Kiwis, food and cholesterol: New Zealand consumers’ food concerns and awareness of nutritional guidelines

Anthony Worsley and Andrea Worsley

Stephanie McConnon

National Centre for Epidemiology and Population Health, Australian National University

Department of Mathematics, University of Otago, New Zealand

Abstract: New Zealand food shoppers’ nutrition and food concerns and attitudes to cholesterol screening were assessed during four consecutive surveys. Over 1000 shoppers were interviewed during each survey, as part of the evaluation of the Heart Food Festival in 1988-89. Over two thirds of the respondents reported that they usually read the ingredients label on food prod- ucts. Over a third were concerned about the presence of additives in foods (36 per cent), along with fat (27 per cent), salt (18 per cent), sugar (14 per cent) and fibre (5 per cent). Over half indicated that reductions in fat intake would make their diets healthier. One in five reported they were aware of the New Zealand nutrition guidelines. Only one third of respondents could correctly identify the bottom row of the healthy food pyramid. Almost one in eight respondents knew their cholesterol levels and a further two thirds wished to know them. Few differences were observed between the responses of early and late school leavers. In contrast, pronounced differences were associated with gender and the respondents’ age groups. The results suggest that awareness of links between nutrition and heart disease is widespread. Educational and empowerment strategies are required to translate such awareness into dietary change. (AwtJ Public Health 1991; 15: 296-300)

here has been increasing interest over the past decade in laypeople’s perceptions of health, T particularly regarding diet-heart disease

relationships. In the United States, for example, large proportions of the population have accurate knowledge of the dieta factors associated with elev- ated serum cholesterol. Considerable dissemination of positive attitudes towards heart disease prevention has also been observed, although this appears to be associated with ignorance of the major sources of dietary cholesterol.’ Similarly in the United King- dom, there is widespread interest in diet-heart disease relationships.’ In Australia, the picture is less focused, though several studies have shown that many Australians have strong interests in diet-health relationships; around one third have their serum cholesterols checked each year.4 Between one and two thirds of the population appear to have adopted simple measures to curtail their fat intake^.^

The key diet-related factors having major roles to play in population prevention strategies are the diet- ary precursors of elevated serum cholesterol and blood pressure levels. Thus, people’s knowledge of important dietary factors (such as dietary fat) and of national strategies and campaigns to influence them could be of major importance for health promoters. No studies in New Zealand have examined such beliefs.

A further point of importance for health pro- motion is the degree to which heart disease preven-

7

Correspondence to Professor Anthony Worsley, National Centre for Epidemiology and Population Health, Australian National University, GPO Box 4, Canberra, ACT 2601.

tion has been accepted by various sectors of the population. Most studies, including those above, suggest that more highly educated people have greater knowledge and more positive attitudes toward the role of nutritional factors in the preven- tion of heart disease. Again, however, it was unclear whether this generalisation applied to New Zealanders or indeed to all the various facets of com- munity concerns.

The launch of the New Zealand Heart Food Festi- val in September 1988 provided the opportunity to investigate consumer concerns about serum choles- terol, diet and nutritional guidelines. The Heart Food Festival and its evaluation are described in full elsewhere.6

Methods Design The Heart Food Festival commenced with four weeks of intensive media coverage at the end of September 1988. Baseline evaluation was carried out at the beginning of September and further post-Festival evaluations were carried out on independent samples of supermarket customers during October and November 1988 and at the end of March 1989.

For each survey, 20 supermarkets were selected in seven cities throughout New Zealand (Auckland, Napier, Hamilton, Wellington, Christchurch, Dunedin and Invercargill). Within each supermarket a minimum of 50 shoppers were randomly selected for interview on the Friday or Saturday morning of the survey week. Care was taken to ensure that cus- tomers were selected at the same time of day in the

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same supermarkets in each survey. Only people who had not responded in the earlier surveys were inter- viewed in later rounds to ensure sample independence.

Procedure and instrument

Short questionnaires of approximately 20 multiple- choice and short-answer questions were admiinis- tered during each survey round. Most of the questions were designed to assess the respondents’ awareness and response to the Heart Food Festival. However, several questions were included to assess their concerns about food constituents, diet, heart disease risk and cholesterol screening, as well as their awareness of the New Zealand nutritional guidelines and the healthy food pyramid. The question content of the questionnaires varied slightly, to accommodate the changing needs of the Heart Food Festival evaluation. Most of the responses reported in this paper are drawn from the first and second surveys since the third and fourth surveys either contained different questions or yielded similar responses (Table 1) though the food label reading and dietary concern questions were asked in all four surveys.

Respondents were randomly selected from check- out aisles, the interviewer moving from aisle to aisle in ascending order from a random starting aisle. One respondent per aisle was selected for interview. The two selection criteria were that the respondents had to be adult and to have completed their shopping in the supermarket. For a small minority of respondents the questions were read aloud (i.e. if they were unable to read the questionnaire themselves); for the majority the questionnaires were self-administered.

Results Details of the shoppers’ responses are shown in Table 1, and their demographic characteristics in Table 2. The mean response rate was 68 per cent.

Dietmy concerns Over two thirds of the respondents reported they usually read the ingredient labels on new or unfam- iliar food products. A further 16 per cent claimed to do so ‘sometimes’. Routine interest in label reading was more pronounced among women (73 per cent) and the over-45s (75 per cent) than among men (59 per cent) or the under-45s (64 per cent).

The principal single area of concern was ’additives’ (36 per cent), followed by fat (27 per cent), salt (18 per cent), sugar (14 per cent) and fibre (5 per cent). More of the under-45s and the later school leavers were concerned about additives than younger people or late school leavers. This pattern remained stable throughout all four surveys.

Ninety per cent of the consumers indicated that a healthy diet can prevent heart disease. When asked how they could make their diets healthier 55 per cent indicated they would consume less fat, 17 per cent avoid additives, 13 per cent consume more fibre, 8 per cent less salt and 7 per cent less sugar.

Awareness of nutrition guidelines Almost one in five consumers claimed to have heard of the New Zealand nutrition guidelines, but a similar proportion were ‘unsure’. Women and the over-45s appeared to be more aware of the guidelines than men or younger people.

The healthy food pyramid had been promoted dur- ing the Heart Food Festival, but only 33 per cent could correctly name the foods on the bottom row of the pyramid. (The pyramid divides foods into three broad groups: those at the bottom can be eaten most, those at the top least.) More women and respondents under 45 years of age answered this question correctly.

Cholesterol and perceived risk of hart disease Almost one in eight of the second sample had had their cholesterol levels checked and could cite a realistic value. Another two thirds, particularly women and respondents under 45 years, wanted to know their cholesterol levels. Only 20 per cent, who tended to be men or people over 45 years, did not want to know.

Almost one in five of the first sample reported they had a moderate or high risk of a heart attack in the next five years. This was more pronounced among the over-45s (27 per cent) than among younger people. More of the early school leavers (who left school before 17 years of age) indicated either that a heart attack was very likely (8 per cent versus 3 per cent) or that they ‘couldn’t say’ (32 per cent versus 22 per cent).

Almost all respondents, particularly women and better educated people, reported that cholesterol is a type of fat.

Discussion The results suggest that most New Zealand food shoppers (the main influence on household food consumption’) are interested in nutrition and heart disease relationships. They are similar to Australians, although awareness of nutritional guidelines appears to be more extensive among New Zealand shoppers today than it was among Victorians in 1984 and 1985.’ A recent random population survey of New Zealand general practitioners showed that positive attitudes to orthodox nutritional agenda were also widespread in the medical comm~nity,~ in contrast to the opinions of their New South Wales counterparts. lo

Such nutritional concerns are likely to influence food choice. However, concern about nonnutritional dietary constituents, such as ‘additives’, may be more powerful influences. This particular concern has emerged repeatedly from consumer surveys in sev- eral countries over several decades.”-I3 Nutritionists have typically denied the importance of such con- sumer opinions as being outside the definition of their discipline. Recently, however, it has been claimed that colouring and flavouring agents are of nutritional relevance since they are added to mix- tures of fats and carbohydrates to make them into

AUSTRALIAN JOURNAL OF PUBLIC HEALTH 1991 VOL. 15 NO. 4 297

palatable and acceptable synthesised food There was some discrepancy between the con- product^.'^ Such products counter the behavioural sumers' dietary concerns and the ways in which they adoption of nutrition guidelines which recommend believed they could make their diets healthier. Whilst reductions in population fat intakes. fat content was secondary to additives as a concern,

Table 1 : Responses of New Zealand food shoppers to questions about food, nutrition and heart disease

Gender Age groupa Educationb Response % overoll %men %women % <45 % >45 % eorly % lote

Do you usuolly reod the ingredient lobel of o new or unfamiliar food product before you buy it? Yes 68 59 73 64 75 69 68 No 16 23 13 16 15 17 15 Sometimes 16 19 14 20 10 14 17

( n = 101 1 ) x2 = 20.1 ***I 19.8"" ns.

If yes (obove), which one ingredient most concerns you? Salt 18 17 18 16 20 .2 1 16 Sugar 13 12 14 13 14 14 13 Additives 36 37 37 44 26 26 44 Fibre 5 6 5 5 6 7 4 Fat 27 29 26 22 33 33 23

In = 69 1 1 n.s. x2 = 26.0"" x2 = 27.2""

Do you think o healthy diet con prevent you getting heort diseose? Yes 90 88 91 92 88 89 91 No 5 7 5 4 7 6 5 Can't say 5 5 5 5 5 5 5

(n= 101 I ) n.s. n.s. n.s.

If you wonted to make your diet heolthier, which one of the following would be the most important thing to do? Consume less fat 55 56 55 54 58 59 52 Consume more fibre 13 1 1 13 13 12 13 13 Consume less sugar 7 8 7 7 6 5 8 Consume less salt 8 7 8 8 8 8 8 Avoid chemical additives 20 18 17 17 17 15 19

(n = 987) n.s. n.s. n.s.

Do you know what your blood cholesterol level is? (Survey 2) Yes 12 15 10 9 16 1 1 13 No, but I would like to know 68 59 71 74 61 66 69 No, it doesn't matter to me 21 25 19 18 24 23 18

( n = 1024) x2 = 12.3"' x2 = 21.2"" n.s.

How likely ore you to hove o heort ottock in the next five years?

A little likely 12 12 13 13 12 10 14 Moderately likely 13 12 13 9 18 13 13

Not likely 43 42 43 53 31 37 47

Very likely 5 9 4 3 9 8 3 I con't say 26 27 26 23 30 32 22

Hove you ever heard of the New Zeolond Nutrition Guidelines? Yes 20 13 22 18 21 18 21 No 63 76 58 62 64 65 61 I'm not sure 17 1 1 20 21 14 18 18

Whot foods are ot the bottom of the Healthy Food Pyramid? (Survey 21 Don't know 17 23 14 14 20 18 15 Dairy products, lean meat, 6 5 7 6 7 8 5

Breads, cereals, fruits, 33 27 34 36 29 30 35

Fats, oils, salt, sugar, olcohol 45 45 45 45 44 44 45

In = 1004) ns. x2 = 64.8"" x2 = 3 1.4"'

( n = 1005) x2 = 27.4"" x2 = 7.4" n.s.

poultry, fish, eggs

vegetables

In= 10211 x2 = 12.5" x2 = 10.5" n.s.

Whot is cholesterol? A form of sugar 3 4 3 3 3 4 3 Artificial sweetener 0 1 0 1 1 1 0 A type of fat 91 87 92 92 89 86 94 I don't know 6 8 5 5 6 9 3

in= 1001) x2= 11.1" n.s. x2 = 20.1 ****

Noten (a) Percentage of respondents under or over 45 years of age. ib) Percentage of respondents who were early or late school leavers, i.e. who left school before or after 17 years of oge. Ic~ *P<0.05; "P<O.Ol; *'*P<O.OOI; ****P<O.O001.

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Table 2: Demographic characteristics of the first and sec- ond survey samples

Survey 1 Survey 2

Percentage of women 73 72 Percentage under 45 yeors 56 54 Percentage early school leavers 45 48

fat reduction was the most popular way of improving diet. This may be because fat is easier to remove or avoid than ‘additives’ which are added during manu- facture to many foods and which are less obvious than fats. Furthermore, while fat has been strongly linked to ill health, ‘additives’ are a much wider cat- egory with less well accepted health consequences.

Although many shoppers are keen to reduce the fat, sugar and salt contents of their diets, concern alone is probably insufficient for dietary change.15 Several other conditions may be necessary, for example adequate income and nutritional knowl- edge. Knowledge of the nutritional constituents of a healthy diet and of the nutritional composition of common foods appear to be important factors. Although a large majority of consumers routinely examine the ingredients labels of new or unfamiliar foods, it is uncertain whether they have a clear idea of the quantities of nutrients in these products, or whether they know the quantities required for health. A recent survey by a group of postgraduate students in Invercargdl showed that consumers knew the approximate quantities of fat in 16 common foods but they exhibited little knowledge of the foods’ salt and dietary fibre contents.

The cost of food relative to household income is a major impediment to healthy dietary choices. The Brotherhood of St Lawrence have shown that financially disadvantaged households put rent or mortgage, transport and telephone costs ahead of food. These are paid for first, the remainder of their income being left for food and other expenses.16 In the United Kingdom, it has been claimed that unem- ployment beneficiaries require an average 35 per cent increase in weekly payments in order to con- sume a diet consistent with the recommendations of the National Advisory Committee on Nutrition Education. l7 Similar financial limitations have been found in Western Sydney to constrain the nutritional choices of financially disadvantaged shoppers.

Our results, however, suggest that concern about nutrition may not be strongly related to social class. In fact, early school leavers (who are likely to be from lower social status groups) appear to be more con- cerned about the dietary guidelines than later school leavers. Thus, the orthodox nutrition agenda seems to have been widely disseminated throughout the population. This may be surprising to some, but it is consistent with recent findings. For example Cole- Hamilton and Lang’? have shown that financially dis- advantaged working-class people are among the most efficient buyers of nutrients (per € sterling) in the British population. In summary then, a majority of

consumers may be interested in improving their nutrition status but may not have the knowledge, skills or economic resources to do so.

Whilst educational group differences were not very apparent, the gender and age group of the respondents affected their answers to the questions. In general, the older respondents (at higher risk of heart disease) and the women (more likely to be responsible for family health were more interested in nutrition and dietary change. Similar gender effects have been observed with regard to perceptions of healthlg and dietary intake.” These factors may prove to be more powerful predictors of nutritional con- cern and dietary change than more conventional socioeconomic classification criteria.

The main exception to this generalisation was the over-45-year-olds’ lesser knowledge of the healthy food pyramid. This is likely to be due to their lesser exposure to the pyramid, which has been promoted mainly among schoolchildren and their families. This suggests the need for more active educational measures to help consumers in this age group. The finding that most of the respondents could not cor- rectly identify the bottom row of the food pyramid is unlikely to be due to misunderstanding of the ques- tion that was asked but suggests the need for more active explanation of such symbolic schemata.

Adolescents who had brief lessons on the meaning of the pyramid could identify the bottom row cor- rectly (postgraduate students, unpublished manu- script). It needs to be emphasised that symbolic nutritional schemata such as pyramids and nutrient labels (‘nutritional hieroglyphics’) are only meaning- ful to those who have the knowledge necessary to decipher and comprehend them. Such schemes always require accompanying educational programs, which so far have not been widely disseminated.

In this study more of the over-45-year-olds (20 per cent) did not want to know their cholesterol level. This is the same age group that a recent consensus conference recommended should know their per- sonal levels.21 This lack of interest may be related to the health fatalism previously observed among Aus- tralian elderly groups.22

The majority of New Zealand shoppers want to know their personal cholesterol levels. Indeed, almost one in eight of them already know their levels. This is consistent with our finding that a third of New Zealand general practitioners routine1 screen all

lence of personal cholesterol awareness is higher than in the United States,24 which has a continuing National Cholesterol Education Pr~gram.’~ The responses to the cholesterol questions suggest there is great potential for the expansion of cholesterol screening and subsequent dietetic advisory services. Some of this has already been realised through the advent of private screening services. More comprehensive meeting of this public demand‘ may require further funding from state resources.

their adult patients’ cholesterol levels.‘ 9 The preva-

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WORSLEY ET AL

Conclusions The widespread interest in reduced fat intake and associated nutritional guidelines and in cholesterol screening suggests there is likely to be ready accept- ance of dietary strategies to prevent heart disease.

Different emphases in nutrition promotion may be necessary for people under and over 45 years of age, for example more encouragement to read nutrition information on food labels among younger people and more explanation of recent nutrition education schema among older people.

The associations between nutrition knowledge and interest and social class, age and gender require further investigation.

Acknowledgments We gratefully acknowledge the support of a grant from the New Zealand National Heart Foundation. We would also like to thank Dr D. Hay, Mr L. Schouskoff, Mr G. Bradley and an anonymous reviewer for their encouragement and assistance, the NHF Regional Health Education officers and the interviewers for their invaluable help during the con- duct of the interviews, and Linda Boock for manu- script preparation.

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