to find how people make use of the information and how their beliefs and attitudes interact with that information.’
One problem, he says, is that people who participate in dietary surveys often misrepresent their own behaviour, probably without realising it.’ People often say they’ve made changes in a positive direction, but there’s some dispute as to whether they always tell the truth. If people know what they should be doing, they say ‘Oh yes! I’m doing that’, but the consumption patterns don’t reflect that.’
Among his strategies for investigating consumer use of labels, Shepherd is to experiment with computerised labels that can easily be altered slightly to stimulate different responses from subjects. He will also be testing consumers ‘on the spot’ in supermarkets.
Shepherd says that the project concerning the risks of biotechnology is timely because it will be possible to identify consumer fears and misconceptions well before such products become widely available. ‘Some of the problem is the perception of the problem by consumers, not the risk itself.’ He also says that products of biotechnology may be judged differently in that issues of safety to the consumer may be supplanted by moral and ethical objections about genetic manipulation per se.
Mela will be investigating why people fail to persevere with or even embark on low-fat diets. ‘It might be a misconception of what changing the diet may entail,’ he said. Or it may be that labels are ‘user unfriendly’. As part of his strategy, Mela is to monitor subjects who are put on low-fat diets with the aim of identifying common disincentives for them to continue. He will also examine whether some labelling might be better targeted at vulnerable subgroups of the population rather than the population at large.
The aim of the entire programme is to understand consumer concerns, and how they affect choice of food. Another aim is to optimise ways of conveying information in a useable form.
Shepherd and Mela denounced accusations that nutritionists can’t agree amongst themselves, and said that the messages have been consistent over several years and after investigations by many committees around the world. ‘No matter how people argue, they can’t say that any of the changes would be harmful. Therefore, there’s no risk (in complying) but there’s possible benefit,’ says Mela. ‘Largely due to the media, which picks up on specifics, people don’t realise the extent of the consensus that there is.’