We have known for decades that diets in rich countries contain too much fat, sugar and salt and are making some of us ill. But as consumers will not change their habits, governments and food companies may have to save us from ourselvesby Rosalind Sharpe / August 22, 2004 / Leave a comment
Food is ubiquitous in rich countries. On top of the array of food in supermarkets and restaurants, it has become almost impossible to leave your home without being confronted by an astounding range of snacks, tailored for the need of the moment.
This represents a triumph for the food industry in its long battle with perishability. Building on the success of tinned corned beef and frozen fish fingers, food technologists have, over the past 30 years or so, developed systems for manufacturing, packaging and transporting food which mean that all kinds of things, from muffins to burgers to cook-chill trout with almonds, can be produced in massive quantities, to a uniform standard, in hygienic protective wrappers, with a long shelf life and at a relatively low cost. And, you may fairly say, a wonderful thing it is too. We do not have to spend as much of our income on food (around 16 per cent now, on average, if you include eating out, compared with just over 25 per cent 50 years ago), we do not have to shop as often, and we do not have to struggle with time-consuming, labour-intensive cooking from raw ingredients. Women, the traditional food providers, have been partly liberated from the kitchen.
The result is that there are millions of tonnes of food swilling around in Britain’s overproductive food system. This system provides between 3,000 and 3,500 calories for every person every day, when the average amount recommended to keep an active adult healthy is at most 2,500. We export food, but import still more of it, sometimes of the same commodities (in 2000, Britain exported 445m litres of liquid milk and imported 105m litres). We compost or plough back into the ground thousands of tonnes of perfectly edible vegetables every year, to keep up the price to growers. Some food (such as beet sugar) we dump on the developing world at subsidised prices, to the disadvantage of local producers. And some of it we simply dump in our dustbins. In 1999, the US department of agriculture estimated that 27 per cent of the food produced by America’s similarly overproductive and heavily subsidised food system was wasted. Nevertheless, we eat most of it, and it is making us fat and ill. Thus, gradually but inexorably, our enviable abundance of food, something a substantial proportion of the world’s population still only dreams of and which Europeans did not enjoy until the 19th century, has become not a blessing but a problem.
This must be baffling for the reasonable people who until recently thought that if you lived in the affluent west and ate sensibly, you could be confident that you were better fed than any preceding generation in history. On the face of it, the facts still support that position. Life expectancy at birth has increased by over 30 years since 1900, and “healthy life” expectancy (the number of years during which we can expect to live disease-free lives) has also increased. Infant mortality has fallen, average height has increased, and the classic deficiency diseases (such as rickets) have all but disappeared. There are still inequalities in life and health expectancy between richer and poorer people, and between regions and ethnic groups. On the whole, though, health trends are improving, and in Britain, at least, the kinds of ill health associated with undernutrition have been eliminated.
Diseases of over-nutrition
They have, however, been replaced by the diseases of over-nutrition, or a new kind of malnutrition from diets which are high in calories but relatively low in nutrients. These diseases include stroke, high blood pressure, diabetes, heart disease and certain forms of cancer. This is not news: the link between fat consumption and heart disease, for instance, has been well established since the 1970s. The first British report to set target reductions for consumption of fat, salt and sugar appeared in 1983, and these targets have long been part of government health policy. It is now estimated that one third of deaths from cancer and heart disease – Britain’s leading causes of death and chronic illness – could be prevented by changes to diet, and beyond these well established connections, poor diet has been linked with the surge in allergies, asthma and even mental illness. Despite the encouraging health trends overall, Britain continues to have one of the highest rates of low birthweight babies among developed countries (7.3 per cent, compared with 6.9 per cent in Portugal and 4.7 per cent in Norway in 1997), and since the weight of babies at birth is closely related to the quality of the mother’s diet around the time of conception and during pregnancy, this statistic suggests that women of childbearing age may be less than optimally nourished. John Krebs, head of the food standards agency, has even raised the possibility that unhealthy diets could reverse the long upward trend in longevity, with today’s children having shorter life expectancy than their parents.
These average statistics mask big differences between socioeconomic groups. A working-class woman is twice as likely to be obese as a woman in the most affluent economic group, and the death rate for coronary heart disease is three times higher among unskilled men of working age than among professionals. Differences in the quality of diet underlie these differences in health. Children from disadvantaged households eat on average half as much fruit and vegetables as children from high income households, and poorer households consume less wholemeal bread, lean meat and fibre than higher income households, and more white bread, full-fat milk, table sugar, and processed meat products. This discrepancy in diet is not simply a result of ill-informed choices. Research has shown that healthy foods are more expensive than less healthy foods (wholemeal bread is more expensive than white, chicken nuggets are cheaper than fresh chicken), and that highly processed convenience foods, likely to be low in nutrients and high in fat, salt and sugar, are more widely available than fresh foods. Yet it would be naive to suggest that culture, familiarity and even old-fashioned fecklessness did not play a part in the choices that lead to these dietary patterns. At Sustain’s Food Poverty Project, where I work, we do come across parents who buy cigarettes instead of fruit and vegetables. There are, of course, discrepancies within classes: not all rich people eat wisely and well, and by no means all poor people eat badly. But it is harder to eat the kind of food that people know they should if they live on a low income and in a part of town where few shops sell fresh fruit and vegetables.
Again, this is not new. Reducing diet-related ill health, both to improve public health overall and to reduce social inequalities in health, has been a part of the government’s policy since it came to power. But it is obesity, the visible consequence of our eating habits, that has focused unprecedented public attention on the connection between food and health. Perhaps this is because it is easier to spot obese people than people with a diet-related cancer, or because the causal connection between eating a lot and getting fatter seems more straightforward. In fact, obesity kills far fewer people than, say, coronary heart disease, and represents less of a charge to the state. In England, obesity is responsible for 9,000 “premature” deaths (before the age of 75) a year, compared with more than 40,000 from coronary heart disease.
But obesity, apart from being disabling in its own right, is also often a precursor of serious illness, and it is now affecting children. The prospect of millions of people from adolescence onwards requiring treatment for diabetes, arthritis, high blood pressure, strokes, heart attacks, cancer and all the other problems which people with too much flesh are heir to, has galvanised governments into tackling diet-related public health with new vigour. The World Health Organisation (WHO) has identified obesity as a “global public health epidemic,” and in England, where the prevalence has almost quadrupled over the past 25 years, the chief medical officer, Liam Donaldson, has called it a “health timebomb.” The recent report on obesity from the House of Commons health select committee concluded that our diet needs to be transformed, and recommended urgent action from government and industry to achieve this.
Industry analysts are now saying similar things. Recent reports from Global Equity Research and JP Morgan warned companies manufacturing “not so healthy” categories of food that they faced the likelihood of market-shrinking restrictions on how products could be promoted, which could in turn lead to a damaging loss of investor confidence. The JP Morgan report concluded that the food industry “will have to review its marketing practices and transform itself.”
Human diet and evolution
But what happened to our diet to make all this necessary? The received wisdom, derived from studies of what different populations eat and the illnesses they suffer from, is that the diet in many developed countries, including ours, contains too much fat, especially saturated fat, too much sugar and too much salt, and not enough fruit and vegetables or fibre. How did this come about? We may not eat an optimal diet, thanks to the tempting abundance unknown in earlier centuries, but surely we are doing better than our forebears, who did not have year-round access to bagged salad and semi-skimmed milk?
One theory is that we are just not adapted to our current diet. In The Origins of Human Disease (1988), Thomas McKeown, a former professor of social medicine, says that the human genetic constitution is much the same now as it was 100,000 years ago, before the advent of any pastoral or industrial activity. As a result, “we face vastly changed conditions of life with the genetic equipment of hunter-gatherers.” According to McKeown’s analysis, non-communicable diseases (such as cancer and heart disease) were rare among hunter-gatherers, who were not very numerous and led active lives in an unpolluted environment. They lived on meat, fish, fruit and vegetables, with about two thirds of their diet coming from vegetable sources. They ate no cereals and almost no dairy produce. Even after diets came to include a high proportion of cereal-based foods and some dairy products (the latter greatly limited by their swift perishability), there was still no sudden increase in non-communicable diseases.
The introduction of agriculture brought people together in settled communities, where crowded living conditions made them prey to the infectious diseases that were to be their main killers until, according to McKeown, improved nutrition gave them the strength to resist infection. In Britain, this happened in the 19th century, when improvements in agriculture and transportation led to a more plentiful and reliable food supply, which in turn led to a fall in deaths from infectious diseases despite the greater exposure to infection.
But this is also, it seems, where things began to go wrong. Fibre intake, important for healthy digestion, fell from the early 19th century, when improvements in milling technology made white bread, from which the fibrous bran has been removed, affordable to the masses, who embraced it eagerly – perhaps because they aspired to eat like the rich, or simply because they preferred the taste. Fat consumption increased from the beginning of the 20th century, when the use of pasteurisation and refrigeration brought widespread consumption of dairy products. As for sugar, which has no inherent food value and often replaces more nutritious calories in the diet, the historian Henry Hobhouse has pointed out that at the time of the Renaissance, Europeans consumed a teaspoonful of sugar per head per year, whereas Europe now consumes around 14m tonnes annually. McKeown concludes that the main factors that have influenced patterns of disease since the industrial revolution are decreased fibre consumption, increased intake of fat and sugar, increased use of tobacco, drugs and possibly alcohol, less exercise and fewer, later pregnancies. Of these, it is changes to diet that have been most important, and they have happened on a large scale only since the start of the 20th century.
This evolutionary approach to diet does not answer the crucial question of why we seem to like foods that are bad for us. George Orwell once remarked that ordinary human beings would rather starve than live on brown bread and raw carrots. Food historians talk about the “omnivore’s paradox.” They mean that the ability to adapt our diet to almost anything available has helped us to survive – unlike, say, pandas which die out as their sole source of food, the bamboo forests, disappear – but at the price of leaving us with no in-built aversion to foods that may harm us.
But if we cannot fully explain our preference for sweet, rich foods, we can at least identify the main sources of sweetness and fat in our diets, and having identified them, perhaps we can make them harder to obtain, or easier to resist, or simply less sweet and fatty. As part of the current spurt of activity on nutrition, the department of health has just produced a document called “Choosing health: choosing a better diet” as part of the consultation preceding the public health white paper expected later in the year. It includes an interesting table on the sources of fat, salt and sugar in the average British adult’s diet. Not surprisingly, the main sources of saturated fat are meat and dairy products. But 26 per cent of the salt we eat also comes from “meat and meat products,” and “cereal products” account for 18 per cent of the saturated fat and 35 per cent of the salt in our diets. Only a third of the added sugars we consume comes from the obviously sugary “sugars, preserves and confectionery”; 37 per cent comes from drinks (both soft and alcoholic) and 19 per cent from those cereal products again.
What this table tells us is that processed foods contain large quantities of the substances we are supposed to be avoiding. But processed foods are already estimated to comprise more than four fifths of our diet, and this proportion is likely to increase, pulled by consumers’ demand for convenience and pushed by producers’ desire to add value to raw materials – in other words, to sell crisps rather than raw potatoes, thus earning a much higher return per kilo of raw material.
“Processing” food can mean anything from mass producing pasta or canning tomatoes to manufacturing ready-to-microwave roast beef dinners or extruding Monster Munches. A loose definition might be “something that happens to food that transforms it from a raw material, such as a carrot or a grain of wheat, into something else.” It is a highly technical large-scale industry. It is based on detailed understanding of the chemical and physical properties of its raw materials, many of which are substances that would not appear in any domestic kitchen. Put crudely, quite a lot of it involves making different combinations of generic ingredients (fat, protein, sweetness, starch) from interchangeable sources (corn or soya, for example, depending on price and availability), with palatability, flavour, appearance, texture and preservability designed in by food scientists. (For the latest news on developments in food manufacturing technology you can read a newsletter, Food Link News, sent out by the department for environment, food and rural affairs.)
All of this may sound unappetising, but sales figures suggest that we are happy with the results. The food industry tends to claim that it is driven by demand, and produces things because we want them. However, it would be difficult to evince a desire for Cheese Strings (sticks of processed orange cheese that peel into fronds like a palm tree) if a food company had not invented them and put them on the market. In other words, manufacturers do not simply respond to demand but also create it. By the same token, our greater interest in food – British television now transmits around 4,000 hours of food-related programming a year – is not reflected in more time spent in food preparation. We spend on average only 20 minutes preparing our main daily meal, down from an hour in 1980.
What can policy achieve?
So the government has a problem that is at least well defined. And the policy levers fall into two categories: those which might persuade individual consumers to choose more wisely from the expanding array of foods, and those which alter the foods before they reach the consumer. Almost certainly, levers in both categories will have to be invented and then pulled in order to achieve the changes now being advocated.
Persuasion directed at the consumer has been the preferred option so far. The idea is that as long as you ensure, on the one hand, that products are clearly and accurately labelled and, on the other, that consumers are sufficiently well informed about what they should be eating, people on balance can be left to make sensible choices about diet. The trouble is, it does not seem to work. Although market research suggests that most of us have a pretty good idea about which foods we should be eating more of and which we should be cutting down on, we just don’t act on it. This may be partly because the “healthy” messages are drowned out by others: in England, for example, around ?1m a year is spent by the health development agency promoting healthy eating, compared with ?130m spent on advertising by Britain’s top ten food and drinks companies in 2000. Or it may just be consumer contrariness. Whatever the cause, a recent article in the WHO bulletin asserted that “against a background of monumental global changes in production, marketing and retailing, the advocacy of changes in individual behaviour has generally failed.”
There may be a case here for stealing the enemy’s clothes. Both the House of Commons health committee report, which was severely critical of junk food advertising to children, and an authoritative review of the effects of food promotion to children produced last year for the food standards agency, suggested that one way to counter the influence of unhealthy food advertising would be to use the same techniques to promote healthier options. For example, a company wishing to advertise, say, a chocolate bar on television might be required to pay for an equivalent advert for vegetables.
And what about using price incentives to encourage people to buy healthier foods? Or eliminating food adverts from children’s television? Or removing vending machines selling unhealthy foods from schools? Many schools have come to depend on the several thousand pounds or more of annual income they make from vending machines, in collaboration with soft drinks and confectionery companies. But supposing the government had to pay every one of Britain’s 4,500 secondary schools, say, ?20,000 a year to make up the shortfall if the machines were removed, the ?90m bill would still be small in comparison with the sums spent treating the consequences of obesity in the future. And how about subsidising corner shops to sell more fresh produce, just as we subsidise farmers to grow (or not grow) certain crops? What about a nutrient tax, applied to undesirable ingredients such as saturated fat or sugar, to discourage manufacturers from using them or shoppers from buying them?
These are ideas that, until recently, the food industry could dismiss and which the government shunned on the grounds that people should not be “nannied” when it came to food choice. Now, however, they are widely canvassed in policy documents, including the health committee report. In some other countries they have been put into effect and have worked; the chief medical officer of England has said he is “not opposed” to seeing some of them tried here.
The “Choosing a better diet” report notes that in Norway, fiscal and regulatory strategies designed to make healthy foods more affordable contributed to a 30 per cent increase in the consumption of vegetables, a 17 per cent increase in fruit consumption and a 13 per cent decrease in total fat intake between 1970 and 1993. In Finland, a combination of measures designed to raise awareness of healthy eating and ensure that healthy alternatives were widely available increased fruit and vegetable consumption and brought significant health benefits. Several US states have experimented with nutrient taxes in the face of well funded opposition from the food industry. In Britain, however, we already have one: ice creams, sweets and fruit juice are already subject to VAT, unlike other foods, which are zero-rated. A paper published in the British Medical Journal a few years ago made a detailed case for using further fiscal measures to reduce heart disease, and calculated that if VAT were extended to whole milk, butter and cheese, which are the main dietary sources of saturated fat, between 900 and 1,000 deaths could be prevented each year.
In a convoluted way, the common agricultural policy (Cap) also operates as a kind of nutrient tax in some areas. EU sugar prices, for example, are almost three times world market prices. Recently announced plans to cut EU sugar production quotas and prices, in order to trim the Cap’s costs and open up Europe’s sugar markets to cane producers in poorer countries, may have the unintended effect of making an “unhealthy” food cost less. The Cap is one of the most complex pieces of food control policy ever devised, and though it was designed to regulate production and trade, it inevitably also affects consumption. The campaign group Sustain, which promotes sustainable food policy, has pointed out how different the Cap would look if public health were its overriding priority, and subsidies and quotas were used to encourage the production and consumption of healthy foods. Currently, livestock farming in its various forms, which produces nearly all the saturated fat in our diets, receives the bulk of support, with less for arable production and almost none for horticulture. Under a common health and agriculture policy (with the appealing acronym Cheap), this situation would be reversed.
Most of these measures involve persuading people to choose healthier foods or making healthier foods more widely available. But another approach is to alter food to meet specific health targets, in a manner undetectable to the taste buds, before it ever reaches the consumer. Technological manipulation may allow us to keep eating exactly what we want, but more healthily. The clearest example of passive manipulation of diet is provided by bread and flour regulations, which require millers to add B vitamins and iron to white flour to replace the nutrients lost in the milling process. These additives do not have to be listed on the label, so consumers are unaware that they are being medicated while they eat. This distinguishes the process from the marketing ploy of producing “healthier” versions of existing products, such as low fat yoghurt, or adding vitamins, minerals or fibre to a range of foods that would not otherwise contain them, such as calcium in orange juice, and advertising the fact on the label. The food industry has adopted these practices so energetically that the EU is currently devising a code to regulate its activities.
With the government’s encouragement, food manufacturers are already working to reduce levels of salt in the standard versions of many processed foods, including sliced bread, baked beans, pizza and soup, so that we can gradually adjust to lower levels of saltiness. Sugar and saturated fat may follow. A diet action plan produced by the Scottish office in 1996 estimated that up to 30 per cent of the target reductions in fat, 80 per cent of the target reduction in salt and significant reductions in sugar intake could be achieved simply by changing the composition of processed foods. The “Choosing a better diet” report notes more cautiously that “altering the nutritional content of foods without changing the taste can have a significant impact on dietary intakes.”
I would like to be able to choose brown bread and raw carrots of my own free will. Unfortunately, however, George Orwell was probably right, and no amount of persuasion will make most people eat better. In this case, without the collaboration and ingenuity of the scientists who design most of our food, the population will surely continue to get fatter. It may be Big Brother, rather than the nanny state, who will have to save us from the consequences of our own choices.